Differences in relationship conflict, attachment, and depression in treatment-seeking veterans with hazardous substance use, PTSD, or PTSD and hazardous substance use.

506274 research-article2013

JIV29710.1177/0886260513506274Journal of Interpersonal ViolenceOwens et al.

Article Journal of Interpersonal Violence 2014, Vol. 29(7) 1318–1337 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260513506274 jiv.sagepub.com

Differences in Relationship Conflict, Attachment, and Depression in Treatment-Seeking Veterans With Hazardous Substance Use, PTSD, or PTSD and Hazardous Substance Use

Gina P. Owens,1 Philip Held,1 Laura Blackburn,1 John S. Auerbach,2 Allison A. Clark,3 Catherine J. Herrera,4 Jerome Cook,5 and Gregory L. Stuart1

Abstract Veterans (N = 133) who were seeking treatment in either the Posttraumatic Stress Program or Substance Use Disorders Program at a Veterans Affairs Medical Center (VAMC) and, based on self-report of symptoms, met clinical norms for posttraumatic stress disorder (PTSD) or hazardous substance use (HSU) completed a survey related to relationship conflict behaviors, attachment styles, and depression severity. Participants were grouped into one of three categories on the basis of clinical norm criteria: PTSD only, HSU only, and PTSD + HSU. Participants completed the PTSD 1University

of Tennessee, Knoxville, USA Florida/South Georgia Veterans Health System, Gainesville, USA 3Naval Hospital Camp Lejeune, NC, USA 4Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA, USA 5James H. Quillen VA Medical Center, Mountain Home, TN, USA 2North

Corresponding Author: Gina P. Owens, Department of Psychology, University of Tennessee–Knoxville, Knoxville, TN 37996-0900, USA. Email: [email protected]

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Checklist–Military, Experiences in Close Relationships Scale–Short Form, Center for Epidemiologic Studies–Depression scale, Alcohol Use Disorders Identification Test, Drug Use Disorders Identification Test, and Psychological Aggression and Physical Violence subscales of the Conflict Tactics Scale. Most participants were male and Caucasian. Significant differences were found between groups on depression, avoidant attachment, psychological aggression perpetration and victimization, and physical violence perpetration and victimization. Post hoc analyses revealed that the PTSD + HSU group had significantly higher levels of depression, avoidant attachment, and psychological aggression than the HSU only group. The PTSD + HSU group had significantly higher levels of physical violence than did the PTSD only group, but both groups had similar mean scores on all other variables. Potential treatment implications are discussed. Keywords war, PTSD, alcohol and drugs, violence Exposure to combat has been found to increase the likelihood of developing post-deployment mental health problems (Hoge, Auchterlonie, & Milliken, 2006), and has been linked to high rates of posttraumatic stress disorder (PTSD), depression, and alcohol use among those returning from deployment (Wells et al., 2010; Wilk et al., 2010). The number of veterans who are seeking services at Veterans Affairs (VA) facilities, not only from more recent conflicts, but also from the Vietnam era, has increased dramatically in recent years (Rosenheck & Fontana, 2007). Recent estimates of the prevalence of PTSD among treatment-seeking veterans in the VA system ranges from approximately 12% in primary care clinics (Magruder et al., 2005) to 20% in an outpatient sample (Hankin, Spiro, Miller, & Kazis, 1999). Veterans also frequently suffer from depression, with some estimates of depression prevalence as high as 31% (Hankin et al., 1999) and prevalence of comorbid PTSD and depression at roughly 36% for veterans seeking VA care (Campbell et al., 2007). The prevalence of substance use disorders (SUDs) among veterans newly seeking treatment in the VA health care system is also high, with findings indicating that 10% of veterans of Iraq and Afghanistan received an Alcohol Use Disorder diagnosis and 5% received a Drug Use Disorder diagnosis between 2001 and 2009 (Seal et al., 2011). Prior research has shown a strong association between PTSD and SUDs. The comorbidity of PTSD and SUDs is commonly explained by the selfmedication hypothesis, which suggests that substances are used to help


