Anger, hostility, and aggression among Iraq and Afghanistan war veterans reporting PTSD and subthreshold PTSD

Journal of Traumatic Stress, Vol. 20, No. 6, December 2007, pp. 945–954 ( C© 2007)

Anger, Hostility, and Aggression Among Iraq andAfghanistan War Veterans Reporting PTSD andSubthreshold PTSD

Matthew JakupcakVA Puget Sound Health Care System, Seattle, WA

Daniel Conybeare and Lori PhelpsVA Puget Sound Health Care System and Mental Illness Research, Education, and ClinicalCenter, Seattle, WA

Stephen HuntVA Puget Sound Health Care System, Seattle, WA

Hollie A. HolmesVA Puget Sound Health Care System and Mental Illness Research, Education, and ClinicalCenter, Seattle, WA

Bradford FelkerVA Puget Sound Health Care System, Seattle, WA

Michele Klevens and Miles E. McFallVA Puget Sound Health Care System and Mental Illness Research, Education, and ClinicalCenter, Seattle, WA

Iraq and Afghanistan War veterans were grouped by level of posttraumatic stress disorder (PTSD)symptomatology and compared on self-report measures of trait anger, hostility, and aggression. Veteranswho screened positive for PTSD reported significantly greater anger and hostility than those in thesubthreshold-PTSD and non-PTSD groups. Veterans in the subthreshold-PTSD group reported signifi-cantly greater anger and hostility than those in the non-PTSD group. The PTSD and subthreshold-PTSDgroups did not differ with respect to aggression, though both groups were significantly more likely to haveendorsed aggression than the non-PTSD group. These findings suggest that providers should screen foranger and aggression among Iraq and Afghanistan War veterans who exhibit symptoms of PTSD andincorporate relevant anger treatments into early intervention strategies.

A recent meta-analysis revealed a strong relationship

between PTSD and anger and PTSD and hostility among

trauma-exposed adults (Orth & Wieland, 2006). Larger

Correspondence concerning this article should be addressed to: Matthew Jakupcak (S116-MHC), Deployment Health Clinic, Seattle VA Medical Center, 1660 South Columbian Way,Seattle, WA 98108. E-mail: [email protected]

C© 2007 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20258

effect sizes were associated with combat exposure (com-

pared to other traumatic events) and a greater period of

time since trauma exposure. Among Vietnam veterans,

945

946 Jakupcak et al.

research has consistently found that levels of anger and

hostility are greater among veterans with PTSD com-

pared to veterans without PTSD (e.g., Beckham, Feldman,

Kirby, Hertzberg, & Moore, 1997; Castillo, Fallon, Baca,

Conforti, & Qualls, 2001; Frueh, Henning, Pellegrin, &

Chobot, 1997; Kubany, Gino, Denny, & Torigoe, 1994),

even after accounting for combat exposure, substance

abuse, or comorbid mental health disorders (Chemtob,

Hamada, Roitblat, & Muraoka, 1994; Lasko, Gurvtis,

Kuhne, Orr, & Pitman, 1994; Novaco & Chemtob, 2002).

Although anger is a diagnostic criterion for PTSD, re-

search indicates that the relationship between anger and

PTSD is not an artifact of measurement overlap. Post-

traumatic stress disorder symptom severity has been sig-

nificantly correlated with multiple measures of anger af-

ter anger items were removed from the PTSD measures

(Lasko et al., 1994; Novaco & Chemtob, 2002). In a study

with combat veterans, severity of anger symptoms at in-

take did not covary with changes in PTSD symptoms fol-

lowing treatment, unlike baseline measures of anxiety, de-

pression, and substance use (Forbes, Creamer, Hawthorne,

Allen, & McHugh, 2003). These findings prompted the

researchers to suggest that anger is independent from,

albeit related to, PTSD. The consistent relationship be-

tween anger and PTSD may exist because anger functions

to facilitate emotional disengagement (Foa, Skeketee, &

Rothbaum, 1989; Jaycox & Foa, 1996) and therefore may

play a role in the formation and maintenance of PTSD. In-

deed, higher initial anger levels predict later PTSD severity

(Andrews, Brewin, Rose, & Kirk, 2000; Feeny, Zoellner,

& Foa, 2000; Koenen, Stellman, Stellman, & Sommer,

2003; Riggs, Dancu, Gershuny, Greenberg, & Foa, 1992)

and poorer treatment outcome (Foa, Riggs, Massie, &

Yarczower, 1995; Forbes et al., 2003; Pitman et al., 1991;

Riggs et al., 1992; Taylor et al., 2001).

