Comorbid treatment of traumatic brain injury and mental health disorders.

BACKGROUND: The Emory Healthcare Veterans Program (EHVP) is a multidisciplinary intensive outpatient treatment program for post-9/11 veterans and service members with invisible wounds, including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), substance use disorders (SUD), and other anxiety- and depression-related disorders. OBJECTIVE: This article reviews the EHVP. METHODS: The different treatment tracks that provide integrated and comprehensive treatment are highlighted along with a review of the standard, adjunctive, and auxiliary services that complement individualized treatment plans. RESULTS: This review particularly emphasizes the adjunctive neurorehabilitation service offered to veterans and service members with a TBI history and the EVHP data that indicate large reductions in PTSD and depression symptoms across treatment tracks that are maintained across 12 months follow up. Finally, there is a discussion of possible suboptimal treatment response and the pilot programs related to different treatment augmentation strategies being deploying to ensure optimal treatment response for all. CONCLUSION: Published data indicate that the two-week intensive outpatient program is an effective treatment program for a variety of complex presentations of PTSD, TBI, SUD, and other anxiety- and depression-related disorders in veterans and active duty service members.

Substance Use after Completion of an Intensive Treatment Program with Concurrent Treatment for Posttraumatic Stress Disorder and Substance Use among Veterans: Examining the Role of PTSD Symptoms.

OBJECTIVE: Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are costly and highly co-occurring diagnoses, particularly among veterans, suggesting a need to understand this comorbidity and effectively treat both disorders among this population. METHODS: The current study aimed to examine substance use outcomes among post-9/11 veterans and service members (N = 48) who completed a two-week intensive outpatient program with concurrent treatment for and PTSD using Prolonged Exposure and substance use. Substance use was assessed at two weeks and three months posttreatment. RESULTS: The intensive program had high completion rates and demonstrated decreases in substance use at two weeks and three months posttreatment. Additionally, lower PTSD symptoms at treatment completion were related to less substance use posttreatment. CONCLUSIONS: Concurrent intensive treatment of PTSD and SUDs can lead to symptom improvement in a short period of time. Findings support the self-medication model, such that PTSD symptoms at treatment completion were related to substance use at follow-up.

A Laboratory Test of Alcohol-Related Intimate Partner Aggression: Expectancies Are Not to Blame.

Background: The role of alcohol expectancies and evaluations (i.e., perceived outcomes of drinking and whether these outcomes are desirable) in alcohol-related intimate partner aggression (IPA) has been debated, with some researchers arguing that expectancies fully account for the alcohol-IPA relationship and others suggesting they play a minimal if any role in alcohol-related IPA. In the current study, we examine the impact of expectancies and evaluations on alcohol-related IPA observed in the lab, in order to clarify what impact, if any, alcohol expectancies have on alcohol-related IPA. Consistent with findings from laboratory studies examining general aggression, we expected that individuals who were intoxicated would display greater IPA than individuals who were sober, but that alcohol expectancies and evaluations would be unrelated to in vivo IPA. Method: Participants were 69 dating couples (total N = 138), randomly assigned to consume either an alcohol or placebo beverage. IPA was measured with an in vivo aggression task based on the Taylor Aggression Paradigm. Results: As expected, alcohol intoxication predicted in vivo IPA following provocation (p < .03), whereas alcohol expectancies and evaluations were not related to IPA. Conclusions: These findings provide further support that alcohol expectancies and evaluations play little if any role in alcohol-related IPA. Rather, intoxication likely increases risk for IPA through its physiological effects on perception and thought. Further, treatments targeting alcohol use, rather than beliefs about outcomes of drinking, may have a greater impact on alcohol-related IPA.

Frequency and correlates of suicidal ideation and behaviors in treatment-seeking Post-9/11 Veterans.

OBJECTIVE: Post-9/11 U.S. veterans and servicemembers are at increased risk for suicide, indicating an important need to identify and mitigate suicidal ideation and behaviors in this population. METHOD: Using data modeling techniques, we examined correlates of suicidal ideation and behavior at intake in 261 Post-9/11 veterans and servicemembers seeking mental health treatment. RESULTS: Our sample endorsed high rates of suicidal ideation and behavior. Approximately 40% of our sample scored in a range on the Suicide Behaviors Questionnaire-Revised (SBQ-R), indicating high clinical risk for suicide. Results from multivariate analyses indicate that greater state and/or trait depression severity, greater anger and anger expression, less impulse control, and lower rank were consistently associated with suicidal ideation and behavior across our models. Negative posttraumatic thoughts about the self, gender, and military branch of service were also significantly associated with suicidal ideation and behavior. CONCLUSIONS: Suicidal ideation and behaviors are common in veterans seeking mental health treatment. State and/or trait depression, anger and impulse control were predictors of increased risk for suicidal ideation and behavior across models. Consistencies and differences across models as well as limitations and practical implications for the findings are discussed.

