The Moderating Role of Alexithymia in the Relationship Between Anger and Intimate Partner Violence Perpetration in Veterans

Abstract

Among the factors influencing intimate partner violence (IPV), alexithymia and anger have emerged as key areas of concern, though few studies have examined these risk factors together. In this study, we examined the interactive effects of alexithymia and anger on psychological and physical IPV perpetration in a sample of 130 male veterans. Participants were recruited through clinician referrals, self-referrals, and court referrals from two major metropolitan areas in the Northeast, and all veterans reported at least one trauma exposure in their lifetime. The following self-report measures were used: the 20-item Toronto Alexithymia Scale, the Trait Anger Scale of the State-Trait Anger Expression Inventory, and the Psychological Aggression and Physical Assault subscales of the Revised Conflict Tactics Scale. Moderation analyses were conducted, and findings revealed a statistically significant interactive effect between anger and alexithymia on psychological IPV. However, the interactive effect was only statistically significant for those without clinically significant alexithymia. At higher levels of alexithymia, there was no interactive effect with anger, suggesting that less emotional awareness is directly associated with psychological IPV use regardless of the individual’s level of anger. These findings underscore the complex interplay between alexithymia, anger, and IPV in veterans and highlight the importance of more nuanced intervention strategies that take varying levels of anger and alexithymia into account. Focusing on promoting healthy anger expression while also targeting emotional awareness and processing may be particularly beneficial for those with lower, but present, levels of anger and alexithymia.

Keywords

alexithymia anger psychological intimate partner violence physical intimate partner violence veterans

Introduction

Intimate partner violence (IPV), which encompasses physical, sexual, and psychological aggression, is a public health crisis that affects millions in the United States each year (Leemis et al., 2022; Veggi et al., 2024). Veterans have unique risks for IPV, as intimate relationships may be impacted by exposure to warzone stress and other unique stressors (Cowlishaw et al., 2024; Klostermann et al., 2012). Approximately 13% of all active-duty personnel and veterans reported recent IPV perpetration (Cowlishaw et al., 2022). Trauma exposure can lead to deficits in social information processing, which influences how one interprets and processes information gathered from the social environment (Cole et al., 2022), as well as anger. Anger’s interference with rational cognitive processing may also exacerbate alexithymia, a condition characterized by difficulty identifying feelings, difficulty expressing feelings, and externally oriented thinking, which increases IPV risk (Berke et al., 2017; Holtzworth-Munroe, 1992). While there is some research examining anger and alexithymia among veterans (Berke et al., 2017; Morland et al., 2012; Varker et al., 2022), few studies have examined the strength of the underlying relationship between anger and alexithymia, and how they may work in conjunction to exacerbate IPV among military populations. Clinically, this might manifest as a veteran who experiences frequent irritability or frustration with their partner but struggles to identify or label these emotional states. As anger intensifies, limited emotional awareness hinders their ability to effectively communicate their feelings, leading to aggressive behaviors toward their partner. This study aimed to explore the interactive effects of alexithymia and anger on IPV perpetration in a sample of male veterans.

The relationship between anger and aggression has been examined in both civilian and military and veteran populations. Although empirical studies consistently show a positive, moderate association between anger and aggression (r = .20–.40; Birkley & Eckhardt, 2015; Eckhardt et al., 2004), these constructs are distinct. According to (Morland et al., 2012), anger is considered an internal emotional state characterized by physiological symptoms, while aggression involves outward behaviors. Anger can contribute to and be influenced by aggression, but anger is not necessary or sufficient for aggression to occur (Novaco, 1976). The State-Trait Anger Expression Inventory (STAXI; Spielberger, 1988) differentiates between state anger (i.e., temporary, in-the-moment feelings of anger) and trait anger (i.e., the frequency with which anger is typically experienced across different situations), as well as the experience of anger (i.e., state and trait anger) and the expression of anger. Thus, the STAXI- particularly the Trait Anger subscale used in the current study- addresses components of anger that are distinct from aggression (Morland et al., 2012).

Examining the association between anger and IPV in this high-risk population requires recognition of the functional role of anger in the military, particularly among those who served in combat (Forbes et al., 2022). Soldiers with combat history reported increased levels of anger and aggression compared to soldiers who were not previously deployed, and those with multiple deployments had especially high levels of anger (Afari et al., 2015; Campbell-Sills et al., 2023). Anger is considered a normal reaction to undesirable circumstances and may serve as an adaptive response by preparing an individual to face a particular threat (Forbes et al., 2022). However, anger is considered problematic at certain levels of frequency or intensity that cause significant distress and interfere with interpersonal functioning and relationships (Spielberger, 1988). Problematic anger is commonly seen in veterans, since trauma exposure can lead to social information processing biases that overestimate perceptions of threat (Chemtob et al., 1997; Dodge et al., 2006). Therefore, veterans may interpret ambiguous stimuli in an overly hostile manner and respond with high levels of aggression (Cole et al., 2022; Morland et al., 2012), increasing the risk of the use of violence in their intimate relationships. Research has identified a positive association between anger and psychological and physical IPV perpetration, as well as the presence of increased levels of outward anger expression and decreased anger control in IPV offenders (Barbour et al., 1998; Birkley & Eckhardt, 2015; Eckhardt et al., 2004, 2008; Murphy et al., 2007; Shorey et al., 2011). Anger among military populations is often considered in the context of post-traumatic stress disorder (PTSD) and is characterized by difficulty recognizing early warning signs, rapid escalations in anger, and trouble engaging in adaptive coping mechanisms (Morland et al., 2012; Varker et al., 2022).

The Anger Avoidance Model (Gardner & Moore, 2008) posits that it is not the experience of anger, but an inability to attend to and communicate emotions associated with anger, that leads to the use of aggression (Birkley & Eckhardt, 2015; Gardner et al., 2014; Strickland et al., 2017; Tull et al., 2007). This model aligns with research findings about the influence of emotion dysregulation on maladaptive anger expression (Birkley & Eckhardt, 2015; Velotti et al., 2016), as well as evidence supporting the idea that alexithymia may influence IPV perpetration among military populations (Garofalo et al., 2018; Romero-Martínez et al., 2019, 2021; Strickland et al., 2017). More specifically, this model lends support to the notion that anger may be more strongly related to IPV when higher levels of alexithymia are also present.