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individuals cope with their PTSD symptoms, such as nightmares, insomnia, flashbacks, and hypervigilance (cf. Brady, Back, & Coffey, 2004). This hypothesis is consistent with theories of emotion regulation (Gross, 1998) that emphasize strategies, such as substance use, that individuals may use to manage and experience positive and negative emotions. Indeed, many individuals use substances to numb their feelings, and thus engage in avoidance coping behaviors, a strategy that has been linked to an increase in PTSD severity (e.g., Held, Owens, Schumm, Chard, & Hansel, 2011). Studies have found prevalence of PTSD among individuals who are in SUD treatment to range from 36% to 50% (Brady et al., 2004; Brown, Stout, & Mueller, 1996). Similarly, research with the veteran population indicates that comorbid PTSD and SUDs are frequently seen in treatment settings (Ouimette, Ahrens, Moos, & Finney, 1997; Seal et al., 2011). Individuals with comorbid PTSD and SUD tend to have more severe psychological symptom presentations than do individuals with PTSD or SUDs alone (Najavits et al., 1998). PTSD and substance use have the potential to impact treatment outcome for veterans who also have depression, a commonly comorbid disorder (Campbell et al., 2007) that may be viewed as a type of emotion dysregulation (Gross, 1998). Two studies with treatment-seeking veterans (Campbell et al., 2007; Walter, Barnes, & Chard, 2012) found that comorbid PTSD and depression complicated treatment, with depression severity remaining higher at all assessment points for those with comorbid PTSD and depression versus those with only one of these diagnoses. Other research suggests that depression was more severe for those in substance use treatment who had PTSD than for those without this comorbidity (Norman, Tate, Wilkins, Cummins, & Brown, 2010). Research has shown that emotion regulation strategies are associated with mood disorders such as depression (e.g., Gross, 1998). These findings highlight the importance of examining potential differences in depression severity between veterans having comorbid PTSD and hazardous substance use (HSU), HSU only, and PTSD. Mental health problems such as PTSD, depression, and SUDs are not the only struggles veterans face when they return from deployments. On homecoming, veterans must transition from the battlefield back to civilian life and from their combat units back to family roles and relationships. Veterans who have mental health problems, such as PTSD, are more likely to report relationship adjustment problems than are veterans without PTSD (Riggs, Byrne, Weathers, & Litz, 1998). Given the frequent occurrence of these difficulties among returning veterans, two aspects of relationship functioning will be examined in the current study: relationship conflict and attachment style. Level of conflict in a partner relationship and attachment style are both


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pertinent to the health of a relationship, but represent different aspects of relationship functioning. In terms of relationship conflict, partner aggression, including psychological abuse and physical violence, has been associated with PTSD in previous research with veterans (e.g., Teten et al., 2010). A cycle may develop in which high conflict relationships may maintain stressors, anxiety and other negative emotions, as well as maladaptive coping such as avoidance (see Marshall, Panuzio, & Taft, 2005, for review). To our knowledge, however, no research has yet investigated whether relationship conflict levels differ for individuals who struggle with PTSD alone, HSU alone, or comorbid PTSD and HSU, a focus of the current study. Better understanding potential differences in relationship conflict in the three aforementioned groups can assist with identifying individuals who may be in particular need for relationship conflict-focused interventions. Attachment style is thought to influence the formation and maintenance of relationships in veterans who suffer from PTSD (Renaud, 2008) and is the second relationship functioning construct of interest in this study. Stable relationships can function as protective factors against PTSD and general mental health problems post-deployment and thus are important variables to examine in treatment-seeking populations (e.g., Brewin, Andrews, & Valentine, 2000). Attachment theory (Bowlby, 1973) proposes that an individual’s early experiences with attachment figures assist with development of internal models of self and significant others that are carried into adulthood. Mikulincer, Shaver, and Pereg (2003) described two dimensions of attachment: (a) attachment anxiety where an individual may feel fears about close relationships and possible rejection, as well as feel a strong need for approval and closeness and (b) attachment avoidance characterized by reliance on oneself rather than others, fears of intimacy, and maintenance of emotional distance from others. Individuals who have lower levels of attachment anxiety and attachment avoidance are considered to be securely attached, and thus, more willing to rely on and seek help from others in times of distress (Mikulincer et al., 2003). Attachment styles are believed to be relatively stable over time; however, research suggests that later critical events may serve to change an individual’s attachment style (Davila & Cobb, 2003; Mikulincer, Ein-Dor, Solomon, & Shaver, 2011). Ghafoori, Hierholzer, Howsepian, and Boardman (2008) examined selfreported attachment styles and their relationship to PTSD severity in veterans and found that secure attachment was negatively associated with PTSD, whereas insecure attachment was positively related to PTSD severity. Other veteran research focused on self-reported attachment anxiety and attachment avoidance suggested that both constructs are positively related to PTSD


