U.S. Public Health Service Capt. Janet Hawkins, Deployment Health Clinical Center on August 29, 2013
U.S. Marine Corps photo by Cpl. Matthew Callahan
Capt. Janet Hawkins is a violence prevention subject matter expert at the Deployment Health Clinical Center. She specializes in posttraumatic stress disorder and interpersonal violence prevention in military populations.
In support of PTSD Awareness Month in June, I was invited to speak at the 2013 Family Advocacy Training Course in Quantico, Va., on the relationship between posttraumatic stress disorder (PTSD) and interpersonal violence. I shared findings from the July 2012 Institute of Medicine report, “Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment,” which examined PTSD treatment programs and services at the Defense Department and Department of Veterans Affairs, and served as a basis for discussing the relationship between the clinical disorder and interpersonal violence. More than 40 Marine Corps leaders attended the annual violence prevention training, including installation sergeant majors, behavioral health managers and family advocacy managers.
From the meeting it was clear that the relationship between PTSD and interpersonal violence is not well understood. Here are some insights to that relationship.
The Institute of Medicine report found that of the 2.6 million service members deployed to Iraq and Afghanistan since 2001, an estimated 13 to 20 percent may have PTSD. PTSD is triggered by exposure to one or more traumatic events, including combat situations and sexual violence, and is characterized by the following symptom clusters:
- Intrusion: Re-experiencing the event through intrusive memories, nightmares, or flashbacks; physiologic reactivity or distress in reaction to trauma-related stimuli
- Avoidance: Avoiding trauma-related thoughts, feelings, or external reminders such as situations, people, places, objects or conversations
- Alterations in cognitions and mood: Inability to remember important aspects of the event; negative beliefs and expectations about oneself and others; reduced interest in activities; feelings of detachment; trauma-related anger, guilt, or shame; or persistent inability to experience positive emotions
- Alterations in arousal and reactivity: Hypervigilance; irritability or aggression; difficulty falling or staying asleep; exaggerated startle response; reckless or destructive behavior; or problems with concentration
While most veterans with PTSD don’t engage in interpersonal violence, current research shows that some combat veterans with the disorder are at greater risk of violent acts than those without it. One recent study found that persistent anger predicted aggression and severe violence against family members, and frequency of flashbacks predicted aggression and severe violence against strangers. Additionally, specific risk factors related to military deployments associated with interpersonal violence among Iraq and Afghanistan combat veterans are being studied. More research is needed to better understand the unique and complex roles that other conditions such as alcohol misuse/abuse and traumatic brain injury play in family violence among combat veterans with PTSD.
How PTSD and Interpersonal Violence Relate
Individuals coping with the disorder can face challenges in maintaining healthy relationships, particularly with family members. So, it’s critical that providers counsel these individuals on the relationship between PTSD and interpersonal violence. Spouses and other family members not aware of or knowledgeable about the disorder may also be unaware of how symptoms can contribute to or escalate family conflict. Some symptoms, such as hypervigilance, depressed mood, detachment and avoidance can interfere with establishing and maintaining intimacy, harmony and commitment in relationships. Characteristic behaviors of interpersonal violence include:
- Physical/sexual assault
- Coercion and threats
- Emotional abuse
- Use of isolation
It’s important to note that a PTSD diagnosis doesn’t excuse an act of interpersonal violence. Rather, individuals with mental health concerns may require additional assessment to determine if interpersonal violence intervention is needed. Service members with PTSD may need additional social support and help reducing sources of chronic stress, such as financial difficulties. Such factors are associated with better mental health outcomes and overall family functioning.
Various resources exist within the Defense Department and Department of Veterans Affairs to help service members and veterans cope with psychological health concerns and family violence issues. Some key patient resources for providers to be aware of include:
- “Strength at Home” is a promising, fairly new intervention designed to prevent conflict and violence in military couples. The program emphasizes strengthening relationships for veterans, service members and their families who are struggling with anger and readjustment after a deployment.
- The DCoE Outreach Center provides 24/7 assistance by phone at 866-966-1020, live online chat or email at email@example.com.
- Military OneSource (800-342-9647) provides support to all branches of the military and offers direct access to medical professionals through face-to-face, online, email and phone sessions.
- Afterdeployment.org offers online, confidential assessments on common post-deployment issues such as post-traumatic stress, sleep disorders, depression, anger, resilience and work adjustment for military members and their families.
- Military Pathways is an online voluntary, anonymous mental health and alcohol education screening program for military members and their families.
- The Real Warriors Campaign website shares information about tools and resources available for psychological health care and support via informative articles, stories of real service members, message boards and more.
Find more information and resources at the National Center for PTSD website. The site includes a section for military members who have experienced trauma, or family members and friends who know someone who has. It also includes information for health care professionals.
You can also download the presentation, audio podcast and resources from the June DCoE webinar, which discussed the increased risk of violence in military veterans.