Alexithymia is also associated with PTSD, in that alexithymia may develop because an individual experiences relief when they are less acutely aware of their own feelings related to the traumatic event (Berke et al., 2017; Dubé et al., 2023; Frewen et al., 2008). Approximately 10% of the population is affected by alexithymia (Franz et al., 2008; Mattila et al., 2006). Alexithymia has biological (Jørgensen et al., 2007; Valera & Berenbaum, 2001), psychological, and environmental component causes (Brown et al., 2016), including structural differences in the brain and exposure to trauma (Zeitlin et al., 1993). Research reveals that individuals higher in alexithymia are more likely to use destructive externalizing behaviors in response to unfavorable situations to regulate distressing and confusing emotions and mitigate negative affective states, such as the experience of anger. (Cohn et al., 2009, 2010; Garofalo et al., 2018; Kahramanol & Dag, 2018; Strickland et al., 2017). In fact, there is evidence that acts of violence or aggression may be an attempt to shield oneself from painful emotional experiences resulting from difficulties reflecting on one’s own emotional states (Velotti et al., 2016). Those with high levels of alexithymia may have less awareness of their anger, especially if they have lower levels of anger, and therefore may not be able to access effective coping skills to implement before becoming aggressive. Therefore, anger may have a stronger association with IPV in the presence of elevated levels of alexithymia.

Since anger increases emotional arousal and alexithymia impairs one’s ability to recognize, understand, and express those emotions constructively, it is expected that alexithymia would moderate the relationship between anger and IPV. In other words, the interplay between anger and alexithymia increases the risk of maladaptive conflict behaviors because emotional arousal (i.e., anger) is not recognized by the individual and therefore goes unmanaged. This is especially relevant to military populations, who are at a higher risk of experiencing both anger and alexithymia due to trauma histories (Berke et al., 2017; Cole et al., 2022; Morland et al., 2012; Varker et al., 2022). Individuals with trauma exposure may exhibit an elevated threat response to ambiguous stimuli (Chemtob et al., 1997; Dodge et al., 2006), increasing the likelihood of aggressive behavior, particularly among those who struggle to identify and manage their anger. We are not aware of studies examining the underlying relationships between anger, alexithymia, and IPV in veterans, or of research examining to what degree anger and alexithymia may jointly influence IPV perpetration.

In the current study, we examined whether alexithymia moderated the relationship between anger and psychological and physical IPV perpetration in a sample of veterans. The following hypotheses were tested: (a) anger and alexithymia would have a significant and direct relationship with psychological IPV; (b) anger and alexithymia would have a significant and direct relationship with physical IPV; (c) alexithymia would significantly moderate the association of anger with psychological and physical IPV, such that individuals with higher levels of alexithymia would be more likely to express anger aggressively in the form of IPV behaviors.

Methods

Participants

This study used data from a randomized clinical trial of the Strength at Home program, a trauma-informed, cognitive behavioral intervention designed to reduce and end IPV (Taft, Macdonald, et al., 2016). Participant data were collected at two Veterans Affairs (VA) hospitals between February 2010 and August 2013. The sample in the parent study included 135 male veterans and service members; however, five of these participants were not included in our analysis because of missing data in one or more of our main variables of interest. Our analysis focused on a subsample of 130 male service members and veterans (96.3% of the current sample). Participants were recruited through clinician referrals, self-referrals, and court referrals from two major metropolitan areas in the Northeast.

In the parent study, inclusion criteria included a report of at least one act of male-to-female physical IPV over the previous 6 months, severe physical IPV over the past 12 months, or an ongoing legal problem with IPV. Exclusion criteria included severe cognitive impairment, current substance dependence not in remission, or current uncontrolled bipolar or psychotic disorder. Enrollment was open to participants regardless of whether they were in an intimate partnership at the time of the study. Of the male participants enrolled, 118 (82.2%) had female partners who provided verbal consent for telephone interviews, allowing us to collect data about IPV victimization experiences (i.e., collateral IPV data). The entire sample was in a heterosexual relationship either during or prior to the study.

The mean age of the sample was 37.88 (SD = 12.72) and 80.5% of the sample identified as White, which is typical of veteran samples drawn from VA clinics. Among participants with available rank data (n = 111), the sample consisted primarily of enlisted personnel (99.1%), including junior enlisted service members (73.4%) and noncommissioned officers (25.7%), with a small proportion of commissioned officers (0.9%). Regarding branch of service, 57.1% served in the Army, 22.3% in the Marine Corps, 15.2% in the Navy, and 5.4% in the Air Force. The majority of participants (62.8%) were veterans of the recent conflicts in Iraq and Afghanistan. All veterans reported at least one trauma exposure in their lifetime, and over 65% of male participants reported exposure to military combat.

Procedure

Study procedures were initially approved by the VA Boston Healthcare System IRB on August 11, 2008 (IRB#2188). All study procedures were also approved by the Institutional Review Boards at each site. Participants provided written informed consent, followed by an initial assessment conducted to determine their eligibility for the study. Veterans completed assessments either in person or through web assessment, and partners completed assessments via a phone call. Participants were paid $50 for completing each assessment. Procedures are described more fully in Taft, Macdonald, et al. (2016).

Measures

Intimate Partner Violence

Lifetime psychological and physical IPV was assessed using the Psychological Aggression (8 items) and the Physical Assault (12 items) subscales of the Revised Conflict Tactics Scale (CTS2; Straus et al.,1996). Both male participants and their female partners reported lifetime perpetration of IPV by the male participant, ranging from 0 (never) to 6 (more than 20 times). To calculate CTS2 scores, the higher score of the two individual item responses was used. This approach is commonly employed to mitigate underreporting, as CTS2 scores reflect the highest reported frequency for each item regardless of whether the response came from the participant or their partner. IPV subscale scores were calculated by summing the number of items that were positively endorsed, known as “variety scores.” This scoring method ensures that each behavior is given equal weight, minimizes skewness from a few individuals who may report very high frequencies of IPV, and is considered the most reliable method given the potential limitations in memory recall regarding frequency of behaviors (Moffitt et al., 1997).