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severity (Renaud, 2008; Solomon, Dekel, & Mikulincer, 2008). Similarly, Clark and Owens (2012) found that high attachment avoidance in intimate relationships, but not attachment anxiety, was positively associated with higher levels of PTSD severity among veterans. Some evidence has suggested that increases in insecure attachment among veterans are associated with increases in PTSD severity over time (Mikulincer et al., 2011). Although certain avoidance symptoms of PTSD (e.g., feelings of detachment from others) are similar to characteristics of attachment avoidance, these constructs are not identical. Attachment styles relate specifically to a person’s emotional connectedness to others, while avoidance symptoms of PTSD also may, for example, relate to avoiding reminders of the trauma, diminished interest in activities, and a sense of a foreshortened future. Renaud (2008) proposed that the strong relationship found between self-reported attachment avoidance and PTSD severity may be due to insecurely attached individuals’ tendency to view others as dangerous or to traumatic events influencing their beliefs about the dangerousness of others which may function, simultaneously with PTSD hyperarousal symptoms, to increase attachment avoidance. Individuals would thereby feel lower demands to seek attachment to others and reduce the occurrence of potential danger cues from others (Renaud, 2008), thereby reducing negative emotions related to trauma cues. To date, no research has investigated possible differences between veterans with PTSD, HSU, or both in terms of their relationship attachment styles. Such differences, if they exist, might help to identify individuals who may benefit from treatment focused on instilling a more secure attachment style. Some researchers (e.g., Flores, 2001; Padykula & Conklin, 2010) view addiction as a disorder of attachment. For those who developed more insecure attachments early in life, possibly because of family environment experiences or traumatic events, substance abuse is believed to develop to assist with internal self-regulation and adaptation to one’s environment (Padykula & Conklin, 2010), such that the addiction may be used as an alternative to interpersonal relationships (Flores, 2001). Research supports these proposed relationships among substance abuse, attachment, and interpersonal problems (Riggs et al., 2007). Furthermore, individuals with substance abuse problems who also have anxious attachment styles on self-report measures tend to report greater difficulties with regulating emotions and higher levels of interpersonal problems (Doumas, Blasey, & Mitchell, 2008; Thorberg & Lyvers, 2010), difficulties that have been shown to be related to PTSD severity (Brewin et al., 2000). To our knowledge, no study has yet examined potential differences in depression severity, relationship conflict, and attachment style between treatment-seeking veterans who, on one hand, suffer from either PTSD or HSU


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and those who have comorbid PTSD and HSU combined. Thus, the present study sought to address this gap in the literature by investigating possible differences on these variables between groups of individuals with HSU only, PTSD only, and comorbid PTSD + HSU. Although our study examines intrapersonal (depression severity) and interpersonal (relationship conflict and attachment style) variables, the emotion regulation literature suggests that efforts to regulate one’s emotions can impact intrapersonal distress as well as interpersonal functioning. Moreover, the frequent co-occurrence of depression, relationship conflict, and difficulties with attachment in previous literature with the veteran population highlights the importance of examining these constructs simultaneously. Increasing our understanding of the interplay of these factors between the various groups may assist in identifying specific areas of intervention that may help improve existing treatments for veterans. Although not conducted with veterans, prior research (Najavits et al., 1998; Najavits et al., 2007) suggests that symptom severity and psychosocial impairment are worse among individuals with comorbid PTSD and substance use than among those with only one of these diagnoses. Based on this research, we hypothesized that the comorbid diagnostic group would have significantly higher mean scores on depression severity, relationship conflict variables of psychological aggression and physical violence, and avoidant and anxious attachment than would the HSU only and PTSD only groups on these dimensions.

Method Participants and Procedure In all, 142 Veterans who were seeking treatment in either the Posttraumatic Stress Program (PTSP) or Substance Use Disorders Program (SUDP) at a Veterans Affairs Medical Center (VAMC) completed the survey for the current study. Because substance abuse and PTSD were variables of interest in analyses, Veterans who did not meet criteria based on clinical norms for HSU or PTSD (n = 9) from self-reports were removed from the dataset for analyses, leaving a total sample of 133. The majority of participants were male (94%). Eighty-two percent of the sample was Caucasian, 14% African American, 2% Native American, and 2% Multiracial. More than half (64%) of participants served in the Vietnam or post-Vietnam eras, 14% Persian Gulf War, 13% Iraq, 4% Afghanistan, and 5% reported “Other” service eras. Ninety-eight percent of the sample were enlisted. Mean age of participants was 51.28 years (SD = 12.05). The mean number of times deployed was 1.5 (SD = 1.92, range = 0-12 times).


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Participants were recruited through announcements made at group meetings in the Posttraumatic Stress and Substance Use Disorders Programs. Veterans who consented to participate in the study completed self-report measures taking approximately 30 min. Each participant was given a US$10 gift card to a local merchant as compensation for completing the questionnaires. All procedures were in compliance with the VA Research and Development Office and university institutional review boards.

