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The Correlation Between PTSD and Criminogenic Behaviors In Incarcerated Veterans

Fleming, M., Simpson, M., & Presecan, N. (2013). The Correlation Between PTSD and Criminogenic Behaviors In Incarcerated Veterans. Corrections Forum, 22(6), 37-40.

The article discusses the research study on the characteristics of post-traumatic stress disorder (PTSD) in incarcerated veterans. It highlights the problems associated with the link between PTSD and criminal behaviors, the prevalence of incarcerated veterans, and the link of PTSD with traumatic brain injury. It also explains the treatment options for PTSD.


Forensic Validity of a PTSD Diagnosis

Claudia Baker, MSW, MPH and Cessie Alfonso, LCSW

National Center for PTSD

Many types of civil and criminal court cases and litigation involve claims of Posttraumatic Stress Disorder. The diagnostic validity of these claims can impact directly upon the defense, plaintiff, or prosecutorial legal strategies, depending upon the nature of use in the case. It is important, therefore, for attorneys and others involved in the legal system to be able to assess the validity of PTSD evaluations and diagnoses. Although only an expert in PTSD can complete an in-depth review of the diagnostic methodology used in a case, it is helpful if those conducting initial reviews know some basic facts about PTSD and what constitutes a sound diagnosis.


Department of the Army: Policy Guidance on the Assessment and Treatment of Post-Traumatic Stress Disorder (PTSD)


PTSD as a Criminal Defense: A Review of Case Law

Berger, O., McNiel, D., & Binder, R. (2012). PTSD as a criminal defense: a review of case law. The Journal Of The American Academy Of Psychiatry And The Law, 40(4), 509-521.

Posttraumatic stress disorder (PTSD) has been offered as a basis for criminal defenses, including insanity, unconsciousness, self-defense, diminished capacity, and sentencing mitigation. Examination of case law (e.g., appellate decisions) involving PTSD reveals that when offered as a criminal defense, PTSD has received mixed treatment in the judicial system. Courts have often recognized testimony about PTSD as scientifically reliable. In addition, PTSD has been recognized by appellate courts in U.S. jurisdictions as a valid basis for insanity, unconsciousness, and self-defense. However, the courts have not always found the presentation of PTSD testimony to be relevant, admissible, or compelling in such cases, particularly when expert testimony failed to show how PTSD met the standard for the given defense. In cases that did not meet the standard for one of the complete defenses, PTSD has been presented as a partial defense or mitigating circumstance, again with mixed success.


PTSD and the Law: An update

PTSD Research Quarterly: Advancing Science and Promoting Understanding of Traumatic Stress

National Center for PTSD

Jim McGuire, PhD & Sean Clarke, JD



Reinvigorating Actus Reus: The Case for Involuntary Actions by Veterans with Post-Traumatic Stress Disorder

Melissa Hamilton, Reinvigorating Actus Reus: The Case for Involuntary Actions by Veterans with Post-Traumatic Stress Disorder, 16 Berkeley J. Crim. L. 340 (2011).

In common law, criminal culpability rests on two basic foundations of criminal intent, or mens rea, and a voluntary act, which comprises the actus reus. While much of the litigation in criminal cases concerns assigning the appropriate mens rea concept to the particular defendant’s mental state, relatively little debate focuses on the element of actus reus. Indeed, case law and commentators generally have devoted scant attention to fleshing out the voluntary act concept despite the historical consensus of both utilitarians and retributivists that one should not be considered morally or legally culpable for his or her involuntary actions. This paper conceptualizes an overall need to reinvigorate the actus reus requirement as a fundamental principal of criminal culpability. It does so by employing a contemporary problem facing the criminal justice system of combat veterans with Post-Traumatic Stress Disorder (PTSD) who commit acts of unlawful violence, including homicide, either in reflexive actions or during dissociative states triggered by re-experiencing combat-related stresses. While the veterans are often convicted of criminal offenses, studies on PTSD substantively support an argument that such violence may actually be conceptualized as automatism and, therefore, should not qualify as voluntary acts justifying criminal culpability. For example, mental health professionals describe PTSD as a neuropsychiatric disorder that involves hypervigilance, and hyperreactivity. Modern combat training is a likely correlate with its emphasis on muscle memory and reflexive responsiveness in the use of lethal weapons, which are adaptive, survival behaviors in the field of battle. The relationship to automatism is also evident in that PTSD is not merely a cognitive disorder as studies have shown PTSD-related alterations to brain structure and function and neurophysiological performance. Thus, this contemporary problem of PTSD in veterans due to wartime service provides a fresh perspective on which to reconsider the importance of the voluntary act requirement of criminal law.