Long-term effectiveness of a prolonged exposure-based intensive outpatient program for veterans with posttraumatic stress disorder.

Empirically-supported psychotherapies for posttraumatic stress disorder (PTSD) are highly effective and recommended as first-line treatments, yet dropout rates from standard outpatient therapy are high. Intensive outpatient programs (IOPs) that provide these therapies in condensed format with complementary interventions show promise, as they have demonstrated similar efficacy and higher retention rates. The current study examined initial and long-term outcomes up to 12-months following a 2-week PTSD IOP involving daily prolonged exposure therapy (PE) and adjunctive interventions for veterans and military service members. Participants (N = 376) demonstrated high retention (91%) and large effect size reductions in self-reported PTSD and depression symptoms after two weeks. Small increases in symptoms occurred after 3 months but these stabilized and large reductions compared to baseline were maintained up to 12 months. Piecewise multilevel modeling indicated that demographic variables did not predict PTSD or depression symptom trajectories. Higher PTSD and depression severity at intake predicted higher symptomatology across timepoints and larger relative gains during treatment. Greater alcohol use prior to treatment was associated with higher PTSD symptomatology but did not affect the magnitude of gains. A history of childhood sexual abuse was associated with greater reduction in depression symptoms over treatment, although this effect faded over follow-up. Together these findings underscore the long-term effectiveness of a PE-based IOP across a diverse range of veterans and service members.

Acquisition, extinction, and return of fear in veterans in intensive outpatient prolonged exposure therapy: A fear-potentiated startle study.

Prolonged exposure (PE) therapy is a first-line treatment for posttraumatic stress disorder (PTSD) and involves repeated presentation of trauma-related cues without aversive outcomes. A primary learning mechanism of PE is fear extinction (new learning that a dangerous cue is now safe) and its retention (maintaining this new learning over time). Extant research suggests extinction is impaired in PTSD patients. In this study, we employed an established fear-potentiated startle-based paradigm to examine fear acquisition, extinction learning and retention before and after completion of intensive outpatient treatment. First, PTSD patients undergoing PE (n = 55) were compared to trauma-exposed patients without PTSD (n = 57). We identified excessive fear in PTSD patients during acquisition and extinction before treatment compared to non-PTSD patients. At post-treatment, we examined the return of fear after extinction in PTSD patients showing high or low treatment response to PE (≥50% change in PTSD symptom severity vs. < 50%). High PE responders maintained fear extinction learning whereas low PE responders showed significant return of fear at post-treatment. These results replicate and extend previous findings of impaired extinction in PTSD and provide support for the proposed theoretical link between fear extinction and PE response.

The relations between C-reactive protein and trauma exposure, PTSD and depression symptoms, and PTSD psychotherapy treatment response in treatment seeking veterans and service members.

While inflammatory markers have been implicated in the link between PTSD and poor health outcomes, there is a paucity of research investigating C-reactive protein (CRP) and psychotherapy treatment response for posttraumatic stress disorder (PTSD). The present study utilized a large, well-characterized sample of veterans and service members (N = 493) engaged in intensive psychotherapy to investigate the associations between CRP, trauma exposure, related variables, and PTSD and depression, as well as investigating if CRP was associated with PTSD psychotherapy treatment response. Bivariate correlation results indicate that CRP was significantly associated with BMI (r = 0.48) and severity of experiences of childhood physical and sexual abuse (r = 0.14 and 0.15, respectively) and was not significantly associated with baseline PTSD total symptom severity, PTSD symptom clusters, or depression symptom severity (rs ranging from -0.03 to 0.04). In multivariate regression models investigating if CRP and related variables were associated with PTSD baseline symptom severity, CRP was not a significant predictor (ß = -0.03). Hierarchical linear modeling did not identify CRP as a significant predictor of PTSD psychotherapy outcome. Given that findings indicate that CRP was broadly elevated in this treatment seeking sample but not associated with PTSD and depression symptom severity, results suggest CRP may not be a specific biomarker for PTSD or depression but may be elevated in psychiatric disease more generally.

