Anger precedes and predicts nonsuicidal self-injury in veterans: Findings from an ecological momentary assessment study

Institutional Betrayal and Closeness Among Women Veteran Survivors of Military Sexual Trauma: Associations with Self-Directed Violence and Mental Health Symptoms

Institutional betrayal is defined as harm caused by an institution to an individual in the context of trust and dependence. High institutional betrayal is associated with poorer health outcomes, and high levels of trust, dependence, or identification with the institution (institutional closeness) may exacerbate the negative effects of institutional betrayal. While military sexual trauma is prevalent among women Veterans and associated with high rates of institutional betrayal, studies of the impact of military sexual trauma-related institutional betrayal have been limited in size and scope and have not examined the potential role of institutional closeness. We conducted a secondary analysis of national survey data collected from women Veterans who screened positive for military sexual trauma (n = 229). Hierarchical logistic and linear regression were used to examine associations between predictor variables (institutional betrayal, institutional closeness, and their interaction) and outcomes of interest and adjusted for age, education, and military sexual assault history. Institutional betrayal was associated with increased odds of suicidal ideation and suicide attempt during or following military service, as well as more severe symptoms of depression and posttraumatic stress disorder (PTSD). Institutional betrayal was not associated with non-suicidal self-injury or lifetime substance misuse. Counter to hypotheses, institutional closeness did not moderate relationships between institutional betrayal and mental health symptoms or self-directed violence. Results underscore the necessity of preventing and addressing institutional betrayal among women Veterans who experience military sexual trauma.

Nonsuicidal self-injury methods among U.S. Veterans: Latent class analysis and associations with psychosocial outcomes

Nonsuicidal self-injury (NSSI) is a debilitating concern among U.S. veterans, with wall/object-punching commonly endorsed as an NSSI method. We examined how this behavior relates to other NSSI methods and psychosocial outcomes. We conducted a latent class analysis (LCA) of NSSI methods among 1,138 Gulf War Era veterans, (77.9% male), 21.7% of whom endorsed lifetime NSSI. We categorized classes based on their associations with age, sex, combat and military sexual assault exposure, then examined the association of class membership with psychosocial indicators. LCA results supported four classes: 1) High punching/banging NSSI (2.5%); 2) Multimethod NSSI methods (6.3%); 3) High-risk, multimethod NSSI (3.1%); and 4) Low-risk NSSI (88.1%). Psychosocial indicators (suicide attempt, ideation, possible depressive or posttraumatic stress disorders, poor psychosocial functioning) were worse for members of the NSSI classes versus those in the low-risk group. A subset of U.S. veterans may engage in NSSI primarily via punching/banging methods. All patterns of NSSI engagement were associated with negative psychosocial outcomes relative to those in the low-risk class of the behavior.

Examining the daily relationship between guilt, shame, and substance use among veterans with psychiatric disorders

Background

Shame and guilt are key emotions known to amplify trauma-related symptoms in veterans. Maintenance of symptoms is facilitated by avoidance behaviors, such as substance use. However, limited research has examined the associations between shame, guilt, and substance use in daily life.

Methods

The current study sought to examine the cross-lagged association between shame, guilt, and substance use. Forty veterans completed 28 days of experience sampling reporting on their current emotional experiences and use of substances.

Results

Results suggest a reciprocal relationship among shame and guilt and substance use, such that shame and guilt separately predicted subsequent substance use, and substance use predicted subsequent shame and guilt.

Conclusions

These results highlight the dynamic relationship among shame, guilt, and substance use and suggest the potential value of conceptualizing these clinical targets as mutually reinforcing to inform integrative intervention strategies that can interrupt the in-the-moment cascade of negative consequences.

Interpersonal stress and nonsuicidal self-injury disorder in veterans: An ecological momentary assessment study

INTRO

Nonsuicidal self-injury (NSSI) is associated with marked functional impairment and is a robust predictor of suicide attempts. Prevalence rates of NSSI, and self-directed violence more broadly, are elevated among military veterans. Despite the inclusion of interpersonal difficulty in the diagnostic criteria for NSSI disorder, the relationship between interpersonal risk factors and NSSI is not well-characterized, especially among veterans. This ecological momentary assessment (EMA) study investigated the hypothesis that interpersonal stressors and associated distress would precede and predict NSSI urge and engagement-but not vice versa-via cross-lagged multilevel modeling.

METHOD

Forty veterans with NSSI disorder completed a 28-day EMA protocol with three daily prompts assessing NSSI urges, NSSI engagement, the occurrence of interpersonal stressors, and associated subjective interpersonal distress.