Post-Traumatic Stress Disorder in the Criminal Justice System: From Vietnam to Iraq and Afghanistan

Marcia G. Shein

September 2010


Exit Wounds: Current Issues Pertaining to Combat-Related PTSD of Relevance to the Legal System


Tramontin, M. (2010). Exit Wounds: Current Issues Pertaining to Combat-Related PTSD of Relevance to the Legal System.Developments In Mental Health Law, 29(1), 23-47.

Written for those in the mental health and legal communities dealing with war veterans embroiled in the criminal justice system, this Article presents an overview of current issues pertaining to the diagnosis, assessment, and treatment of combat-related post-traumatic stress disorder (PTSD). The objective is to provide information that can assist the legal system when addressing PTSD-related issues of combat veterans charged with crimes, with a specific focus on those returning from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). As part of this discussion, insights from clinical practice for assessing and treating combat veterans are offered and considered in light of state of the art trends from the complex and evolving field of traumatic stress studies. [ABSTRACT FROM AUTHOR]


Studies’ Estimates of PTSD Prevalence Rates for Returning Service Members Vary Widely

Rajeev Ramchand, Terry L. Schell, Benjamin R. Karney, Karen Chan Osilla, Rachel M. Burns, Leah B. Caldarone

RAND Corporation 2010

Summarizes analyses of existing posttraumatic stress disorder (PTSD) studies for war zone veterans, finding that the prevalence estimates vary widely and are linked to the use of different PTSD diagnostic definitions and divergent study samples.


Disparate Prevalence Estimates of PTSD Among Service Members Who Served in Iraq and Afghanistan: Possible Explanations


Ramchand, R., Schell, T. L., Karney, B. R., Osilla, K., Burns, R. M., & Caldarone, L. (2010). Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. Journal Of Traumatic Stress, 23(1), 59-68. doi:10.1002/jts.20486

The authors reviewed 29 studies that provide prevalence estimates of posttraumatic stress disorder (PTSD) among service members previously deployed to Operations Enduring and Iraqi Freedom and their non-U.S. military counterparts. Studies vary widely, particularly in their representativeness and the way PTSD is defined. Among previously deployed personnel not seeking treatment, most prevalence estimates range from 5 to 20%. Prevalence estimates are generally higher among those seeking treatment: As many as 50% of veterans seeking treatment screen positive for PTSD, though much fewer receive a PTSD diagnosis. Combat exposure is the only correlate consistently associated with PTSD. When evaluating PTSD prevalence estimates among this population, researchers and policymakers should carefully consider the method used to define PTSD and the population the study sample represents.


Posttraumatic Stress Disorder and Criminal Responsibility

Friel, A., White, T., & Hull, A. (2008). Posttraumatic stress disorder and criminal responsibility. Journal of Forensic Psychiatry & Psychology, 19(1), 64-85. doi:10.1080/14789940701594736

There has been an increased interest in the relationship between posttraumatic stress disorder (PTSD) and violence, and in the factors that mediate their linkage. PTSD is a common, often underdiagnosed, condition with high levels of psychiatric comorbidity. It often has poor outcomes, with many cases becoming chronic, leading to substantial costs both to the individual and society as a whole. In this paper we report on the literature on PTSD, its diagnosis, assessment, and treatment. The difficulties encountered when assessing PTSD – the subjective nature of the symptoms, the risk of malingering, and the possibility of secondary gain – have been highlighted. Assessment and treatment in forensic settings is further complicated by the possibility of perpetrator PTSD. We have reviewed the prevalence of PTSD with particular reference to offender and forensic populations. The association between PTSD and violence, its relevance across the spectrum of criminal responsibility, and relevant case law are explored.


