Transcript Post-traumatic stress disorder

Posttraumatic Stress Disorder
and 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
Men
Women
100
80
60
40
20
0
Any
One
Multiple
Kessler 2000
Combat Exposure in Iraq
Seeing Dead Bodies/Remains
Shot At/Receiving Small Arms Fire
Being Attacked/Ambushed
Receiving Artillery, Rocket, Mortar Fire
Knowing Someone Killed/Ser. Injured
Clearing/Searching Homes
Shooting/Directing Fire at Enemy
Ill/Injured Women/Child Couldn't Help
Seeing Dead/Serious Inj. Americans
Handling/Uncovering Human Remains
Resp. for Death of Enemy Combatant
Participating in Demining Ops
Buddy Shot/Hit Near You
Engaged in Hand-to-Hand Combat
Saved Soldier/Civilian Life
Being Wounded or Injured
Responsible for Noncombatant Death
Close Call/Hit but Saved by Gear
0%
Hoge, et al, 2004, NEJM
95%
93%
89%
86%
86%
80%
77%
69%
65%
50%
48%
38%
22%
22%
21%
14%
14%
8%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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)
Accountability
Targeted Aggression
Tactical Awareness vs.
Lethally Armed
Emotional Control
Mission OPSEC
Individual Responsibility
Non-Defensive Driving
Discipline and Ordering
vs.
Withdrawal
vs.
Controlling
vs.
Inappropriate Aggression
Hypervigilance
vs.
“Locked and Loaded” at Home
vs.
Anger/Detachment
vs.
Secretiveness
vs.
Guilt
vs.
Aggressive Driving
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
Percent
60
PTSD
No PTSD
50
40
30
20
10
0
GAD
MDD
Som
Drug Abuse
Asthma
Ulcer
Hypertension
Davidson 1991
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
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
Substance Use Disorders and
Trauma/PTSD
Estimates of trauma exposure:
In general population:
In SUD population:
40% - 70%
35% - 90%
Estimates of PTSD
In general population:
In SUD population:
5% - 12.5%
30% - 50%
Estimates of Alcohol Dependence
In general population:
In PTSD population:
7% - 9%
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
In
st
gi
us
/
ry
Pa
ra
si
ti c
ar
y
at
o
ry
ta
l
to
i to
ur
in
ul
pi
ra
c
em
lo
al
m
en
t
ke
la
Sy
Ci
rc
Re
s
G
en
io
e
at
o
M
Sy
st
e
ul
os
es
tiv
us
c
fe
ct
M
Di
g
us
De
rm
Ne
rv
o
Increased Medical Problems in PTSD
GW1 Veterans
100
PTSD
No PTSD
80
Percent
60
40
20
0
Barrett et al., 2002
Decreased Quality of Life with PTSD
GW1 Veterans
100
PTSD
No PTSD
80
Score
60
40
20
0
Physical
Funct
Physical
Role
Pain
General
Health
Vitality
Social
Funct
Emotional
Role
Mental
Health
Physical
Mental
Summary Summary
Barrett et al., 2002
Decreased Quality of Life with PTSD
Vietnam Veterans
60
PTSD
No PTSD
Percent
40
20
0
Physical Limitation
Lower Well-being
Poor Health
Sever Violence
Not Working
Zatzick et al., 1997
Impaired Quality of Life in PTSD
PTSD
US Population
100
Depression
75
SF-36
Score
50
25
0
Vitality
Malik et al. J Trauma Stress. 1999;12:387.
Social Function
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
Internal Trauma Cues
Sights
Sounds
Smells
Situations
Emotional State
Physical State
Thoughts
Traumatic Reactions
Emotions
Thoughts
Arousal
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
Positive Scales
Overall PS
PTSD
Negative Scales
-.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
Social Information Processing
3
Response
Selection
4
Response
Generation
Emotions
Memories
Experience
Cue
2 Interpretation
Attention
1
5
Enactment
Skills
Impact of Trauma Memory on
Social Information Processing
4
Limited Response
Generation
3
Biased Response
Selection
Activated
Trauma
Memory and
Emotion
lnterpretational
Bias
2
Attentional Bias
1
Impaired Enactment
Skills
5
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
DV
PTSD
Trauma
severity
Depression
Accept
violence
Anger
Low Social
support
Substance use
Poor problem solving
Traditional
sex roles
Marital distress
Trauma
processing
Marital conflict
Stress
Jealousy