Understanding PTSD and Partner Violence Prevention

1. Post Traumatic Stress Disorder and Partner Violence Prevention Casey Taft, Ph.D. National Center for PTSD, VA Boston Healthcare System Boston University School of Medicine

2. Overview • PTSD Overview • Neurobiology of PTSD • PTSD and General Family Functioning • PTSD and Partner Violence • Strength at Home Program

3. 6 Criteria for PTSD Diagnosis • Stressor- A threatening event accompanied by fear, helplessness, or horror • Reexperiencing • Avoidance • Arousal • Duration (> 1 month) • Distress or Impairment

4. Avoidance Reexperiencing • Flashbacks • Thoughts & feelings • Intrusive memories • Activities/Places/People • Dreams P T S D • Amnesia ost • Loss of interest • Psychological distress • w/ reminders • Detachment 1 3 raumatic • Restricted affect • Physiological PTSD • Foreshortened • reactivity • future tress 2 isorder Sleep difficulties Hypervigilance • Irritability & anger • Startle • Concentration Arousal

5. Think of PTSD as a failure to recover from a traumatic event • If the event is severe enough, nearly everyone will have symptoms reflective of PTSD

6. Functional Brain Changes [fMRI] Gray Matter Volumetry Identifying Biomarkers of PTSD

7. Fear Circuitry Brain Structures • Amygdala • Threat detection and fear conditioning • Exaggerated activation in response to trauma-related memories • Exaggerated activation for non trauma-related stimuli • Activation positively related to PTSD symptom severity • Medial Prefrontal Cortex • Extinction (learn stimuli no longer aversive) • Anterior Cingulate Cortex (rACC): Diminished activation in PTSD • Dorsal Anterior Cingulate Cortex (dACC) : Exaggerated activation • Hippocampus • Memory encoding (e.g., context during fear conditioning) • Diminished activation in PTSD and lower hippocampal volumes

8. R amygdala PTSD>Control, Fear vs. Happy PTSD participants viewing fearful facial expressions during fMRI Shin et al., 2005 Arch Gen Psychiatry

9. Imaging of Treatment Bryant et al., 2008 Psychological Medicine

10. How well do treatments work? Results from Meta-Analysis Psychotherapies shown in green Drugs shown in yellow Cognitive-behavioral therapy is most effective Note. Effect sizes are computed from the difference between groups in individual studies at posttreatment Watts et al., 2007

11. PTSD and General Family Functioning

12. Relationship “Quantity” • National Comorbidity Study (Kessler et al., 1998) • Nationally representative population survey • Psychiatric disorders and divorce • Prior psychiatric disorders leading to future divorce • 1.6 greater odds of divorce for PTSD • .9 odds ratio for Social and Specific Phobias • 3.2 odds ratio for Manic Episode • 1.7 odds ratio for MDD • Higher than all substance use disorders

13. Relationship “Quantity” • National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990) • Combat veterans with PTSD compared with those without PTSD were: • Less likely to marry • 2X more likely to divorce (70% vs 34.9%) • 3X more likely to have multiple divorces (22% vs 8%)

14. PTSD and Relationship Quality • In veterans, PTSD associated with: • More relationship distress • Less cohesion • Less emotional expressiveness and engagement • More intimacy difficulties • More areas of relationship conflict • Domestic violence and problems with anger

15. PTSD and Relationship Satisfaction Re-experiencing Avoidance/Numbing Hyperarousal Emotional Numbing Effortful Avoidance

16. Other Mechanisms • Secondary traumatization • Caregiver burden • Changes in family roles

17. Secondary Traumatization “The natural consequent behaviors and emotions resulting from knowledge about a stressful event experienced by a significant other” (Figley, 1998).