RESULTS

Interpersonal stressors preceded and predicted subsequent NSSI urges, but not NSSI engagement, whereas subjective interpersonal distress preceded and predicted both NSSI urges and NSSI engagement.

CONCLUSION

Results identified interpersonal stressors as a risk factor for NSSI urges, and interpersonal distress as a risk factor for both NSSI urges and NSSI engagement. Findings highlight the importance of temporally assessing interpersonal factors related to NSSI and suggest that interpersonal distress may be a modifiable risk factor for NSSI.

Development and refinement of the mobile anger reduction intervention for veterans with posttraumatic stress disorder

OBJECTIVE

Problematic anger is commonly reported among veterans with posttraumatic stress disorder (PTSD) and is associated with numerous psychosocial impairments. There is a clear need to develop innovative and effective anger interventions. One of the cognitive mechanisms associated with anger is the hostile interpretation bias, which is the tendency to interpret ambiguous interpersonal situations as hostile. The current study presents a successive cohort design methodology to develop and refine a mobile treatment application, entitled Mobile Anger Reduction Intervention (MARI), which uses interpretation bias modification techniques to modify hostile interpretation bias.

METHOD

Two cohorts (total N = 13) of veterans with PTSD and problematic anger used the MARI application for 4 weeks. After each cohort, qualitative and quantitative data were used to modify the MARI application. The intervention is described, as well as the qualitative and quantitative findings and subsequent changes made to the mobile application based on participant feedback.

RESULTS

Treatment adherence was high (90% of participants completed all sessions). Participants reported that they found the treatment helpful and easy to use and experienced improvements in hostile interpretation bias and problematic anger.

CONCLUSIONS

This study demonstrates the utility of a successive cohort treatment design for the development of mobile interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Experiential Avoidance, Posttraumatic Stress Disorder, and Self-Injurious Thoughts and Behaviors: A Moderation Analysis in a National Veteran Sample

Experiential avoidance (EA) is associated with posttraumatic stress disorder (PTSD) and self-injurious thoughts and behaviors (SITBs) across different populations, and extant literature has demonstrated a strong relationship between PTSD and SITBs. However, no study has explored the potential moderating role EA plays in the association of PTSD with nonsuicidal self-injury (NSSI), suicidal ideation, and suicide attempts. The objective of the present study was to determine if EA would moderate the association with PTSD and SITBs such that the association between PTSD and individuals SITBs would be stronger among individuals with higher EA. In a large national sample of Gulf War Era veterans (N = 1,138), EA was associated with PTSD, lifetime and past-year NSSI, current suicidal ideation, and lifetime suicide attempts in bivariate analyses. Multivariate analyses detected a significant EA by PTSD interaction on lifetime NSSI (AOR = 0.96), past-year NSSI (AOR = 1.03), and suicide attempts (AOR =1.03). Probing of the interactions revealed that the respective associations between PTSD, lifetime and past-year NSSI, and suicide attempts were stronger at lower levels of EA (i.e., better), counter to our hypotheses. These preliminary findings contextualize the relationship between these variables in a Gulf War veterans sample and signal the need to further investigate these relationships. Further, these findings highlight the need for advancement in assessment and intervention of EA and SITBs.

Effects of Social Network Characteristics on Mental Health Outcomes Among United States Army Reserve and National Guard Soldiers

We sought to examine the relative salience of multiple social network structural characteristics (e.g., size, composition, quality, substance use) for understanding soldiers' mental health symptoms (anger, anxiety, depression, PTSD). Data are drawn from soldiers (N = 421) participating in the Operation: SAFETY study. Negative binomial regression models examined the relationship between ten social network characteristics and mental health outcomes, controlling for age, sex, years of military service, and deployment history. Greater number of close network ties was associated with fewer symptoms of anger, anxiety, and depression (ps < 0.05), but not PTSD. Having more illicit drug-using network ties was associated with greater severity of anxiety symptoms (p < 0.05). Finally, more days spent drinking with network members was related to higher levels of anger (p < 0.05). Interpersonal relationships that entail substance use are associated with greater anxiety and anger while a greater number of close ties is associated with fewer anger, anxiety, and depression symptoms.

Multilevel analysis of sleep quality and anger in emergency medical service workers

OBJECTIVE

Poor sleep quality characterizes the emergency medical service (EMS) profession. Anger is particularly affected by sleep disturbance and may be related to sleep quality at both between- and within-person levels, yet this has never been examined. The current study performed a multilevel analysis of the relationship between sleep quality and anger among EMS workers.

DESIGN

Ecological momentary assessment PARTICIPANTS: Seventy-nine EMS workers employed at an emergency medical service provider in Central New York.