In addition to documenting the relationship between

PTSD and anger and between PTSD and hostility, nu-

merous studies have found that veterans with PTSD are

more likely to commit aggressive acts than veterans without

PTSD or the general public (e.g., Beckham et al., 1997;

Kulka et al., 1990; Lasko et al., 1994; McFall, Fontana,

Raskind, & Rosenheck, 1999). In one study, Vietnam

combat veterans with PTSD reported an average of 20

acts of violence in the past year compared to less than 1

act reported by combat veterans without PTSD (Beckham

et al., 1997). In another study, veterans receiving inpatient

PTSD treatment were approximately 7 times more likely

than non-PTSD veterans receiving inpatient psychiatric

care to have committed aggression in the 4 months prior

to treatment (McFall et al., 1999). There is also evidence

that veterans with PTSD are more prone than veterans

without PTSD to express hostility and physical aggression

within their intimate relationships (Carroll, Rueger, Foy,

& Donahoe, 1985; Glenn et al., 2002; Jordan et al., 1992).

Overall, there is strong agreement among veterans, spouses,

and clinicians that anger and aggressive behavior are major

concerns in the families of veterans with PTSD (Biddle,

Elliott, Creamer, Forbes, & Devilly, 2002; Calhoun et al.,

2002; Jordan et al., 1992).

Despite the consistent relationships found between

PTSD and anger, PTSD and hostility, and PTSD and

aggression, much of the extant research has focused on the

experiences of Vietnam combat veterans assessed decades

after their military service. With a growing number of

combat veterans returning from deployments in Iraq and

Afghanistan, additional research is needed to determine

whether these relationships exist among this new cohort.

Recent findings suggest high rates of post-deployment

mental health disorders, including symptoms of PTSD

experienced by approximately 10% to 20% of returning

servicemen and service women (Hoge et al., 2004; Hoge,

Terhakopian, Castro, Messer, & Engel, 2007; Vasterling

et al., 2006), along with significant PTSD-related impair-

ment in occupational functioning (Hoge et al., 2007).

Furthermore, many Iraq and Afghanistan veterans may

be suffering from subthreshold levels of PTSD. Previous

research has found that subthreshold levels of PTSD are as-

sociated with significant impairment (Mylle & Maes, 2004;

Stein, Walker, Hazen, & Forde, 1997; Weiss et al., 1992;

Zlotnick, Franklin, & Zimmerman, 2002) and may pre-

dict delayed onset PTSD (Carty, O’Donnell, & Creamer,

2006). Subthreshold levels of PTSD found in veterans

have been shown to be associated with physical and mental

health impairment, as well as limitations in occupational

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Anger and Aggression in Iraq and Afghanistan Veterans 947

and interpersonal functioning (Grubaugh et al., 2005;

Kulka et al., 1990; Schnurr, Friedman, & Rosenberg, 1993;

Weiss et al., 1992).

The current study sought to compare anger, hostility,

and aggression, based on level of PTSD symptomatology,

among treatment-seeking Iraq and Afghanistan War veter-

ans. A retrospective review was conducted of self-report re-

sponses to clinical intake questionnaires assessing problem-

atic alcohol use, combat exposure, PTSD, anger, hostility,

and aggression. It was predicted that veterans who screened

positive for PTSD would report significantly greater trait

anger and hostility, and be more likely to have reported ag-

gressive behavior than veterans reporting subthreshold and

nonclinical levels of PTSD. It was also predicted that the

veterans reporting subthreshold PTSD symptoms would

report greater trait anger and hostility, and be more likely

to have reported aggressive behavior than the non-PTSD

group.

M E T H O D

Participants

The sample for this retrospective review study was com-

prised of consecutive Iraq and Afghanistan War combat vet-

erans (N = 117), who presented with a variety of concerns

to the Deployment Health Clinic of the VA Puget Sound

Health Care System between May 2004 and June 2005.

The University of Washington Human Subjects Division

and the Veterans Administration Research and Develop-

ment Committee approved the protocol for this study.

Veterans who denied any combat exposure (n = 6) or who

were missing responses to study variables (n = 6) were not

included in the study.

The Deployment Health Clinic is structured to screen

for and provide both physical and mental healthcare ser-

vices to Iraq and Afghanistan War veterans within a primary

care setting. Because the nature of the referral to the clinic

was not assessed by the intake questionnaires, the reasons

for seeking treatment are not available.

