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. Author manuscript; available in PMC: 2026 Feb 27.
Published in final edited form as: Psychol Trauma. 2025 Feb 27;18(3):542–548. doi: 10.1037/tra0001894

Anger mediates the relationship between changes in alcohol use and violence: A longitudinal examination among Iraq/Afghanistan-era veterans

Krista Miloslavich 1, Pallavi Aurora 2,3, Jean C Beckham 2,3,4, Eric B Elbogen 2,4,5, Kirsten H Dillon 2,3,4,*
PMCID: PMC12353023  NIHMSID: NIHMS2045667  PMID: 40014492

Abstract

Objective:

Interpersonal violence is a common barrier to reintegration into civilian life in post-9/11 veterans. Alcohol use and anger, also common among veterans, are both risk factors for violence. The current study used longitudinal data to examine relationships between these factors.

Method:

Post 9/11-era veterans (N = 302) were assessed via clinical interviews and self-report questionnaires at baseline, 6-months, and 12-months on alcohol use, anger, violence, and PTSD symptom severity. Multilevel structural modeling was used to compare two different mediation models across the three waves of data.

Results:

The indirect effect of changes in alcohol use on violence via changes in anger was significant (p=.046). When covarying for PTSD symptom severity, the effects of path a and path b were consistent, however the indirect effect between alcohol use and violence was no longer significant (p=.076). The indirect effect of changes in anger on violence via changes in alcohol use was not significant (p = .074).

Conclusions:

Alcohol use, anger, and violence are variables closely influencing one another. The association between changes in anger and subsequent violence was not mediated by changes in alcohol use. The association between changes in alcohol use and subsequent violence was mediated by changes in anger; however, this mediating effect disappeared when controlling for PTSD severity. These findings shed light on the importance of anger and PTSD as contributors to the relationship between alcohol use and violence. They suggest that assessing and treating anger may reduce violence among veterans with problematic alcohol use.

Keywords: alcohol use, anger, violence, veterans, PTSD

Following the conflicts in Afghanistan and Iraq, many veterans (post-9/11) report psychiatric and functional impairments that may interfere with reintegration into civilian life. The nature of combat and injuries experienced by post-9/11 veterans differ from pre-9/11 veterans due to higher rates of deployment and technologically advanced weaponry (Parker et al., 2019). Interpersonal violence represents a major barrier to reintegration, with rates as high as 20% being observed in veteran populations (MacManus et al., 2015; Varker et al., 2022). Interpersonal violence in veterans is often linked to combat exposure (MacManus et al., 2015) and posttraumatic stress disorder (Dyer et al., 2009; Taylor et al., 2020), although other work shows that veterans with subthreshold or no PTSD symptoms (Jakupcak et al., 2007; Tharp et al., 2016) and without combat exposure (Kwan et al., 2017) still show elevated rates of interpersonal violence, suggesting that combat exposure and PTSD alone do not fully account for heightened violence in veterans. Although most veterans do not report engaging in interpersonal violence, those that do experience additional barriers to reintegration such as unstable housing and disruption of social networks (Jakupcak et al., 2007), marking a critical public health need to understand pathways to interpersonal violence in veterans.

Alcohol use has been related to increased conflict with others and an increase in potential violent behavior (i.e., homicide, assault; Harford et al., 2018; Mann et al., 2006; Wahlsten et al., 2007). Notably, large-scale studies have shown that alcohol was more strongly related to violent crimes (i.e., homicide, physical assaults and sexual assaults) compared to non-violent offenses (i.e., robbery; Felson & Staff, 2010), suggesting that alcohol use might be an important behavior associated with violent delinquent behavior. Studies examining this effect in post-9/11 veterans found not only higher rates of arrests for violent crimes and alcohol misuse among veterans compared to nonveterans (Elbogen et al., 2010, 2014), but also an association between alcohol misuse and subsequent violence (Elbogen et al., 2014).

Anger is one such factor that has been identified at higher rates in veterans and is strongly associated with both violence and alcohol use. Difficulty controlling anger is one of the most prevalent post-deployment concerns reported by post-9/11 veterans (Sayer et al., 2010; Sippel et al., 2016) and anger has been consistently identified as a critical concern for those with PTSD (Orth & Wieland, 2006; Van Voorhees et al., 2016, 2018). Anger has also been linked to alcohol use severity (Kessler et al., 2006; Miloslavich et al., 2023; Sharma et al., 2017), wherein greater anger is associated with more alcohol use, higher levels of intoxication, and more symptoms of alcohol use disorder (Leibsohn, 1994). Additionally, anger has been identified as the key emotion in violent behavior, wherein violent behavior functions as a means of regulating anger (Bushman et al., 2001; Gardner & Moore, 2008; Jakupcak & Tull, 2005). Importantly, anger has also been shown to increase risk of violence in veterans, even after controlling for comorbid mental health issues (Varker et al., 2022), suggesting that anger uniquely contributes to the risk of violence in this population.

