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. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: J Aggress Maltreat Trauma. 2022 Nov 30;32(4):574–591. doi: 10.1080/10926771.2022.2151961

Childhood Maltreatment and Use of Aggression among Veterans with Co-occurring PTSD and Alcohol Use Disorder: The Mediating Role of Hostile Cognitions

Andrea A Massa 1,2, Lauren Sippel 3,4, Charli M Kirby 1, Alexander J Melkonian 5, Sudie E Back 1,2, Julianne C Flanagan 1,2
PMCID: PMC10139741  NIHMSID: NIHMS1857328  PMID: 37124837

Abstract

History of childhood maltreatment is common among military veterans, particularly those with posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Childhood maltreatment is associated with negative psychosocial outcomes, including use of aggression during adulthood. Prior research has identified maladaptive cognitions as a key mediating variable in the association between early life trauma and aggression. Given the high rates of comorbid PTSD and AUD among veterans and the increased risk of aggression when these conditions co-occur, it is critical to examine malleable intervention targets, such as maladaptive cognitions, for this population. The current secondary analyses examined the mediating role of hostile cognitions on the associations between childhood maltreatment and adulthood aggression in a sample of dually diagnosed veterans. Participants were veterans with co-occurring PTSD and AUD (N = 73) who were enrolled in a larger randomized controlled laboratory trial. Participants completed self-report measures of childhood maltreatment, hostile cognitions, and aggressive behavior. Three models were tested to examine the mediating effect of hostility on the associations between childhood maltreatment, abuse, and neglect on aggression. Results indicated that hostility fully mediated the effect of maltreatment on aggression and partially mediated the effect of childhood abuse on aggression. The effect of childhood neglect on aggression was nonsignificant. Hostile cognitions may be a critical intervention target for veterans with co-occurring PTSD and AUD and history of childhood maltreatment, particularly for those who have experienced higher levels of childhood abuse.

Keywords: childhood maltreatment, veteran, comorbidity, hostility, aggression

Childhood maltreatment is common among military veterans, particularly those who seek mental health and substance use treatment (Koola et al., 2013; Young et al., 2020). These early adverse experiences are associated with interpersonal and psychological consequences, including aggression during adulthood (Chen et al., 2012; Hussey et al., 2006; Osofsky, 2003; Zhu et al., 2020) and higher rates of posttraumatic stress disorder (PTSD; Fritch et al., 2010; Koola et al., 2013) and substance misuse (Roos et al., 2016; Straus et al., 2020; Westermeyer et al., 2001). Given the devastating consequences of aggression, including disrupted relationships, criminal justice system involvement, property damage, injury, and death (Bennett et al., 2018; Morland et al., 2012; Taylor et al., 2020), it is critical to develop a firmer understanding of how early trauma may exacerbate adulthood aggression and to identify malleable intervention targets.

There are few effective interventions for trauma-related aggression. Evidence-based PTSD treatment is associated with reduced anger (Galovski et al., 2014; Stapleton et al., 2006) but few studies have examined effects of PTSD treatment on aggression. In a study of veterans in residential PTSD treatment, PTSD symptom reduction was associated with decreased aggression (Watkins et al., 2018). Strength at Home, a trauma-informed intimate partner violence (IPV) intervention, has been shown to reduce IPV (Taft et al., 2021; Taft et al., 2016). Notably, the treatment is less effective for those with more severe PTSD symptoms (Creech et al., 2017) and alcohol misuse (Hocking et al., 2021), suggesting the need for additional treatment to optimize outcomes for veterans who present with frequently co-occurring PTSD and alcohol use disorder (AUD; Smith et al., 2016; Young et al., 2020). It is also important to address aggression targeting non-intimate partners. Identification of mediating variables that explain aggression among veterans with a history of childhood maltreatment could offer insight into novel intervention approaches (Shea et al., 2013; Taft et al., 2016). The current study is the first of which we are aware to examine the mediating role of hostile cognitions on the association between childhood maltreatment and aggression among veterans with PTSD and AUD.

Childhood Maltreatment and Aggression

Childhood maltreatment encompasses physical, sexual, and emotional abuse as well as child neglect, or failing to meet a child’s emotional, physical, or educational needs or to protect a child from harm (Leeb et al., 2008). Both abuse and neglect have been consistently linked with later use of aggression (Fitton et al., 2020; Lee & Hoaken, 2007; Li et al., 2020), and a recent meta-analysis of prospective studies estimated that individuals who experience childhood maltreatment are nearly twice as likely (OR = 1.8) to use aggression later in life compared to those who do not experience maltreatment (Fitton et al., 2020). However, the measurement of childhood maltreatment has been inconsistent across studies, with some studies using global assessments of maltreatment (e.g., combined abuse and neglect) and others focusing on specific types of maltreatment (e.g., physical abuse only; Fitton et al., 2020; Lee & Hoaken, 2007). Due to these inconsistencies, unique associations between specific types of childhood maltreatment and adulthood aggression, as well as mechanisms underlying these associations, are unclear.

Some studies that have examined childhood abuse and childhood neglect separately have found evidence suggesting that the association between childhood abuse and aggression may be mediated by cognitive biases (e.g., hostile attribution bias, attentional bias toward threatening stimuli), while the association between childhood neglect and aggression may be better explained by emotion dysregulation (Lee & Hoaken, 2007). However, conflicting findings suggest that childhood abuse is associated with increased negative affect (Shackman & Pollak, 2014), and combined measures of abuse and neglect have been associated with both cognitive biases (Keil & Price, 2009; Zhu et al., 2020) and emotion dysregulation (Dugal et al., 2021; Zhu et al., 2020). Given the inconsistent measurement of these constructs and mixed findings regarding mechanisms underlying the links between childhood abuse, childhood neglect, and aggression, we primarily focused on a broad indicator of childhood maltreatment (including physical, sexual, and emotional abuse and physical and emotional neglect) in the current study. In our exploratory analyses, we examined separate pathways from childhood abuse and neglect to aggression to inform future work in this area.