Combat Veterans, Mental Health Issues, and the Death Penalty: Addressing the Impact of Post-Traumatic Stress Disorder and Traumatic Brain Injury

Anthony E. Giardino

May 2009

More than 1.5 million Americans have participated in combat operations in Iraq and Afghanistan over the past seven years. Some of these veterans have subsequently committed capital crimes and found themselves in our nation’s criminal justice system. This Essay argues that combat veterans suffering from post-traumatic stress disorder or traumatic brain injury at the time of their offenses should not be subject to the death penalty. Offering mitigating evidence regarding military training, post-traumatic stress disorder, and traumatic brain injury presents one means that combat veterans may use to argue for their lives during the sentencing phase of their trials. Alternatively, Atkins v. Virginia and Roper v. Simmons offer a framework for establishing a legislatively or judicially created categorical exclusion for these offenders, exempting them from the death penalty as a matter of law. By understanding how combat service and service-related injuries affect the personal culpability of these offenders, the legal system can avoid the consequences of sentencing to death America's mentally wounded warriors, ensuring that only the worst offenders are subject to the ultimate punishment.


Aggression Among Combat Veterans: Relationships With Combat Exposure and Symptoms of Posttraumatic Stress Disorder, Dysphoria, and Anxiety Severity of Posttraumatic Stress Disorder and Involvement with the Criminal Justice System

Taft, C., Vogt, D., Marshall, A., Panuzio, J., & Niles, B. (2007). Aggression among combat veterans: relationships with combat exposure and symptoms of posttraumatic stress disorder, dysphoria, and anxiety. Journal Of Traumatic Stress, 20(2), 135-145.

Prior research has revealed heightened aggressive behavior among veterans with PTSD. This study tested a model examining the interrelationships among combat exposure, posttraumatic stress disorder (PTSD) symptoms, dysphoric symptoms, and anxiety symptoms in predicting aggressive behavior in a sample of 265 male combat veterans seeking diagnostic assessment of PTSD. Combat exposure was indirectly associated with aggression primarily through its relationship with PTSD symptoms. Symptoms of PTSD were directly related to aggression, and indirectly related to aggression through dysphoric symptoms. Results highlight the role of PTSD symptoms and dysphoric symptoms with respect to aggressive behavior among this population, and suggest the relevance of aggression theory to the study of combat veterans.


Posttraumatic Intrusion, Avoidance, and Social Functioning: A 20-Year Longitudinal Study


Solomon, Z., & Mikulincer, M. (2007). Posttraumatic intrusion, avoidance, and social functioning: A 20-year longitudinal study. Journal Of Consulting And Clinical Psychology, 75(2), 316-324. doi:10.1037/0022-006X.75.2.316

The study assesses posttraumatic intrusion, avoidance, and social functioning among 214 Israeli combat veterans from the first Lebanon War with and without combat stress reaction (CSR) 1, 2, 3, and 20 years after the war. CSR veterans reported higher intrusion and avoidance than did non-CSR veterans. With time, there was a decline in these symptoms. In addition, intrusion and avoidance were associated with problems in social functioning on a given year, and they longitudinally predicted social dysfunction 2, 3, and 20 years after the war. CSR veterans presented stronger temporal covariations between intrusion-avoidance and social functioning. The findings suggest that CSR is a marker for future psychopathology and point to the role of avoidance in social dysfunction. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)


Post-traumatic Stress Disorder and the Casual Link to Crime: A Looming National Tragedy

Daniel, D. L. (2008). Post-traumatic Stress Disorder and the Casual Link to Crime: A Looming National Tragedy. US Army, US Army Combined Arms Center. doi:10.1037/e614642009-001

The purpose of this paper is to investigate if there is a correlation between PTSD and criminal behavior in soldiers that have been incarcerated after returning from the GWOT and to determine the obligations of the U.S. government/DoD to prevent, treat, and/or mitigate the problem. This study includes data collected, examined and analyzed from three primary sources. First, an existing study on PTSD and criminal behavior by James J. Collins and Susan L. Bailey which examines the correlation between PTSD and criminal behavior primarily in 1140 nonveteran North Carolina inmates. This study is included to establish whether a general causal link exists between PTSD and an incidence of violent criminal behavior. Next, statistical data compiled by the Bureau of Justice Statistics (BJS) section of the Office of Justice Programs, U.S. Department of Justice (DoJ) is analyzed for trends in incarceration rates among veterans in Federal and State correctional facilities. The BJS data is included to examine whether the incarceration rates of veterans for violent criminal offenses has peaked during and after periods of war. Finally, this study will look closely at aggregate exempt inmate data recently compiled by the administrative and mental health staff of the United States Disciplinary Barracks, Fort Leavenworth, Kansas (USDB). The data from the USDB is part of an ongoing survey of the inmates (n=440) to determine the incidence of PTSD and mental health disorders within the prisoner population for treatment purposes and program analysis. This paper explores the history of PTSD in previous conflicts, the characteristics of the disorder and briefly discusses current treatment approaches. The data presented, particularly the initial results of the current USDB survey, strongly supports the current hypothesis that there is a correlation between PTSD and criminal behavior in soldiers that have been incarcerated after returning from the GWOT. As such the final contribution of this paper is to offer some brief recommendations on what our national leaders should do to prevent or mitigate the impending problem in our society of more veterans involved in violent criminal behavior. (PsycEXTRA Database Record (c) 2013 APA, all rights reserved)