Alexithymia

Alexithymia was assessed using the 20-item Toronto Alexithymia Scale (TAS-20; Bagby et al.,1994). The TAS-20 is comprised of three subscales: Difficulty Identifying Feelings (e.g., “I am often confused about what emotion I am feeling”), Difficulty Describing/Expressing Feelings (e.g., “It is difficult for me to find the right words for my feelings”), and Externally Oriented Thinking (EOT). Those who score high on the EOT subscale tend to process information in an externally oriented, pragmatic manner and often have difficulty engaging in introspection and recognizing the emotional aspects of their experiences. Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating higher levels of alexithymia. The TAS-20 uses cutoff scoring, with scores equal to or less than 51 indicating non-alexithymia, scores of 52 to 60 indicating possible alexithymia, and scores equal to or greater than 61 indicating alexithymia. The TAS-20 total score has shown acceptable reliability and validity among clinical populations (Bagby et al., 2007; Thorberg et al., 2011). The TAS-20 exhibited excellent internal consistency in the current sample (α = .92).

Anger

Anger was assessed using the 10-item Trait Anger Scale of the STAXI, a validated self-report measure designed to evaluate individual differences in the disposition to experience anger (Spielberger, 1988). The scale asks participants to answer questions about self-characterizations as to whether or not they tend to be angry. Items are rated on a 4-point Likert scale ranging from 1 (almost never) to 4 (almost always), with higher scores indicating a greater disposition toward anger. Although the updated version of the scale (STAXI-2) contains revised items and improved psychometric properties (Spielberger, 1999), the original STAXI also demonstrates excellent psychometric characteristics and strong evidence of construct validity (Spielberger, 1988). The Trait Anger Scale exhibited excellent internal consistency in the current sample (α = .90).

Data Analytic Strategy

The distributional properties of all study variables (i.e., anger, alexithymia, psychological IPV, and physical IPV) were examined. Each variable demonstrated skewness and kurtosis values within acceptable ranges for normal distributions (i.e., + or −2). Specifically, skewness values ranged from −0.52 to 0.12, and kurtosis values ranged from −1.15 to −0.19, indicating no substantial deviations from normality. Although the Shapiro-Wilk test of normality was significant for both IPV variables, this pattern is expected because the CTS2 psychological and physical IPV variables represent count-based behaviors and include many low-frequency responses, which typically produce floor effects in veteran and military samples. Histograms and Q-Q plots indicated only slight deviations from normality. The data also met the statistical assumptions of linear regression. Specifically, linearity and homoscedasticity were assessed by examining standardized residuals and indicated no violations. Residuals were approximately normally distributed, and predictors were not too highly correlated with each other. Therefore, multicollinearity was not a concern. No significant outliers were identified.

All analyses were conducted using IBM SPSS version 29.0. First, descriptive statistics and Pearson bivariate correlations among main variables were examined. To test our hypotheses, we conducted two regression analyses by entering anger (STAXI Trait score) and alexithymia (TAS-20 total score) at step 1, and their interaction at step 2, using the CTS2 scale scores for psychological and physical IPV as criterion variables. To probe significant interaction effects post-hoc, we used both simple slope analyses and the Johnson-Neyman approach because each provides complementary information about the nature of the moderation. Simple slope analyses allowed us to examine the strength of the association between anger and IPV outcomes at low and high levels of alexithymia, defined as one standard deviation (SD) below and above the mean, respectively. These levels roughly correspond to non-alexithymic, potentially alexithymic, and alexithymic ranges, putting our results in the context of existing literature that uses these categorical dimensions. The Johnson-Neyman approach identified a specific range of scores for which the effect of anger and IPV use was significant, revealing the exact point at which the association transitions between significant and non-significant (Bauer & Curran, 2005; Spiller et al., 2018). This facilitates a more precise and continuous understanding of the moderator. Together, these approaches provide both a continuous and categorical perspective of the moderation effect.

Results

A summary of descriptive statistics and bivariate correlations is provided in Table 1. Participants in this sample endorsed an average STAXI trait anger score of 23.01 (SD = 6.75) and a TAS-20 score of 57.2 (SD = 13.2), with scores between 52 and 60 indicative of possible alexithymia (Bagby et al., 1994). Based on the TAS-20 cutoff scores, 33.8% of participants were classified as non-alexithymic, 23.3% as possibly alexithymic, and 42.9% met criteria for alexithymia. Participants reported using psychological IPV an average of 5.8 times (SD = 1.7) in their lives, and physical IPV an average of 4.5 times (SD = 3.0). Correlations revealed a significant moderate, positive association between anger and alexithymia and lifetime use of psychological and physical IPV. Smaller correlations were observed for lifetime use of psychological IPV with anger and alexithymia. Consistent with expectations for moderated relationships, lifetime use of physical IPV was not correlated with anger or alexithymia in this sample.

Table 1.

Descriptive Statistics and Bivariate Correlations.

Variable	1	2	3	4
1. Anger^a	—
2. Alexithymia^b	.49^**	—
3. Psychological IPV^c	.24^**	.18*	—
4. Physical IPV^c	.12	.14	.48^**	—
Mean	23.01	57.25	5.84	4.46
SD	6.74	13.25	1.69	2.95

Note. N = 135. Anger = STAXI Trait subscale (Spielberger, 1988); Alexithymia = TAS-20 total score (Bagby et al.,1994); Psychological IPV and Physical IPV = CTS2 subscales (Straus et al., 1996); IPV = intimate partner violence.

Predictor.

Moderator.

Outcome.

p < .01. *p < .05.