According to social information processing theory (Crick & Dodge, 1994; Holtzworth-Munroe, 1992; McFall, 1982), early trauma such as childhood maltreatment can lead to long-lasting information processing deficits that result in interpersonal difficulties, including aggression. For example, children who are maltreated exhibit a greater degree of hostile cognitions (e.g., viewing others with suspicion and distrust) and attentional bias toward threat cues (e.g., angry faces), which in turn are linked with aggression (Keil & Price, 2009; Lee & Hoaken, 2007; Shackman & Pollak, 2014; Zhu et al., 2020). These information processing biases may serve an adaptive, self-protective purpose in dangerous settings (e.g., in the context of maltreatment); however, the tendency to rapidly appraise, interpret, and respond to potential threats can become maladaptive in safer environments (Lee & Hoaken, 2007). Many of the studies that have demonstrated associations between childhood maltreatment, cognitive biases, and aggression have done so in non-clinical samples of children, undergraduate students, and community adults (Lee & Hoaken, 2007; Shackman & Pollak, 2014; Zhu et al., 2020), revealing that these biases occur even in the absence of other trauma-related difficulties such as PTSD and AUD. However, these commonly co-occurring conditions may exacerbate information processing deficits and further increase risk for aggression.

PTSD, AUD, and Aggression

Although separate bodies of literature have examined links between aggression and PTSD, and between aggression and AUD, these associations are rarely examined among individuals with co-occurring PTSD and AUD. Overall, meta-analyses estimate a small to medium association between PTSD and aggression (Augsburger & Maercker, 2020; Birkley et al., 2016; Taft et al., 2011). Cognitive models of PTSD posit that cognitive distortions play a central role in maintaining PTSD and contribute to associated negative outcomes (e.g., aggression). According to one model (Ehlers & Clark, 2000), trauma appraisals, or thoughts, feelings, and behaviors elicited by trauma, lead to chronic overgeneralized threat perception and attentional bias toward potential threat cues. This overactive threat detection triggers cognitive (e.g., hostility) and emotional (e.g., anger) sequelae, which impede the generation of nonaggressive responses and facilitate aggression (Marshall et al., 2011). This model has been supported by studies of veterans in which hostility partially explained why PTSD increases aggression risk (Jakupcak et al., 2007; Van Voorhees et al., 2016).

Alcohol may also exacerbate the link between trauma-related hostile cognitions and aggression. The association between alcohol and aggression is well-established (Duke et al., 2018; Leonard & Quigley, 2017), and alcohol’s effects on cognition may underlie this association. According to alcohol myopia theory (AMT), acute intoxication limits cognitive resources and narrows attention onto the most salient cues in the environment (Steele & Josephs, 1990). AMT has been applied to alcohol-facilitated aggression and has been supported by laboratory studies (e.g., Eckhardt, 2007; Eckhardt et al., 2021; Giancola et al., 2010; Massa et al., 2019). Findings suggest that intoxication amplifies biases in the processing of stimuli that the individual already finds salient. For those with a history of childhood maltreatment and PTSD, intoxication may exacerbate their elevated threat perception and the subsequent generation and selection of maladaptive responses to these cues (e.g., hostile cognitions and aggression).

The Current Study

While hostility has been implicated as a potential mechanism underlying both trauma- and alcohol-related aggression, it is unclear whether these processes extend to veterans with co-occurring PTSD and AUD. Given the high rate of comorbid PTSD and AUD among veterans (Dworkin et al., 2018; Seal et al., 2011; Smith et al., 2016) and the increased risk for aggression when PTSD and alcohol misuse co-occur (Elbogen et al., 2014), it is critical to examine targets of intervention for this unique population. The goal of the current study was to examine the mediating role of hostility on the association between childhood maltreatment and adulthood aggression among treatment-seeking veterans with PTSD and AUD. We predicted that (1) severity of childhood maltreatment and hostility would be positively associated with aggression and (2) hostility would partially mediate the association between childhood maltreatment and aggression. Given inconsistent findings in the literature regarding the mechanisms underlying the associations between childhood abuse, childhood neglect, and aggression, we also explored patterns of associations when examining childhood abuse and neglect separately to inform future hypothesis-driven work.

Method

Participants and Recruitment

Participants included in this secondary analysis were U.S. veterans (N = 73) who were enrolled in a randomized controlled laboratory trial of intranasal oxytocin for stress reactivity and craving (Flanagan et al., 2019). Participants were recruited through Institutional Review Board (IRB)-approved flyers posted around the study site campus, affiliated clinics, and community centers; clinician referrals at the local Veterans Administration Medical Center; and online (e.g., Craigslist) and newspaper advertisements.

Participants were eligible for the parent study if they (1) were aged 21-65 years, (2) were a U.S. military veteran, (3) were able to provide informed consent, (4) could speak and understand English, (5) met Diagnostic and Statistical Manual, 4th Edition (DSM-IV; American Psychiatric Association, 1994) diagnostic criteria for past-year AUD as assessed through the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998), (6) met DSM-5 current PTSD diagnostic criteria as assessed through the Clinician Administered PTSD Scale (CAPS-5; Weathers et al., 2013), and (7) were able to maintain five days of sobriety from alcohol and abstain from any substances (excluding nicotine and caffeine) before the laboratory session (assessed through self-report, breathalyzer and urine drug screen tests). Individuals were ineligible if they had (1) untreated or unstable bipolar disorder, (2) past or current psychotic disorder, (3) current suicidal or homicidal ideation with intent, or (4) increased risk for suicide during their study participation (i.e., high-risk for hospitalization), or (5) if they were currently pregnant or breastfeeding. Additional exclusion criteria pertinent to the parent study’s medication or experimental procedures have been published previously (Flanagan et al., 2019).

In total, 107 individuals were screened for participation. Seventy-three participants were eligible and completed the study; all were included in the present analyses. The majority (91.8%) of the sample were veteran men. Participants had a mean age of 48.36 (SD = 10.51) and completed an average of 13.60 (SD = 1.86) years of education. They identified as African American (60.3%), Caucasian (35.6%), Native American or Alaska Native (1.4%), Hispanic (4.1%), and more than one race (2.7%). The majority (70.8%) were unemployed, followed by disabled (11.1%), employed full-time (9.7%), retired (4.2%), and students (4.2%). About one third (35.6%) reported being divorced or annulled, followed by single, never married (27.4%), separated (20.5%), married (13.7%), and widowed (2.7%). Just over half (58.9%) reported combat exposure. On average, participants reported a hazardous level (M = 23.61, SD = 8.62) of drinking indicative of AUD on the AUDIT (Babor et al., 2001), and all met DSM-IV criteria for severe (97.2%) or moderate (2.8%) AUD as assessed by the MINI (Sheehan et al., 1998).

