Posttraumatic Stress Disorder and Domestic Violence

1. Posttraumatic Stress Disorderand Domestic Violence David S. Riggs, Ph.D. Center for Deployment Psychology

2. 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

3. Domestic Violence in the Military Rates obtained from anonymous surveys are larger

4. 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)

5. 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)

6. 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

7. PTSD: Definition and Description

8. Lifetime Prevalence Of Trauma Percent Kessler 2000

9. Combat Exposure in Iraq Hoge, et al, 2004, NEJM

10. 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

11. 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

12. 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

13. 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

14. Diagnosis of PTSD: Associated Symptoms • Guilt, shame, despair • Hostility, aggression • Social isolation, loss of beliefs • Feeling constantly threatened • Poor health

15. PTSD and Domestic Violence:Potential Links

16. 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

17. 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

18. Increased Morbidity With PTSD Percent Davidson 1991

19. 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

20. 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: * p<0.001; † p<0.01 PTSD and trauma vs control: ‡ p<0.001 Warshaw et al Am J Psychiatry 1993;150:1514

21. 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%

22. 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

23. 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

24. 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)

25. 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

26. Increased Medical Problems in PTSDGW1 Veterans Percent Barrett et al., 2002

27. Decreased Quality of Life with PTSDGW1 Veterans Score Barrett et al., 2002

28. Decreased Quality of Life with PTSD Vietnam Veterans Percent Zatzick et al., 1997

29. Impaired Quality of Life in PTSD SF-36 Score Malik et al. J Trauma Stress. 1999;12:387.

30. 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

31. 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)

32. Cued Traumatic Responses External Trauma Cues Sights Sounds Smells Situations Internal Trauma Cues Emotional State Physical State Thoughts Traumatic Reactions Emotions Thoughts Arousal

33. 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

34. PTSD and Problem-Solving Deficits

35. Response Selection 4 Response Generation 3 Emotions Memories Experience Enactment Skills 5 Cue Interpretation 2 Attention 1 Social Information Processing

36. Biased Response Selection 4 Limited Response Generation 3 Activated Trauma Memory and Emotion Impaired Enactment Skills 5 lnterpretational Bias 2 Attentional Bias 1 Impact of Trauma Memory on Social Information Processing

37. 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

38. Pre-Trauma Characteristics That Contribute to Persistent PTSD • Personal History Characteristics • Psychiatric History • Prior Trauma • Child Abuse • Other adverse childhood events • Family Psychiatric History

39. DV PTSD Accept violence Trauma severity Depression Anger Substance use Poor problem solving Marital distress Marital conflict Stress Traditional sex roles Low Social support Trauma processing Jealousy