What Can Specific PTSD Symptom Profiles Tell Us about Suicidality and Non-Suicidal High Risk Behavior in Military Veterans?

Objective: Military veterans are disproportionally represented among individuals with posttraumatic stress disorder (PTSD), which has been linked to preventable premature death. While much study has been devoted to PTSD and suicide risk, there has been little investigation of links between PTSD and non-suicidal high risk behaviors (NSHRB), which may account for a significant proportion of premature death in veterans. We argue that the interpersonal-psychological theory of suicide, which locates suicide in the context of (1) perceived burdensomness, (2) thwarted belonging, and (3) acquired capability for suicide, can be extended to help elucidate elevated rates of potentially lethal NSHRB in veterans with PTSD. The aim of this study was to examine the relationship between specific PTSD symptoms, suicidality, and NSHRB in veterans.

Method: Data for these analyses were drawn from a survey of 1356 veterans in a large urban Southern California county. All responses were collected via a paper and pencil or online survey. A four pronged sampling strategy leveraging state agency administrative data, partnerships with community agencies serving veterans, local social service centers, and snowball sampling techniques were used to account for the diversity of the area’s veteran population. Independent variables were PTSD symptoms operationalized by the PCL. Outcomes included the dichotomous variables suicidal ideation and suicide plan, and dichotomous items capturing the NSHRB reckless driving, starting fights, carrying a weapon, and taking unnecessary risks to life.

Results: After exploratory and confirmatory factor analysis of individual measurement models for PTSD symptoms and NSHRB indicated a good fit to the data, a structural equation model was employed to test relationships between PTSD symptom clusters, suicidality and NSHRB. Results indicated a good fit to the data, with χ²(N=848, 238)= 777.87, p<.01, CFI=.97, RMSEA= .05 (95% CI: .05, .06). The re-experiencing factor showed a direct effect on suicidality (γ = .31, p<.05) as did the avoidance factor (γ = .28, p<.05). The hyperarousal factor demonstrated a direct effect on NSHRB (γ = .76, p<.05). There was an indirect effect of re-experiencing on high risk behavior partially mediated by suicidality (c’+ab = .07).

Implications: This study is the first to examine relationships between PTSD symptoms, suicidality, and NSHRB in a single model. Consistent with the literature, we found re-experiencing symptoms to have the strongest association with suicidality. Results suggest that reexperiencing and avoidance symptoms below the PLC clinical cut-point may warrant intervention. Our analyses also showed a strong relationship between hyperarousal and NSHRB. Study limitations included a cross-sectional design and missing data which may limit generalizability. Study findings indicate that veterans who experience hyperarousal symptoms and who have an enhanced tolerance for physical discomfort acquired through military service may be more likely to engage in high risk behaviors with lethal potential. In the context of hyperarousal symptoms and acquired capability for tolerating physical distress, this constellation of risk factors may place veterans in significant danger of early mortality.