Critical Concerns in Iraq/Afghanistan War Veteran-Forensic Interface: Combat-Related Postdeployment Criminal Violence

Postdeployment Criminal Violence Among Iraq and Afghanistan Veterans

At the outset, it should be noted that stereotypes such as the violent “wacko-vet”⁴ are harmful to those who have served honorably in the military, as they forward a view of the combat veteran as threatening⁵ and untrustworthy.⁶ Moreover, the stereotype of the violent combat veteran is not supported by national offender data. The Bureau of Justice 2004 Survey (published in 2007) found no relationship between combat and violent crime in veterans.¹ For incarceration rates across all offenses, the most recent U.S. Department of Justice Bureau of Justice Statistics (BJS) 2004 prison data showed that rates were lower for veterans than for nonveterans: veterans were incarcerated at a rate of 630 prisoners per 100,000 adult male veteran population, less than half the rate of nonveterans (1,390 prisoners per 100,000 adult male nonveterans). In addition to overall incarceration rates, one of the authors of the current paper (J.M.), utilizing the BJS 2004 survey estimates for state and federal prisoners, compared the nonveteran violent offender rate per 100,000 population to veteran violent offender rates. The calculated male violent offender rate for veterans was 338 prisoners per 100,000 male veterans and for nonveterans was 595 per 100,000 male nonveterans. This rate can be considered as a populationwide (across adult male veteran and nonveteran populations) comparison, in contrast to the in-prison (i.e., only prison population) percentages listed in the BJS report. The rate indicates that the nonveteran violent offender rate per 100,000 adult male population is 1.75 times higher than the veteran rate. (Data available upon request from author J.M.)

Turning to combat status, the BJS 2004 survey¹ of veterans in state and federal prison in 2004 indicated that 20 percent of veterans incarcerated in state prison had served in combat, and for Federal prisoners, 26 percent of incarcerated veterans had served in combat. BJS found earlier (1997 survey⁷) that veterans who reported combat duty during their military service were no more likely to be violent offenders than were other veterans. Although not specific to combat status, military research has similarly found, with the exception of rape, lower rates of violent crime in the active duty Army than in the civilian population.⁸ Such findings support the view that veterans, inside and outside the military, are less violent as a population than are nonveterans.

As most of the available combat status-violent crime statistics are heavily weighted with veterans from the Vietnam era, data as to the link between combat exposure and civilian violence among Iraq and Afghanistan veterans remain limited. BJS in 2004 did find that 57 percent of veterans in state prison were serving sentences for a violent crime compared with 47 percent of nonveterans. The breakdown of the type of violent offense was 15 percent for homicide and 23 percent for sexual assault (including rape), although data were not broken out by combat/noncombat status in relation to offense rates.

Burchett et al.⁹ examined the facts in the 121 cases identified by Sontag and Alvarez² to clarify the association between combat exposure and violence. They used additional media outlet sources and were able to access substantially more information about the veterans than appeared in the New York Times article. To verify combat exposure, the researchers analyzed media reports of testimony of commanding officers or fellow unit members of decorated soldiers, war zone injuries, improvised explosive device (IED) and mortar exposure, and family reports or as determined by the unit location in Iraq. Burchett and colleagues⁹ found that all but one were male, 90 percent had served in Iraq, and two had served in both Iraq and Afghanistan. The homicide victims were strangers (35%), friends and acquaintances (19%), children (8%), or of unknown relationship in 15 percent of the cases. The most common charge was first-degree murder (56%), and 21 percent of the cases were vehicular manslaughter involving the death of a passenger of a vehicle driven by an intoxicated veteran. Of note, in less than half the cases (40%) were the extent and nature of combat exposure rated as certain. Consideration of combat exposure to sentencing or mitigation was unclear, though none received an insanity acquittal. Although the researchers cautioned that the nature of the data as assessed through media sources did not allow for formal diagnosis, the media-based information did allow for identification of significant psychiatric symptoms. As to psychiatric symptoms present, PTSD symptoms (e.g., nightmares, insomnia, intrusive thoughts, intense anger, survivor guilt, hyperarousal, hypervigilance, depressed mood, and suicidal ideation) were identified in 70 percent of the cases (n = 85) through family and other court reports. It was estimated that 34 percent of the sample demonstrated only PTSD symptoms; 19 percent had PTSD and comorbid substance abuse; and almost 17 percent displayed a combination of PTSD, substance abuse, and antisocial personality disorder (ASPD). Of note, 39 of the cases were found to have significant features of ASPD, such as homicide for material gain committed in the course of another felony such as a robbery, cautioning against the conclusion that combat exposure explained the postdeployment violence.