Most of the participants were men (97%) and White

(71%), with a mean age of 32.7 (SD = 8.5) and 14.0

(SD = 2.3) years of education. Nearly one half of partici-

pants were married (49.6%), 34.8% single, and 13.0% di-

vorced. Approximately one quarter (23.4%) of the sample

reported a household income of $50,000 or more, 40.5%

between $25,000 and $50,000, and 34% below $25,000.

The majority (78.1%) reported serving in the Army or the

National Guard, and 69.8% reported they were on reserve

status when called to duty.

Measures

Combat exposure was assessed using the 10 items from

Laufer’s Combat Exposure Scale (Laufer, Gallops, & Frey-

Wouters, 1984) and 17 non-redundant items from the

Desert Storm Trauma Questionnaire (see Southwick et al.,

1993). On both surveys, respondents indicate (yes or no)

whether they were exposed to a number of stressful combat-

related events (e.g., witnessed injury or death, experienced

sniper fire), and a summary score is calculated by summing

the number of items positively endorsed. The Laufer Com-

bat Exposure Scale has demonstrated good psychometric

properties (Gallops, Laufer, & Yeager, 1981). Although no

published psychometrics were found for the Desert Storm

Trauma Questionnaire, the measure has been used to assess

trauma in Gulf War I veterans and has previously demon-

strated positive associations with PTSD symptom severity

(Southwick et al., 1993). In the current study, internal

consistency for the 27 items was good (α = .84).

Problem drinking was assessed using the Patient His-

tory Questionnaire (PHQ; Spitzer, Kroenke, & Williams,

1999), a self-report measure based on the clinician-

administered Primary Care Evaluation of Mental Disor-

ders (PRIME-MD; Spitzer et al., 1994). The PHQ in-

cludes five items that assess symptoms of alcohol abuse

by asking respondents to indicate whether they have en-

gaged in problematic behavior (e.g., drove an automobile

while intoxicated) or experienced negative outcomes asso-

ciated with alcohol consumption (e.g., failed to complete

daily responsibilities due to alcohol use). Prior research

suggests that the PHQ has good psychometric properties

and is an effective screening measure for psychiatric con-

ditions (Spitzer et al., 1999). In the current study, internal


948 Jakupcak et al.

consistency for the five PHQ alcohol items was adequate

(α = .59; see Nunnally, 1967).

Posttraumatic stress disorder symptoms were assessed

using the PTSD Checklist Military Version (PCL-M;

Weathers, Litz, Herman, Huska, & Keane, 1993), a 17-

item self-report instrument that asks respondents to rate

the degree to which they have been bothered by symptoms

of PTSD as defined by the Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition (DSM-IV ; American

Psychiatric Association, 1994) within the last month on a

5-point scale from 1 (not at all) to 5 (extremely). The in-

strument has demonstrated good psychometric properties

(Weathers et al., 1993), and previous research supports the

screening classification of PTSD in a combat veteran popu-

lation using a global cut-off score of 50 or greater (Forbes,

Creamer, & Biddle, 2001). The PCL-M scores ranging

from 35 to 49 were classified as subthreshold PTSD; those

who scored <35 were classified as non-PTSD (i.e., both-

ered no more than a little bit on any of the items). In

the current study, internal consistency for the PCL-M was

excellent (α = .97).

Anger was assessed using the Trait-Anger Scale (T-Anger

Scale; Spielberger, Jacobs, Russel, & Crane, 1983), a 10-

item subscale of the State-Trait Anger Expression Inventory

(Spielberger, 1988) that assesses an individual’s disposition

to experience anger. Respondents rate the degree to which

they react in an angry fashion from 1 (almost never) to

4 (almost always), and responses are summed for a global

score. The T-Anger Scale has been shown to have good

psychometric properties and there is good support for the

measure’s construct validity (Spielberger et al., 1983). In

the current study, internal consistency for the T-Anger

Scale was good (α = .90).

Hostility was assessed using the hostility subscale of the

Brief Symptom Inventory (BSI; Derogatis & Melisaratos,

1983), which asks respondents rate the degree to which

they engage in five hostile reactions on a 5-point scale from

0 (not at all) to 4 (extremely). Individual item scores are

averaged for a global score. Overall, the BSI has demon-

strated good psychometric properties, and there is good

support for the construct validity of the measure, includ-

ing the hostility subscale (Derogatis, 1993). In the current

study, internal consistency for the subscale was good (α =.88).

