Posttraumatic Stress Disorderand Domestic Violence

David S. Riggs, Ph.D.

Center for Deployment Psychology

Domestic Violence in the Military

Rates of domestic violence within the military are difficult to establish (also true in civilian settings)

Rates of reported cases 1990 - 1.9%1996 - 2.6%2004 - 1.4%

Counts only cases of violence against a legal spouse reported to military authorities or Family Advocacy Programs

Domestic Violence in the Military

Rates obtained from anonymous surveys are larger

Sample Size DV Rates

Pan et al., (1994) 15,023 30%

Heyman & Neidig (1999) 27,502

2537

13.3%

17.5%

Rosen et al., (2002) 716 32%

Bohannon et al., (1995) 94 47%

Links Between PTSD and Domestic Violence

National Vietnam Veterans Readjustment Survey

– About 1/3 of veterans with PTSDS perpetrated violence in the prior year (Jordan et al., 1990)

– PTSD veterans were 2-3 times more likely to perpetrate than those without PTSD

– More severe PTSD symptoms were associated with more severe DV (Orcutt et al., 2003)

Links Between PTSD and Domestic Violence

Other Studies of Vietnam Veterans

– Veterans with PTSD were more likely to perpetrate violence (Beckham et al., 1997)

– More severe PTSD is associated with more severe DV (Byrne & Riggs, 1996; Beckham et al., 1997)

– Over ½ of a group of veterans being treated for PTSD reported DV (Hiley-Young et al., 1995)

Links Between PTSD and Domestic Violence

Studies of Other Samples

– In a civilian sample seeking treatment for PTSD or for substance abuse, those with PTSD were more likely to perpetrate DV (Parrott et al., 2003)

– In adolescents, More severe trauma-related symptoms are associated with more severe violence in dating relationships (Wolfe et al., 2004)

– In a sample of WW II and Korean War POW’s, more severe PTSD was related to more severe DV

PTSD: Definition and Description

Lifetime Prevalence Of Trauma

0

20

40

60

80

100

Any One Multiple

Men

Women

Kessler 2000

Per

cen

t

Combat Exposure in Iraq

95%93%

89%86%86%

80%77%

69%65%

50%48%

38%22%22%

21%14%14%

8%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Seeing Dead Bodies/RemainsShot At/Receiving Small Arms Fire

Being Attacked/AmbushedReceiving Artillery, Rocket, Mortar Fire

Knowing Someone Killed/Ser. InjuredClearing/Searching Homes

Shooting/Directing Fire at EnemyIll/Injured Women/Child Couldn't Help

Seeing Dead/Serious Inj. AmericansHandling/Uncovering Human RemainsResp. for Death of Enemy Combatant

Participating in Demining OpsBuddy Shot/Hit Near You

Engaged in Hand-to-Hand CombatSaved Soldier/Civilian LifeBeing Wounded or Injured

Responsible for Noncombatant DeathClose Call/Hit but Saved by Gear

Hoge, et al, 2004, NEJM

Common Reactions to Trauma

Fear and anxiety

Intrusive thoughts about the trauma

Nightmares of the trauma

Sleep disturbance

Feeling jumpy and on guard

Concentration difficulties

Common Reactions to Trauma

Avoiding trauma reminders

Feeling numb or detached

Feeling angry, guilty, or ashamed

Grief and depression

Negative image of self and world– The world is dangerous – I am incompetent– People can not be trusted

PTSD: Diagnostic Criteria

• Reexperiencing (1 of 5)– Thoughts, nightmares, flashbacks, emotional reactions,

physiological reactions

• Avoidance (3 of 7)– Avoid thoughts, avoid reminders, amnesia,detachment,

numbing, anhedonia, forshortened future

• Arousal (2 of 5)– Sleep disturbance, concentration problems, anger,

hypervigilance, startle

BattleMind Training

• Battlemind skills helped you survive in combat, but may cause you problems if not adapted when you get home.

Buddies (cohesion) vs. Withdrawal

Accountability vs. Controlling

Targeted Aggression vs. Inappropriate Aggression

Tactical Awareness vs. Hypervigilance

Lethally Armed vs. “Locked and Loaded” at Home

Emotional Control vs. Anger/Detachment

Mission OPSEC vs. Secretiveness

Individual Responsibility vs. Guilt

Non-Defensive Driving vs. Aggressive Driving

Discipline and Ordering vs. Conflict

Diagnosis of PTSD: Associated Symptoms

• Guilt, shame, despair

• Hostility, aggression

• Social isolation, loss of beliefs

• Feeling constantly threatened

• Poor health

PTSD and Domestic Violence:Potential Links

Risk Factors For DV(From Riggs et al., 2000 and Stith et al., 2004)

• Depression• Substance use• Marital distress and conflict• Life Stress• Anger and hostility• Intense emotional reactions to threat• Poor problem solving skills• Violence in the family of origin

Risk Factors For DV(From Riggs et al., 2000 and Stith et al., 2004)

• Depression• Substance use• Marital distress and conflict• Life Stress• Anger and hostility• Intense emotional reactions to threat• Poor problem solving skills• Violence in the family of origin