The main and interactive effects of anger and alexithymia on psychological and physical IPV are depicted in Table 2. For lifetime use of psychological IPV, significant main effects were observed for anger (B = 0.25, SE = 0.10, p < .05) and alexithymia (B = 0.09, SE = 0.04, p < .05), such that those with higher levels of anger and those with greater difficulties with emotional awareness reported more moments of using psychological IPV in their lifetime. Standardized coefficients from Step 1 indicated small effects for both anger (β = .20) and alexithymia (β = .08). Of note, the direct effect of alexithymia was not significant in Step 1 before the interactive effect of anger and alexithymia was added to the model. In step 2, the interactive effect was significant (B = −0.004, SE = 0.002, p < .05, ΔR² = .03). Standardized coefficients from the final model indicated large effects for anger (β = 1.00), alexithymia (β = .70), and the interaction term (β = −1.24). Simple slope analyses were conducted to probe the interaction at low (1 SD below the mean) and high (1 SD above the mean) levels of alexithymia (Figure 1). These analyses revealed that anger was significantly associated with lifetime use of psychological IPV for those with low (B = 0.09, SE = 0.03, p < .05) but not high (B = 0.002, SE = 0.03, NS) alexithymia. The Johnson-Neyman technique indicated that the association between anger and psychological IPV was statistically significant only when alexithymia scores fell below 57.6, and 46.9% of the current sample reported alexithymia scores in this range. Below this value, changes in anger were not significantly associated with psychological IPV use. However, above this value, higher levels of anger were associated with greater psychological IPV use. The full model accounted for 30% of the variance in lifetime use of psychological IPV (F[3,126] = 4.27, p < .01, R² = .30). To further clarify the significant alexithymia-anger interaction predicting psychological IPV, we conducted simple slopes and Johnson-Neyman analyses with anger specified as the moderator (Figure 2). Simple slopes analyses indicated that alexithymia was positively associated with psychological IPV at high levels of anger (1 SD above mean), but not at low levels of anger (1 SD below the mean). Consistent with these findings, Johnson-Neyman analyses indicated that the association between alexithymia and psychological IPV was statistically significant only when anger scores exceeded 16.6.

Table 2.

Main and Interactive Effects of Trait Anger and Alexithymia on Psychological and Physical IPV.

Variable	B	β	SE	t	p	95% CI		ΔR ²
Psychological IPV
Step 1
Anger	0.05	.20	0.02	2.02	<.05	0.001	0.098
Alexithymia	0.011	.08	0.01	0.829	.409	−0.015	0.036	.06
Step 2
Anger	0.25	1.00	0.10	2.51	<.05	0.053	0.448
Alexithymia	0.09	.70	0.04	2.23	<.05	0.010	0.171
Anger × Alexithymia	−0.004	1.24	0.002	−2.08	<.05	−0.007	−0.0002	.03
Physical IPV
Step 1
Anger	0.03	.08	0.04	0.749	.455	−0.054	0.120
Alexithymia	0.02	.10	0.02	1.00	.317	−0.022	0.069	.02
Step 2
Anger	0.27	.61	0.18	1.49	.138	−0.087	0.621
Alexithymia	0.11	.50	0.07	1.60	.111	−0.027	0.255
Anger × Alexithymia	−0.004	.81	0.003	−1.35	.179	−0.010	0.002	.01

Note. N = 135. Bolded paths indicate significance at p < .05. Psychological and Physical IPV = CTS2 subscales (Straus et al., 1996); Anger = STAXI Trait subscale (Spielberger, 1988); Alexithymia = TAS-20 total score (Bagby et al., 1994); IPV = intimate partner violence.

Figure 1.

Simple slopes of anger predicting psychological aggression at low and high levels of alexithymia.

Figure 2.

Simple slopes of alexithymia predicting psychological aggression at low and high levels of anger.

For lifetime use of physical IPV, neither the direct effects of anger and alexithymia, nor the interactive effect was significant.

Discussion

The aim of this study was to examine the direct and interactive effects of alexithymia and anger on lifetime psychological and physical IPV use in a sample of male veterans. Although previous research confirms that higher levels of anger and alexithymia are independently associated with physical and psychological IPV use, no study to date has examined the interrelationships between anger, alexithymia, and IPV within military populations. Specifically, little is known about whether the association between anger and IPV differs as a function of emotional awareness, such that anger may lead to increased risk for IPV at higher levels of alexithymia. Consistent with prior research and our hypotheses (Barbour et al., 1998; Berke et al., 2017; Eckhardt et al., 2008; Shorey et al., 2011), anger and alexithymia both demonstrated a significant main effect on psychological IPV. A significant interactive effect between alexithymia and anger was observed for psychological IPV; however, the interactive effect was only significant at lower levels of alexithymia. Inconsistent with our hypotheses and previous research, there was no main effect of anger or alexithymia, nor an interactive effect of these two variables, on physical IPV perpetration (Eckhardt et al., 2008; Shorey et al., 2011).

The interpretation of these findings should be considered in the context of the severity of anger and alexithymia observed in this sample. Trait anger scores in the current sample were modestly elevated compared to normative data for adult men in the general population but remained below levels typically observed in psychiatric samples (Spielberger, 1999). This suggests that while anger is clinically relevant in veteran samples, anger’s role in IPV perpetration may depend on co-occurring alexithymia rather than anger intensity alone. The mean TAS-20 score was higher than published normative data for general adult male and psychiatric samples (Preece et al., 2018), with 66.2% of the current sample meeting criteria for alexithymia or possible alexithymia. This indicates that deficits in emotional awareness are highly prevalent in veteran populations and may play a salient role in IPV perpetration.

Regarding psychological IPV, the interactive effect was only significant for veterans who reported higher levels of emotional awareness (i.e., low alexithymia). Alternatively, for those with lower levels of emotional awareness (i.e., high alexithymia), there was no interactive effect with anger. These findings suggest that individuals with lower levels of emotional awareness use more psychological IPV compared to those with greater emotional awareness, regardless of their anger level. Notably, the Johnson-Neyman inflection point (i.e., where the interaction between anger and alexithymia changes from significant to not significant) is a score of 61.5 on the TAS-20, which closely aligns with the established cutoff score of 61, indicating alexithymia, and lends additional support to the interpretation of our findings. Overall, anger and alexithymia independently predicted psychological IPV; however, among individuals with poorer emotional insight and awareness (i.e., high alexithymia), anger did not influence their tendency to engage in psychological IPV with their partner.