Link Between Combat Exposure and Violence

The credibility of a combat-linked defense is challenged by the infrequency with which combat veterans with similar war zone exposure and diagnoses commit murders or serious violence. One conceptual model, that of diathesis-stress¹⁰ is of value in understanding the process of emotional derailment that leads to lethal or serious violence among a small subgroup of Iraq and Afghanistan combat veterans. The diathesis-stress theoretical model describes the genetic predisposition (vulnerability or strength) and its interaction with life stressors that lead to the development of a disorder. In the veteran context, the veteran's intrinsic resilience (diathesis) may become vulnerable to deterioration due to combat exposure and injury (stress) when confronted with cumulative stressors in the civilian arena, thereby leading to decompensation of inner controls and subsequent violence. Diathesis stress was in fact employed over 60 years ago by the California Supreme Court in People v. Danielly,¹¹ a case of murder committed by a World War II combat veteran. In that case, the defendant argued that he had no recollection of the killing because of his combat-related nervous disability and therefore the murder conviction should be reduced to manslaughter. That nervous disability (diagnosed then as psychoneurosis neurasthenia, for which he was discharged from the military) would now likely be diagnosed as PTSD given his symptoms of startle, battle dreams, anxiety, irritability, and insomnia. Moreover, the defendant had been injured by the explosion of an enemy bomb and could have incurred, in current diagnostic parlance, traumatic brain injury as well. The lower courts rejected the defendant's insanity plea. While the California Supreme Court ultimately affirmed the lower court's judgment of the murder conviction, the higher court acknowledged the veteran-defendant as a victim of war. The court noted that the war experience had hampered the veteran's emotional stability and that his ability to cope with the demands of life (diathesis) had been impaired by his war injury (stress).

PTSD as a defense used in homicide cases gained credibility once this diagnosis was included in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980.^12,–,14 This diagnosis has been successful, on occasion, in defense arguments for sentencing mitigation (such as diminished capacity) or exculpation (such as insanity defenses) among Vietnam veterans facing criminal charges.^15,–,17 Expressed symptoms are more likely to be malingered, given that PTSD is widely known by the public and applied to numerous civilian traumatic experiences (e.g., school shootings, car accidents, sexual assault).¹⁷ Jurors may have experienced trauma themselves (or have family members, friends, or coworkers who have) that could cause a stress disorder, yet that trauma did not provoke severe violence; thus, the trauma defense may not be viewed as legitimate. Miller¹² further noted that so-called combat addiction (i.e., hyperarousal and thrill-seeking) may be misattributed to PTSD and in some cases more correctly attributed to antisocial personality. Therefore, the forensic expert must be able to explain the unique aspects of Iraq and Afghanistan war zone exposure and how these elements may have a nexus with the development of conditions that create vulnerability for aggressive behavior. We next turn to an examination of the types of injuries that are represented in this group of returning veterans and their impact on anger and aggression.