Measures

Childhood Trauma Questionnaire

The 28-item Childhood Trauma Questionnaire Short Form (CTQ-SF; Bernstein et al., 2003) assessed childhood maltreatment on a scale of “1” (never true) to “5” (very often). The CTQ-SF includes three validity items and five clinical subscales: emotional abuse (e.g., felt hated by family), physical abuse (e.g., hit badly enough to be noticed), sexual abuse (e.g., molested), emotional neglect (e.g., did not feel loved), and physical neglect (e.g., not enough to eat). A total Childhood Maltreatment score was computed by summing the five subscales. Possible scores ranged from 25-125, with higher scores indicating greater severity. For exploratory analyses, we summed the two neglect subscales and the three abuse subscales to compute total scores for neglect and abuse, respectively. This measure has demonstrated good reliability in veteran samples (Alter et al., 2021; Murphy et al., 2020; Scher et al., 2001; Young et al., 2020). This measure demonstrated good internal consistency in the current study (Cronbach’s α = .93, .91, and .87 for total maltreatment, abuse, and neglect, respectively).

The Aggression Questionnaire

The Aggression Questionnaire (AQ; Buss & Perry, 1992) measures theoretically distinct components of aggression, including behavioral aggression (e.g., physical and verbal acts of aggression) and cognitive interpretations (e.g., hostility). This measure has demonstrated a consistent factor structure including four facets of aggression across a variety of samples (Gerevich et al., 2007). Low partial correlations between the hostility and aggression subscales indicate they each assess unique features of overall aggression (Buss & Perry, 1992). Each subscale has demonstrated novel correlations with alternate measurements of behavioral aggression and cognitive attributions of hostility (Archer & Webb, 2006). This measure has demonstrated good convergent validity, internal consistency, and test-retest reliability in various populations, including treatment-seeking veterans (Suris et al., 2005; Teten et al., 2010) and individuals with AUD (McPherson & Martin, 2010) and PTSD (Mathes et al., 2020).

Physical and Verbal Aggression.

The 5-item verbal and 9-item physical aggression subscales of the AQ assessed participants’ tendency enact behavioral aggression. Sample items include “I can’t help getting into arguments when people disagree with me” (verbal) and “Once in a while I can’t control the urge to strike another person” (physical). Response options ranged from “1” (extremely uncharacteristic of me) to “5” (extremely characteristic of me). The aggression variable was computed by summing the verbal and physical subscales, with higher scores indicating greater tendency toward aggressive behavior. The verbal and physical subscales yielded good reliability (Cronbach’s α = .75, .83, respectively) in this sample.

Hostile Cognitions.

The 8-item hostility subscale of the AQ assessed current dispositional hostility, defined as aggression-related cognitions and interpretations (e.g., “I wonder why sometimes I feel so bitter about things” and “I sometimes feel that people are laughing at me behind my back”). The items were summed, with higher scores indicating greater severity. The hostility subscale has demonstrated high concurrent validity with measures of hostility and cognitive-affective interpretations and good divergent validity with the other AQ subscales (Bryant & Smith, 2001). The hostility subscale demonstrated good reliability in this sample (Cronbach’s α = .86).

Procedures

Participants who were deemed eligible after an initial telephone screen were invited to participate in a laboratory session. Research staff explained the purpose of the study and all procedures. Participants read and signed an IRB-approved informed consent form. Participants of childbearing potential completed a urine pregnancy test to establish eligibility for the parent study, and all participants completed baseline questionnaires. All measures used in the current analyses were completed prior to beginning laboratory procedures. Full procedures and outcomes from a priori hypotheses have been previously reported (Flanagan et al., 2019). All study procedures were IRB-approved.

Analytic Approach

We used SPSS 28 to examine correlations and descriptive statistics. We used Model 4 (i.e., simple mediation) of the PROCESS macro (Hayes, 2017) to test our mediation models. PROCESS uses an ordinary least squares regression-based path analytic framework for estimating direct and indirect effects and a percentile bootstrapping procedure (10,000 bootstrap samples) to determine 95% confidence intervals. In our main model, we entered childhood maltreatment as the independent variable (IV), hostility as the mediator, and aggression as the dependent variable (DV). In the two exploratory models, we substituted childhood maltreatment with abuse and neglect.1

Results

Preliminary Analyses

According to the CTQ-SF cutoff scores, 52.1% of the sample reported moderate-severe emotional abuse (M = 11.36, SD = 5.59), 69.9% reported moderate-severe physical abuse (M = 11.11, SD = 5.49), 26.0% reported moderate-severe sexual abuse (M = 7.99, SD = 5.41), 37.0% reported moderate-severe emotional neglect (M = 12.44, SD = 5.52), and 52.1% reported moderate-severe physical neglect (M = 9.16, SD = 4.39). We examined six potential covariates, including age, gender, race, combat exposure, CAPS-5 (Weathers et al., 2013) PTSD symptom severity, and alcohol misuse as measured by the AUDIT (Babor et al., 2001). Age and PTSD symptoms were significantly correlated with aggression and were controlled for in subsequent analyses. As hypothesized, childhood maltreatment and hostility were positively correlated with each other and with aggression. See Table 1 for descriptive statistics and bivariate correlations.

Table 1.

Descriptive Statistics and Bivariate Correlations

Variable M SD 1 2 3 4 5 6
1. Age 48.36 10.51 -
2. PTSD symptoms 35.21 9.10 −.07 -
3. Maltreatment 52.05 20.79 −.10 .36** -
4. Abuse 30.45 13.50 −.07 .30** .95*** -
5. Neglect 21.60 8.89 −.11 .38** .89*** .71*** -
6. Hostility 30.15 11.94 −.09 .41*** .42*** .37** .43*** -
7. Aggression 54.42 17.02 −.34** .29* .38** .40** .30* .57***
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Note.