MEASUREMENTS

Participants completed 8 daily assessments that inquired about sleep quality and anger.

RESULTS

EMS workers who typically experienced poorer sleep quality reported greater anger levels; for instance, workers who routinely experienced poor sleep quality reported anger levels that were 18%-35% higher compared to workers receiving fair sleep quality. Regardless of their typical sleep quality, days when workers experienced poorer sleep than usual was characterized by higher levels of anger: on a day when a worker experienced poorer sleep quality than usual for them, their anger levels were 5% higher on that day regardless of their typical sleep quality.

CONCLUSIONS

EMS workers regularly experiencing poor sleep quality experience more anger. However, even workers who typically have better sleep quality experience anger elevations following poor sleep. These findings suggest that interventions targeting both between- and within-person factors impacting sleep may be important for addressing sleep quality's influence on anger in the EMS profession.

Qualitative analysis of participant experiences during an ecological momentary assessment study of nonsuicidal self-injury among veterans

Ecological momentary assessment (EMA) is a useful tool to investigate antecedents and consequences of nonsuicidal self-injury (NSSI), a robust predictor of Veteran suicide risk. Despite elucidating temporal changes among dynamic variables, EMA remains underutilized to study NSSI among veterans, perhaps due to concerns of safety and utility. The present study analyzed data collected from semi-structured interviews of veterans following a 28-day EMA study of NSSI, including benefits, challenges, and recommendations for improvement. Participants included 34 veterans endorsing NSSI history, most meeting criteria for NSSI Disorder. Qualitative analysis of de-identified transcripts used the rigorous and accelerated data reduction (RADaR) technique and thematic analysis. Findings revealed all veterans reported at least one emotional/social benefit to participation, including finding it therapeutic, gaining self-awareness/insight, and improved social functioning. Challenges and recommendations were primarily technology-related, including adjustment to device use. Many expressed interest in incorporation of clinical resources, use of personal devices/VA app, and ability to share responses with providers. Assessment frequency/content was never described as triggering suicidal/nonsuicidal urges and over half of participants noted urge/behavior reduction. Results support acceptability and safety of EMA for NSSI among veterans and potential clinical utility as a psychotherapy adjunct to promote self-awareness and NSSI reduction.

Affective states and nonsuicidal self-injury (NSSI): Results from an ecological momentary assessment study of veterans with NSSI disorder

BACKGROUND

The affective states most strongly associated with nonsuicidal self-injury (NSSI) remain poorly understood, particularly among veterans. This study used ecological momentary assessment (EMA) to examine relationships between affect ratings and NSSI urges and behaviors among veterans with NSSI disorder.

METHODS

Participants (N = 40) completed EMA entries via mobile phone for 28 days (3722 total entries). Entries included intensity ratings for five basic affective states, as well as NSSI urges and behaviors, during the past 4 hours.

RESULTS

Bivariate analyses indicated that each affect variable was significantly associated with both NSSI urges and behaviors. Angry/hostile and sad were most strongly associated with both NSSI urges and behaviors. A multivariate regression revealed that angry/hostile, disgusted with self, and happy (inversely related) were contemporaneously (within the same period) associated with NSSI behaviors, whereas all five basic affective states were contemporaneously associated with NSSI urges. In a lagged model, angry/hostile and sad were associated with subsequent NSSI urges but not behaviors.

CONCLUSIONS

Findings highlight the relevance of particular affective states to NSSI and the potential utility of targeting anger in treatments for NSSI among veterans. There is a need for future EMA research study to further investigate temporal relationships between these variables.

Anger, impulsivity and wall/object punching in a sample of U.S. veterans with psychiatric disorders

Nonsuicidal self-injury (NSSI) has been identified as one of the strongest predictors of suicide attempts. Wall/object punching is a particularly prevalent form of NSSI among male veterans that has been linked to both impulsivity and anger. The objective of the present study was to examine the indirect effect of impulsivity on wall/object punching via anger. Participants included 124 veterans (32 identified as women, 92 identified as men) with at least one psychiatric disorder. A third of the sample met criteria for NSSI disorder (33.1%) with nearly a half of the remaining sample endorsing NSSI. Almost half (41.94%) of the sample endorsed wall/object punching. Consistent with our hypothesis, impulsivity was significantly associated with anger, which was, in turn, significantly associated with wall/object punching. Impulsivity was found to be indirectly related to wall/object punching via anger. These findings underscore the significance of assessing and treating anger among veterans engaging in wall/object punching. Improving our knowledge of anger and impulsivity and their relationship with this particularly prevalent form of NSSI among veterans may lead to a better understanding of suicide risk among veterans and inform future treatments.