Taken together, studies suggest that alcohol use and anger occur at high rates in veteran populations (Sayer et al., 2010; Sippel et al., 2016; Wright et al., 2012). Alcohol use and anger have separately been associated with violence in clinical (Harford et al., 2018; Mann et al., 2006; Wahlsten et al., 2007) as well as veteran populations (Elbogen et al., 2014; Varker et al., 2022). There is evidence that alcohol use and anger interact with one another to increase risk of violence perpetration (Norström & Pape, 2010; Parrott & Zeichner, 2002). However, the relationships between these three variables have not been examined over time and the indirect effects of alcohol use on violence via anger and anger on violence via alcohol use among veterans has yet to be examined.

Theoretically, both models propose plausible pathways linking anger, alcohol use and violent behavior, however the model in which anger serves as the mediator between alcohol misuse and violence is more strongly supported by existing research. Due to anger’s tendency to spur action (i.e., violent behavior; Carver & Harmon-Jones, 2009; Harmon-Jones & Allen, 1998; Tsypes et al., 2019), it is likely that anger would increase the risk of alcohol-related violence. Indeed, anger is a strong predictor of violence (Dewi & Kyranides, 2022; Varker et al., 2022). Alcohol intoxication, specifically the disinhibitory effects and impairment of judgment, has been shown to increase aggressive behavior in those with higher levels of anger (Miller et al., 2009), suggesting that anger is a key factor in the relationship between alcohol use and violence. Alternatively, it is possible that anger difficulties may lead to alcohol misuse (as a maladaptive coping strategy), which may increase the risk of violent behavior.

Altogether, the current literature suggests that alcohol use and violence may be related through changes in anger, that anger and violence may be related through changes in alcohol use, or that both pathways may simultaneously contribute to violence. The current study sought to examine these mechanisms by longitudinally assessing the associations between alcohol use, anger, and violence risk in a large sample of post-9/11 veterans. Due to the strong evidence supporting anger as a mechanism by which alcohol use is associated with violence, we predicted that anger would be a significant mediator between the alcohol use and violence. Alternatively, we predicted that alcohol use would not significantly mediate the relationship between anger and violence.

Methods

Participants and Procedures

The current study was conducted by analyzing data from a larger, three-wave longitudinal study of post-9/11 veterans’ psychological health (N = 319). Data were collected at baseline, 6-month, and 12-month time points between June 2009 and March 2013. English-speaking veterans between 18 and 70 years of age who had served in the U.S. military after September 11, 2001 were recruited. Participants were recruited through advertisements, clinician referrals, mailings to veterans who were registered with the VA healthcare system and had served in the military after September 11, 2001, and enrollment in the registery database for the Study of Post-Deployment Mental Health (Brancu et al., 2016). There were no exclusionary criteria. The present study utilized a Multilevel structural equation modeling (MSEM) to examine whether anger mediated the relationship between alcohol use and violence. A multilevel modeling approach allows for analyzing repeated observations (e.g. three waves), across multiple participants (Searle et al., 2009). Applying path analysis to multilevel data allows for testing mediation hypotheses. Institutional Review Board approval was obtained before data collection. Additional details can be found in prior publications from this dataset (Dillon et al., 2020; Glenn et al., 2020).

Measures

Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993).

Problematic alcohol use was assessed using the AUDIT. This is a 10-item self-report questionnaire that asks about alcohol consumption, drinking behavior, and problems associated with alcohol use. Possible total scores can range from 0 to 40 points, with higher scores indicating greater levels of problematic alcohol use. The AUDIT has demonstrated good validity and reliability (Saunders et al., 1998). In the current sample, internal consistency for the AUDIT at baseline was α = 0.87.

Symptom Checklist-90-R (SCL-90-R; (Derogatis & Lazarus, 1994).

Anger was assessed using the hostility subscale of the SCR-90-R. In this six-item subscale, participants rated how distressing each item had been over the past week on a 5-point Likert scale ranging from 0 (“not at all”) to 4 (“extremely”). Items were summed to create a total score. The SCL-90-R has evidenced good test-retest reliability, construct validity, and internal consistency (Derogatis & Lazarus, 1994). In the current sample, internal consistency for the SCL-90-R hostility subscale at baseline was α = 0.88.