Attorneys as First-Responders: Recognizing the Destructive Nature of Posttraumatic Stress Disorder on the Combat Veteran’s Legal Decision-Making Process

Captain Evan R. Seamone

Winter 2009


The Veterans’ Lawyer as Counselor: Using Therapeutic Jurisprudence to Enhance Client Counseling For Combat Veterans with Posttraumatic Stress Disorder

Captain Evan R. Seamone

Winter 2009


PTSD Symptoms, Demographic Characteristics, and Functional Status Among Veterans Treated in VA Primary Care Clinics


Magruder, K. M., Frueh, B. C., Knapp, R. G., Johnson, M. R., Vaughan, J. A., Carson, T. C., Powell, D. A. and Hebert, R. (2004), PTSD symptoms, demographic characteristics, and functional status among veterans treated in VA primary care clinics. Journal of Traumatic Stress, 17: 293–301. doi: 10.1023/B:JOTS.0000038477.47249.c8

We hypothesized that PTSD symptomatology would have an inverse relationship with functional status and would vary as a function of sociodemographic variables. Primary care patients (N = 513) at two VA Medical Centers were randomly selected and recruited to participate. After adjustment for other demographic variables. PTSD symptom levels were significantly related to age (younger patients had more severe symptoms), employment status (disabled persons had higher symptom levels), war zone experience, and clinic location. PTSD symptomatology was inversely related to mental and physical functioning, even after control for potential confounding. These findings have implications for screening and service delivery in VA primary care clinics, and support the more general finding in the literature that PTSD is associated with impaired functioning.


Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?


Richard J. McNally, Richard A. Bryant, and Anke Ehlers

November 2003

In the wake of the terrorist attacks at the World Trade Center, more than 9,000 counselors went to New York City to offer aid to rescue workers, families, and direct victims of the violence of September 11, 2001. These mental health professionals assumed that many New Yorkers were at high risk for developing posttraumatic stress disorder (PTSD), and they hoped that their interventions would mitigate psychological distress and prevent the emergence of this syndrome. Typically developing in response to horrific, life-threatening events, such as combat, rape, and earthquakes, PTSD is characterized by reexperiencing symptoms (e.g., intrusive recollections of the trauma, nightmares), emotional numbing and avoidance of reminders of the trauma, and hyperarousal (e.g., exaggerated startle, difficulty sleeping). People vary widely in their vulnerability for developing PTSD in the wake of trauma. For example, higher cognitive ability and strong social support buffer people against PTSD, whereas a family or personal history of emotional disorder heightens risk, as does negative appraisal of one's stress reactions (e.g., as a sign of personal weakness) and dissociation during the trauma (e.g., feeling unreal or experiencing time slowing down). However, the vast majority of trauma survivors recover from initial posttrauma reactions without professional help. Accordingly, the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery. The need for controlled evaluations of early interventions has only recently been widely acknowledged.

Psychological debriefing—the most widely used method—has undergone increasing empirical scrutiny, and the results have been disappointing. Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma.

Recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. Providing information about the trauma and its consequences is also important. However, research evaluating the efficacy of such “psychological first aid” is needed.

Some researchers have developed early interventions to treat individuals who are already showing marked stress symptoms, and have tested methods of identifying those at risk for chronic PTSD. The single most important indicator of subsequent risk for chronic PTSD appears to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (provided that the event is over and that there is no ongoing threat).

Cognitive-behavioral treatments differ from crisis intervention (e.g., debriefing) in that they are delivered weeks or months after the trauma, and therefore constitute a form of psychotherapy, not immediate emotional first aid. Several controlled trials suggest that certain cognitive-behavioral therapy methods may reduce the incidence of PTSD among people exposed to traumatic events. These methods are more effective than either supportive counseling or no intervention.

