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