Measures Probable PTSD diagnosis. The PTSD Checklist–Military (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item measure designed to assess PTSD symptom severity and was used to determine probable PTSD criteria in the current study. Respondents use a 5-point scale, ranging from 1 (not at all) to 5 (extremely), to report the extent to which they have experienced symptoms of PTSD over the past month. Total scores range from 17 to 85, with higher scores indicating greater PTSD symptom severity. A cutoff of 50 indicates a probable PTSD diagnosis when this scale is used as a screening measure (Weathers et al., 1993) and has been used previously with treatmentseeking veterans (e.g., Forbes, Creamer, & Biddle, 2001). The PCL-M has high internal consistency (Cronbach’s α = .89-.92; Weathers et al., 1993), and convergent and discriminant validity have been supported (Adkins, Weathers, McDevitt-Murphy, & Daniels, 2008). Reliability for the PCL-M in the current study was .95. Probable HSU diagnosis. The Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, De La Fuente, & Grant, 1993) and Drug Use Disorders Identification Test (DUDIT; Stuart, Moore, Kahler, & Ramsey, 2003) were used to determine probable HSU criteria. A total score above the cutoff on either the AUDIT or the DUDIT was used to determine a probable HSU diagnosis. The AUDIT is a 10-item scale designed to determine individuals’ use of alcohol and hazardous drinking in the past year. The AUDIT assesses the quantity and frequency of drinking, symptoms of tolerance and dependence, and alcohol-related negative consequences. Items are rated from 0 to 4, with total scores ranging from 0 to 40. A cutoff score of 8 or more suggests that the individual is drinking in a hazardous manner (Saunders et al., 1993) and this cutoff score has been used previously with treatment-seeking veteran samples (e.g., Bradley, Bush, McDonell, Malone, & Fihn, 1998). Sensitivity (66%) and specificity (86%) analyses suggest that this cutoff is adequate for identifying heavy drinkers (Bradley et al., 1998). The AUDIT has high internal consistency, ranging from .81 to .93, and has been found to


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successfully discriminate between patients with and without alcohol drinking histories, supporting discriminant validity (Saunders, Aasland, Amundsen, & Grant, 1993). Reliability for the current study was .96. The DUDIT (Stuart et al., 2003). The DUDIT is a 14-item scale used to indicate individuals’ use of cannabis, cocaine, hallucinogens/PCP, nonprescribed stimulants, nonprescribed sedatives/hypnotics/anxiolytics, nonprescribed opiates, and “other” substances during the past year. The DUDIT assesses symptoms of dependence and drug-related negative consequences and its construction and scoring were modeled after the AUDIT (Saunders et al., 1993). Total scores on the DUDIT range from 0 to 56, with a cutoff score of 8 used to indicate hazardous use of illegal drugs. The DUDIT has internal consistency of .90 (Stuart, Moore, Ramsey, & Kahler, 2004). The internal consistency coefficient in the present study was .92. Relationship conflict. The 12-item Psychological Aggression and 16-item Physical Violence subscales of the Conflict Tactics Scale, Form N (CTS; Strauss, 1979) are designed to determine strategies, such as insulting a partner (i.e., psychological aggression), and choking or hitting (i.e., physical violence acts), used during conflict with a partner in the past year. Participants responded to items to indicate (a) whether they had used a particular strategy and (b) whether their partner had used that strategy in the past year. Items are rated on a Likert-type scale to indicate the frequency of a particular behavior or strategy. Responses range from this has never happened to this happened more than 20 times; the score range for each item is 0 to 25. The CTS subscales are scored by adding the frequency of each of the behaviors in the past year reported on each subscale. Totals are calculated for the respondent and the respondent’s partner for each subscale. Higher scores correspond with greater use of a particular strategy. Reliability coefficients for the CTS subscales for partners ranged from .79 to .80 for Psychological Aggression and .82 to .83 for Physical Violence and construct validity has been supported (Strauss, 1979). Internal consistency coefficients for the subscales in our sample were .85 (Psychological Aggression Perpetration), .75 (Psychological Aggression Victimization), .94 (Physical Violence Perpetration), and .92 (Physical Violence Victimization). Attachment. The Experiences in Close Relationships Scale–Short Form (ECR-S; Wei, Russell, Mallinckrodt, & Vogel, 2007) is a 12-item scale designed to measure adult attachment styles in romantic relationships. The measure has two subscales, Attachment Anxiety, representing a person’s need for approval and anxiety about rejection from others, and Attachment Avoidance, indicating an individual’s fear of intimacy with others and


