MILITARY SERVICE MEMBERS and POSTTRAUMATIC STRESS DISORDER Jamie Anderson Natalie Miklas

1. MILITARY SERVICE MEMBERS and POSTTRAUMATIC STRESS DISORDER Jamie Anderson & Natalie Miklas

2. THROUGH THE EYES OF A COMBAT VETERAN� �Even when I am happy, I am sad. The war is like a permanent dent in my heart and mind�All I feel is anger and pain about what happened over there, yet I am sick and tired of thinking about it. Why can�t I turn off the memories?�In my dreams, dismembered bodies�and the people I killed come back to life�angry at me�Deep down I hate myself�hate myself, hate myself, hate myself�for what I became over there, for things that weren�t even my fault�Damn, where do I go to get away from my own head�.

3. FAST FACTS The U.S. is nearing its ninth year of continuous combat and U.S. military could be engaged at some level in both Afghanistan and Iraq for years to come (Tanielian & Jaycox, 2008) There are currently 1,638,817 deployed service members in Afghanistan and Iraq (Tanielian & Jaycox, 2008) 11% of soldiers and 18% of soldiers returning home from Iraq and Afghanistan respectively will be diagnosed with posttraumatic stress disorder (PTSD) (Hoge et al., 2004)

4. OVERVIEW OF PTSD According to the Diagnostic and Statistical Manual, text revision (DSM-IV-TR), diagnostic criteria for PTSD: History of exposure to a traumatic event Symptoms in two of the three clusters: Re-experiencing Avoidance and numbing Hyperarousal Symptoms that last longer than three months Significant distress or impairment in social, occupational, or other important areas of functioning (American Psychological Association, 2000)

5. BIOLOGY OF PTSD When a person is exposed to repeated or prolonged trauma, functioning of various transmitters, neurohormones, and other biochemical changes occur (Matsakis, 2007) The adrenal glands are stimulated when faced with a perceived or real threat (Matsakis, 2007) The normal restraint on the amygdala is disrupted; creating an abnormal state of hypervigilence (Friedman, 2006)

7. PTSD AND INTIMATE PARTNER RELATIONSHIPS ��veterans see themselves as toxic because they expect to harm others with their knowledge of the hideousness of war�if you knew what I knew, it would fuck you up.� Dr. Jonathan Shay, author & psychiatrist

8. RELATIONSHIP STRESSORS IN A MILITARY COUPLE Military personnel and families experience unique stressors: long separations � as much as 10 months/year frequent moves combat training exposure to violence fear of death low pay/financial stress infidelities

9. PTSD AND INTIMATE PARTNER RELATIONSHIPS Additionally, family life has traditionally been molded to fit the needs of the military, putting military first and family issues as less of a priority. Stressors can have a negative impact on a relationship and even contribute to episodes of domestic violence.

10. DISTRESS IN INTIMATE RELATIONSHIPS National Vietnam Veterans Readjustment Study (NVVRS) found that male Vietnam veterans diagnosed with PTSD and their partners reported more numerous and severe relationship problems, more aggression and violence, greater parenting problems, and generally poorer family adjustment compared with those without PTSD 70% of military couples in which soldier has PTSD reported relationship distress Soldiers with PTSD are less self-disclosing and expressive with partners, and have more anxiety about intimacy compared to those without PTSD Their partners reported lower happiness and life satisfaction and higher demoralization relative to partners of soldiers without PTSD Greater PTSD symptom severity is related to higher relationship distress

11. DISTRESS IN INTIMATE RELATIONSHIPS PTSD symptoms particularly damaging to relationships: Emotional numbing a natural and normal response in a situation of crisis; however, once back at home it hinders the ability to establish or maintain close relationships often the primary factor interfering with the quality of relationship functioning after combat trauma constricted intimacy and expressiveness, limited expression of emotion, and lack of self-disclosure

12. DISTRESS IN INTIMATE RELATIONSHIPS cont. Emotional/behavioral withdrawal - often follows episodes of dramatic re-experiencing of trauma cues or angry outbursts Hyper-arousal - appears to be particularly strongly associated with violence perpetration Partners and family members often mistake the soldier�s symptoms or trigger reactions as signs of rejection. Foster feelings of helplessness, loneliness, frustration, irritability, and resentment toward the soldier

13. SECONDARY TRAUMATIZATION Individuals living in close proximity to victims of violent trauma can themselves become indirect victims of that trauma: an individual who has not been directly exposed to a trauma develops trauma symptoms after learning of an event indirectly through someone who experienced it refers to any transmission of distress from someone who experienced a trauma to those around them Spouses can also experience PTSD related to the soldier�s trauma; symptoms are positively related to perceptions of the severity of soldiers� PTSD symptoms

14. INTIMATE PARTNER VIOLENCE AND PTSD Intimate partner violence is defined as �a physical assault committed by a spouse, ex-spouse, or current or former boyfriend.� (Marshall, Panuzio, & Taft, 2005, p. 863) 26.4 million veterans in U.S.; 13% of all people over 18 1.6 million active duty personnel; 52% are married, 85% are male Rates of IPV range from 13.5% to 58% among veterans and active duty servicemen; vary due to comorbidity IPV in military community occurs at 2-3 times the civilian rate Army wives reported significantly higher rates of IPV compared to civilian wives: moderate violence (13.1% vs. 10%), severe violence (4.4% vs. 2%)