*

p < .05

**

p < .01

***

p < .001. Maltreatment is a composite score of the Childhood Abuse and Childhood Neglect subscales. Abuse includes childhood physical, emotional, and sexual abuse subscales. Neglect includes childhood emotional and physical neglect subscales.

Primary Mediation Analysis

To test hypothesis 2, we examined the indirect effect of childhood maltreatment (IV) on aggression (DV) through hostility (mediator; see Figure 1A). The model was significant (F(4, 68) = 12.810, R2 = .430, p < .001). Results revealed significant effects of maltreatment on hostility (B = .178, SE = .064, 95% CI [.051, .306], p = .007); mean square error [MSE] = 110.380), and of hostility on aggression (B = .681, SE = .152, 95% CI [.378, .983], p < .001; MSE = 174.854). The direct effect of maltreatment on aggression was not significant after adding hostility to the model (B = .122, SE = .085, 95% CI [−.048, .291], p = .157). The indirect effect was significant (B = .121, SE = .051, 95% CI [.034, .235]).

Figure 1. Mediation Results.

Figure 1

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Note. *p < .05, **p < .01, ***p < .001. Panel A: Results from the primary mediation analysis with total childhood maltreatment as the independent variable. Panel B: Results from the exploratory mediation analysis with childhood abuse as the independent variable.

Exploratory Mediation Analyses

We tested two additional exploratory models with abuse and neglect as the IVs. The model with childhood abuse as the IV was significant (F(4, 68) = 13.677, R2 = .446, p < .001; see Figure 1B), with significant effects of abuse on hostility (B = .231, SE = .098, 95% CI [.036, .427], p = .021; MSE = 113.561), and hostility on aggression (B = .668, SE = .147, 95% CI [.374, .962], p < .001; MSE = 169.916). The direct effect of abuse on aggression decreased but remained significant after adding hostility to the model (B = .251, SE = .124, 95% CI [.003, .500], p = .047). The indirect effect was significant (B = .155, SE = .069, 95% CI [.029, .302]).

The direct effect of childhood neglect on aggression was not significant after controlling for covariates (B = .356, SE = .222, p = .112). Therefore, we did not test this mediation model.

Discussion

This study is the first known examination of the mediating role of hostility on the association between childhood maltreatment and aggression in a sample of veterans with co-occurring PTSD and AUD. Results largely supported our hypotheses, such that childhood maltreatment and hostility were each positively associated with self-reported use of aggression, and hostility fully mediated the association between childhood maltreatment and aggression. Exploratory analyses revealed that hostility partially mediated the association between childhood abuse and aggression. After controlling for relevant covariates (i.e., age and PTSD symptom severity), the effect of childhood neglect on aggression failed to reach significance. These findings suggest that childhood abuse may be more strongly associated with aggression compared to childhood neglect for veterans with co-occurring PTSD and AUD. However, these analyses warrant replication given their exploratory nature. The present results are largely consistent with prior research (Shackman & Pollak, 2014; Taft et al., 2008; Zhu et al., 2020) and provide additional evidence that hostile cognitions may play a critical role in explaining why childhood maltreatment may lead to adulthood aggression. Moreover, hostility appears to explain the association between childhood maltreatment and aggression above and beyond the effect of PTSD symptom severity in this sample. Thus, hostility may need to be targeted directly when treating veterans with PTSD and AUD who have a history of childhood maltreatment and who may be at risk for aggression.

The current findings are consistent with prior research examining the links among childhood maltreatment, cognitive biases, and aggression. In particular, our findings suggest that biases in the perception and interpretation of social cues may play a key role in the link between childhood maltreatment and aggression, particularly for veterans who have experienced more severe childhood abuse. These findings are consistent with prior research that has demonstrated in non-clinical samples a mediating effect of cognitive biases, including hostile attribution bias, on the association between childhood maltreatment and aggression (Keil & Price, 2009; Lee & Hoaken, 2007; Zhu et al., 2020). This finding also provides further evidence that cognitive biases may play an important role in explaining why individuals who have experienced childhood abuse specifically may later engage in aggression (Keil & Price, 2009).

The present findings are also consistent with theory and research examining the role of cognition in PTSD- and alcohol-related aggression. Our findings are in line with cognitive models of PTSD (e.g., Ehlers & Clark, 2000), which state that individuals with PTSD develop distortions in information processing, including an overactive threat detection system, attentional bias toward perceived threat cues, and faulty hostile interpretations of ambiguous stimuli. These cognitive deficits increase the risk for responding to such cues with aggression (Marshall et al., 2011). When alcohol comes on board, alcohol myopia theory suggests that these cognitive distortions can become further exacerbated and more likely to potentiate aggression (Steele & Josephs, 1990). However, our ability to tease apart the unique effects of childhood maltreatment, PTSD, and AUD on the hostile cognitions and aggression reported in the current study is limited given that all participants in our sample met diagnostic criteria for both PTSD and AUD. Additional research is needed to test the unique and interactive effects of PTSD and AUD on cognitive biases and aggression among individuals who have experienced childhood maltreatment.

Limitations

Limitations of this study include the cross-sectional nature of the data and use of self-report measures that are subject to shared measurement variance, social desirability, and memory bias. We ran alternative models to account for the cross-sectional nature of the data (see Footnote 1). Our finding that aggression mediated the association between childhood maltreatment and hostility suggests that both hostility and aggression may be fruitful treatment targets, supporting the utility of both cognitive and behavioral interventions for this population. The hostility and aggression subscales used in the current study were derived from the same parent measure, which may have further contributed to shared measurement variance. Our assessments examined trait-like tendencies toward hostility and aggression without considering acute risk factors (e.g., intoxication), the function of intoxication, past aggression, or specific targets of aggression.

While the nature of our sample of veterans with co-occurring PTSD-AUD is a strength of our methodology, findings may not generalize to non-veterans or to women. Our sample size was modest and did not allow for examination of distinct sub-groups of participants, such as men vs. women, veterans who experienced neglect but not abuse and vice versa, and combat vs. non-combat veterans. Veterans with PTSD who experienced both childhood maltreatment and combat may be the most inclined toward sensitivity to threat and hostile attributions since this “survival mode,” adaptive in a dangerous developmental environment, would be reinforced within a war-zone (Chemtob et al., 1988).