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hesitance to self-disclose. Respondents use a 7-point Likert-type scale ranging from 1 (strongly disagree) to 7 (strongly agree) to indicate their level of agreement with statements about their romantic relationships. Participants are asked to respond according to “how you feel in romantic relationships,” and their responses reflect how they “generally experience relationships, not just in what is happening in a current relationship.” The ECR-S has adequate internal consistency, with coefficient alphas of .78 (Anxiety) and .84 (Avoidance). Construct validity of the ECR-S has been supported by correlations in expected directions with theoretically related constructs such as reassurance-seeking, distress disclosure, and fear of intimacy (Wei et al., 2007). The ECR-S has been used in previous work with veterans, with subscale reliabilities reported at .81 (Attachment Avoidance) and .73 (Attachment Anxiety; Clark & Owens, 2012). In the current study, internal consistency coefficients were .77 and .68 for the Attachment Avoidance and Attachment Anxiety scales, respectively. Depression. The Center for Epidemiological Studies–Depression Scale (CESD; Radloff, 1977) is a 20-item scale designed to measure symptoms of depression in the general population. Respondents use a 4-point Likert-type scale, ranging from 0 (rarely or none of the time) to 3 (most or all of the time), to indicate the frequency at which a symptom occurred in the past week. Scores range from 0 to 60, with higher scores indicating greater depression symptom severity (Radloff, 1977). Total scores of 16 or higher suggest probable depression when this scale is used as a screening measure (Radloff, 1977), and prior work indicates this cutoff is adequate in its sensitivity (60% and above across 5 studies) and specificity (80% and above across 5 studies) for screening purposes (see Radloff & Teri, 1986, for review). The CES-D has high internal consistency, ranging from .85 to .90, and construct and concurrent validity have been demonstrated (Radloff, 1977). Internal consistency in the present study was .82.

Data Analysis Although intake procedures on the respective units involved formally diagnosing participants, veterans were not necessarily new admissions to treatment at the time of the current study. Thus, screening measures were utilized to determine current symptomatology. Participants were divided into three groups for comparison purposes based on their self-report of symptoms: individuals who met clinical norms for HSU only (n = 30), individuals meeting clinical norms for PTSD only (n = 55), and individuals meeting clinical norms for HSU + PTSD (n = 48).Total scores of 8 and above on either the


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AUDIT or the DUDIT were used to indicate hazardous use of alcohol or drugs (Saunders et al., 1993; Stuart et al., 2003). Likewise, the clinical cutoff of 50 or above on the PCL-M (Weathers et al., 1993) was used to indicate probable PTSD. ANOVAs were conducted to determine potential differences on variables of interest. Post hoc analyses using Tukey’s HSD (honestly significant difference) test were conducted to investigate significant differences between groups.

Results Intercorrelations among variables and descriptive statistics are presented in Table 1. These patterns of correlations are consistent with the construct validity of the variables measured. Means and standard deviations for all variables are presented by group (HSU only, PTSD only, and PTSD + HSU) in Table 2. Because of high skewness for the Physical Violence perpetration and victimization scores, we conducted natural log transformations on these two variables prior to ANOVA analyses to assist in normalizing the distribution. All other variables were in acceptable ranges for skewness and kurtosis. Results of the ANOVAs indicated significant differences between the three groups (PTSD only, HSU only, and PTSD + HSU) on the following variables: depression, F(2, 125) = 17.59, p < .001; avoidant attachment, F(2, 127) = 5.57, p < .01; psychological aggression perpetration, F(2, 113) = 3.46, p < .05; psychological aggression victimization, F(2, 108) = 3.40, p < .05; physical violence perpetration, F(2, 112) = 3.88, p < .05; and physical violence victimization, F(2, 111) = 3.71, p < .05. No significant differences between groups were found for anxious attachment. Post hoc analyses using the Tukey HSD multiple comparisons approach were used to explore significant differences among groups. Regarding depression, mean scores for the HSU only group were significantly lower than were the PTSD only and PTSD + HSU groups means (p < .001). Means for the PTSD only and PTSD + HSU group were not significantly different from each other. Means for avoidant attachment were significantly lower for the HSU only group than for the PTSD only and PTSD + HSU groups (p < .01). The PTSD + HSU group had significantly higher levels of psychological aggression victimization and perpetration than did the HSU only group (p < .05) but not the PTSD only group. Mean scores for physical violence victimization and physical violence perpetration were significantly higher for the PTSD + HSU group than for the PTSD only group (p < .05) but not the HSU only group.


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— .24** .20* .12 .07 −.06 −.06 .60*** −.09 .04

26.86 (32.96)

17.31 (20.65)

1.56 (6.77) 2.24 (8.13) 58.32 (16.20)

12.73 (13.00) 9.57 (12.70)

1

33.70 (8.95) 26.40 (7.09) 25.25 (7.72)

M (SD)

−.07 .22*

.19* .19* .19*

.22*

.29**

— — .23**

2

−.05 .02

.14 .01 .39***

.26**

.30***

— — —

3

.04 .17

.51*** .26** .29**

.68***

—

— — —

4

.15 .19*

.57*** .54*** .24*

—

—

— — —

5

.23* .25**

— .55*** .02

—

—

— — —

6

.22* .35***

— — .09

—

—

— — —

7

−.24** −.10

— — —

—

—

— — —

8

— .37***

— — —

—

—

— — —

9

Note. CES-D = Center for Epidemiological Studies–Depression Scale; ECR-S = Experiences in Close Relationships Scale–Short Form; CTS = Conflict Tactics Scale; PCL = PTSD Checklist–Military; AUDIT = Alcohol Use Disorders Identification Test; DUDIT = Drug Use Disorders Identification Test. aNatural log transformations were conducted on these values prior to their use in correlational and ANOVA analyses due to skewness. *p < .05. **p < .01. ***p < .001.