Physical and Sexual Intimate Partner Aggression Among College Students: Examining the Roles of Cyber Intimate Partner Aggression and Alcohol Use.

Intimate partner aggression (IPA) is a serious and prevalent problem among college students. Two factors that may increase risk for in-person IPA are cyber IPA and alcohol use. This study examines the interaction between three types of cyber IPA (cyber psychological, stalking, and sexual IPA) and alcohol use in predicting in-person physical and sexual IPA perpetration. Participants were 268 undergraduate students, who participated in a mass screening at a large midwestern university. More than half of the sample reported perpetrating cyber IPA. A multivariate logistic regression model was used to examine study hypotheses. The R2 for physical IPA perpetration was .69 and the R2 for sexual IPA perpetration was .46. Cyber stalking IPA and alcohol interacted to predict physical IPA perpetration, such that the relationship between cyber stalking IPA and physical IPA perpetration was stronger among individuals who used more alcohol. Contrary to expectations, cyber IPA and alcohol did not interact to predict sexual IPA. However, consistent with hypotheses, cyber stalking IPA was positively associated with sexual IPA perpetration. The high prevalence of cyber IPA and its association with in-person IPA perpetration suggests that prevention programs targeting cyber IPA on college campuses may be warranted.

A Dyadic Analysis of PTSD and Psychological Partner Aggression Among U.S. Iraq and Afghanistan Veterans: The Impact of Gender and Dual-Veteran Couple Status.

Posttraumatic stress disorder (PTSD) symptoms have been repeatedly linked to intimate partner aggression (IPA), and previous research has suggested that this association may be stronger among veterans and men. However, few studies have examined veteran status and gender as moderators of the association between PTSD and psychological IPA, taking both partners' perspectives into account (i.e., within a dyadic framework). The current study aimed to address this limitation by using dyadic multilevel modeling to examine the association between PTSD symptoms and psychological IPA perpetration among a sample of 159 Operation Iraqi Freedom and Operation Enduring Freedom veterans and their partners (N = 318 participants). Findings revealed that both one's own and one's partner's PTSD symptoms were positively associated with greater psychological IPA. In addition, the effects of partner PTSD symptoms on psychological IPA perpetration differed across gender and veteran status. Results suggested that the association of partner PTSD and IPA perpetration may be stronger for male veterans than for female veterans. Findings from the current study are consistent with previous research showing associations between PTSD and IPA, and have clinical implications for treatment of PTSD and IPA among Operation Iraqi Freedom and Operation Enduring Freedom veterans.

Heterogeneity of posttraumatic stress symptomatology and social connectedness in treatment-seeking military veterans: a longitudinal examination.

Elucidating whether PTSD symptoms predict poorer social connectedness over time (i.e. social erosion) and/or that poor social connectedness contributes to maintenance of PTSD (i.e. social causation) has implications for PTSD treatment and relapse prevention. Most extant research has been cross-sectional and examined overall PTSD symptoms. Evidence of longitudinal associations among heterogeneous PTSD symptom clusters and social connectedness could provide insight into more nuanced targets for intervention. Using data from 1,491 U.S. military veterans in residential treatment for PTSD at 35 Department of Veterans Affairs facilities, we evaluated a two-wave cross-lagged panel model including a five-factor model of PTSD and two aspects of social connectedness. PTSD, quality of connectedness (i.e. degree of distress related to interpersonal conflict), and structural social support (i.e. number of days of contact with supportive loved ones) in the past 30 days were assessed at baseline and 4 months after discharge. The largest effect was greater severity of PTSD dysphoric arousal symptoms (i.e. irritability/anger, poor concentration, and sleep problems) at baseline predicting more conflict-related distress at follow-up (ß = 0.43). Post-hoc symptom-level analyses indicated that irritability/anger drove this association. In addition, conflict-related distress predicted greater PTSD symptom severity across all five clusters (ß's = 0.10 to 0.14, p's < 0.01). More days of contact predicted lower severity of avoidance and numbing symptoms (ß's = -.05 and -.07, p's < 0.01), along with individual symptoms within these clusters, plus flashbacks. Results support both social erosion and social causation models. Engaging loved ones in veterans' treatment and targeting dysphoric arousal symptoms, particularly anger and irritability, may improve long-term PTSD and relationship outcomes, respectively.