Future Research Directions

Further examination of the interactive effects of PTSD and AUD and how these co-occurring conditions may heighten risk for aggression is warranted. Our cross-sectional models require replication in the form of longitudinal designs, laboratory research, or ecological momentary assessment with clinical populations that are capable of more clearly elucidating these temporal associations and contextual factors. Such approaches can shed light on whether hostility is more prevalent during acute intoxication or if this is a more general, pervasive cognitive bias among veterans with comorbid PTSD and AUD, as well as the function(s) of intoxication and the target(s) of aggression. Similarly, these designs could elucidate whether the causal sequence maps on to social information processing models, which underlie current trauma-informed treatment for aggression (Taft et al., 2016). In addition, given the heterogeneous nature of PTSD (Galatzer-Levy & Bryant, 2013), better understanding which symptom clusters are most strongly associated with aggression among individuals with a history of childhood maltreatment would inform the development of more targeted treatments. While examining PTSD symptom clusters was beyond the scope of the current study, we are aware of one study that has examined the mediating role of PTSD symptom clusters in the association between childhood maltreatment and aggression among children in a residential treatment program. This study found that re-experiencing symptoms and negative alterations in mood and cognition explained the relationship between childhood maltreatment and aggression (McRae et al., 2022). Further research is needed to replicate these findings and to extend this work to adults and to individuals with co-occurring PTSD and AUD.

Clinical Implications

Our finding that hostility mediated the association between childhood maltreatment and aggression suggests that targeting hostile cognitions should reduce propensity toward aggression. This premise is supported by research showing reductions in anger and aggression among active-duty servicemembers after Cognitive Processing Therapy, in which cognitive restructuring of trauma-related beliefs is the key intervention (Miles, Dillon, et al., 2020). However, most of these service members continued to report aggression after treatment, suggesting that treatments that more directly focus on hostility may be needed. Cognitive-behavioral anger management treatments in which hostile attributions are typically a target have shown efficacy for reducing anger among individuals with PTSD (Miles, Kent, et al., 2020; Morland et al., 2010; see Taft et al., 2012 for a review; Taft et al., 2016) although few of these studies directly measured aggression; one pilot study that addressed these limitations showed marginally significant effects of CBT for anger and aggression among veterans (Shea et al., 2013). Lastly, the Strength at Home intervention that directly targets IPV was less effective for veterans with AUD (Hocking et al., 2021), suggesting that integrated treatments for co-occurring PTSD, AUD, and aggression may be more effective at reducing aggression than interventions that treat any condition alone.

The current study extends past research investigating hostile cognitions as a mediating variable between childhood maltreatment and aggression to a unique and clinically relevant sample of veterans with PTSD and AUD. Present findings suggest that hostility may be a critical target of intervention for this population, particularly among those who have experienced childhood abuse. Future research should disentangle the proximal and distal influences of acute intoxication, alcohol-related problems, and PTSD symptoms to inform treatment development for veterans with co-occurring PTSD and AUD who may be at risk for aggression.

Acknowledgments

This work was funded in part by the Department of Defense under Grant W81XWH-12-2-0048, the National Institute on Alcohol Abuse and Alcoholism under Grant K23AA023845, and the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment. This work does not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

Footnotes

Disclosure Statement

The authors report that there are no competing interests to declare.

1

To account for the cross-sectional nature of the data, we tested three alternative models in which we entered each childhood maltreatment variable as the IV, aggression as the mediator, and hostility as the DV, controlling for PTSD symptom severity. Aggression fully mediated the associations between childhood maltreatment and hostility and between childhood abuse and hostility. Aggression did not mediate the association between childhood neglect and hostility.

