Posttraumatic Stress Disorder and Domestic Violence

1
Posttraumatic Stress Disorderand Domestic
Violence

• David S. Riggs, Ph.D.
• Center for Deployment Psychology

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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

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Domestic Violence in the Military

• Rates obtained from anonymous surveys are larger

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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)

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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)

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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 POWs, more
  severe PTSD was related to more severe DV

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PTSD Definition and Description
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Lifetime Prevalence Of Trauma
Percent
Kessler 2000
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Combat Exposure in Iraq
Hoge, et al, 2004, NEJM
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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

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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

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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

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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
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Diagnosis of PTSD Associated Symptoms

• Guilt, shame, despair
• Hostility, aggression
• Social isolation, loss of beliefs
• Feeling constantly threatened
• Poor health

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PTSD and Domestic ViolencePotential Links
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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

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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

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Increased Morbidity With PTSD
Percent
Davidson 1991
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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, 1995
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Anxiety Disorders Impact of Trauma and PTSD
Anxiety Disorder Patients
No Trauma
Trauma
PTSD
Suicide attempts () 6 16 30 Hospitalization
() 30 38 48 Alcohol abuse/dependence
() 21 34 38
PTSD vs other groups plt0.001 plt0.01 PTSD
and trauma vs control plt0.001
Warshaw et al Am J Psychiatry 19931501514
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Substance Use Disorders and Trauma/PTSD
Estimates of trauma exposure In general
population 40 - 70 In SUD population 35 -
90 Estimates of PTSD In general
population 5 - 12.5 In SUD population 30
- 50 Estimates of Alcohol Dependence In
general population 7 - 9 In PTSD
population 30 - 68
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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

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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

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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)

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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

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Increased Medical Problems in PTSDGW1 Veterans
Percent
Barrett et al., 2002
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Decreased Quality of Life with PTSDGW1 Veterans
Score
Barrett et al., 2002
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Decreased Quality of Life with PTSD Vietnam
Veterans
Percent
Zatzick et al., 1997
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Impaired Quality of Life in PTSD
SF-36 Score
Malik et al. J Trauma Stress. 199912387.
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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

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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)

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Cued Traumatic Responses
External Trauma Cues Sights Sounds Smells Situati
ons
Internal Trauma Cues Emotional State Physical
State Thoughts
Traumatic Reactions Emotions Thoughts Arousal
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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

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PTSD and Problem-Solving Deficits
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Social Information Processing
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Impact of Trauma Memory on Social Information
Processing
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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

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Pre-Trauma Characteristics That Contribute to
Persistent PTSD

• Personal History Characteristics
• Psychiatric History
• Prior Trauma
• Child Abuse
• Other adverse childhood events
• Family Psychiatric History

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