通过阐明PTSD症状是否预测随着时间推移社会联结性较差（即，社会退化模型）和/或社会联结较弱促进PTSD的维持（即，社会因果关系模型），以期对创伤后应激障碍治疗和复发预防提供建议。大多数现存的研究都是对PTSD整体症状的横断研究。提供异质PTSD症状簇与社会联结的纵向关联的证据可以为更细致的干预目标提供见解。利用美国退伍军人事务部35个部门的1491名美国退伍军人住院治疗PTSD的数据，我们评估了一个双波交叉滞后面板模型，包括PTSD的五因子模型和社会联结的两个因子。在进行评估基线和出院后4个月评估了PTSD，过去30天内的联结质量（即与人际冲突有关的痛苦程度）和结构性社会支持（即与支持性亲人接触的天数）。基线时更严重的PTSD焦虑唤醒症状（即烦躁/愤怒，注意力不集中和睡眠问题）预测随访时更多与冲突相关的痛苦具有最大的效应（r = 0.43）。事后症状水平分析表明，烦躁/愤怒主要推动了这种关联。此外，与冲突相关的痛苦预测所有五个PTSD症状簇更高严重程度（r's = 0.10至0.14，p <0.01）。更多的接触天数可预测回避和麻木症状的较低严重程度（r's = −.05和-.07，p <0.01），以及这些症状簇中的单个症状和闪回。研究结果支持社会退化和社会因果关系模型。让亲近的人参与退伍军人的治疗，并针对焦虑唤醒的症状（特别是愤怒和烦躁）可分别改善长期PTSD和关系结果。.

Feasibility and preliminary efficacy of dialectical behaviour therapy skills groups for Veterans with suicidal ideation: pilot.

BACKGROUND: Veterans are at high risk for suicide; emotion dysregulation may confer additional risk. Dialectical behaviour therapy (DBT) is a well-supported intervention for suicide attempt reduction in individuals with emotion dysregulation, but is complex and multi-component. The skills group component of DBT (DBT-SG) has been associated with reduced suicidal ideation and emotion dysregulation. DBT-SG for Veterans at risk for suicide has not been studied. AIMS: This study sought to evaluate the feasibility and acceptability of DBT-SG in Veterans and to gather preliminary evidence for its efficacy in reducing suicidal ideation and emotion dysregulation and increasing coping skills. METHOD: Veterans with suicidal ideation and emotion dysregulation (N = 17) enrolled in an uncontrolled pilot study of a 26-week DBT-SG as an adjunct to mental health care-as-usual. RESULTS: Veterans attended an average 66% of DBT-SG sessions. Both Veterans and their primary mental health providers believed DBT-SG promoted Veterans' use of coping skills to reduce suicide risk, and they were satisfied with the treatment. Paired sample t-tests comparing baseline scores with later scores indicated suicidal ideation and emotion dysregulation decreased at post-treatment (d = 1.88, 2.75, respectively) and stayed reduced at 3-month follow-up (d = 2.08, 2.59, respectively). Likewise, skillful coping increased at post-treatment (d = 0.85) and was maintained at follow-up (d = 0.91). CONCLUSIONS: An uncontrolled pilot study indicated DBT-SG was feasible, acceptable, and demonstrated potential efficacy in reducing suicidal ideation and emotion dysregulation among Veterans. A randomized controlled study of DBT-SG with Veterans at risk for suicide is warranted.

Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions.

Posttraumatic stress disorder (PTSD) is a chronic, often debilitating mental health disorder that may develop after a traumatic life event. Fortunately, effective psychological treatments for PTSD exist. In 2017, the Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) each published treatment guidelines for PTSD, which are a set of recommendations for providers who treat individuals with PTSD. The purpose of the current review article is to briefly review the methodology used in each set of 2017 guidelines and then discuss the psychological treatments of PTSD for adults that were strongly recommended by both sets of guidelines. Both guidelines strongly recommended use of Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and trauma-focused Cognitive Behavioral Therapy (CBT). Each of these treatments has a large evidence base and is trauma-focused, which means they directly address memories of the traumatic event or thoughts and feelings related to the traumatic event. Finally, we will discuss implications and future directions.

The Unique Roles of Emotional Numbing and Arousal Symptoms in Relation to Social Connectedness Among Military Veterans in Residential Treatment for PTSD.

