Nonsuicidal self-injury and interpersonal violence in U.S. veterans seeking help for posttraumatic stress disorder
Introduction
Nonsuicidal self-injury (NSSI) is defined as deliberately damaging one's body tissue without conscious suicidal intent (Chapman et al., 2006, Kimbrel et al., 2016, Kimbrel et al., 2015, Kimbrel et al., 2014). The most common methods of NSSI include self-burning, self-cutting, self-hitting, and severe scratching (Klonsky, 2011). It is estimated that 6% of the U.S. general population will engage in NSSI at some point in their lifetime (Briere and Gil, 1998, Klonsky, 2011). Although NSSI has historically been viewed as more common among females than males, population-based studies of NSSI have consistently failed to find evidence for sex differences in rates of NSSI among adults (Kimbrel et al., 2016). NSSI has been associated with significantly increased risk of suicidal behavior in military and veteran samples (Bryan et al., 2015, Kimbrel et al., 2016, Kimbrel et al., 2014). Further, high rates of NSSI have been found among treatment seeking, psychiatric populations of veterans (Bryan and Bryan, 2014, Kimbrel et al., 2016, Kimbrel et al., 2015, Kimbrel et al., 2014). Studies of treatment seeking male veterans with posttraumatic stress disorder (PTSD) have documented that as many as 57–66% have a lifetime history of NSSI (Kimbrel et al., 2016, Kimbrel et al., 2015, Kimbrel et al., 2014, Sacks et al., 2008). Although NSSI is a form of self-directed violence, it may also be associated with increased risk for interpersonal violence (Kleiman et al., 2015, Wolff et al., 2014), however, to date the association between NSSI and interpersonal violence has not been studied among veterans with PTSD.
PTSD has been shown to be associated with anger, aggressiveness, and interpersonal violence (Calhoun et al., 2002, Crawford et al., 2007). Help-seeking male veterans with PTSD are more likely to exhibit violence and report problems with violent behavior than help-seeking veterans without PTSD (Beckham et al., 1997, Elbogen et al., 2010b, Freeman and Roca, 2001). A recent study of U.S. Iraq and Afghanistan era veterans indicated that 67% reported that they had threatened someone or engaged in other types of aggressive behavior in the past month (Wright et al., 2012). Thus, it is critically important that the potential for aggression and violence in veterans with PTSD be systematically evaluated. Approaches to the assessment of violence potential in veterans have called for the application of empirically-supported models that examine dispositional factors (e.g., younger age), historical factors (e.g., combat exposure, past violent behavior), contextual factors (e.g., unemployment), and clinical factors such as PTSD, depression, and substance abuse (Elbogen et al., 2010a).
From this perspective, given that NSSI is associated with PTSD in veterans, which in turn has been shown to be related to elevated violence risk (Elbogen et al., 2010a), NSSI itself may be an important clinical factor to examine with respect to interpersonal violence. Indeed, several studies have indicated that NSSI is positively associated with aggression in adolescents in both community (Brunner et al., 2007, Fliege et al., 2009, Sourander et al., 2006) and psychiatric settings (Boxer, 2010, Vivona et al., 1995). To date, no studies have examined the association between NSSI and interpersonal violence in a veteran population.
The objective of the current study was to examine the association between NSSI and interpersonal violence in help-seeking male veterans with PTSD. We hypothesized that NSSI would be positively associated with aggression and reports of interpersonal violence. In order to examine whether NSSI might be an important clinical factor associated with identifying other-directed violence, the second objective of the present study was to examine whether NSSI was uniquely related to interpersonal violence after accounting for well-established dispositional, historical, contextual and clinical risk factors associated with violence including: age, race, marital status, unemployment, socioeconomic status (SES), combat exposure, PTSD symptom severity, depression, alcohol misuse, and reported difficulty controlling violence (Elbogen et al., 2010a). Given previous work documenting differential associations between NSSI and suicide as a function of NSSI severity ( Kimbrel et al., 2014), we explored potential differences in the association between NSSI and violence among those who engaged in less severe forms of NSSI (e.g., only scratching/picking) and more severe NSSI (e.g., cutting/hitting/burning oneself).