With respect to physical IPV, neither anger nor alexithymia nor the interaction between these two variables demonstrated a significant effect. Although this finding is surprising and contradicts existing literature that posits a relationship between anger and physical IPV (Maldonado et al., 2015; O’Hair 2022; Shorey et al., 2008, 2011), there are a few possible explanations for these results. Consistent with the broader literature on community veteran samples (Kwan et al., 2020), participants in the current study reported lower frequencies of physical IPV compared to psychological IPV. This means that the range was restricted, reducing the statistical power to detect main and interaction effects. In addition, prior studies revealing a relationship between anger and physical IPV used samples comprising female offenders and college students, whereas our sample included male veterans. The mean age of 37.97 suggests that veteran samples tend to be slightly older and therefore in longer-term relationships, and physical IPV may be more prevalent earlier and in younger relationships. Military socialization may also play a role: the military emphasizes discipline and behavioral control (Manekin, 2017), potentially shifting aggression toward non-physical forms of IPV (i.e., psychological IPV). Finally, the underlying mechanisms that facilitate IPV may differ among different groups. Of note, Shorey et al. (2011) found that trait anger significantly predicted physical IPV among women when regressed simultaneously with impulsivity. The absence of a main effect of anger on physical IPV among our sample reflects the influence of other potential moderators—such as impulsivity, substance use, and PTSD arousal—that may be more proximal predictors of physical IPV than anger alone.

These results have important clinical implications for IPV intervention programs. For instance, interventions should help individuals address anger expression, as well as target emotional awareness and processing to reduce reliance on maladaptive suppression strategies and improve relational dynamics. Focusing on promoting healthy anger expression while also targeting emotional awareness and processing may be particularly beneficial for those with lower, but present, levels of anger and alexithymia. However, it is important to consider that individuals who receive treatment for anger and IPV often have severe presentations prior to treatment. Treatments that address alexithymia by facilitating greater emotional insight may be more beneficial for individuals with low or moderate levels of anger, whereas for individuals with high levels of anger, there may be no additional benefit. In addition, it has been demonstrated among samples of individuals who use IPV that deficits in cognitive processing and emotion regulation may impact/weaken their response to intervention (Strickland et al., 2017). This is particularly important to keep in mind when working with individuals who have less emotional awareness (i.e., high alexithymia). Specific treatment approaches tailored to the needs of people who use IPV and are challenged by alexithymia, including those with alexithymia because of trauma or that co-occurs with autism, may require approaches that address unique learning style differences, the need for support related to social communication challenges, and executive function accommodations.

A primary limitation of this study is that the sample characteristics may limit the generalizability and interpretation of findings within military and veteran populations. The sample was drawn from a VA clinical population and therefore reflects treatment-seeking veterans rather than the broader U.S. military, consistent with prior IPV research with veterans conducted in VA healthcare settings (Taft et al., 2016a). As such, our findings primarily reflect the experiences of enlisted veterans and may not generalize to commissioned officers or non-treatment–seeking service members. Military experiences are heterogeneous, and factors such as rank and combat exposure may substantially shape behavioral health outcomes, emotional functioning, and IPV experiences. Due to the limited variability of rank in the present sample, we were unable to meaningfully examine rank-related differences in the current analyses. Future studies with more diverse military samples should examine the role of rank, combat exposure, referral source (i.e., self-referral versus court-ordered), and military sexual trauma as potential moderators of these associations.

In addition, the sample included mainly white and heterosexual veterans, further limiting the generalizability to more diverse military populations, including racial and ethnic minorities, women, LGBTQ+ populations, and non-veterans. The exclusion of participants with substance dependence also likely resulted in a sample with a more moderate risk profile, given the increased risk for substance use disorders among military and veteran populations with PTSD (U.S. Department of Veterans Affairs, 2025). This may have contributed to reduced variability in the variables examined, possibly attenuating observed effects. Restricting the sample to male-to-female IPV also narrows the scope of our results, since the relationship between anger, alexithymia, and IPV perpetration may differ in female-to-male or male-to-male perpetration.

A further limitation is that data were collected through self-report measures to assess our main outcomes of interest. Therefore, participants may have underreported the frequency of IPV use due to social desirability bias stemming from societal norms and community standards against relationship violence (Berke et al., 2017). In addition, individuals with alexithymia who have trouble identifying their emotions may not reliably or accurately report on self-report measures related to anger, emotions, and IPV. These concerns may be especially relevant in military and veteran populations, where concerns related to disclosure may influence reporting of emotional experiences and aggressive behaviors. This study attempted to address these biases by collecting collateral IPV data from partners to improve the accuracy of IPV assessment. Follow-up investigations may also be enhanced by including performance-based assessments of cognitive and emotional experiences, as well as a multimethod assessment of IPV use (Berke et al., 2017), to inform intervention efforts.

The current study provides new information regarding the interplay between alexithymia, anger, and IPV perpetration in the veteran population. Results revealed that alexithymia and anger demonstrated a direct effect on psychological, but not physical IPV, and that their interaction was significant for individuals with greater emotional awareness. This suggests that anger may play a more salient role in driving psychological IPV among veterans who can better identify and interpret their emotions, whereas those with high alexithymia report similar patterns of psychological IPV use regardless of anger. In contrast, physical IPV was not significantly predicted by either anger or alexithymia in this sample, diverging from existing research based on civilian and female samples. These findings emphasize the need for more nuanced intervention strategies that focus on promoting healthy anger expression while also targeting emotional awareness and processing, particularly when working with veterans with low to moderate levels of anger.

Footnotes

ORCID iDs

Marisa J. Alkalay

Maya Zegel

Emily F. Rothman

Casey T. Taft

Ethical Considerations

Study procedures were initially approved by the VA Boston Healthcare System IRB on August 11, 2008. IRB#2188.

Consent to Participate

All survey participants were provided written informed consent.