15. INTIMATE PARTNER VIOLENCE AND PTSD Numerous studies have demonstrated increased IPV (psychological and physical) among men with PTSD symptoms NVVRS reported 33% of Army servicemen with PTSD admitted to perpetrating IPV in a one-year period, and 13.5% of veterans without PTSD perpetrated IPV male veterans with PTSD perpetrate IPV at a rate 2-3 times higher than those without PTSD There is a significant relationship between PTSD severity and domestic violence severity

16. PTSD SYMPTOMS IN VICTIMS OF PARTNER VIOLENCE

17. INTIMATE PARTNER VIOLENCE AND PTSD Military service is a unique human experience that may contribute to aspects of domestic violence we do not understand. Domestic Homicides at Fort Bragg, North Carolina in 2002 within 6 weeks, four military wives were dead at the hands of their husbands, 3 of whom had recently returned from a tour of duty in Afghanistan led to increased interest and concern over military families� difficulties and IPV, as well as the impact of war zone exposure on an individual and their family

18. INTIMATE PARTNER VIOLENCE AND PTSD Stress of deployment? Or culture of training? Cultural Spillover Theory Proposed by Baron, Straus, and Jaffee in the 1980s The more any given culture/subculture endorses the use of violence to attain socially approved ends, the greater the likelihood that this legitimization of violence will be generalized to other spheres of life in which violence is less socially approved Information-processing-based model for PTSD Chemtob, Novaco, Hamada, Gross, & Smith, 1997

19. INTIMATE PARTNER VIOLENCE AND PTSD cont. Combat veterans with PTSD, in line with their prior experience of life threat, are more likely to perceive threats in their environment, even when there are no realistic threats; their response is to enter �survival mode� which is characterized by heightened arousal, hostile appraisal of events, an inclination toward threat confirmation, increased vigilance in recognizing a threat, and a lower threshold for responding to the threat; these cognitive processes negatively impact their ability to regulate anger and engage in self-monitoring behavior, resulting in a propensity toward aggression.

20. HOW PTSD FROM COMBAT EXPOSURE LEADS TO IPV Trauma/combat exposure in the war zone impacts perpetration of IPV indirectly through PTSD symptoms It is also possible that trauma exposure has a direct effect on violence by exposing individuals to violence in a manner that they come to view it as acceptable A study of Vietnam veterans found support that combat exposure and perceived threat were both directly and indirectly related to IPV via PTSD symptomatology

21. COMORBIDITY Substance abuse substance abuse and PTSD are highly comorbid among military servicemen and veterans 74% of male veterans with PTSD met lifetime criteria for alcohol abuse alcohol consumption potentiates the impact of PTSD hyper-arousal symptoms on IPV perpetration substance use among both veterans and active duty servicemen associated with increased risk and frequency of IPV

22. COMORBIDITY cont. Identified risk factors for IPV in military servicemen with PTSD major depressive episodes drug abuse and dependence poor marital adjustment high levels of trauma exposure higher rates of all were found in partner-violent veterans versus non-violent veterans with PTSD

23. COMORBIDITY cont. Psychopathology Psychiatric comorbidity with PTSD may play a large role in IPV and perpetration frequency Major depression Antisocial personality traits Narcissistic personality traits majority of domestic violence perpetrators show evidence of personality pathology one study showed narcissistic and antisocial personality characteristics were directly related with IPV

24. COMORBIDITY cont. Typical personality profiles of veterans who have been perpetrators of IPV: MCMI-II study of veterans Vietnam Korea Persian Gulf Profiles fell into three clusters Subclinical Narcissism Narcissistic Personality Disorder High General Psychopathology/Substance Dependence

25. VETERAN RECOUNTS KILLING WIFE http://www.cbsnews.com/video/watch/?id=4763136n January 30, 2009

26. ASSESSING PTSD Challenges in assessing military service members (Friedman, 2006) Combat-related hardships Additional stressors faced by military service members First step is to verify that the person has been exposed to a traumatic event (Keane, Street, & Stafford, 2004)

27. ASSESSMENT TOOLS Exposure to Traumatic Event 7-item Combat Exposure Scale Clinical Interviews PTSD modules can be found in the Diagnostic Interview Schedule-IV (DIS-IV) Structured Clinical Interview for DSM-IV (SCID) Anxiety Disorders Interview Schedule-IV (ADIS-IV) PTSD structured interviews used with veterans include: Clinician-Administrated PTSD Scale (CAPS) PTSD Interview (PTSD-I) Structured Interview for PTSD (SI-PTSD) (Keane et al.., 2004)

