Elsevier

Psychiatry Research

Volume 247, January 2017, Pages 250-256
Psychiatry Research

Nonsuicidal self-injury and interpersonal violence in U.S. veterans seeking help for posttraumatic stress disorder

https://doi.org/10.1016/j.psychres.2016.11.032Get rights and content

Highlights

  • Veterans with PTSD are at increased risk for engaging in other-directed violence.

  • Nonsuicidal self-injury (NSSI) is a form of self-directed violence.

  • This study examined NSSI and interpersonal violence in 729 veterans with PTSD.

  • NSSI predicted violence after accounting for well-known violence risk factors.

  • Clinicians should assess NSSI when conducting risk assessments for violence as well as suicide.

Abstract

Nonsuicidal self-injury (NSSI) has been defined as deliberately damaging one's body tissue without conscious suicidal intent. NSSI is a robust predictor of suicidal ideation and attempts in adults. While NSSI has been associated with other-directed violence in adolescent populations, the link between NSSI and interpersonal violence in adults is less clear. The current study examined the cross-sectional relationship between NSSI and past-year interpersonal violence among 729 help-seeking veterans with posttraumatic stress disorder (PTSD). Veterans who reported a recent history of engaging in cutting, hitting, or burning themselves were significantly more likely to report making violent threats and engaging in violent acts, including the use of a knife or gun, in the past year than veterans without NSSI. NSSI was uniquely associated with interpersonal violence after controlling for a variety of dispositional, historical, contextual, and clinical risk factors for violence, including age, race, socio-economic status, marital status, employment status, combat exposure, alcohol misuse, depression, PTSD symptom severity, and reported difficulty controlling violence. These findings suggest that clinicians working with veterans with PTSD should review NSSI history when conducting a risk assessment of violence.

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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