Funding

The authors disclosed receipt of the following financial support for the research and/or authorship of this article: This work was supported by a grant from the Department of Defense, PT073945. ClinicalTrials.gov identifier: NCT01435512.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are not publicly available due to their sensitive nature but are available from the corresponding author on reasonable request.*

Author Biographies

Marisa J. Alkalay, BA, is a research technician at the National Center for PTSD, VA Boston Healthcare System. Her research focuses on attitudes and beliefs surrounding campus sexual assault and risk factors for engaging in intimate partner violence. She is interested in evaluating and disseminating sexual assault and intimate partner violence prevention programs among college students and minoritized populations.

Maya Zegel, PhD, is an interprofessional advanced addictions fellow at VA Boston Healthcare System. Her research explores mechanisms that underly PTSD and alcohol use, particularly among veterans, first responders, and couples.

Emily F. Rothman, ScD, is professor and chair of the Occupational Therapy Department at Boston University, with a secondary appointment at the BU School of Public Health. Her research has focused on understanding the etiology of, and preventing, intimate partner and sexual violence. More recently, she has been developing interventions to prevent sexual and intimate partner violence for autistic people.

Casey T. Taft, PhD, is a staff psychologist at the National Center for PTSD, VA Boston Healthcare System and a professor of psychiatry at Boston University Aram V. Chobanian & Edward Avedisian School of Medicine. His research focuses on understanding and preventing partner violence. He is the primary developer of Strength at Home, an intimate partner violence intervention program.

References

Afari

Pittman

Floto

Owen

Buttner

Hossain

Baker

D. G.

Lindamer

Lohn

J. B.

(2015). Differential impact of combat on postdeployment symptoms in female and male veterans of Iraq and Afghanistan. Military Medicine, 180(3), 296–303. https://doi.org/10.7205/milmed-d-14-00255

Bagby

R. M.

Parker

J. D.

Taylor

G. J.

(1994). The twenty-item Toronto Alexithymia Scale—I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38(1), 23–32. https://doi.org/10.1016/0022-3999(94)90005-1

Bagby

R. M.

Taylor

G. J.

Quilty

L. C.

Parker

J. D.

(2007). Reexamining the factor structure of the 20-item Toronto alexithymia scale: Commentary on Gignac, Palmer, and Stough. Journal of Personality Assessment, 89(3), 258–264. https://doi.org/10.1080/00223890701629771

Barbour

K. A.

Eckhardt

C. I.

Davison

G. C.

Kassinove

(1998). The experience and expression of anger in maritally violent and maritally discordant-nonviolent men. Behavior Therapy, 29, 173–191. https://doi.org/10.1016/S0005-7894(98)80001-4

Bauer

D. J.

Curran

P. J.

(2005). Probing interactions in fixed and multilevel regression: Inferential and graphical techniques. Multivariate Behavioral Research, 40(3), 373–400. https://doi.org/10.1207/s15327906mbr4003_5

Berke

D. S.

Macdonald

Poole

G. M.

Portnoy

G. A.

McSheffrey

Creech

S. K.

Taft

C. T.

(2017). Optimizing trauma-informed intervention for intimate partner violence in veterans: The role of alexithymia. Behaviour Research and Therapy, 97, 222–229. https://doi.org/10.1016/j.brat.2017.08.007

Birkley

E. L.

Eckhardt

C. I.

(2015). Anger, hostility, internalizing negative emotions, and intimate partner violence perpetration: A meta-analytic review. Clinical Psychology Review, 37, 40–56. https://doi.org/10.1016/j.cpr.2015.01.002

Brown

Fite

P. J.

Stone

Bortolato

(2016). Accounting for the associations between child maltreatment and internalizing problems: The role of alexithymia. Child Abuse & Neglect, 52, 20–28. https://doi.org/10.1016/j.chiabu.2015.12.008

Campbell-Sills

Kautz

J. D.

Choi

K. W.

Naifeh

J. A.

Aliaga

P. A.

Jain

Sun

Kessler

R. C.

Stein

M. B.

Ursano

R. J.

Bliese

P. D.

(2023). Effects of prior deployments and perceived resilience on anger trajectories of combat-deployed soldiers. Psychological Medicine, 53, 2031–2040. https://doi.org/10.1017/S0033291721003779

10.

Chemtob

C. M.

Novaco

R. W.

Hamada

R. S.

Gross

D. M.

(1997). Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 65(1), 184–189. https://doi.org/10.1037/0022-006X.65.1.184

11.

Cohn

A. M.

Seibert

L. A.

Zeichner

(2009). The role of restrictive emotionality, trait anger, and masculinity threat in men’s perpetration of physical aggression. Psychology of Men & Masculinity, 10(3), 218–224. https://doi.org/10.1037/a0015151

12.

Cohn

A. M.

Jakupcak

Seibert

L. A.

Hildebrandt

T. B.

Zeichner

(2010). The role of emotion dysregulation in the association between men’s restrictive emotionality and use of physical aggression. Psychology of Men & Masculinity, 11(1), 53–64. https://doi.org/10.1037/a0018090

13.

Cole

H. E.

Gilbar

Gnall

K. E.

Eckhardt

C. I.

Taft

C. T.

(2022). Examining executive functioning as a moderator of intimate partner violence risk in veterans. Journal of Family Violence, 37(8), 1419–1430. https://doi.org/10.1007/s10896-021-00339-5

14.

Cowlishaw

Freijah

Kartal

Sbisa

Mulligan

Notarianni

Couineau

A. L.

Dubé

Tremblay-Perreault

Allard-Cobetto

Hébert

(2024). Alexithymia as a mediator between intimate partner violence and post-traumatic stress symptoms in mothers of children disclosing sexual abuse. Journal of Family Violence, 39(3), 359–367. https://doi.org/10.1007/s10896-023-00512-y

15.

Cowlishaw

Freijah

Kartal

Sbisa

Mulligan

Notarianni

Couineau

A. L.

Forbes

O’Donnell

Phelps

Iverson

K. M.

Heber

O’Dwyer

Smith

Hosseiny

(2022). Intimate partner violence (IPV) in military and veteran populations: A systematic review of population-based surveys and population screening studies. International Journal of Environmental Research and Public Health, 19(14), 8853. https://doi.org/10.3390/ijerph19148853

16.