Increased Morbidity With PTSD

Davidson 1991

0

10

20

30

40

50

60

GAD MDD Som Drug Abuse Asthma Ulcer Hypertension

PTSD

No PTSD

Percent

PTSD comorbidity

• Lifetime PTSD and…• 1 or more psychiatric disorder: 79-88%

• 3 or more psychiatric disorders: 44-59%

• PTSD typically precedes the onset of comorbid psychiatric disorders

Kessler et al, 1995Kessler et al, 1995

Anxiety Disorders: Impact of Trauma and PTSD

Suicide attempts (%) 6 1630*

Hospitalization (%) 30 3848†

Alcohol abuse/dependence (%) 21 34

38‡

Warshaw et al Am J Psychiatry 1993;150:1514

Anxiety Disorder Patients

No Trauma Trauma PTSD

PTSD vs other groups: * p<0.001; † p<0.01

PTSD and trauma vs control: ‡ p<0.001

Substance Use Disorders and Trauma/PTSD

Estimates of trauma exposure:In general population: 40% - 70%In SUD population: 35% - 90%

Estimates of PTSDIn general population: 5% - 12.5%In SUD population: 30% - 50%

Estimates of Alcohol DependenceIn general population: 7% - 9%In PTSD population: 30% - 68%

PTSD and Substance Use

In PTSD Patients, substance abuse is associated with:

more severe PTSD dissociative symptoms borderline personality characteristics

In Substance Abusers, trauma is associated with:

more severe substance use higher rates of depression more anxiety antisocial personality suicide attempts

Risk Factors For DV(From Riggs et al., 2000 and Stith et al., 2004)

• Depression• Substance use• Marital distress and conflict• Life Stress• Anger and hostility• Intense emotional reactions to threat• Poor problem solving skills• Violence in the family of origin

PTSD and Marital Distress

• Vietnam Veterans with PTSD experience more marital distress than those without PTSD (Carroll et al., 1985; Jordan et al., 1992; Riggs et al., 1998)

• More severe PTSD symptoms are associated with greater distress and relationship conflict

(Riggs et al., 1998)

• In WW II and Korean War POWs, more severe PTSD related to greater relationship distress (Cook et al., 2004)

Risk Factors For DV(From Riggs et al., 2000 and Stith et al., 2004)

• Depression• Substance use• Marital distress and conflict• Life Stress• Anger and hostility• Intense emotional reactions to threat• Poor problem solving skills• Violence in the family of origin

Increased Medical Problems in PTSDGW1 Veterans

Barrett et al., 2002

0

20

40

60

80

100PTSD

No PTSD

Percent

Decreased Quality of Life with PTSDGW1 Veterans

Barrett et al., 2002

0

20

40

60

80

100

PhysicalFunct

PhysicalRole

Pain GeneralHealth

Vitality SocialFunct

EmotionalRole

MentalHealth

PhysicalSummary

MentalSummary

PTSD

No PTSD

Score

Decreased Quality of Life with PTSD Vietnam Veterans

Zatzick et al., 1997

0

20

40

60

Physical Limitation Lower Well-being Poor Health Sever Violence Not Working

PTSD

No PTSDPercent

0

25

50

75

100

Vitality Social Function

PTSD

US Population

Depression

Impaired Quality of Life in PTSD

Malik et al. J Trauma Stress. 1999;12:387.

SF-36 Score

Risk Factors For DV(From Riggs et al., 2000 and Stith et al., 2004)

• Depression• Substance use• Marital distress and conflict• Life Stress• Anger and hostility• Intense emotional reactions to threat• Poor problem solving skills• Violence in the family of origin

PTSD and Anger

• PTSD has been repeatedly associated with higher levels of anger and hostility

• Veterans with PTSD respond with more hostility in non-provoking interpersonal interactions (Beckham et al., 1996)

• Veterans with PTSD experience an increase in anger following trauma primes (Pitman et al., 1997; Taft et al., 2005)

Cued Traumatic Responses

External Trauma Cues

SightsSoundsSmells

Situations

Internal Trauma Cues

Emotional StatePhysical State

Thoughts

Traumatic ReactionsEmotionsThoughtsArousal

Risk Factors For DV(From Riggs et al., 2000 and Stith et al., 2004)

• Depression• Substance use• Marital distress and conflict• Life Stress• Anger and hostility• Intense emotional reactions to threat• Poor problem solving skills• Violence in the family of origin

PTSD and Problem-Solving Deficits

PTSD PTSD

Positive Scales Negative Scales

Overall PS -.64

Positive Orientation -.44 Negative Orientation .68

Rational PS -.44 Impulsive Style .53

Problem Definition -.44 Avoidant Syyle .56

Generation of Alternatives

-.45

Decision Making -.37

Implementation -.36

EmotionsMemoriesExperience

Attention

1

Cue Interpretation2

Response Generation

Response Selection

Enactment Skills

3

5

4

Social Information Processing

ActivatedTrauma

Memory andEmotion

Attentional Bias

1

lnterpretational Bias2

Limited Response Generation

Biased Response Selection

Impaired Enactment Skills

3

5

4

Impact of Trauma Memory on Social Information Processing

Risk Factors For DV(From Riggs et al., 2000 and Stith et al., 2004)

• Depression• Substance use• Marital distress and conflict• Life Stress• Anger and hostility• Intense emotional reactions to threat• Poor problem solving skills• Violence in the family of origin

Pre-Trauma Characteristics That Contribute to Persistent PTSD

• Personal History Characteristics

– Psychiatric History– Prior Trauma – Child Abuse– Other adverse childhood events– Family Psychiatric History

PTSD DV

Traumaseverity

Low Socialsupport

Traumaprocessing

Acceptviolence

Traditionalsex roles

Jealousy

Depression

Anger

Substance use

Poor problem solving

Marital distress

Marital conflict

Stress