18. Secondary Traumatization in Peacekeepers’ Partners Dirkzwager, Bramsen, Ader, & van der Ploeg, 2005

19. Caregiver Burden • Degree to which caregivers perceive their emotional or physical health, social life, or financial status to be affected by caring for their impaired partner • Many stressors for caregivers • Crisis management • Symptom management • Social isolation • Financial problems • Family strain

20. Emotional Cycles of DeploymentStage 1: Pre-deployment • Warning order for deployment to actual deployment • Denial of separation • Anticipation of loss • Conflict as couple attempts to get affairs in order • Sadness and anger as couple emotionally prepares for hurt of separation • Easier to express anger • Fears of infidelity and relationship loss • Concerns about children • Emotional distance and closing off emotions

21. Emotional Cycles of DeploymentStage 2: Deployment • Departure through first month • Roller coaster of mixed emotions • Some feel disoriented or overwhelmed • Others may feel relieved no longer have to appear strong • Residual anger at tasks left undone • Feelings of numbness, sadness, abandonment • Difficulty sleeping and anxiety about coping • Concerns about family and household

22. Emotional Cycles of DeploymentStage 3: Sustainment • First month through the fifth month of deployment • Establish new routines and sources of support • May feel more confident and in control • Frustration from inconsistent contact with spouse • Coping with rumors

23. Emotional Cycles of DeploymentStage 4: Re-deployment • One month before return from deployment • Intense anticipation • Conflicting emotions • Excitement for reunion • Concerns about changes in partner and relationship • Concerns about changes in family roles

24. Emotional Cycles of DeploymentStage 5: Post-deployment • Begins with arrival to home station • “Homecoming” can be disappointing • “Honeymoon” period in which couples reunite physically, but not necessarily emotionally • Negotiating changes in family roles • Resentments of “abandonment” may remain • Spouse may be more irritable and desire more space • Relationships may be strengthened

25. PTSD and Partner Violence

26. Partner Violence Rates • Yearly: 13.3% to 32% • Heyman and Neidig (1999) • Military versus civilian rates • Representative data adjusting for demographic differences • Unadjusted rates substantially higher in military sample • Adjusted rates • Military sample reported more severe violence • Rates of moderate violence more comparable

27. Deployment and Relationship Conflict • Iraq Active and Reserve Soldiers (Milliken, Auchterlonie, & Hoge, 2007) • Initial mental health screening (PDHA) and 3-6 month follow-up (PDHRA) • Concerns about interpersonal conflict increased 4-fold • The largest increase of any mental health concern • 3.5% to 14% in Active Duty • 4.2% to 21.1% in Reserves

28. PTSD and Partner Violence • Military service members not more violent than civilians in absence of significant stress and/or PTSD (Bradley, 2007) • National Vietnam Veterans Readjustment Study (Kulka et al., 1990) • Past year rates: • Veterans with PTSD = 33% • Veterans without PTSD = 13.5%

29. PTSD and Partner Violence Re-experiencing Avoidance/Numbing Hyperarousal

31. Survival Mode Model • Vigilance to threats in warzone leads combat veteran to enter into survival mode inappropriately when stateside • Perceive unrealistic threats • Exhibit hostile appraisal of events • Overvalue aggressive responses to threats • Exhibit lower threshold for responding to the threat Chemtob et al., 1997

32. Information Processing Model for Domestic Violence • Violent men exhibit cognitive deficits (e.g., faulty attributions, irrational beliefs) that impact interpretation (decoding stage) • Violent men have difficulty generating a variety of nonviolent responses (decision-making stage) • Violent men may lack the behavioral skills to enact a competent response (enactment stage) • The process influenced by “transitory factors” such as alcohol use, traumatic brain injury, etc. Holtzworth-Munroe, 1992

33. Other Contributing Factors • Depression • Alcohol use problems • Traumatic brain injury

34. Depression • 1/3 to 2/3 of veterans with PTSD have lifetime depression (Erickson et al., 2001) • Taft et al. (2005) • Comorbid depression a strong risk factor for partner violence in those with PTSD • Cognitive Neoassociationistic Model (Berkowitz, 1990) • Dysphoric affect connected to anger-related feelings, thoughts, memories, and aggressive inclinations • Dysphoric affect activates entire anger network