Dodge

K. A.

Coie

J. D.

Lynam

(2006). Aggression and antisocial behavior in youth. In Eisenberg

Damon

Lerner

R. M.

(Eds.), Handbook of child psychology: Social, emotional, and personality development (6th ed., pp. 719–788). John Wiley & Sons, Inc.

17.

Dubé

Tremblay-Perreault

Allard-Cobetto

Hébert

(2023). Alexithymia as a mediator between intimate partner violence and post-traumatic stress symptoms in mothers of children disclosing sexual abuse. Journal of Family Violence, 39, 359–367. https://doi.org/10.1007/s10896-023-00512-y

18.

Eckhardt

Holtzworth-Munroe

Norlander

Sibley

Cahill

(2008). Readiness to change, partner violence subtypes, and treatment outcomes among men in treatment for partner assault. Violence and Victims, 23(4), 446–475. https://doi.org/10.1891/0886-6708.23.4.446

19.

Eckhardt

Norlander

Deffenbacher

(2004). The assessment of anger and hostility: A critical review. Aggression and Violent Behavior, 9(1), 17–43. https://doi.org/10.1016/S13591789(02)00116-7

20.

Forbes

Metcalf

Lawrence-Wood

Adler

A. B.

(2022). Problematic anger in the military: Focusing on the forgotten emotion. Current Psychiatry Reports, 24, 789–797. https://doi.org/10.1007/s11920-022-01380-x

21.

Franz

Popp

Schaefer

Sitte

Schneider

Hardt

Decker

Braehler

(2008). Alexithymia in the German general population. Social Psychiatry and Psychiatric Epidemiology, 43(1), 54–62. https://doi.org/10.1007/s00127-007-0265-1

22.

Frewen

P. A.

Dozois

D. J.

Neufeld

R. W.

Lanius

R. A.

(2008). Meta-analysis of alexithymia in post-traumatic-stress disorder. Journal of Traumatic Stress, 2, 243–246. https://doi.org/10.1002/jts.20320

23.

Gardner

F. L.

Moore

Z. E.

(2008). Understanding clinical anger and violence: The anger avoidance model. Behavior Modification, 32(6), 897–912. https://doi.org/10.1177/0145445508319282

24.

Gardner

F. L.

Moore

Z. E.

Dettore

(2014). The relationship between anger, childhood maltreatment, and emotion regulation difficulties in intimate partner and non-intimate partner violent offenders. Behavior Modification, 38(6), 779–800. https://doi.org/10.1177/0145445514539346

25.

Garofalo

Velotti

Cavatina

G. C.

(2018). Emotion regulation and aggression: The incremental contribution of alexithymia, impulsivity, and emotion dysregulation facets. Psychology of Violence, 8, 470–483. https://doi.org/10.1037/vio0000141

26.

Holtzworth-Munroe

(1992). Social skill deficits in maritally violent men: Interpreting the data using a social information processing model. Clinical Psychology Review, 12(6), 605–617. https://doi.org/10.1016/0272-7358(92)90134-T

27.

Jørgensen

M. M.

Zachariae

Skytthe

Kyvik

(2007). Genetic and environmental factors in alexithymia: A population-based study of 8,785 Danish twin pairs. Psychotherapy and Psychosomatics, 76(6), 369–375. https://doi.org/10.1159/000107565

28.

Kahramanol

Dag

(2018). Alexithymia, anger and anger expression styles as predictors of psychological symptoms. Düşünen Adam: Journal of Psychiatry and Neurological Sciences, 31(1), 30–39. https://doi.org/10.5350/DAJPN2018310103

29.

Klostermann

Mignone

Kelley

M. L.

Musson

Bohall

(2012). Intimate partner violence in the military: Treatment considerations. Aggression and Violent Behavior, 17(1), 53–58. https://doi.org/10.1016/j.avb.2011.09.004

30.

Kwan

Sparrow

Facer-Irwin

Thandi

Fear

N. T.

MacManus

(2020). Prevalence of intimate partner violence perpetration among military populations: A systematic review and meta-analysis. Aggression and Violent Behavior, 53, Article 102419. https://doi.org/10.1016/j.avb.2020.101419

31.

Leemis

R. W.

Friar

Khatiwanda

Chen

M. S.

Kresnow

Smith

S. G.

Caslin

Basile

K. C.

(2022). The National Intimate Partner and Sexual Violence Survey: 2016/2017 report on Intimate partner violence. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/124646

32.

Maldonado

R. C.

Watkins

L. E.

DiLillo

(2015). The interplay of trait anger, childhood physical abuse, and alcohol consumption in predicting intimate partner aggression. Journal of Interpersonal Violence, 30(7), 1169–1189. https://doi.org/10.1177/0886260514539850

33.

Manekin

(2017). The limits of socialization and the underproduction of military violence: Evidence from the IDF. Journal of Peace Research, 54(5), 606–619. https://doi.org/10.1177/0022343317713558

34.

Mattila

A. K.

Salminen

J. K.

Numbi

Joukamaa

(2006). Age is strongly associated with alexithymia in the general population. Journal of Psychosomatic Research, 61(5), 629–635.

35.

Moffitt

T. E.

Caspi

Krueger

R. F.

Magdol

Margolin

Silva

P. A.

Sydney

(1997). Do partners agree about abuse in their relationship?: A psychometric evaluation of interpartner agreement. Psychological Assessment, 9(1), 47–56. https://doi.org/10.1037/1040-3590.9.1.47

36.

Morland

L. A.

Love

A. R.

Mackintosh

M. A.

Greene

C. J.

Rosen

C. S.

(2012). Treating anger and aggression in military populations: Research updates and clinical implications. Clinical Psychology: Science and Practice, 19(3), 305–322. https://doi.org/10.1111/cpsp.12007

37.

Murphy

C. M.

Taft

C. T.

Eckhardt

C. I.

(2007). Anger problem profiles among partner violent men: Differences in clinical presentation and treatment outcome. Journal of Counseling Psychology, 54(2), 189–200. https://doi.org/10.1037/0022-0167.54.2.189

38.