28. ASSESSMENT TOOLS cont. Self-Report Checklists PTSD checklist (PCL) (Bliese, Wright, Adler, Cabrera, Castro, & Hoge, 2008) Posttraumatic Stress Scale-Revised (PPTSD-R) The Self-Rating Inventory for PTSD (SIPS) Keane PTSD Scale of the MMPI Mississippi Scale for Combat-Related PTSD The 15-item Impact of Event Scale (IES) (Keane, et al., 2004)

29. ASSESSMENT TOOLS cont. Psychophysiological Assessment Can provide unique information on the extent of autonomic hyperarousal and startle responses in PTSD Usually involves presenting an individual with standardized stimuli (e.g. combat photos, noises, odors) or personalized stimuli (e.g. taped transcripts of their traumatic experiences). Psychophysiological responses such as heart rate, blood pressure, muscle tension, skin conductance level and response, and peripheral temperature are then measured. (Keane et al., 2004)

30. TREATMENT FOR PTSD�SOLDIER Risk of Comorbidity with other mental health issues The frequently co-occurring conditions with PTSD are depression, substance abuse, and anxiety disorders (Brady, Killen, Brewerton, & Lucerini, 2000) A recent study shows that two-thirds of those diagnosed with PTSD also met the criteria for another mental disorder (Tanielian & Jaycox, 2008) Important for the clinician to recognize the symptoms of possible comorbid disorders as they can interfere with a service member�s ability to engage in, or even tolerate, treatment

31. TREATMENT FOR PTSD�SOLDIER cont. Pharmocological Treatments Selective serotonin reuptake inhibitors (SSRI�s) prevent the reuptake of serotonin has been shown to reduce symptoms of depression, intrusion and avoidance, hyperarousal, and numbing (Lesch and Merschdorf, 2000) Tricyclic antidepressants (TCA�s) prevent the uptake of the neurotransmitters norepinephrine and serotonin have been proven to be effective in treating insomnia, nightmares, anxiety, guilt, flashbacks, and depression (McEwen, 2000)

32. TREATMENT FOR PTSD�SOLDIER cont. Pharmocological Treatments cont. Monamine oxidase inhibitors (MAOIs) Inhibit the breakdown of the monoamine neurotransmitter; which is believed to increase serotonin, dopamine, and norepinephrine in the brain MAOIs are effective in the treatment of depression and some anxiety disorders (Albucher & Liberzon, 2002) Atypical neuroleptics Now being examined as a pharmacological intervention for PTSD patients with severe symptoms of flashbacks, nightmares, and paranoia (Marmar, Neylan, & Schoenfeld, 2002)

33. TREATMENT FOR PTSD�SOLDIER cont. Psychotherapy Treatments Cognitive-behavioral therapy (CBT) Proven to be a safe and an effective treatment for PTSD Focuses on the interpretation of events versus the events themselves as the source of emotional distress Primary objectives: Identify and confront dysfunctional thought patterns To reduce the frequency and intensity of symptoms Enhance management of chronic symptoms Improve the quality of life (Stewart & Wrobel, 2009)

34. TREATMENT FOR PTSD�SOLDIER cont. Cognitive-behavioral therapy (CBT) cont. Treatment Components Psychoeducation Exposure Virtual Reality Cognitive restructuring Anxiety Management (Harvey, Bryant, & Tarrier, 2003)

35. TREATMENT FOR PTSD�COUPLE THERAPY Cognitive-Behavioral Conjoint Therapy (CBCT) Couple is treated as unit for therapy purposes Simultaneous goals of: Improving PTSD in one or both individuals of the couple Improving the their intimate relationship functioning Three stages, 15 sessions consisting of: Treatment orientation, psychoeducation, and safe building Behavior interventions Cognitive interventions (Monson et al., 2008)

36. TREATMENT FOR PTSD�COUPLE THERAPY cont. Integrative Behavioral Couple Therapy (IBCT) Goals: To help partners accept aspects of each other and their relationship that have come to be viewed as intolerable and insoluble To reduce conflict To encourage intimacy through acceptance and skill strategies Consists of two phases Assessment Intervention 12-14 sessions Emotional acceptance component is useful targeting the experiential avoidance endemic to PTSD (Erbes, Polusny, MacDermid, & Compton, 2008)

37. BARRIERS TO TREATMENT FOR PTSD AND IPV The military does offer counseling, however: Soldier has to want to seek treatment Fear of how it will make them look Jeopardize career or chances of promotion Lack of reimbursement for private counseling The Army goes out of its way not to prosecute perpetrators of violence because under federal law, those convicted lose their right to carry a gun, rendering them useless as soldiers Base commanders pressure wives not to press charges

38. FINAL FAST FACTS With evidence-based treatments, complete remission can be achieved in 30-50% of PTSD cases. Partial improvement can be expected with most patients. Studies continue to raise a hopeful possibility that PTSD maybe reversed if soldiers can be helped to cope with stresses in their current life. (Tanielian & Jaycox, 2008)

39. DISCLAIMER Any research findings reported by the presenters do not reduce the responsibility of the individual for perpetrating violence. It is our belief that responsibility for perpetrating violence lies ultimately with the individual.

40. ?? QUESTIONS ??

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