OBJECTIVE: While poor social connectedness is often a consequence of living with posttraumatic stress disorder (PTSD) symptoms, little is known about whether PTSD symptom clusters may be uniquely related to different aspects of social connectedness. This information can inform case conceptualization and treatment planning to potentially facilitate sustained recovery for individuals with PTSD. METHOD: We examined associations among a five-factor model of PTSD and two aspects of social connectedness-distress related to problems getting along with others and days of contact with supportive loved ones in the past 30 days-in a sample of 2,600 U.S. military veterans seeking residential treatment for PTSD. RESULTS: A large proportion of veterans reported experiencing distress related to problems getting along with others (66.2%) and few days of contact with supportive people (43.5%). Ordinal regression models controlling for intercorrelations among PTSD symptom clusters revealed that emotional numbing symptoms were independently associated with greater distress (ß = 0.130, p < 0.001) and fewer days of contact (ß = -0.159, p < 0.001); dysphoric arousal symptoms were associated with more distress (ß = 0.236, p < 0.001), while anxious arousal was associated with more days of contact (ß = 0.058, p < 0.05). CONCLUSIONS: Findings reveal high rates of difficulties in social connectedness and distinct associations among these difficulties with emotional numbing, dysphoric arousal, and anxious arousal symptoms in veterans receiving residential treatment for PTSD. Future studies should examine whether targeting poor social connectedness during treatment improves interpersonal functioning and supports sustained trauma recovery, which may be particularly beneficial to veterans with more severe emotional numbing and dysphoric arousal symptoms.

Clinically Significant Change in Posttraumatic Stress Disorder Symptoms Is Associated With Lower Levels of Aggression After Residential Treatment Discharge.

Although the link between posttraumatic stress disorder (PTSD) and aggression has been repeatedly demonstrated, to our knowledge no research has examined whether PTSD symptom reductions are linked to less aggression after treatment. The current study aimed to address this gap in the literature by examining the association between reductions in PTSD symptoms and posttreatment aggression among 2,275 veterans in residential treatment for PTSD across 35 Veterans Health Administration sites. We estimated a multilevel model that examined the effect of clinically significant PTSD symptom change on aggression at 4-month posttreatment follow-up, and found significant within-site and between-site contextual effects of clinically significant changes in PTSD symptoms on follow-up aggression. Findings revealed that veterans who reported clinically significant changes in their PTSD symptoms had lower levels of aggression at follow-up than veterans at the same treatment site who did not report clinically significant PTSD change. After we controlled for individual clinically significant PTSD change, participants in treatment sites where the rates of clinically significant PTSD change were higher overall had lower levels of aggression at follow-up. The model explained over one-fourth of the variability in aggression, R2 = .26. Findings from the current study extend previous research that has shown associations between PTSD and aggression, by revealing that clinically significant change in PTSD during residential treatment is associated with less aggression at follow-up. These findings suggest that interventions that effectively reduce PTSD symptoms may also help reduce risk for aggression.

Alcohol Intoxication Moderates the Association between a Polygenic Risk Score and Unprovoked Intimate Partner Aggression.

Despite evidence that genetic variation contributes to aggression, few studies have examined how genetic variation contributes to IPA specifically. In the current study, 69 couples from a Midwestern university completed self-report measures of IPA, childhood trauma exposure, and hazardous alcohol use, and were randomly assigned to consume either a placebo or alcohol beverage before participating in an analogue aggression task against their partner. Genetic risk (i.e., association with lower transcriptional efficiency) for aggression was measured with a polygenic risk score (PRS) created from four polymorphisms (HTR1B rs13212041, HTR2B rs6437000, 5-HTTLPR, and MAOA uVNTR). Among individuals with a low PRS, individuals who consumed alcohol (BrAC = 0.07%) showed greater unprovoked IPA than individuals who consumed a placebo. Findings contribute to our limited understanding regarding the etiology of IPA and suggest that individuals who have increased transcriptional activity in certain serotonin system genes may be at higher risk of IPA when intoxicated.

An Overview of Internet- and Smartphone-Delivered Interventions for Alcohol and Substance Use Disorders.

Substance use disorders are a serious public health concern that affect approximately one in 12 individuals 12 years and older. Despite the high need for effective treatments for substance use disorders, the underutilization of services is well documented. One potential method of increasing access to care is through the use of technology. Treatment through the Internet or smartphone provides attractive solutions for those who are ambivalent to seeking treatment, because these treatments are easy to access from almost anywhere, self-paced, low commitment, and anonymous. The purpose of this review is to summarize the literature on Internet and smartphone interventions for substance use disorders that were developed on the basis of evidence-based treatments. The authors discuss these interventions within two broad categories: brief motivational or feedback-oriented interventions, which typically include one or two sessions, and longer interventions, which include multiple modules and are based on cognitive-behavior therapy, relapse prevention, contingency management, or a community reinforcement approach. These therapeutic adaptations through new technologies allow for increased access to substance use treatments and appear to yield overall positive results in adjusting norms about substance use, decreasing and ceasing substance use, and improving confidence to manage substance use.