References

  1. Alter S, Wilson C, Sun S, Harris RE, Wang Z, Vitale A, Hazlett EA, Goodman M, Ge Y, Yehuda R, Galfalvy H, & Haghighi F (2021). The association of childhood trauma with sleep disturbances and risk of suicide in US veterans. Journal of Psychiatric Research, 136, 54–62. 10.1016/j.jpsychires.2021.01.030 [DOI] [PubMed] [Google Scholar]
  2. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. American Psychiatric Association. [Google Scholar]
  3. Archer J, & Webb IA (2006). The relation between scores on the Buss-Perry Aggression Questionnaire and aggressive acts, impulsiveness, competitiveness, dominance, and sexual jealousy. Aggressive Behavior, 32(5), 464–473. 10.1002/ab.20146 [DOI] [Google Scholar]
  4. Augsburger M, & Maercker A (2020). Associations between trauma exposure, posttraumatic stress disorder, and aggression perpetrated by women: A meta-analysis. Clinical Psychology Science and Practice, 27, e12322. 10.1111/cpsp.12322 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Babor TF, Higgins-Biddle JC, Saunders JB, & Monteiro MG (2001). The Alcohol Use Disorders Identification Test. World Health Organization. [Google Scholar]
  6. Bennett DC, Morris DH, Sexton MB, Bonar EE, & Chermack ST (2018). Associations between posttraumatic stress and legal charges among substance using veterans. Law and Human Behavior, 42(2), 135–144. 10.1037/lhb0000268 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, Stokes J, Handelsman L, Medrano M, Desmond D, & Zule W (2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Neglect, 27(2), 169–190. 10.1016/s0145-2134(02)00541-0 [DOI] [PubMed] [Google Scholar]
  8. Birkley EL, Eckhardt CI, & Dykstra RE (2016). Posttraumatic stress disorder symptoms, intimate partner violence, and relationship functioning: A meta-analytic review. Journal of Traumatic Stress, 29(5), 397–405. 10.1002/jts.22129 [DOI] [PubMed] [Google Scholar]
  9. Bryant FB, & Smith BD (2001). Refining the architecture of aggression: A measurement model for the Buss-Perry Aggression Questionnaire. Journal of Research in Personality, 35(2), 138–167. 10.1006/jrpe.2000.2302 [DOI] [Google Scholar]
  10. Buss AH, & Perry M (1992). The aggression questionnaire. Journal of Personality and Social Psychology, 63(3), 452–459. 10.1037//0022-3514.63.3.452 [DOI] [PubMed] [Google Scholar]
  11. Chemtob CM, Roitblat HL, Hamada RS, Carlson J, & Twentyman C (1988). A cognitive action theory of posttraumatic stress disorder. Journal of Anxiety Disorders, 2(3), 253–275. 10.1016/0887-6185(88)90006-0 [DOI] [Google Scholar]
  12. Chen P, Coccaro EF, Lee R, & Jacobson KC (2012). Moderating effects of childhood maltreatment on associations between social information processing and adult aggression. Psychological Medicine, 42(6), 1293–1304. 10.1017/S0033291711002212 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Creech SK, Macdonald A, Benzer JK, Poole GM, Murphy CM, & Taft CT (2017). PTSD symptoms predict outcome in trauma-informed treatment of intimate partner aggression. Journal of Consulting and Clinical Psychology, 85(10), 966–974. 10.1037/ccp0000228 [DOI] [PubMed] [Google Scholar]
  14. Crick NR, & Dodge KA (1994). A review and reformulation of social information-processing mechanisms in children's social adjustment. Psychological Bulletin, 115, 74–101. 10.1037/0033-2909.115.1.74 [DOI] [Google Scholar]
  15. Dugal C, Girard M, Belanger C, Sabourin S, Bates EA, & Godbout N (2021). Psychological intimate partner violence and childhood cumulative trauma: The mediating role of affect dysregulation, maladaptive personality traits, and negative urgency. Journal of Interpersonal Violence, 36(11-12), 5101–5121. 10.1177/0886260518801022 [DOI] [PubMed] [Google Scholar]
  16. Duke AA, Smith KMZ, Oberleitner LMS, Westphal A, & McKee SA (2018). Alcohol, drugs, and violence: A meta-meta-analysis. Psychology of Violence, 8(2), 238–249. 10.1037/vio0000106 [DOI] [Google Scholar]
  17. Dworkin ER, Bergman HE, Walton TO, Walker DD, & Kaysen DL (2018). Co-occurring post-traumatic stress disorder and alcohol use disorder in U.S. military and veteran populations. Alcohol Research, 39(2), 161–169. https://www.ncbi.nlm.nih.gov/pubmed/31198655 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Eckhardt CI (2007). Effects of alcohol intoxication on anger experience and expression among partner assaultive men. Journal of Consulting and Clinical Psychology, 75(1), 61–71. 10.1037/0022-006X.75.1.61 [DOI] [PubMed] [Google Scholar]
  19. Eckhardt CI, Parrott DJ, Swartout KM, Leone RM, Purvis DM, Massa AA, & Sprunger JG (2021). Cognitive and affective mediators of alcohol-facilitated intimate partner aggression. Clinical Psychological Science, 9(3), 385–402. 10.1177/21677026209662 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Ehlers A, & Clark DM (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319–345. 10.1016/s0005-7967(99)00123-0 [DOI] [PubMed] [Google Scholar]
  21. Elbogen EB, Johnson SC, Wagner HR, Sullivan C, Taft CT, & Beckham JC (2014). Violent behaviour and post-traumatic stress disorder in US Iraq and Afghanistan veterans. The British Journal of Psychiatry, 204, 368–375. 10.1192/bjp.bp.113.134627 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Fitton L, Yu R, & Fazel S (2020). Childhood maltreatment and violent outcomes: A systematic review and meta-analysis of prospective studies. Trauma, Violence, & Abuse, 21(4), 754–768. 10.1177/1524838018795269 [DOI] [PubMed] [Google Scholar]
  23. Flanagan JC, Allan NP, Calhoun CD, Badour CL, Maria MS, Brady KT, & Back SE (2019). Effects of oxytocin on stress reactivity and craving in veterans with co-occurring PTSD and alcohol use disorder. Experimental and Clinical Psychopharmacology, 27(1), 45–54. 10.1037/pha0000232 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Fritch AM, Mishkind M, Reger MA, & Gahm GA (2010). The impact of childhood abuse and combat-related trauma on postdeployment adjustment. J Trauma Stress, 23(2), 248–254. 10.1002/jts.20520 [DOI] [PubMed] [Google Scholar]
  25. Galatzer-Levy IR, & Bryant RA (2013). 636,120 ways to have posttraumatic stress disorder. Perspectives on Psychological Science, 8(6), 651–662. 10.1177/1745691613504115 [DOI] [PubMed] [Google Scholar]