1. Depression severity (CES-D) 2. Attachment anxiety (ECR-S) 3. Attachment avoidance (ECR-S) 4. Psych. aggression perpetration (CTS) 5. Psych. aggression victimization (CTS) 6. Violence perpetration (CTS)a 7. Violence victimization (CTS)a 8. PTSD symptom severity (PCL) 9. Alcohol use (AUDIT) 10. Drug use (DUDIT)

Variable

Table 1. Means, Standard Deviations, and Correlations Among Variables for Total Sample (N = 133).

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Owens et al. Table 2. Means and Standard Deviations by Group. Variable 1. Depression symptom severity (CES-D) 2. Attachment anxiety (ECR-S) 3. Attachment avoidance (ECR-S) 4. Psychological abuse perpetration (CTS) 5. Psychological abuse victimization (CTS) 6. Violence perpetration (CTS)a 7. Violence victimization (CTS)a 8. PTSD symptom severity (PCL) 9. Alcohol use (AUDIT) 10. Drug use (DUDIT)

HSU Only

PTSD Only

PTSD + HSU

26.20 (9.56)

35.71 (7.54)

36.42 (7.21)

25.89 (8.37) 21.11 (6.53) 13.38 (19.47)

26.45 (5.47) 26.21 (8.19) 26.51 (33.18)

26.65 (7.99) 26.64 (7.08) 35.17 (36.75)

9.04 (15.88)

16.64 (19.06)

22.68 (23.32)

0.20 (.68) 0.33 (.76) 32.69 (11.95) 19.17 (12.27) 12.67 (11.11)

0.14 (.42) 0.17 (.59) 65.53 (7.87) 2.61 (6.54) 0.57 (1.61)

0.56 (1.03) 0.68 (1.17) 64.23 (10.11) 20.08 (11.42) 17.75 (14.25)

Note. HSU = hazardous substance use; PTSD = posttraumatic stress disorder; PCL = PTSD Checklist–Military; CES-D = Center for Epidemiological Studies–Depression Scale; ECR-S = Experiences in Close Relationships Scale–Short Form; CTS = Conflict Tactics Scale; AUDIT = Alcohol Use Disorders Identification Test; DUDIT = Drug Use Disorders Identification Test. aNatural log transformations were conducted on these values prior to their use in correlational and ANOVA analyses due to skewness.

Discussion The current study investigated differences among treatment-seeking veterans who met criteria based on clinical norms from self-reports for HSU, PTSD, and PTSD + HSU on variables of depression symptom severity, attachment, and relationship conflict. Significant differences were found between groups on all variables except for anxious attachment. With regard to mental healthrelated variables, the PTSD + HSU group had significantly higher mean scores than the HSU only group for depression severity and avoidant attachment. However, the PTSD + HSU group was not significantly different from the PTSD only group on these variables. The PTSD only group also displayed significantly higher levels than did the HSU only group for these variables. Although no prior research has examined differences between HSU and PTSD groups, our findings follow earlier work indicating associations between higher PTSD symptom severity and avoidant attachment styles (e.g., Clark & Owens, 2012; Renaud, 2008; Solomon et al., 2008). Means for attachment avoidance groups in the current study were roughly 10 points higher than means in a non-treatment-seeking veteran sample (Clark & Owens, 2012) and undergraduates in the original development of the measure