Dual Challenges: PTSD and TBI

The signature wounds of returning Iraq and Afghanistan war veterans are represented by the dual conditions of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI).¹⁸ Anger and aggression can be correlates of both conditions. Mild traumatic brain injury, as related to multiple exposures to direct IED explosions (where the individual or vehicle is hit by the explosive device) or indirect hits (where the explosion occurs nearby, though the individual or vehicle is not directly affected), may result in cumulative brain trauma.¹⁹ There is a relatively high rate of mild traumatic brain injury among returning Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans. Iverson¹⁹ reported an estimated 11.2 percent to 22.8 percent rate of service members who sustained a deployment-related mild traumatic brain injury for the period after the attacks in September 2001. Iverson further noted that the number of military TBIs increased between the years of 2006 to 2008, though the reason for this was not clear and may simply reflect better screening of returning troops for this condition. It may also reflect increased exposure of troops deployed to Iraq and Afghanistan to blast injuries as a result of enemy combatant use of IEDs. In combat settings concussions occur through a variety of means: bullet fragments, attacks with weapons such as rocket-propelled grenades, bomb blasts, land mines, and vehicle crashes. In the Iraq and Afghanistan wars, bomb blast exposures typically occurred through IEDs, although there are also discharges of bombs employed by the military to destroy enemy areas.²⁰ Recent meta-analytic studies suggest that, in most cases, the course of mild TBI from a single event results in symptom remission, although a small percentage of individuals report chronic cognitive and emotional complaints.²¹ Of note, the debate continues about definitions of combat-related conditions, such as postconcussive syndrome versus mild traumatic brain injury that some have argued lead to misattribution of symptoms.²² In addition, combat-based TBI is complicated by the overlapping impact of PTSD and pain and the effect of other physical injuries sustained. Furthermore, multiple exposures to events that cause traumatic injury without prolonged loss of consciousness can occur over a tour (or multiple tours) of deployment (typically one year for Army troops).¹⁹

Another facet of Iraq and Afghanistan war zone TBI is that it can involve multiple exposures to blast waves from IED and vehicle-borne explosive device (VBED) explosions.¹⁹ Blast-related injuries to the brain are unique and complex. Ziejewski et al.²⁰ described blast injuries as occurring as a result of blast wave-induced changes in atmospheric pressure. Brain injury can result from blast waves going through the brain. There can be additional injuries to the head from projectiles unleashed from a blast. In addition, the force of the blast can cause acceleration-deceleration injuries from the brain's moving and hitting the bony parts of the skull. Although advances in protective devices, including headwear, have resulted in a decrease in the number of soldiers killed in action, there is a corresponding increase in head wounds and serious disabilities among these surviving veterans. Included among the residual effects of blast TBI are concentration problems and other cognitive deficits. Classic symptoms of TBI such as sleep disturbance, headache, vertigo, and anxiety can follow even mild TBI (defined as confusion or loss of consciousness lasting less than 30 minutes).²¹ Emotional deregulation, temper dyscontrol, and anger outbursts can accompany damage to areas of the frontal and temporal lobes as a consequence of blast- or bomb-related TBI.^19,23 Nonetheless, a recent study of 676 Iraq and Afghanistan veterans did not find a direct effect between deployment traumatic brain injury and reports of problems with anger and violence.²⁴ The authors noted instead a considerable overlap between the symptoms of PTSD and TBI, as well as possible alcohol misuse, which raised the question of an interactive or additive effect of these conditions (PTSD, alcohol abuse, and TBI) on lowered control of anger and aggression.

In early studies of service members returning from Iraq and Afghanistan, the rates of PTSD have been estimated at 19 percent and the rates of TBI at 20 percent, with approximately 31 percent of returning troops estimated to experience mental health problems or TBI.³ Other studies have also linked new-onset combat exposure with psychological distress²⁵ and violent combat experiences to an increased likelihood of postdeployment risky behavior.²⁶ Moreover, Elbogen et al.,²⁴ in their study of Iraq and Afghanistan war veterans found that those with poorly controlled hyperarousal PTSD symptoms also had greater self-reported difficulty in controlling anger, aggressive impulses, and violent impulses. In a recent monograph, Daniel²⁷ described the rates of PTSD symptoms, combat exposure, and violence in a sample of 440 Iraq and Afghanistan veterans who were inmates at the United States Disciplinary Barracks, Fort Leavenworth, Kansas. One hundred ninety-nine of the inmates surveyed described some symptoms of PTSD; of those, 48 percent reported having been under fire in combat and 14 percent reported being wounded. The average age of first offense was 24. Twenty-three had an established diagnosis of PTSD in their mental health records; of those, 20 had been deployed to a combat zone, 17 had received hostile fire, 10 had been wounded in action, 13 were deployed once, 5 were deployed twice, and 2 were deployed three times. It was noted that 92 percent of the inmates with an established PTSD diagnosis by record had committed a violent offense (of the remaining inmates, one was a threat to kill, and the other committed a drug offense). While these data do not establish a causal link of combat exposure to postdeployment violence, the findings strongly suggest a relationship between high rates of reports of PTSD symptoms, exposure to hostile fire in a combat zone, and subsequent criminal behavior, primarily of a violent nature.