Aggression was measured using four items that have

been adapted from the National Vietnam Adjustment

Study (see McFall et al., 1999). Respondents indicate

whether they have engaged in behaviors including destroy-

ing property, threatening the use of violence (with and

without a weapon), or physically assaulting another per-

son. In the current study, internal consistency for the four

items was adequate (α = .65).

R E S U L T S

Preliminary Analyses

Based on PCL-M scores, 47 veterans screened positive for

PTSD (M = 63.9, SD = 8.0), 21 were classified as sub-

threshold PTSD (M = 42.7, SD = 4.6), and 49 were

classified as non-PTSD (M = 24.0, SD = 5.1). Scores

on measures of combat exposure, trait anger, and hostil-

ity were linearly and normally distributed. Mean combat

exposure scores for the PTSD, subthreshold-PTSD, and

non-PTSD groups were 13.4 (SD = 5.8), 13.0 (SD =5.1), and 8.9 (SD = 5.5), respectively. Problem drink-

ing and the summed aggression variables were significantly

positively skewed. Efforts to transform the distributions

of these variables were unsuccessful and therefore both

measures were treated as dichotomous variables (yes = 1,

no = 0; see Tabachnick & Fidell, 2001), based on whether

veterans endorsed at least one item on each measure. Over

one half of the veterans in the PTSD-group (53.2%) and

the subthreshold-PTSD group (52.4%) endorsed at least

one act of aggression in the past 4 months, compared to

20.4% in the non-PTSD group; the modal number of

aggressive acts for those who screened positive for aggres-

sion was one. Frequencies for specific aggressive acts are

presented in Table 1.

Combat exposure, problem drinking, and demographic

variables (age, race, education, and income) were examined

as potential covariates by computing their associations with

anger, hostility, and aggression. Age was significantly nega-

tively associated with the dichotomous aggression variable,



Table 1. Number of Veterans Reporting Specific Aggressive Acts

PTSD Subthreshold PTSD Non-PTSD(n = 47) (n = 21) (n = 49)

n % n % n %

Destroyed property 9 19.1 5 23.8 3 6.1Threatened physical violence (no weapon) 12 25.5 8 38.1 5 10.2Threatened someone with a weapon 1 2.1 3 14.3 2 4.1Had a physical fight with someone 8 17.0 2 9.5 2 4.1

Note. PTSD = Posttraumatic stress disorder.

r = −.19, p < .05, but was not significantly related to trait

anger, r = −.13, ns, or hostility, r = .08, ns. No other sig-

nificant associations emerged between demographic vari-

ables and anger, hostility, and aggression. Combat expo-

sure was significantly positively associated with trait anger,

r = .20, p < .05, and hostility, r = .18, p < .05, but was

not significantly related to aggression, r = .14, ns. Prob-

lem drinking was significantly positively associated with

trait anger, r = .27, p < .01, hostility, r = .25, p <

.01, and aggression, χ2(1, N = 117) = 5.85, p < .05.

Only covariates significantly associated with the respective

outcome variables were retained for further analyses (see

Tabachnick & Fidell, 2001).

Primary Analyses

The results of an analysis of covariance (ANCOVA) in-

dicated that, after accounting for combat exposure and

problem drinking, the PTSD group variable significantly

predicted differences in trait anger, F (2, 112) = 20.05,

p < .01, η2 = .26. Results of planned t-test analy-

ses indicated that the PTSD-group reported significantly

greater trait anger (M = 23.9, SD = 5.9) than both the

subthreshold-PTSD group (M = 19.1, SD = 6.6), t(66) =2.72, p < .01, and the non-PTSD group (M = 15.1, SD =4.6), t(94) = 7.61, p < .01. In addition, the subthreshold-

PTSD group reported significantly greater trait anger than

the non-PTSD group, t(68) = 2.90, p < .01.

The results of a second ANCOVA indicated that, after

accounting for combat exposure and problem drinking, the

PTSD group variable significantly predicted differences in

hostility, F (2, 112) = 42.80, p < .01, η2 = .43. Results

of planned t-test analyses indicated that the PTSD-group

reported significantly greater hostility (M = 2.4, SD = .9)

than both the subthreshold-PTSD group (M = 1.6, SD

= 1), t (66) = 3.24, p < .01, and the non-PTSD group

(M = .07, SD = .07), t (94) = 10.34, p < .01. In addi-

tion, the subthreshold-PTSD group reported significantly

greater hostility than the non-PTSD group, t (68) = 4.61,

p < .01.