Violence Assessment.

Violent behavior was coded using the same procedures as other violence risk assessment studies (Elbogen et al., 2014; Monahan et al., 2000). Severe violence was measured by endorsement of specific items on the Conflict Tactics Scale (i.e. ‘Used a knife or gun’, ‘Beat up the other person’ or ‘Threatened the other person with a knife or gun’) or on the MacArthur Community Violence Scale (i.e. ‘Did you threaten anyone with a gun or knife or other lethal weapon in your hand?’, ‘Did you use a knife or fire a gun at anyone?’ or ‘Did you try to physically force anyone to have sex against his or her will?’). Other physical aggression in the past year was assessed using additional items from these two scales addressing less lethal/serious physically aggressive acts (i.e. kicking, slapping, using fists, getting into fights).A composite of any violent behavior (1 = “any violent behavior”; 0 = “no violent behavior”) was calculated if the veteran endorsed items of the Conflict Tactics Scale or the MacArthur Community Violence Scale indicating any level of physical aggression or violence (i.e., use of weapons, threatening with weapons, assault, sexual violence, kicking, slapping, using fists, fighting).

Davidson Trauma Scale (DTS; Davidson et al., 1997).

PTSD symptoms were assessed using the DTS. The DTS is 17-item self-report measure of DSM-IV PTSD symptoms that has been found to have good reliability and validity (Davidson et al., 1997; McDonald et al., 2009). Participants rated each of the 17 PTSD symptoms on a 5-point Likert scale with respect to frequency (0 = “not at all” to 4 = “everyday”) and severity (0 = “not at all distressing” to 4 = “extremely distressing”). Items were summed to create a total score. The total DTS score for the analyses presented here did not include the item assessing PTSD-related anger (“Have you been irritable or had outbursts of anger?”). In the current sample, internal consistency for the DTS at baseline was α = 0.98

Data Analytic Plan

Multilevel structural equation modeling (MSEM) was used to examine whether anger mediated the relationship between alcohol use and violence or whether alcohol use mediated the relationship between anger and violence. Multilevel modeling (MLM) was employed to account for the repeated observations of data across multiple participants as well as accounting for the nested nature of waves within each participant. The use of MLM models allows us to account for time at Level 1 (time-varying) variables and Level 2 (time-invariant) variables. MSEM was utilized to run a mediation analysis by applying path analysis to the multilevel data. Lagged scores were used to create change scores from t-1 to wave t and to control for prior levels of the variables of interest. A lagged score was created for AUDIT and anger scores. Given the lagged nature of the data, mediation analyses only predicted outcomes at waves 2 and 3. The models are displayed in Figure 1. Path A of the mediation model assessed the effect of changes in the independent variable (alcohol use or anger, respectively) from t-1 to wave t on concurrent changes in the mediating variable (anger or alcohol use, respectively). Path B assessed the effect of changes in the mediating variable (anger or alcohol use, respectively) from t-1 to wave t on violence while controlling for the independent variable (alcohol use or anger, Path C’). The mediation analyses aimed to test whether the direct effect of the independent variable on violence at wave t, will attenuate in the presence of the mediator. The significance of the mediation effect was tested by calculating the indirect effect by multiplying paths A and B and the total effect was calculated by adding the indirect effect of Path C’. In addition to the primary analysis, we were also interested in testing the same mediation analysis while controlling for PTSD symptomology. All analyses were conducted using Mplus 7.

Figure 1.

Figure 1.

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Multilevel mediation models examining two pathways to predicting violence. Change scores were calculated by subtracting scores at wave t-1 from those measure at wave t. Unstandardized regression coefficients are reported in the figure. Bolded coefficients are indicating controlling for PTSD, while non-bolded coefficients are indicating that PTSD was not covaried for. *p < .05, **p < .01.

Results

A total of 302 veterans had complete T1 data available for analysis. Of these, 239 (78.8%) had complete data at T2, and 229 (75.8%) had complete data at T3. At T1, 130 (43%) of participants scored above the suggested clinical cut off of 40 on the DTS, suggesting a probable diagnosis of PTSD (Davidson et al., 1997). Demographics and descriptive statistics for the sample can be found in Table 1.

Table 1.

Demographic Characteristics and Baseline Scores of Study Participants

Demographic Characteristics
N %
Sex
   Male 261 83.39
   Female 52 16.61
Race
   White/European 123 39.55
   Black/African 162 52.09
   Other 26 8.36
M SD
 Age 41.79 10.51
 AUDIT 3.97 5.16
 Anger 3.71 4.74
 PTSD symptoms* 35.61 34.49
 Violence 0.43 0.50
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*

Note: PTSD symptom severity score does not include anger symptom.