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(Wei et al., 2007). Our results suggest that attachment avoidance may be especially relevant for individuals with PTSD and comorbid PTSD and HSU. Although certain PTSD avoidance symptoms such as feelings of detachment from others overlap with characteristics of avoidant attachment, these constructs are not the same. Avoidant attachment relates specifically to an individual’s emotional connection to others in relationships and therefore not only will impact intimate relationships with significant others, but also may affect the therapeutic relationship. Regarding the use of psychological aggression tactics in their relationship with a spouse/partner, veterans in the PTSD + HSU group had significantly higher levels for victimization and perpetration than did the HSU only group, but not the PTSD only group. Our findings support prior work with Iraq, Afghanistan, and Vietnam veterans indicating that veterans with PTSD displayed higher rates of psychological aggression than did veterans with no PTSD (Teten et al., 2010). Similarly, Byrne and Riggs (1996) identified PTSD as a correlate of psychological aggression perpetration among Vietnam veterans and found that perpetration was more likely when relationship problems existed. Byrne and Riggs hypothesized that use of psychological aggression might occur when problem-solving skills are lacking and the individual then turns to aggression. Results for physical violence in spouse/partner relationships contrast with our psychological aggression results in that the PTSD + HSU group had significantly higher levels for physical violence victimization and perpetration than did the PTSD only group but not the HSU only group. Thus, it may be that HSU is more strongly linked to use of physical violence in partner relationships for this sample. This finding makes sense when considering the effects of substance abuse in lowering one’s inhibitions and emotion regulation capacity (e.g., Marshall et al., 2005). Although our results are partially consistent with prior literature that suggests that having comorbid PTSD and HSU often results in a more severe symptom presentation (Najavits et al., 1998), the PTSD + HSU group was not significantly different from the PTSD only group in terms of depression severity, avoidant attachment, and psychological aggression perpetration or victimization. Because PTSD symptom severity levels were similar between these two groups, these findings emphasize the strong impact that PTSD may have on these variables with or without comorbid substance abuse problems in the veteran population.

Limitations and Future Directions for Research There are several limitations to the current study. Our sample of veterans consisted of volunteers, and we have no way of knowing how these


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individuals differ from those who chose not to participate in the current study. It is possible that those who chose not to participate may have had more severe symptom levels or that those who did participate may have been more interested in mental health issues. Although formal diagnosis of PTSD and SUD would have occurred prior to admission to a particular unit, we used screening measures, rather than diagnostic interviews, to determine our group classifications due to our desire to capture current symptomatology for all measures. Therefore, some of the individuals may have been missed that would have met criteria for a particular group, had more precise clinician-administered interviews been used. Although the DUDIT construction and scoring was modeled after the AUDIT, the criteria for the clinical norm (≥8) has not been validated previously with treatment-seeking veterans and might have influenced characterization of the drug use group. In addition, hazardous drug users in this study constituted a heterogeneous group, with many endorsing polysubstance use. Future researchers should consider examining specific drug groups separately with a larger sample size. In addition, the relatively low internal consistency for the Attachment Anxiety scale of the ECR-S in this sample is a potential limitation for the study, although the measure has been used previously with veterans (Clark & Owens, 2012). All veterans were in treatment for SUDs or PTSD; however, length of time in treatment varied among participants and could not be controlled for in our analyses because this information was not collected on the survey. Veterans who have received treatment for longer time periods may differ on the variables examined from those who only recently entered treatment. Furthermore, we were also limited to a crosssectional examination of these variables and were unable to compare the groups longitudinally to investigate potential differences during the course of treatment and treatment outcome. Future research should investigate the relationships of attachment style, psychological aggression, and physical violence longitudinally with this population to increase our understanding of changes across treatment in these variables. Other variables, such as presence of personality disorders, social support, unit cohesion during deployment, and duration of current mental health disorders, could affect the variables under investigation in this study and future research should explore these potential confounds. In addition, because the sample consisted almost entirely of male veterans, the current findings may not generalize to female veterans. Future research should explore relationships among these variables with a larger sample of female veterans to extend these findings. Finally, although our findings support the association between PTSD and attachment avoidance, they of course do not permit us to assess the extent to which attachment avoidance is a premorbid


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personality characteristic of individuals who later develop PTSD. It would be important to study prospectively whether attachment avoidance is also a predictor of PTSD. Overall our results suggest that insecure attachment styles, particularly avoidant attachment, may be important for clinicians to consider during treatment with veterans with PTSD or PTSD + HSU. Individuals with an avoidant attachment style may have more difficulty with trusting a clinician due in part to their fears of intimacy and also may be harder to engage in experiencing their emotions in therapy, given the desire to maintain emotional distance from others. In addition, assessment of psychological aggression perpetration and victimization appears to be more relevant for individuals with PTSD than for veterans with HSU alone and interventions in this area may be a relevant adjunct to treatment. Physical violence, however, seemed to be more strongly linked to HSU in this sample, a finding that emphasizes the importance of assessing this construct during treatment and possibly adding some focus on violence to the treatment intervention process. Authors’ Note The content of this manuscript does not reflect the views of the Department of Veterans Affairs or U.S. Government.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Gina P. Owens is an associate professor of psychology at the University of Tennessee–Knoxville. She received a PhD in counseling psychology from the University of Kentucky. Her research focuses on military service members’ cognitive processing of combat exposure events and factors that may aid in coping with posttraumatic stress disorder (PTSD), such as meaning in life, posttraumatic growth, and emotion regulation skills. She is also interested in the relationships among PTSD, substance use, and relationship conflict. Philip Held is a fourth-year student in the doctoral program in counseling psychology at the University of Tennessee. His research interests concern risk factors for posttraumatic stress disorder and substance use disorders, such as trauma-related guilt and shame, as well as coping strategies. Laura Blackburn is a graduate student in the doctoral program in Counseling Psychology at the University of Tennessee, Knoxville. She received her BS in psychology from Florida State University and previously worked as a research coordinator at the Birmingham VA Medical Center. Her research interests include posttraumatic stress disorder and how buffers such as self-efficacy and meaning in life may impact the effects of trauma. John S. Auerbach is a staff psychologist in the Psychiatric Rehabilitation and Recovery Center, North Florida/South Georgia Veterans Affairs Health System. He received a PhD in clinical psychology from the University at Buffalo/State University of New York. When this study was conducted, he was affiliated with the Psychosocial Recovery Treatment Program, James H. Quillen VA Medical Center and Department of Psychiatry and Behavioral Sciences, East Tennessee State University. His research interests include narcissism, borderline disorders, the Object Relations Inventory, attachment theory, and intersubjectivity theory.