A binomial logistic regression predicting aggression (yes

or no) was conducted in which age and problem drink-

ing were entered into the model as covariates at Step 1

and the PTSD group variable was entered into Step 2.

There was a significant main effect for PTSD group. As

shown in Table 2, veterans in the PTSD-group were more

likely than the veterans in the non-PTSD group to have

reported aggression. Veterans in the subthreshold-PTSD

group were also more likely than the veterans in the non-

PTSD group to have reported aggression. There was no

significant difference in aggression comparing the PTSD

and subthreshold-PTSD groups. To verify that findings

from the ANCOVA and logistical regression were not ar-

tifacts of the PCL-M anger-related item, all analyses were

rerun after omitting that item from the PTSD symptom

severity variable; the significance and magnitude of the

results did not change.

D I S C U S S I O N

Results from the current study confirm the hypothesis that

symptoms of PTSD are associated with anger, hostility,


950 Jakupcak et al.

Table 2. Results of a Binomial Logistic Regression of PTSD Group on Aggression (yes/no) Controllingfor Age and Problem Drinking (N = 117)

Variable Wald df Exp(B) 95% CI

Step 1 Age 2.33 1 0.96 .92–1.0Problem drinking 4.53* 1 0.38 .15–.93

Step 2 Age 2.02 1 0.95 .19–1.3Problem drinking 3.72* 1 0.50 .91–1.0PTSD group

1. PTSD vs. non-PTSD 8.81** 1 4.17 1.6–10.72. PTSD vs. Subthreshold <1 1 1.17 .40–3.53. Subthreshold vs. non-PTSD 7.12** 1 4.89 1.5–15.7

Note. PTSD = Posttraumatic stress disorder.*p < .05. **p < .01

and aggression among Iraq and Afghanistan War veter-

ans. Veterans who screened positive for PTSD reported

greater trait anger and hostility and were more likely to have

endorsed recent aggression than veterans who screened neg-

ative for PTSD. Likewise, veterans reporting subthreshold-

PSTD symptoms indicated greater trait anger and hostil-

ity and were more likely to endorse recent aggression than

the non-PTSD veterans. Although the PTSD-group re-

ported significantly greater trait anger and hostility than

the subthreshold-PTSD group, they were not more likely to

report aggression. The nature of the results did not change

after eliminating the anger item from the PTSD measure,

thus replicating previous findings (e.g., Lasko et al., 1994;

Novaco & Chemtob, 2002). This further supports the no-

tion that the relationship between anger and PTSD is not

a methodological artifact.

These results contribute to the research examining the

relationship between PTSD and anger among combat

veterans in two important ways. First, the strong asso-

ciations between PTSD and anger, hostility, and aggres-

sion have been consistently demonstrated among Vietnam

combat veterans, although assessment of these factors was

conducted decades following military service (Beckham,

Moore, & Reynolds, 2000). The current study suggests

that anger, hostility, and aggression associated with symp-

toms of PTSD are present in Iraq and Afghanistan War vet-

erans within the first few years after returning from combat

duty and that these associations are significant even after

accounting for other factors such as combat exposure and

problem drinking. As such, early intervention may be par-

ticularly important in this population given that rates and

severity of PTSD may increase over time (Gray, Bolton,

& Litz, 2004; Southwick et al., 1995; Wolfe, Erickson,

Sharkansky, King, & King, 1999), along with the strength

of the relationship between PTSD and anger (Orth &

Wieland, 2006).

Second, this study confirms previous research indicat-

ing that subthreshold-PTSD is associated with clinically

significant impairment among treatment-seeking Vietnam

veterans (Grubagh et al., 2005) and community members

from an epidemiological sample (Stein et al., 1997). In the

current study, veterans with subthreshold levels of PTSD

symptoms had greater anger and hostility than veterans

without PTSD and were just as likely to have endorsed ag-

gression as were veterans who screened positive for PTSD.