Examining Changes in Anger as a Mediator

MSEM indicated that changes in alcohol use (AUDIT score) from wave t-1 to t were associated with concurrent changes in anger from wave t-1 to t (B = 0.198, p = .009) when controlling for lagged AUDIT score. Results also indicated that anger from wave t-1 to t was associated with concurrent changes in violence (B = 0.021, p = .006) when controlling for lagged anger. Consequently, the changes in AUDIT scores on violence were reduced (B = 0.020, p = .012). Results indicated the indirect effect of changes in alcohol use on violence via changes in anger was significant (p = .046).

Given the significant association between anger, alcohol, and violence with PTSD we were also interested in testing whether the primary analysis held when controlling for PTSD. Results indicated that when controlling for PTSD symptoms, changes in alcohol use (AUDIT score) from wave t-1 to t were associated with concurrent changes in anger from wave t-1 to t (B=0.153, p=.033). Results also indicated that when controlling for PTSD symptoms, anger from wave t-1 to t was associated with concurrent changes in violence (B = 0.020, p = .012). Consequently, the changes in AUDIT scores on violence were reduced (B = 0.018, p = .025) when controlling for PTSD symptoms. Interestingly, the indirect effect of changes in alcohol use on violence via changes in anger was no longer significant (p = .076) when controlling for PTSD symptoms.

Examining Changes in AUDIT as a Mediator

MSEM indicated that changes in anger from wave t-1 to t were associated with concurrent changes in alcohol use (AUDIT) from wave t-1 to t (B = 0.263, p = .004) when controlling for lagged anger score. Results also indicated that AUDIT from wave t-1 to t was associated with concurrent changes in violence (B = 0.020, p = .013) when controlling for lagged AUDIT. Consequently, the changes in anger scores on violence were reduced (B = 0.021, p = .005). Results indicated the indirect effect of changes in anger on violence via changes in alcohol use was not significant (p = .074).

Given the significant association between anger, alcohol, and violence with PTSD we were also interested in testing whether the these analysis held when controlling for PTSD. Results indicated that when controlling for PTSD symptoms, changes in anger from wave t-1 to t were associated with concurrent changes in AUDIT from wave t-1 to t (B=0.207, p=.014). Results also indicated that when controlling for PTSD symptoms, AUDIT from wave t-1 to t was associated with concurrent changes in violence (B = 0.018, p = .026). Consequently, the changes in anger scores on violence were reduced (B = 0.020, p = .010) when controlling for PTSD symptoms. Again, the indirect effect of changes in anger on violence via changes in alcohol use was not significant (p = .101) when controlling for PTSD symptoms.

Discussion

The present study examined whether anger mediated the relationship between alcohol use and violence or whether alcohol use mediated the relationship between anger and violence in a sample of United States veterans, using a longitudinal design. Consistent with our hypotheses, when we examined anger as a mediator, we found the association between alcohol use and violence over one year was mediated by changes in anger. In contrast, we did not find a significant effect for alcohol use as a mediator between anger and violence. Additionally, each of the direct effects of the models suggested that alcohol use, anger, and violence are variables closely influencing one another. These findings provide continued evidence of the robust relationship between alcohol use and violence, while also adding to our understanding of how affective states such as anger, might influence this relationship. These findings provide support for the need to target emotions commonly associated with increased use of alcohol use and violence. Furthermore, alcohol use, violence, and anger are also highly comorbid with PTSD. Thus, we were also interested in exploring whether controlling for PTSD symptom severity maintained the associations between alcohol use, violence, and anger. Results indicated that the main effects between alcohol use and anger, and anger and violence remained significant. However, the indirect effect between alcohol use and violence via anger was no longer significant. These findings shed light on the unique role of PTSD symptoms in the associations between alcohol use, violence, and anger, suggesting that PTSD might be an important contributor to the relationship between alcohol use and violence.

It is notable that we found that the alcohol and violence relationship was mediated by changes in anger, but that the anger and violence relationship was not mediated by changes in alcohol use. Prior research has found that the relationship between alcohol and violence is moderated by anger (Norström & Pape, 2010; Parrott & Zeichner, 2002), but to our knowledge no other studies have looked at the longitudinal relationships between changes in these variables over time. Our findings indicate the importance of changes in anger are a potential mechanism in explaining the relationship between alcohol use and violence and highlight the importance of treating anger difficulties in veterans with alcohol use problems.