In this monograph, we review risk factors for PTSD, research on psychological debriefing, recent recommendations for crisis intervention and the identification of individuals at risk of chronic PTSD, and research on early interventions based on cognitive-behavioral therapy. We close by placing the controversy regarding early aid for trauma survivors in its social, political, and economic context.


Posttraumatic stress disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment.


Brunello, N.; Davidson, J.; Deahl, M.; et al. 2001. Postraumatic Stress Disorder: Diagnostic and Epidemiology, Comorbidity and Social Consequences, Biology and Treatment. Neuropsychobiology 43:150–162.

Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorders, and several symptoms overlap with major depressive disorders, anxiety disorders and substance abuse; this may contribute to diagnostic confusion and underdiagnosis. This anxiety disorder provokes significant occupational, psychiatric, medical and psychosocial disability, and its consequences are enormously costly, not only to the survivors and their families, but also to the health care system and society. Work impairment associated with PTSD is very similar to the amount of work impairment associated with major depression. The pathophysiology of PTSD is multifactorial and involves dysregulation of the serotonergic as well as the noradrenergic system. A rational therapeutic approach should normalize the specific psychobiological alterations associated with PTSD. This can be achieved through the use of antidepressant drugs, mainly of those that potentiate serotonergic mechanisms. Recent double-blind placebo-controlled studies report the efficacy of selective serotonin reuptake inhibitors. Several cognitive-behavioral and psychosocial treatments have also been reported to be efficacious and could be considered when treating PTSD patients.


Aggression and Its Correlates in Vietnam Veterans with and Without Chronic Post-Traumatic Stress Disorder


Lasko, N.B., Guruits, T.V., Kuhne, A.A., Orr, S.P., & Pitman, R.K. (1994). Aggression and its correlates in Vietnam veterans with and without chronic post-traumatic stress disorder. Comprehensive Psychiatry, 35, 373-381.

This study measured self-reported aggression, hostility, and anger in Vietnam combat veterans with (n = 27) and without (n = 15) posttraumatic stress disorder (PTSD). On the Buss-Durkee Hostility Inventory, Past Feelings and Acts of Violence Scale, Episodic Dyscontrol Scale, and State-Trait Anger Expression Inventory (STAXI), PTSD subjects scored significantly higher than non-PTSD subjects, whose scores fell in the range reported for normative, noncombat populations. The PTSD versus non-PTSD group differences were not explained by combat exposure, which did not correlate significantly with the psychometric aggression measures. These findings suggest that increased aggression in war veterans is more appropriately regarded as a property of PTSD, rather than a direct consequence of military combat. The association between compromised neurologic and neuropsychologic status and the psychometric measures was modest and explained little of the group differences.


Paying the Price for Vietnam: Post-traumatic Stress Disorder and Criminal Behavior

Erlinder, C. P. (1984). Paying the price for Vietnam: Post-traumatic Stress Disorder and criminal behavior. Boston College Law Review, 25(2). 305-347.


The Vietnam Veteran on Trial: The Relation of Post-Traumatic Stress Disorder to Criminal Behavior


Wilson, J. P., & Zigelbaum, S. D. (1983). The Vietnam Veteran on Trial: The Relation of Post-Traumatic Stress Disorder to Criminal Behavior. Behavioral Sciences & The Law, 1(3), 69-83.

The purpose of this paper is to conceptualize the relationship of Post-Traumatic Stress Disorder (PTSD) in Vietnam veterans to criminal behavior. A conceptual framework is discussed which proposes that the disposition to criminal behavior is determined by whether or not the veteran enters into the survivor mode of functioning as a behavioral defense mechanism against the disorder. It is hypothesized that there exists a relationship between the severity of PTSD and the tendency to commit illegal acts. The Vietnam Era Stress Inventory (Wilson and Krauss, 1980) was used to assess PTSD among a volunteer national sample of Vietnam combat veterans (N = 114) participating in the Veterans Administration's counseling program known as Operation Outreach. The results strongly supported the hypothesis and indicated that combat role variables, exposure to stressors in Vietnam and the severity of PTSD were significantly correlated with criminal acts. [ABSTRACT FROM AUTHOR]