Although rates of PTSD among soldiers serving in the Iraq

and Afghanistan Wars have been estimated to range from

10% to 20% (Hoge et al., 2004; Vasterling et al., 2006), an

additional percentage of returning soldiers are likely experi-

encing subthreshold levels of PTSD symptoms, which may

contribute to difficulties with anger and aggression. Clin-

icians may underestimate the impairment associated with

subthreshold levels of symptoms and subthreshold-PTSD

veterans may be less likely to seek mental health services

than those with PTSD (Grubaugh et al., 2005). This has

important implications for the Department of Veterans

Affairs and community health care providers, underscor-

ing the need to screen for symptoms of PTSD in settings



such as primary care clinics (Ramaswamy et al., 2005)

and to encourage the use of appropriate mental health

services.

Results from the current study should be considered in

light of certain limitations. First, given the nature of the

clinic from which the sample was drawn, we cannot infer

whether veterans experiencing PTSD symptoms initially

presented for medical concerns or were seeking treatment

for mental health issues. This makes it difficult to choose

relevant norms for comparing levels of self-reported PTSD,

anger, hostility, and aggression. For example, trait anger

scores among the PTSD and subthreshold-PTSD groups

in the current study were lower than those reported by

Vietnam combat veterans receiving outpatient PTSD treat-

ment (Lasko et al., 1994), and rates of aggression among

the PTSD and subthreshold-PTSD groups were lower than

those reported by Vietnam combat veterans seeking inpa-

tient PTSD treatment (McFall et al., 1999). However, di-

rect comparisons between the current sample and previous

samples are problematic without knowing why the current

sample presented to the clinic. Second, the current study

relied on self-report methodology to assess level of PTSD

symptoms, although there are more detailed ways in which

to assess subthreshold levels of PTSD (see Mylle & Maes,

2004). In addition, although the PCL-M has demonstrated

good sensitivity and specificity for detecting PTSD based

on structured clinical interviews (Forbes et al., 2001), other

factors that may influence self-report of symptom severity

were not assessed and therefore may have influenced results.

For example, efforts to seek disability and compensation

for PTSD were not considered, although these factors have

been associated with inflated reports of symptom severity

among veterans (Gold & Frueh, 1999). In addition, med-

ical factors that may impact anger or aggression were not

assessed, such as traumatic brain injury, the incidence of

which is estimated to be prominent during military ser-

vice in Iraq (Warden, 2006). Finally, the cross-sectional

design of the current study makes it problematic to infer

causality among the relationships between anger, hostility,

aggression, and PTSD.

Prior research also has concluded that anger is an im-

portant symptom to address among Vietnam veterans with

PTSD (Frueh et al., 1997; Koenen et al., 2003; McFall

et al., 1999). The results of the current study suggest that

introducing anger management skills should also be a pri-

ority in treating Iraq and Afghanistan War veterans with

symptoms of PTSD. There is preliminary support for a

brief four-session cognitive–behavioral anger management

intervention among active duty military personnel, al-

though attrition rates as high as 50% were noted (Linkh &

Sonnek, 2003). In addition, anger management skills train-

ing has been found to improve anger control among Viet-

nam combat veterans with PTSD (see Chemtob, Novaco,

Hamada, & Gross, 1997). Future research should inves-

tigate the effectiveness of these approaches with this new

population of veterans, along with potential differential

treatment outcome based on level of PTSD symptoma-

tology. Research also should be devoted to examining

possible factors that predict whether veterans will be at

risk for experiencing subthreshold versus diagnostic levels

of PTSD symptoms following combat. Level of combat

exposure did not distinguish between veterans reporting

subthreshold-PTSD and PTSD in the current study; how-

ever, other factors may include pre-existing trauma expo-

sure (see Donovan, Padin-Rivera, Dowd, & Blake, 1996)

or intelligence level (see Macklin et al., 1998).

It would also be helpful to examine whether results from

the current study apply to female and minority veterans.

One prior study examined the relationship between PTSD

and hostility among female veterans and found that those

with PTSD reported significantly higher levels of hostility

than those without PTSD (Butterfield, Forneris, Feldman,

& Beckham, 2000), but more attention to this population

is needed as an increasing number of women are serving

in combat-related roles in the military. In addition, several

studies have indicated that minority veterans experience

a more negative course of PTSD than do White veter-

ans (Koenen et al., 2003; Kulka et al., 1990), although

racial differences specific to PTSD-related anger have not

been explored. Prospective research using structured assess-

ment interviews and larger, more diverse samples of Iraq

and Afghanistan War veterans is needed to replicate these

findings and to explore interactive effects that might exist

between PTSD and other factors.


952 Jakupcak et al.

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Documents

Anger, hostility, and aggression among Iraq and Afghanistan war veterans reporting PTSD and subthreshold PTSD