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Allison A. Clark is a staff psychologist and commissioned officer with the United States Navy, currently stationed at Naval Hospital Camp Lejeune. She earned her PhD in counseling psychology from the University of Tennessee while completing research projects investigating factors affecting mental health functioning in current era war fighters. Specific interests include posttraumatic stress disorder and protective factors such as unit cohesion, personality characteristics, and morale in U.S. sailors and marines. Catherine J. Herrera is an Army captain and staff psychologist at Dwight D. Eisenhower Army Medical Center. She received her PhD in counseling psychology from the University of Tennessee-Knoxville. Her research interests include resilience and multicultural factors in military populations. Jerome Cook is a staff psychologist in the Substance Use Disorders Program at the James H. Quillen VA Medical Center. He is also a clinical assistant professor of Psychiatry and Behavioral Sciences in the James H. Quillen College of Medicine at East Tennessee State University. He received his PhD in clinical psychology at Vanderbilt University. His research interests include substance abuse, PTSD, and motivational interviewing. Gregory L. Stuart is a professor of psychology at the University of Tennessee– Knoxville and the director of Family Violence Research at Butler Hospital. He is also a professor (adjunct) in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University. His research focuses primarily on the comorbidity of intimate partner violence and substance abuse. He is particularly interested in interventions that address substance use and relationship aggression.


Relations Between Pain, PTSD Symptoms, and Substance Use in Veterans.

To reduce or abstain? Substance use goals in the treatment of veterans with substance use disorders and comorbid PTSD.

Relationships between GAT1 and PTSD, Depression, and Substance Use Disorder.

Concurrent Treatment of Substance Use and PTSD.

Exploring the relationship between eating disorder symptoms and substance use severity in women with comorbid PTSD and substance use disorders.

Correlates of Recent and Lifetime Aggression among Veterans with Co-Occurring PTSD and Substance Use Disorders.

Family composition and symptom severity among Veterans with comorbid PTSD and substance use disorders.

Examination of the Relationship Between PTSD and Distress Tolerance in a Sample of Male Veterans With Comorbid Substance Use Disorders.

Substance Use Attenuates Physiological Responses Associated With PTSD among Individuals with Co-Morbid PTSD and SUDs.

Coping among military veterans with PTSD in substance use disorder treatment.

PTSD and substance use disorder among veterans: characteristics, service utilization and pharmacotherapy.

Trauma exposure and PTSD in women with schizophrenia and coexisting substance use disorders: comparisons to women with severe depression and substance use disorders.

PTSD-related alcohol expectancies and impulsivity interact to predict alcohol use severity in a substance dependent sample with PTSD.

Treatment outcomes for veterans with PTSD and substance use: Impact of specific substances and achievement of abstinence.

Negative cognitions as a moderator in the relationship between PTSD and substance use in a psychiatrically hospitalized adolescent sample.

or Substance Use Services.

Effect of traumatic event reexposure and PTSD on substance use disorder treatment response.

Integrated Treatment of PTSD and Substance Use Disorders: Examination of Imaginal Exposure Length.

Suicidal Ideation Associated with PCL Checklist-Ascertained PTSD among Veterans Treated for Substance Abuse.

Treatment Attendance Among Veterans With Depression, Substance Use Disorder, and Trauma.

Perinatal smoking and depression in women with concurrent substance use.

Screening and Intervention for Comorbid Substance Disorders, PTSD, Depression, and Suicide: A Trauma Center Survey.

Hazardous alcohol use in general psychiatric outpatients.

Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, African-American men and women.