Section snippets
Participants and procedure
The study sample was drawn from an archival dataset that included 729 male, help-seeking veterans with PTSD who were evaluated at an outpatient Veterans Affairs (VA) specialty PTSD clinic from 2000 to 2014, who completed the measures described below. Veterans completed a structured clinical interview and a battery of self-report measures as part of their standard diagnostic procedure. PTSD diagnosis was based on the Clinician-Administered PTSD Scale [CAPS; (Blake et al., 1995)] following
Rates of NSSI and violence among help-seeking veterans
High levels of combat exposure and PTSD symptoms were present in the sample of male, help-seeking veterans with PTSD (see Table 1). Rates of violence were also highly prevalent in the sample. The majority of the sample of veterans with PTSD (64%, n=473) reported making violent threats at least once in the past year. Almost half of the sample (49%, n=355) reported engaging in minor violence (e.g., pushing, shoving, slapping someone). Forty-four percent (n=320) engaged in one or more forms of
Discussion
Consistent with other studies of veterans with PTSD (Calhoun et al., 2002, Elbogen et al., 2010a, Jakupcak et al., 2007, Wright et al., 2012), high rates of violence were found in the current sample. Results are comparable to data collected as part of the National Vietnam Veterans Readjustment Study (NVVRS) which found that Vietnam veterans with PTSD reported significantly higher levels of interpersonal violence than era veterans without PTSD (McFall et al., 1999). As hypothesized, the current
Acknowledgements
This work was supported in part by the VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center. Dr. Van Voorhees is supported by a VA Career Development Award from the Rehabilitation Research and Development Service of VA Office of Research and Development (ORD) (IK2RX001298). Dr. Beckham is supported by a VA Research Scientist Award from the Clinical Sciences Research and Development Service (CSR&D) of VA Office of Research and Development (ORD). Dr. Dedert is supported by a VA
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2023, Cognitive and Behavioral PracticeCitation Excerpt :In service members and veterans, lifetime prevalence estimates of NSSI range from 6% to 25% (Bryan & Bryan, 2014; Holliday et al., 2018; Kimbrel et al., 2015, 2016, 2018; Monteith et al., 2020; Villatte et al., 2015). As is common in the civilian population, rates of NSSI are higher in treatment-seeking samples of veterans (e.g., 50% lifetime prevalence for veterans seeking treatment for PTSD; Calhoun et al., 2017). Common methods of NSSI reported by service members and veterans include cutting/carving, hitting oneself, picking at one’s body, burning, inserting sharp objects, and scraping the skin (Bryan & Bryan, 2014).
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2022, Psychiatry ResearchCitation Excerpt :The finding that veterans with a history of NSSI engagement had significantly different clinical characteristics reflecting a pattern of more severe psychopathology, worse physical health, and more impaired psychosocial functioning is in line with previous research and reflects the high level of functional impairment and clinical severity in this clinical subgroup (Patel et al., 2021; Selby et al., 2012). Findings that NSSI engagement was associated with high risk for death by suicide, occurrence of suicidal behaviors, violent behavior, and substance misuse also replicates previous work (Calhoun et al., 2017; Ose et al., 2021; Victor and Klonsky, 2014). These clinical correlates with the potential for harm to self and others further underscore the importance of systematic screening for NSSI across healthcare settings.
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2021, Journal of Psychiatric ResearchCitation Excerpt :In another study Kimbrel et al. (2018) found 82% of treatment-seeking veterans with PTSD reported a lifetime history of NSSI and 64% engaged in NSSI in the past two weeks. Similar to the general population, NSSI is a relatively strong predictor of suicidal ideation and suicide attempts among veterans (Kimbrel et al., 2016; Villatte et al., 2015) and in one study NSSI was also a predictor of violence towards others (Calhoun et al., 2017). Given rising concerns regarding suicide in the veteran population (e.g., Hoge, 2019) and the association of NSSI with risk for injury and suicide, this behavior represents a targetable risk factor to prevent more dangerous behavior in veterans.
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2021, Journal of Affective DisordersCitation Excerpt :Both NSSI and DSH are extremely common, particularly among adolescent and young adults, reaching in this population a lifetime prevalence of 18% for NSSI and 16.1% for DSH (Muehlenkamp et al., 2012). Self-harm is a defining criteria for borderline personality disorder, but may also present among individuals with other disorders, without a psychiatric diagnosis or even with neurological conditions (Andrewes et al., 2018; Calhoun et al., 2017; Carroll et al., 2014; Cucchi et al., 2016; Esposito-Smythers et al., 2010; Grant et al., 2012; Huisman et al., 2017; Maddox et al., 2017; Mathews et al., 2004; Meszaros et al., 2017; Mori et al., 2006; Stanford and Jones, 2010). Overall, 70% of adolescents displaying NSSI reported at least one lifetime suicide attempt, while 55% reported multiple attempts (Nock et al., 2006).
Suicidal ideation, suicide attempt, and non-suicidal self-injury among female veterans: Prevalence, timing, and onset
2020, Journal of Affective DisordersCitation Excerpt :Interestingly, although prior research suggests that NSSI often begins in early adolescence (Nock, 2009), of the female veterans in our sample who reported experiencing NSSI, 48.2% indicated onset during their military service or following separation. The high occurrence of initial onset in adulthood may suggest the development of NSSI in response to stressful or traumatic experiences common among female veterans (e.g., military sexual trauma, interpersonal violence; Calhoun et al., 2017; Holliday et al., 2018). Indeed, NSSI can function as a coping behavior to escape intrusive thoughts or aversive emotional states following stressors and trauma (Smith et al., 2014).