  26. Galovski TE, Elwood LS, Blain LM, & Resick PA (2014). Changes in anger in relationship to responsivity to PTSD treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 6(1), 56–64. 10.1037/a0031364 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Gerevich J, Bácskai E, & Czobor P (2007). The generalizability of the Buss-Perry Aggression Questionnaire. International Journal of Methods in Psychiatric Research, 16(3), 124–136. 10.1002/mpr.221 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Giancola PR, Josephs RA, Parrott DJ, & Duke AA (2010). Alcohol Myopia Revisited: Clarifying Aggression and Other Acts of Disinhibition Through a Distorted Lens. Perspectives on Psychological Science, 5(3), 265–278. 10.1177/1745691610369467 [DOI] [PubMed] [Google Scholar]
  29. Hayes AF (2017). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach (2nd edition ed.). The Guilford Press. [Google Scholar]
  30. Hocking E, Livingston NA, Creech SK, & Taft C (2021). The moderating effect of alcohol use disorder on intimate partner violence intervention outcomes in veterans. Partner Abuse, Online first publication. 10.1891/PA-2020-0004 [DOI] [Google Scholar]
  31. Holtzworth-Munroe A (1992). Social skill deficits in maritally violent men: Interpreting the data using a social information processing model. Clinical Psychology Review, 12, 605–617. 10.1016/0272-7358(92)90134-T [DOI] [Google Scholar]
  32. Hussey JM, Chang JJ, & Kotch JB (2006). Child maltreatment in the United States: Prevalence, risk factors, and adolescent health consequences. Pediatrics, 118(3), 933–942. 10.1542/peds.2005-2452 [DOI] [PubMed] [Google Scholar]
  33. Jakupcak M, Conybeare D, Phelps L, Hunt S, Holmes HA, Felker B, Klevens M, & McFall ME (2007). Anger, hostility, and aggression among Iraq and Afghanistan War veterans reporting PTSD and subthreshold PTSD. Journal of Traumatic Stress, 20(6), 945–954. 10.1002/jts.20258 [DOI] [PubMed] [Google Scholar]
  34. Keil V, & Price JM (2009). Social information-processing patterns of maltreated children in two social domains. Journal of Applied Developmental Psychology, 30, 43–52. 10.1016/j.appdev.2008.10.003 [DOI] [Google Scholar]
  35. Koola MM, Qualls C, Kelly DL, Skelton K, Bradley B, Amar R, & Duncan EJ (2013). Prevalence of childhood physical and sexual abuse in veterans with psychiatric diagnoses. Journal of Nervous and Mental Disease, 201(4), 348–352. 10.1097/NMD.0b013e318288e333 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Lee V, & Hoaken PNS (2007). Cognition, emotion, and neurobiological development: Mediating the relation between maltreatment and aggression. Child Maltreatment, 12(3), 281–298. 10.1177/1077559507303778 [DOI] [PubMed] [Google Scholar]
  37. Leeb RT, Paulozzi L, Melanson C, Simon T, & Arias I (2008). Child maltreatment surveillance: Uniform definitions for public health and recommended data elements, Version 1.0. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. [Google Scholar]
  38. Leonard KE, & Quigley BM (2017). Thirty years of research show alcohol to be a cause of intimate partner violence: Future research needs to identify who to treat and how to treat them. Drug and Alcohol Review, 36(1), 7–9. 10.1111/dar.12434 [DOI] [PubMed] [Google Scholar]
  39. Li S, Zhao F, & Yu G (2020). A meta-analysis of childhood maltreatment and intimate partner violence perpetration. Aggression and Violent Behavior, 50, Online first publication. 10.1016/j.avb.2019.101362 [DOI] [Google Scholar]
  40. Marshall AD, Robinson LR, & Azar ST (2011). Cognitive and emotional contributors to intimate partner violence perpetration following trauma. Journal of Traumatic Stress, 24(5), 586–590. 10.1002/jts.20681 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Massa AA, Subramani OS, Eckhardt CI, & Parrott DJ (2019). Problematic alcohol use and acute intoxication predict anger-related attentional biases: A test of the alcohol myopia theory. Psychology of Addictive Behaviors, 33(2), 139–143. 10.1037/adb0000426 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Mathes BM, Kennedy GA, Morabito DM, Martin A, Bedford CE, & Schmidt NB (2020). A longitudinal investigation of the association between rumination, hostility, and PTSD symptoms among trauma-exposed individuals. Journal of Affective Disorders, 277, 322–328. 10.1016/j.jad.2020.08.029 [DOI] [PubMed] [Google Scholar]
  43. McFall RM (1982). A review and reformulation of the concept of social skills. Behavioral Assessment, 4, 1–33. 10.1007/BF01321377 [DOI] [Google Scholar]
  44. McPherson A, & Martin C (2010). A contemporary review of the alcohol/aggression relationship and the Buss-Perry Aggression Questionnaire for use in an alcohol dependent population. Journal of Aggression, Conflict, and Peace Research, 2, 45–56. 10.5042/jacpr.2010.0004 [DOI] [Google Scholar]
  45. McRae EM, Stoppelbein L, O'Kelley SE, Fite PK, & Smith SB (2022). Pathways from child maltreatment to proactive and reactive aggression: The role of posttraumatic stress symptom clusters. Psychological Trauma: Theory, Research, Practice, and Policy, 14(3), 357–366. 10.1037/tra0001051 [DOI] [PubMed] [Google Scholar]
  46. Miles SR, Dillon KH, Jacoby VM, Hale WJ, Dondanville KA, Wachen JS, Yarvis JS, Peterson AL, Mintz J, Litz BT, Young-McCaughan S, Resick PA, & Consortium SS (2020). Changes in anger and aggression after treatment for PTSD in active duty military. Journal of Clinical Psychology, 76(3), 493–507. 10.1002/jclp.22878 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Miles SR, Kent TA, Stanley M, Thompson KE, Sharp C, Niles BL, Young-McCaughan S, Mintz J, Roache JD, Litz BT, Hale WJ, Stanford MS, Keane TM, & Peterson AL (2020). Manage emotions to reduce aggression: A pilot study of a brief treatment to help veterans reduce impulsive aggression. The Journal of Nervous and Mental Disease, 11, 897–903. 10.1097/NMD.0000000000001229 [DOI] [PubMed] [Google Scholar]
  48. Morland LA, Greene CJ, Rosen CS, Foy D, Reilly P, Shore J, He Q, & Frueh BC (2010). Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: A randomized noninferiority trial. Journal of Clinical Psychiatry, 71(7), 855–863. 10.4088/JCP.09m05604blu [DOI] [PubMed] [Google Scholar]
  49. Morland LA, Love AR, Mackintosh MA, Greene CJ, & Rosen CS (2012). Treating anger and aggression in military populations: Research updates and clinical implications. Clinical Psychology: Science and Practice, 19(3), 305–322. 10.1111/cpsp.12007 [DOI] [Google Scholar]
  50. Murphy D, Shevlin M, Pearson E, Greenberg N, Wessely S, Busuttil W, & Karatzias T (2020). A validation study of the International Trauma Questionnaire to assess post-traumatic stress disorder in treatment-seeking veterans. The British Journal of Psychiatry, 216(3), 132–137. 10.1192/bjp.2020.9 [DOI] [PubMed] [Google Scholar]