Novaco

R. W.

(1976). Treatment of chronic anger through cognitive and relaxation controls. Journal of Consulting and Clinical Psychology, 44(4), 681–681. https://doi.org/10.1037/0022-006x.44.4.681

39.

O’Hair

(2022). Alcohol use, trait anger, and intimate partner violence in college student couples (Master’s Thesis). University of Wisconsin-Milwaukee. https://dc.uwm.edu/etd/2928

40.

Preece

Becerra

Robinson

Dandy

(2018). Assessing alexithymia: Psychometric properties and factorial invariance of the 20-item Toronto alexithymia scale in nonclinical and psychiatric samples. Journal of Psychopathology and Behavioral Assessment, 40(2), 276–287. https://doi.org/10.1007/s10862-017-9634-6

41.

Romero-Martínez

Á.

Lila

Moya-Albiol

(2019). The importance of considering alexithymia during initial stages of intimate partner violence interventions to design adjuvant treatments. International Journal of Environmental Research and Public Health, 16(19), 3695. https://doi.org/10.3390/ijerph16193695

42.

Romero-Martínez

Á.

Lila

Moya-Albiol

(2021). Alexithymic traits are closely related to impulsivity and cognitive and empathic dysfunctions in intimate partner violence perpetrators: New targets for intervention. Applied Neuropsychology: Adult, 28(1), 71–79. https://doi.org/10.1080/23279095.2019.1594233

43.

Shorey

R. C.

Brasfield

Febres

Stuart

G. L.

(2011). The association between impulsivity, trait anger, and the perpetration of intimate partner and general violence among women arrested for domestic violence. Journal of Interpersonal Violence, 26, 2681–2697.

44.

Shorey

R. C.

Cornelius

T. L.

Bell

K. M.

(2008). An examination of the association between difficulties with emotion regulation and dating violence perpetration. Journal of Aggression, Maltreatment and Trauma, 20(8), 870–885. https://doi.org/10.1080/10926771.2011.629342

45.

Spielberger

C. D.

(1988). State-Trait Anger Expression Inventory (STAXI) [Database record]. APA PsycTests.

46.

Spielberger

C. D.

(1999). State-Trait Anger Expression Inventory–2 (STAXI-2): Professional manual. Psychological Assessment Resources.

47.

Spiller

S. A.

Fitzsimons

G. J.

Lynch

J. G.

McClelland

G. H.

(2018). Spotlights, floodlights, and the magic number zero: Simple effects tests in moderated regression. Journal of Marketing Research, 50(2), 277–288. https://doi.org/10.1509/jmr.12.0420

48.

Straus

M. A.

Hamby

S. L.

Boney-McCoy

Sugarman

D. B.

(1996). The revised Conflict Tactics Scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17(3), 283–316. https://doi.org/10.1177/019251396017003001

49.

Strickland

Parry

C. L.

Allan

M. M.

Allan

(2017). Alexithymia among perpetrators of violent offences in Australia: Implications for rehabilitation. Australian Psychologist, 52(3), 230–237. https://doi.org/10.1111/ap.12187

50.

Taft

C. T.

Macdonald

Creech

S. K.

Monson

C. M.

Murphy

C. M.

(2016a). A randomized controlled clinical trial of the strength at home men’s program for partner violence in military veterans. Journal of Clinical Psychiatry, 77(9), 1168–1175. https://doi.org/10.4088/JCP.15m10020

51.

Taft

C. T.

Murphy

C. M.

Creech

S. K.

(2016b). Trauma-informed treatment and prevention of intimate partner violence (pp. 35–40). American Psychological Association. https://doi.org/10.1037/14918-004

52.

Thorberg

F. A.

Young

R. M.

Sullivan

K. A.

Lyvers

Connor

J. P.

Feeney

G. F.

(2011). Alexithymia, craving and attachment in a heavy drinking population. Addictive Behaviors, 36, 427–430. https://doi.org/10.1016/j.addbeh.2010.12.016

53.

Tull

M. T.

Jakupcak

Paulson

Gratz

K. L.

(2007). The role of emotional inexpressivity and experiential avoidance in the relationship between posttraumatic stress disorder symptom severity and aggressive behavior among men exposed to interpersonal violence. Anxiety, Stress and Coping, 20(4), 337–351. https://doi.org/10.1080/10615800701379249

54.

U.S. Department of Veterans Affairs. (2025). Treatment of co-occurring PTSD and substance use disorder in VA. National Center for PTSD. https://ptsd.va.gov/PTSD/professional/treat/cooccurring/tx_sud_va.asp

55.

Valera

E. M.

Berenbaum

(2001). A twin study of alexithymia. Psychotherapy and Psychosomatics, 70(5), 239–246. https://doi.org/10.1159/000056261

56.

Varker

Cowlishaw

Baur

McFarlane

A. C.

Lawrence-Wood

Metcalf

Van Hooff

Sadler

O’Donnell

M. L.

Hodson

Benassi

Forbes

(2022). Problem anger in veterans and military personnel: Prevalence, predictors, and associated harms of suicide and violence. Journal of Psychiatric Research, 151, 57–64. https://doi.org/10.1016/j.jpsychires.2022.04.004

57.

Veggi

Benfante

Di Tella

Roveta

Castelli

Zara

(2024). Intimate partner violence and alexithymia: Do emotions matter? A systematic review and meta-analysis. Journal of Trauma, Violence, & Abuse, 25(3), 2521–2534. https://doi.org/10.1177/15248380231217045

58.

Velotti

Garofalo

Callea

Bucks

R. S.

Roberton

Daffern

(2016). Exploring anger among offenders: The role of emotion dysregulation and alexithymia. Psychiatry, Psychology and Law, 24(1), 128–138. https://doi.org/10.1080/13218719.2016.1164639

59.

Zeitlin

S. B.

McNally

R. J.

Cassiday

K. L.

(1993). Alexithymia in victims of sexual assault: An effect of repeated traumatization? American Journal of Psychiatry, 150, 661–663. https://doi.org/10.1176/ajp.150.4.661