The current findings highlight the potential importance of assessing and treating anger in Veterans with alcohol use and/or PTSD to prevent violence and aggression. Existing alcohol use risk assessments do not typically assess anger (e.g., Alcohol Use Disorder Identifications Test; Saunders et al., 1993) and common PTSD assessments often categorize anger with other negative emotions (PTSD Checklist for DSM-5; Blevins et al., 2015). Furthermore, evidence-based treatments for alcohol use, such as motivational interviewing (W. R. Miller & Rollnick, 2012), and PTSD, such as cognitive processing therapy (Resick & Schnicke, 1992) or prolonged exposure (Foa et al., 2008), do not specifically address anger despite high endorsement of anger in these treatment settings (Barrett et al., 2013; Orth et al., 2006; Van Voorhees et al., 2021). Our results suggest that interventions to reduce anger difficulties may be beneficial for reducing risk of violence. Additional research is needed to examine the effects of anger management treatment on subsequent alcohol use, PTSD symptoms and violence.

This study had several noteworthy strengths including its longitudinal design, high rates of participant compliance over time, and robust assessments. The longitudinal design of this study made it possible to clarify the direction of associations between variables and to ensure that the mediator (i.e., anger) temporally preceded the outcome (i.e., violence), an assumption of formal mediation (Kazdin & Nock, 2003). Second, the study retained 78.8% of participants at a 6-month follow-up, which allowed for a relatively large sample size to be included in the mediation. Further, this study employed a robust assessment of violence which was captured across two evidence-based measures, capturing a variety of violent behaviors, bolstering the results related to violence. Lastly, this was one of the few studies to date to examine longitudinal patterns of anger, violence, and alcohol use in post-9/11 era veterans.

The results of this study should be considered considering several limitations. The study relied upon self-report measures to assess alcohol use, anger, and aggressive behavior, which may have been affected by response biases. The potential stigma associated with disclosure of these variables may have led the data to be an underestimate of these constructs. In the future, it may be helpful to obtain collateral reports from partners or family members. Relatedly, PTSD was assessed using the Davidson Trauma Scale, which is based on DSM-IV criteria for PTSD. Although the DSM-IV and DSM-5 criteria for PTSD both included a symptom of irritable behavior or anger outbursts, a new symptom of “persistent negative affect” was added to DSM-5, which could include persistent anger; therefore, it is possible the these results would be different with the newer conceptualization of PTSD. Future work should seek to replicate these results using a measure based on the most current criteria for PTSD. Additionally, the study sample was predominantly male, which limits our ability to generalize results to female veterans. The sample was not necessarily representative of the current veteran population. Minorities were over-represented relative to national averages but were consistent with local demographics. Further research is needed to replicate these findings in a nationally representative veteran sample. Although the multiple assessment points were a strength of this study, the period between data collection points was lengthy (6 months), which limited our ability to determine the rate at which alcohol use contributed to aggression via changes in anger. In future research, ecological momentary assessment (EMA) methods, with assessments only hours apart, may help to clarify the relationships between these variables in a shorter period (e.g., within a day or a week).

In summary, these findings indicate anger as a prominent barrier to readjustment for post-9/11 veterans as well as a risk factor for alcohol use and violence. Further, these findings suggest that assessing and treating anger may reduce these harmful outcomes, especially within the context of PTSD treatment. Individuals who engage in violence and/or problematic drinking may benefit from anger management therapy, which has been shown to reduce violence perpetration (Félix-Junior et al., 2023) and alcohol use (Walitzer et al., 2015) via increasing anger control, as a part of PTSD treatment as well as a stand-alone intervention. It will be important to further assess these relationships and their implications for treatment in post-9/11 veterans, in addition to civilians, to target these harmful outcomes more specifically.

Clinical Impact Statement.

Problematic anger and alcohol misuse are common concerns among post-9/11 era veterans. Both of these difficulties have been associated with violence; however, the pathway to violence overtime is unknown. This study found that alcohol misuse is related to subsequent violence via changes anger; however, anger is not related to subsequent violence via changes in alcohol misuse.

Funding Details

This work was supported by Career Development Award IK2RX002965 (to K.D.) from the Rehabilitation Research and Development Service of VA Office of Research and Devlepment (ORD), Senior Research Career Scientist Award IK6BX003777 (to J.B.) from the Clinical Sciences Research and Development Service of VA ORD, a Merit Review (to J.B.) from the Rehabilitation Research and Development Service of VA ORD, and funding from the National Institute of Mental Health (#R01MH080988; to E.E.). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA or the United States government or any of the institutions with which the authors are affiliated.

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