By: Joshua Camins
One of the most commonly discussed sequalae of stressful deployment experiences is posttraumatic stress disorder (PTSD). Estimates of military service-connected PTSD range from 8.1% to 23% with the rates varying by conflict at time of service (Fulton et al., 2015; Gradus, 2017). Over the last two decades, there have been many instances in which post-deployment veterans have demonstrated violence. Although not all of these individuals have a diagnosis of PTSD, these instances often evoke sensationalized connections between PTSD and violence (e.g., Lamothe, 2015).Given the number of veterans impacted by PTSD, the relationship between military PTSD and violence warrants exploration. This article reviews the relationships between PTSD and criminal offending, a PTSD diagnosis and violence/aggression, and PTSD symptom clusters and violence/aggression. This information is particularly relevant in the context of understanding best practices for violence risk assessment with veterans.
PSTD and Criminal Offending
Data from the Bureau of Justice Statistics indicates that 1 in 35 adults in the U.S., approximately 2.8% of the population, are involved with the legal system (Kaeble & Glaze, 2014). Current estimates suggestapproximately 8% of all inmates in U.S. jails and prisons are military veterans (Bronson, Carson, Noonan, & Berzofsky, 2015). Although rates of veteran incarceration are proportionally lower than civilian counterparts (May, Stives, Wells, & Wood, 2016), understanding what influences veteran offending is crucial for detection and prevention. The rates and type of offending in veterans varies based on era of service. For example, relative to veterans from other eras, Operation Enduring Freedom (OEF)/Operation Iraq Freedom (OIF)/Operation New Dawn (OND) veterans appear to be incarcerated at a lower rate (Tsai, Rosenheck, Kasprow, & McGuire, 2013). A plethora of research has explored predictors of criminal justice involvement in civilians, including the utility of PTSD and other mental health related issues. One study found aPTSD diagnosis was associated with 1.4 times higher odds of criminal recidivism in civilians (Sadeh & McNiel, 2015). Data suggests veteran offenders from the most recent conflict eras (i.e., OEF/OIF/OND) are three times more likely to have a combat-related diagnosis of PTSD (Tsai, Rosenheck, Kasprow, & McGuire, 2013).
Findings from Elbogen and colleagues’ (2012a) study suggest 9% of recent conflict veterans had been arrested since returning from deployment. PTSD in combination with high irritability was predictive of post-deployment arrest (Elbogen et al., 2012a). Despite consistent findings in veterans, research with active duty servicemembers is mixed. Findings from a large-scale study on predictors of minor violent crime perpetration in military servicemembers suggest that although outpatient use of services for mental health, martial, or stressor-related problems predict contact, specific diagnoses (i.e., PTSD) were not in the final model (Rosellini et al., 2017). In contrast, a stress-related disorder was predictive of major violence in male servicemembers only (Rosellini et al., 2016). Although inconsistent with veteran samples, these findings suggest problematic symptoms may not emerge until later. Thus, although PTSD may be relevant, individuals with clinically significant PTSD may either be medically discharged, or not experience distress until after service.
PTSD and Aggression
There is consistent evidence that PTSD symptoms are associated with increased expressions of anger and aggressive behavior in veterans (Elbogen, Johnson, & Beckham, 2011; Blongien et al., 2016). The relationship between PTSD and intimate partner violence is also well established in the literature (Elbogen et al., 2010). In a study by Elbogen and colleagues (2012b), 33% of the veteran sample reported at least one act of violence or aggression in the community as measured by endorsement of specific items on the Conflict Tactics Scale (e.g., “beat up another other person”) or MacArthur Community Violence Scale (e.g., “threaten anyone with a gun or knife”). The authors determined that a probable diagnosis of PTSD yielded higher odds of severe violence or physical aggression (Elbogen et al., 2012b). However, multiple studies have suggested intermediate factors may account for the relationship. In one study, after controlling for the co-occurrence of alcohol use or anger, the impact of a PTSD diagnosis on the prediction of violent behavior was non-significant (Blakey, Love, Linquist, Beckham, & Elbogen, 2017).
The interaction between substance use and PTSD is consistent across the studies reviewed (e.g., Blonigen et al., 2016). Data collected from a multi-wave study indicate there was no significant difference in seriousviolence perpetration between veterans diagnosed with PTSD without co-occurring alcohol use problems and veterans without a PTSD diagnosis or problematic alcohol use; however, there perpetration of less severe aggression was more common in veterans with PTSD (Elbogen et al., 2014). Other factors that have been identified as possibly playing an intermediate role include hostility (Sippel et al., 2016), impulsivity (Heinz et al., 2015), and anger (Novaco & Chemtob, 2015). For example, Wilk and Colleagues (2015) found a connection between PTSD and aggression at high levels of trait anger but not at low levels of trait anger (Wilk et al., 2015).
PTSD Symptoms and Aggression
To better understand PTSD and aggression, researchers have explored the relationship between PSTD symptom clusters and aggression. Van Voorhees and colleagues (2016) observed that all three DSM-IV-TR PTSD symptom clusters were equally predictive of aggression in a longitudinal sample. However, cross-sectional analysis identified the hyperarousal cluster as increasing odds of aggression. The authors also identified hostility as a mechanism impacting the relationship between PTSD status and physical aggression. Specifically, hostility increased risk of aggression.
The hyperarousal cluster is consistently associated with increased trait anger, aggression, and violence (Elbogen et al., 2010; Elbogen et al., 2011). Although the association may be exacerbated by veteran substance use (Elbogen et al., 2010), there is ample evidence to support this assertion (e.g., Donley et al., 2012; Makin-Byrd et al., 2012; Van Voorhees et al., 2016). In contrast, elevations in the avoidance/numbing cluster appear to be predictive of violence in some, but not all samples (Elbogen et al., 2010). In a different study examining specific PTSD symptoms, although anger symptoms predicted family violence, symptoms associated with flashbacks, being on guard, numb, or physically upset were not predictive (Sullivan & Elbogen, 2014). Within the same framework, the authors observed violence towards strangers was predicted by flashbacks but not anger symptoms, being on guard, numb, or physically upset (Sullivan & Elbogen, 2014).
Although PTSD represents one risk factor that is correlated with criminal behaviors, aggression, and violence, the literature does not elucidate a causal relationship. Rather, the available data suggest other factors (e.g., substance use or trait anger) may strengthen or weaken the relationship between PTSD and criminal offending, aggression, and violence. Regardless, the potential impact of PTSD on the lives of servicemembers is substantial. In making decisions about PTSD and potential dangerousness, it is imperative that careful assessment be conducted (Elbogen et al., 2010). Although a diagnosis of PTSD or PTSD symptoms may increase the likelihood of violence, factors such as substance use and trait anger also impact potential dangerousness and should be considered in evaluating risk (Elbogen et al., 2010). The use of violence risk instruments and an in-depth clinical interview will help elucidate patient-specific risk factors (Elbogen et al., 2010; Elbogen et al., 2014). Ultimately, psychological and, if necessary, crime-reducing t treatments (e.g., Moral Reconation Therapy) should be administered only after considering all potential risk factors for criminal offending and violence, not just the presence or absence of PTSD (Timko et al., 2014).
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Joshua Camins is a fifth-year doctoral student at Sam Houston State University in Huntsville, Texas. He conducts research at the intersection of forensic and military psychology. In addition to research, he is involved in a variety of clinical activities including trauma treatment with veterans, forensic evaluations in a state hospital, and psychotherapy with psychiatric patients.