Little is known about factors associated with risk of post-deployment anger and hostility in Iraq and Afghanistan veterans. This study provides a step toward understanding broad categories of factors that may be implicated. The results indicate that several factors related to anger and hostility in veterans from previous conflicts—witnessing of family violence, history of abuse, and combat exposure (15
)—had a modest empirical association in Iraq and Afghanistan veterans with at least some facets of anger and hostility measured. Analyses also indicated that PTSD reexperiencing symptoms and avoidance and numbing symptoms were not consistently associated with anger and hostility but that hyperarousal symptoms were significantly related to all three measures of anger and hostility analyzed. The latter result is consistent with research finding a link between PTSD hyperarousal symptoms and aggression in Vietnam veterans (17
). Thus, clinicians treating Iraq and Afghanistan veterans should be aware that hyperarousal symptoms of PTSD may constitute one of the more important clinical symptom clusters to investigate in those with hostility and anger on return to civilian life.
Our data also suggest that the effects of traumatic brain injury and alcohol misuse on anger and hostility are not straightforward; significant bivariate associations between traumatic brain injury and alcohol misuse and the anger and hostility measures were not retained in multivariate analyses. Alcohol misuse has been statistically associated with anger and hostility in veterans from previous conflicts (22
). Head injury has been speculated to increase the risk of aggression in Iraq and Afghanistan veterans; in December 2008, the Institute of Medicine released a report requested by the VA documenting long-term health consequences of traumatic brain injury, including violence, in Gulf War veterans (37
). However, research has not always confirmed direct effects of these factors in veterans; for instance, studies have shown that alcohol abuse mediates the relationship between PTSD and aggression (20
) and PTSD may be related to anger and hostility only when heavy drinking is involved (17
). Similarly, brain injury has been found to be related to aggression in veterans when combined with certain cognitive deficits (23
). In the present study, PTSD symptoms had considerable overlap with both traumatic brain injury and probable alcohol misuse, raising an interesting question: Might PTSD coupled with traumatic brain injury, or PTSD in conjunction with alcohol abuse, have unique additive effects on aggressiveness or anger and hostility? Future research should examine two-way interactions between combinations of risk factors to determine whether combined factors contribute more than individual factors to post-deployment problems.
Anger management interventions have been developed and implemented for veterans of previous conflicts (36
). Our results suggest that clinicians treating Iraq and Afghanistan veterans who present complaining of anger problems should investigate specific types of behaviors and particular sets of risk factors. Clinicians can first ask whether the veteran has had problems controlling violent behavior. If the veteran answers affirmatively, the multivariate model in would guide clinicians to investigate aspects of the veteran’s background involving violence and aggression, including whether he or she had experienced high levels of violence in the past (e.g., witnessing family violence) and more recently (e.g., firing a weapon in combat, having a longer deployment). If the veteran denies such problems but reports aggressive urges, our analyses suggest that clinicians gather information about psychopathology and trauma, such as a family history of mental illness, a history of abuse, and current PTSD reexperiencing symptoms, potentially from working in a war zone. If the veteran does not report aggressive urges, the data suggest that clinicians should investigate aspects of the anger as related to past and current relationships and conflict, including whether the veteran had a chaotic upbringing (e.g., a history of parental incarceration), how PTSD avoidance symptoms relate to potential problems in current relationships, and in what ways the veteran might be expressing anger with his or her spouse. Differences between the dependent measures provide empirical support for individually tailoring assessment and interventions addressing symptoms of anger and hostility in Iraq and Afghanistan veterans.
Several study limitations should be noted. The MIRECC registry consists of a self-selected sample of Iraq and Afghanistan veterans from the Mid-Atlantic region of the United States who responded to advertisements and volunteered to participate in research. It is unknown whether the sample is representative of all Iraq and Afghanistan veterans. Research is needed to verify whether the rates of psychiatric disorders and alcohol risk observed in our sample as well as in other recent reports (39
) are representative of Iraq and Afghanistan veterans. As such, this study was not designed to provide prevalence estimates of anger and hostility in Iraq and Afghanistan veterans; rather, its purpose was to evaluate potential correlates of anger and hostility in order to suggest promising avenues for mental health assessment and treatment of troops returning from combat. This is an urgent clinical need for which little or no guidance is available from empirical analysis.
Although it could be argued that, prima facie, the three dependent variables in this study seem too closely related, correlations revealed considerable non-collinearity, and multivariate analyses confirmed substantially different statistical models of each, strongly supporting the thesis that they are separate, distinct constructs. Other study limitations include the cross sectional structure of the analysis, precluding causal ordering of risk factors and restricting inference to the level of association. Self-report measures may underestimate actual problems with aggressiveness and alcohol use. Also, while this study measured anger, aggressiveness, and perceived problems controlling violence, it did not include a measure of violent acts; hence, it is unknown whether the risk factors we identified are associated with actual violence. Finally, additional investigation is needed of other risk and protective factors, including personality disorders, drug abuse, use of health services (e.g., involvement in rehabilitation, adherence to medications), and situational factors (e.g., social support, coping skills, details of work, and financial stability).
When veterans become angry, aggressive, or violent, the cost to individuals, their families, their communities, and society is high. There are nearly 1 million veterans from this era who have already been discharged, and tens of thousands more troops will return from combat in Iraq and Afghanistan in the next few years. Given data revealing post-deployment mental health problems, we urgently need theoretically sophisticated, evidence-based knowledge to identify those most prone to anger and hostility and to evaluate how the risk can be effectively managed. This study takes a step toward this goal by identifying variables that could ultimately be used among evidence-based approaches for mental health providers and military staff helping to alleviate and prevent post-deployment adjustment problems.