Combat Battlemind as Maladaptive in the Civilian Environment

There are qualitative elements specific to the Iraq and Afghanistan wars, in contrast to the Vietnam war (such as multiple deployments, differing terrain and survival of injuries that were lethal in prior wars) that may be of value in understanding the context of the development of PTSD or combat stress among Iraq and Afghanistan veterans returning home. Battlemind training (Walter Reed Army Institute Land Combat Study Team)²⁸ represents a methodology used by the military to identify the soldier's mindset and skills toward survival in the combat zone and may influence ability to adjust to civilian life. These descriptions are summarized in Table 1. The military survival mindset is adaptive to the war zone, but maladaptive in the civilian arena. Strategies such as aggressive and erratic driving, used by combat-zone personnel toward avoiding IEDS and VBEDs, are clearly maladaptive on the home front. Additional examples include combat zone high alert-high adrenaline states characterized by anger and hypervigilance and coupled with quick reactions to perceived threats, sometimes lethal, to the goal of staying alive and protecting fellow personnel. Clearly, these reactions in civilian life can be highly problematic, as they frequently represent a misjudgment of the situation, leading to interpersonal anger, aggression, and, at times, lethal violence.

Moreover, reliance on a weapon for safety and carrying one at all times is a combat mandate. For some combat veterans returning home, this mindset carries over with the belief that having a weapon on one's person at all times is necessary for safety. For a very few, a survival mindset may become the maladaptive mechanism that fosters hypervigilance and paranoia and may potentiate violence or homicide.

In sum, although most combat veterans appear to develop effective coping responses to the stressors experienced in the military and upon re-entry to civilian life, research and media reports suggest that a significant proportion of service members returning from current wars either as a result of mental health problems or as a result of their military training or combat experience are at high risk for contact with the criminal justice system. While the literature presented here highlights domains that are relevant to forensic evaluation of returning veterans who become involved with the justice system, further studies, including DOJ surveys that specifically reflect OIF/OEF veterans, are needed to examine the precise degree and nature of the relationships between military training and experience and criminal behavior.

Guide for Review of the Link Between PTSD/TBI Combat Exposure and Civilian Violence

The Postdeployment Criminal Violence Rating Guide represents a methodology for organizing and analyzing data relevant to forensic case formulation. It is a conceptual template that addresses qualitative factors as they relate to the potential impact of combat-related injuries and postdeployment violence (as depicted in Table 2). We used research on warzone trauma exposure and descriptions of military training to propose a guide for use in forensic evaluation settings. In addition, we propose a guide informed by the diathesis-stress model to encompass military trauma and training that can result in symptoms, cognitive dysfunctions and conditioning, and impulsive or learned behavioral responses. The guide suggests important data elements to gather and a methodology for descriptive analysis of the findings before examining the connection between military experience and criminal behavior.

For the forensic clinician addressing combat exposure and postdeployment violence as it affects mens rea, this template provides for a focused evaluation of war zone-related PTSD and TBI symptoms. Moreover, the template provides a method for describing the rationale of how combat exposure may lead to impaired emotionality and cognition and may offer a basis for legal defenses (e.g., insanity, competency, diminished actuality/capacity, and sentence mitigation). As a cautionary note, this process does not establish a link legally between the offense and military training, PTSD, or combat exposure; rather, it represents a clinical guide to certain potentially relevant aspects of combat exposure. Of note, the guide assumes that the clinician has verification of the Iraq and Afghanistan veteran military service (through DD214, i.e., the official military discharge document and other military records), and it is cautioned that the assessment cannot be based solely on self-reported combat or combat zone exposure, a lesson learned by forensic evaluators of veterans from earlier eras.^15,16 We offer a fictional case example as a method of demonstrating how this guide may be used in a forensic context.

Use of the Clinical Guide With a Fictional Case Example

This case was created to reflect the demographics of those who have served in Iraq or Afghanistan, but does not represent the cumulative history of actual cases or an individual case; however, it does reflect the types of clinical conditions and postdeployment social situations encountered by returning veterans.