35. Alcohol Use Problems • Alcohol abuse/dependence the most highly comorbid psychiatric problem with PTSD (Kulka et al., 1990) • PTSD related to binge drinking in particular (Adams et al., 2006) • Self-medication hypothesis • Alcohol leads to aggression through impact on executive functioning (Giancola, 2000) • Alcohol use disinhibits violence among those high in hyperarousal (Savarese et al., 2001) and anger (Eckhardt, 2007)

36. Traumatic Brain Injury • Reported by 19% of OEF/OIF soldiers during their deployment (Tanielian & Jaycox, 2008) • Associated with executive functioning deficits such as self-regulation and awareness (Knight & Taft, 2004) • Associated with personality changes, loss of temper, communication difficulties, and relationship problems (Warnken et al., 1994) • Can lead to difficulties inhibiting behavior and regulating emotions among those with PTSD • TBI rates range from 40% - 61% in abusers

37. Core Themes • Trust • Self- and Other-Esteem • Power Conflicts

38. Trust • Trust in others disrupted by trauma • Trauma may have been caused by someone who was supposed to be trustworthy • Others may have made poor decisions or mistakes • Soldiers may feel that they can’t trust anyone or others are out to hurt or betray them • Mistrust can carry over into relationships • Controlling behavior may result

39. Self- and Other-Esteem • Veterans with PTSD may unfairly blame selves for traumas • Low self-esteem leads to depression, insecurity in relationships, and abuse • Trauma and PTSD can also influence views of other people • Traumas may lead one to believe that people are not good or can’t be respected • May generalize this belief to everyone, leading to problems with social withdrawal and anger

40. Power Conflicts • Exposure to trauma may contribute to a sense of powerlessness (Rosenbaum & Leisring, 2003) • Feelings of powerlessness contribute to conflicts regarding power in relationships (e.g., Schwartz et al., 2005) • Partner violence theories highlight beliefs related to power in relationships (Pence & Paymar, 1993)

41. Strength at Home Program

42. Strength at Home: Couples Program • Centers for Disease Control and Prevention • Goal is to prevent conflict and domestic violence in OEF/OIF veterans with PTSD • Relationship distress but no current violence • Couples-based group format (10 sessions) • 3-5 couples per group • Male and female co-therapist

43. Strength at Home: Couples Program • Phase I (Sessions 1-3): Psychoeducation • Education on PTSD and impact on relationships • Promoting insight into relationship difficulties • Core themes • Phase II (Sessions 4-5): Conflict Management • Roots of conflict management style • Assertiveness training • Time Outs to de-escalate difficult situations • Stress reduction • Phase III (Sessions 6-9): Communication Skills • Listening skills • Emotional expression • Communication “traps” • Phase IV (Session 10): Termination

44. Strength at Home: Veterans Program • VA and Department of Defense • Goal is to prevent conflict and domestic violence in OEF/OIF veterans with PTSD • Some recent conflict or violence • Individual (non-couple) group format (12 sessions) • 6-10 veterans per group • Male and female co-therapist

45. Strength at Home: Veterans Program • Session 1: Introduction and Welcoming • Session 2: PTSD and Relationships • Session 3: Conflict Management I: Understanding Anger • Session 4: Conflict Management II: Time Outs • Session 5: Coping Strategies I:Anger-related Thinking • Session 6: Coping Strategies II: Dealing with Stress • Session 7: Communication Skills I: Roots of Your Communication Style • Session 8: Communication Skills II: Active Listening • Session 9: Communication Skills III: Assertive Messages • Session 10: Communication Skills IV: Expressing Feelings • Session 11: Communication Skills V: Common Communication Traps • Session 12: Reviewing Treatment Gains and Planning for Future

46. www.StrengthAtHome.com Contact Sarah Krill (857) 364-4173 Sarah.Krill@va.gov