  51. Osofsky JD (2003). Prevalence of children's exposure to domestic violence and child maltreatment: Implications for prevention and intervention. Clinical Child and Family Psychology Review, 6(3), 161–170. 10.1023/a:1024958332093 [DOI] [PubMed] [Google Scholar]
  52. Roos LE, Afifi TO, Martin CG, Pietrzak RH, Tsai J, & Sareen J (2016). Linking typologies of childhood adversity to adult incarceration: Findings from a nationally representative sample. American Journal of Orthopsychiatry, 86(5), 584–593. 10.1037/ort0000144 [DOI] [PubMed] [Google Scholar]
  53. Scher CD, Stein MB, Asmundson GJ, McCreary DR, & Forde DR (2001). The childhood trauma questionnaire in a community sample: Psychometric properties and normative data. Journal of Traumatic Stress, 14(4), 843–857. 10.1023/A:1013058625719 [DOI] [PubMed] [Google Scholar]
  54. Seal KH, Cohen G, Waldrop A, Cohen BE, Maguen S, & Ren L (2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence, 116(1-3), 93–101. 10.1016/j.drugalcdep.2010.11.027 [DOI] [PubMed] [Google Scholar]
  55. Shackman JE, & Pollak SD (2014). Impact of physical maltreatment on the regulation of negative affect and aggression. Development and Psychopathology, 26(4 Pt 1), 1021–1033. 10.1017/S0954579414000546 [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Shea MT, Lambert J, & Reddy MK (2013). A randomized pilot study of anger treatment for Iraq and Afghanistan veterans. Behaviour Research and Therapy, 51(10), 607–613. 10.1016/j.brat.2013.05.013 [DOI] [PubMed] [Google Scholar]
  57. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, & Dunbar GC (1998). The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59, 22–33. [PubMed] [Google Scholar]
  58. Smith SM, Goldstein RB, & Grant BF (2016). The association between post-traumatic stress disorder and lifetime DSM-5 psychiatric disorders among veterans: Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Journal of Psychiatric Research, 82, 16–22. 10.1016/j.jpsychires.2016.06.022 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Stapleton JA, Taylor S, & Asmundson GJ (2006). Effects of three PTSD treatments on anger and guilt: Exposure therapy, eye movement desensitization and reprocessing, and relaxation training. Journal of Traumatic Stress, 19(1), 19–28. 10.1002/jts.20095 [DOI] [PubMed] [Google Scholar]
  60. Steele CM, & Josephs RA (1990). Alcohol myopia: Its prized and dangerous effects. American Psychologist, 45(8), 921–933. 10.1037//0003-066x.45.8.921 [DOI] [PubMed] [Google Scholar]
  61. Straus E, Normal SB, & Pietrzak RH (2020). Determinants of new-onset alcohol use disorder in U.S. military veterans: Results from the National Health and Resilience in Veterans Study. Addictive Behaviors, Advance online publication. [DOI] [PubMed] [Google Scholar]
  62. Suris AM, Lind LM, Kashner MT, Bernstein IH, Young K, & Worchel J (2005). Aggression and impulsivity instruments: An examination in veterans. Military Psychology, 17(4), 283–297. 10.1207/s15327876mp1704_3 [DOI] [Google Scholar]
  63. Taft CT, Creech SK, & Kachadourian L (2012). Assessment and treatment of posttraumatic anger and aggression: A review. Journal of Rehabilitation Research & Development, 49(5), 777–788. 10.1682/jrrd.2011.09.0156 [DOI] [PubMed] [Google Scholar]
  64. Taft CT, Franz MR, Cole HE, D'Avanzato C, & Rothman EF (2021). Examining strength at home for preventing intimate partner violence in civilians. Journal of Family Psychology, 35(6), 857–862. 10.1037/fam0000732 [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Taft CT, Macdonald A, Creech SK, Monson CM, & Murphy CM (2016). A randomized controlled clinical trial of the Strength at Home Men's Program for partner violence in military veterans. Journal of Clinical Psychiatry, 77(9), 1168–1175. 10.4088/JCP.15m10020 [DOI] [PubMed] [Google Scholar]
  66. Taft CT, Schumm JA, Marshall AD, Panuzio J, & Holtzworth-Munroe A (2008). Family-of-origin maltreatment, posttraumatic stress disorder symptoms, social information processing deficits, and relationship abuse perpetration. Journal of Abnormal Psychology, 117(3), 637–646. 10.1037/0021-843X.117.3.637 [DOI] [PubMed] [Google Scholar]
  67. Taft CT, Watkins LE, Stafford J, Street AE, & Monson CM (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79(1), 22–33. 10.1037/a0022196 [DOI] [PubMed] [Google Scholar]
  68. Taylor EN, Timko C, Nash A, Owens MD, Harris AHS, & Finlay AK (2020). Posttraumatic stress disorder and justice involvement among military veterans: A systematic review and meta-analysis. Journal of Traumatic Stress, 33(5), 804–812. 10.1002/jts.22526 [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Teten AL, Miller LA, Stanford MS, Petersen NJ, Bailey SD, Collins RL, Dunn NJ, & Kent TA (2010). Characterizing aggression and its association to anger and hostility among male veterans with post-traumatic stress disorder. Military Medicine, 175(6), 405–410. 10.7205/milmed-d-09-00215 [DOI] [PubMed] [Google Scholar]
  70. Van Voorhees EE, Dennis PA, Neal LC, Hicks TA, Calhoun PS, Beckham JC, & Elbogen EB (2016). Posttraumatic stress disorder, hostile cognitions, and aggression in Iraq/Afghanistan era veterans. Psychiatry, 79(1), 70–84. 10.1080/00332747.2015.1123593 [DOI] [PMC free article] [PubMed] [Google Scholar]
  71. Watkins LE, Sippel LM, Pietrzak RH, Hoff R, & Harpaz-Rotem I (2018). Clinically significant change in posttraumatic stress disorder symptoms is associated with lower levels of aggression after residential treatment discharge. Journal of Traumatic Stress, 31(2), 265–272. 10.1002/jts.22275 [DOI] [PubMed] [Google Scholar]
  72. Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, & Keane TM (2013). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). [Assessment] Available from www.ptsd.va.gov. [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. Westermeyer J, Wahmanholm K, & Thuras P (2001). Effects of childhood physical abuse on course and severity of substance abuse. The American Journal on Addictions, 10(2), 101–110. 10.1080/105504901750227769 [DOI] [PubMed] [Google Scholar]
  74. Young LB, Timko C, Pulido RD, Tyler KA, Beaumont C, & Grant KM (2020). Traumatic childhood experiences and posttraumatic stress disorder among veterans in substance use disorder treatment. Journal of Interpersonal Violence, Online first publication. 10.1177/0886260519900937 [DOI] [PubMed] [Google Scholar]
  75. Zhu W, Chen Y, & Xia L-X (2020). Childhood maltreatment and aggression: The mediating roles of hostile attribution bias and anger rumination. Personality and Individual Differences, 162, Advance online publication. 10.1016/j.paid.2020.110007 [DOI] [Google Scholar]

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