The Cyber Aggression in Relationships Scale: A New Multidimensional Measure of Technology-Based Intimate Partner Aggression.

The purpose of this study was to develop and provide initial validation for a measure of adult cyber intimate partner aggression (IPA): the Cyber Aggression in Relationships Scale (CARS). Drawing on recent conceptual models of cyber IPA, items from previous research exploring general cyber aggression and cyber IPA were modified and new items were generated for inclusion in the CARS. Two samples of adults 18 years or older were recruited online. We used item factor analysis to test the factor structure, model fit, and invariance of the measure structure across women and men. Results confirmed that three-factor models for both perpetration and victimization demonstrated good model fit, and that, in general, the CARS measures partner cyber aggression similarly for women and men. The CARS also demonstrated validity through significant associations with in-person IPA, trait anger, and jealousy. Findings suggest the CARS is a useful tool for assessing cyber IPA in both research and clinical settings.

Oxytocin receptor gene polymorphisms, attachment, and PTSD: Results from the National Health and Resilience in Veterans Study.

The human oxytocin system is implicated in social behavior and stress recovery. Polymorphisms in the oxytocin receptor gene (OXTR) may interact with attachment style to predict stress-related psychopathology like posttraumatic stress disorder (PTSD). The objective of this study was to examine independent and interactive effects of the OXTR single nucleotide polymorphism (SNP) rs53576, which has been associated with stress reactivity, support-seeking, and PTSD in prior studies, and attachment style on risk for PTSD in a nationally representative sample of 2163 European-American (EA) U.S. military veterans who participated in two independent waves of the National Health and Resilience in Veterans Study (NHRVS). Results revealed that insecure attachment style [adjusted odds ratio (OR) = 4.29; p < 0.001] and the interaction of rs53576 and attachment style (OR = 2.58, p = 0.02) were associated with probable lifetime PTSD. Among individuals with the minor A allele, the prevalence of probable PTSD was significantly higher among those with an insecure attachment style (23.9%) than those with a secure attachment style (2.0%), equivalent to an adjusted OR of 10.7. We attempted to replicate these findings by utilizing dense marker data from a genome-wide association study of 2215 high-risk civilians; one OXTR variant, though not rs53576, was associated with PTSD. Exploratory analyses in the veteran sample revealed that the interaction between this variant and attachment style predicting probable PTSD approached statistical significance. Results indicate that polymorphisms in the OXTR gene and attachment style may contribute to vulnerability to PTSD in U.S. military veterans.

Co-occurring aggression and suicide attempt among veterans entering residential treatment for PTSD: The role of PTSD symptom clusters and alcohol misuse.

Aggression and suicidality are two serious public health concerns among U.S. veterans that can co-occur and share many overlapping risk factors. The current study aims to elucidate the contribution of posttraumatic stress disorder (PTSD) symptom clusters defined by a five-factor model and alcohol misuse in predicting aggression and suicide attempts among veterans entering residential treatment for PTSD. Participants were 2570 U.S. veterans across 35 Veterans Health Administration sites. Multinomial logistic regression models were used to identify correlates of aggression only (n = 1471; 57.2%), suicide attempts only (n = 41; 1.6%), co-occurring aggression and suicide attempts (n = 202; 7.9%), and neither behavior (n = 856; 33.3%) over the past four months. When compared to veterans endorsing neither behavior, greater PTSD re-experiencing symptoms were related to suicide attempts (odds ratio [OR] = 1.58, 95% confidence interval [CI] = 1.09-2.30), aggression (OR = 1.13, 95% CI = 1.02-1.26), and co-occurring aggression and suicide (OR = 1.38, 95% CI = 1.13-1.68), and higher PTSD dysphoric arousal symptoms and alcohol misuse symptoms were related to aggression (OR = 1.54, 95% CI = 1.38-1.71; OR = 1.30, 95% CI = 1.18-1.44, respectively) and co-occurring aggression and suicide (OR = 1.66, 95% CI = 1.35-2.04; OR = 1.50, 95% CI = 1.28-1.75, respectively). Our findings suggest that assessment of PTSD symptom clusters and alcohol misuse can potentially help to identify veterans who endorse suicide attempts, aggression, or both concurrently. These results have important implications for risk assessment and treatment planning with U.S. veterans seeking care for PTSD.