Violence in War and Violence Back Home

War is the most violent of human endeavors, and the conflicts in Iraq and Afghanistan have been no exception. Killing the enemy while preserving one’s own life and the lives of one’s comrades is the warrior’s foremost and omnipresent goal. In preparation for combat, service members are rigorously trained to become highly proficient in the multiple techniques of deadly force. Eliminating a perceived threat with maximum violence and speed becomes a rapid reflexive response that becomes stronger with repeated combat deployments. Yet when our service members return home, the violent elimination of a perceived threat, which was essential and even heroic in the combat environment, is now a criminal act, and the hyperarousal that was often key to life-saving instantaneous recognition of hidden improvised explosive devices and ambushes “downrange” is now maladaptive and psychopathologic.

That the majority of our returned warriors are able to adjust to the often stressful demands of family, work, and community in civilian life without violent behavior is a testament to the character and resilience of the American service member. Within the incarcerated population, the calculated violent offender rate for veterans (338 prisoners per 100,000 veterans) is actually substantially lower than for nonveterans (595 prisoners per 100,000 nonveterans) (1). Yet many combat veterans are involved in one or more episodes of domestic or community interpersonal violence (2, 3). In this issue, Elbogen and colleagues (4) demonstrate the validity of a brief violence risk assessment tool that utilizes empirically derived questions designed specifically for military veterans. The instrument, the Violence Screening and Assessment of Needs (VIO-SCAN), queries for the presence of five factors associated with interpersonal violence in veterans: financial instability, combat experience (personally witnessed someone being seriously wounded or killed), alcohol misuse, history of violence or arrests, and probable posttraumatic stress disorder (PTSD) with frequent anger outbursts (5–7). The tool was administered at baseline, and data on violent behaviors were collected 1 year later in each of two veteran samples returned from combat deployments to Afghanistan or Iraq. The first was a large random sample of 1,388 veterans from the National Post-Deployment Adjustment Survey of over 1 million Afghanistan and Iraq war veterans. The second was a self-selected sample of dyads consisting of veterans plus a family member or friend serving as a collateral informant, both of whom were evaluated in depth at the Durham VA Medical Center. In both samples, each baseline risk item was associated significantly with violence during the follow-up, and associations with severe violence during follow-up increased in a stepwise manner with the number of risk factors present at baseline.

The VIO-SCAN is valuable in and of itself because it prompts the health care provider to inquire about a veteran’s history of violent behavior. Crucial to treating any problem is recognizing its existence and defining its risk factors. The VIO-SCAN alerts the clinician to three violence risk factors that, if present, are potentially modifiable: probable PTSD with anger outbursts, alcohol misuse, and financial instability. The word “potentially” is important in this context because effective approaches to reduction of each of these risk factors are a challenge. To our knowledge, there are no specific psychiatric or behavioral medicine treatments clearly demonstrated to be effective for violent behavior. Below, we focus on approaches to PTSD low anger threshold and provide some thoughts on financial instability and the stigma associated with soldiers and veterans seeking help. The complex issue of a personalized medicine approach to alcohol misuse has been discussed elsewhere (8).

Among the modifiable violence risk factors, PTSD low anger threshold may be the most approachable. PTSD irritability and low anger threshold are manifestations of hyperarousal. At a neurobiologic level, excessive brain noradrenergic activity contributes to hyperarousal. Therefore, drugs that reduce the noradrenergic contribution to hyperarousal are reasonable candidates for PTSD anger reduction. One such drug, the alpha-1 adrenoreceptor antagonist prazosin, has been demonstrated to be effective for PTSD hyperarousal symptoms (including irritability and anger) in U.S. combat veterans. In a randomized clinical trial of 57 combat-experienced active-duty soldiers returned from Iraq and Afghanistan (9), prazosin was found to be effective for the PTSD hyperarousal symptom cluster as well as for reducing trauma nightmares and improving sleep. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been shown in randomized clinical trials to reduce PTSD hyperarousal symptoms in civilian samples, although this has not been demonstrated empirically in U.S. combat veterans. Psychotherapeutic approaches directed at anger episode reduction may be helpful for veterans with PTSD. Results from small pilot studies of cognitive-behavioral therapy-based anger treatment in Vietnam veterans with PTSD and aggression (10) and in Iraq and Afghanistan veterans (11) are encouraging. The latter study was superior in its use of randomization and a convincing comparison condition, but only 25% of veteran participants had PTSD.

An alternative psychotherapeutic approach to reduction of PTSD low anger threshold and aggression is based on several studies demonstrating that experiential avoidance and suppression of angry emotions may increase domestic violence and other interpersonal aggressive acts in veterans returned from Iraq and Afghanistan (12, 13). These findings suggest that acceptance and mindfulness-based treatments that nonjudgmentally reinforce a willingness to experience emotional distress may be useful in reducing the risk of violence in veterans. Optimum treatment for PTSD low anger threshold will likely combine effective pharmacotherapy and psychotherapy, but more studies are needed to define which therapies or combinations of therapies are effective for a given individual.

Addressing financial instability in any population is difficult. When a veteran has survived a harsh, grueling, and dangerous combat deployment, he or she may decide to “live for the moment” with purchases that exceed income and assets. Such unfortunately common veterans’ issues as attorney fees and child support payments following divorce, as well as the financial costs of infractions such as driving under the influence and domestic violence, place some veterans in severe financial distress. Potential strategies to reduce this risk factor include increasing the availability of marital counseling and support, veterans’ courts, and low-cost legal advice, as well as education on the dangers of high-interest credit card balances and “payday loan” short-term credit for returned veterans.

Two other factors make the task of reducing veterans’ risk factors for violence even more challenging. The first is the high incidence among Iraq and Afghanistan veterans of blast and blunt-force traumatic brain injuries (TBIs) comorbid with PTSD. Even the common repetitive “mild” TBIs from repeated concussions produce troublesome, persistent postconcussive symptoms. Neuroimaging studies in veterans with multiple mild TBIs demonstrate persistent subtle brain dysfunction years after return from deployment (14). Lowered impulse control and chronic migraine headaches are persistent postconcussive symptoms that may further lower the threshold for violent behavior.

We must also continue to reduce the stigma associated with soldiers and veterans seeking help from mental health providers (15). The credo of self-reliance that is essential on the battlefield works against admitting the presence of a behavioral problem. Moreover, admitting and seeking treatment for behavioral problems is often seen as “career suicide” by commissioned and noncommissioned officers for whom the military is a long-term career. The more our most accomplished active-duty and veteran war fighters publicly acknowledge that they have benefited from assistance with PTSD anger symptoms, alcohol misuse (as a means of self-medication), and other violence risk factors, the more other soldiers and veterans will be willing to seek help for their own problems. Seeking such help should be described in military parlance as a critical part of their mission to provide for their families, their communities, and themselves.