The Impact of PTSD on Veterans’ Family Relationships: Mechanisms of Distress and Available Treatments

1 Chapter One: Introduction.2 PTSD Symptoms.3 Purpose and Scope of Project.4 Chapter Two: Key Relationship Factors Affected by Veterans’ PTSD Symptoms.6 Attachment.6 Intimacy.13 Communication.16 Shared Activities.31 Sexual Relations.34 Aggression.46 Chapter Three: Additional Factors Accounting for Distress in Veterans’ Partners.55 Secondary Traumatic Stress.55 Caregiver Burden.64 Ambiguous Loss.67 Comorbid Disorders.70 Chapter Four: The Impact of PTSD on Veterans’ Children.73 Chapter Five: Current Treatments Involving Veterans’ Family Members.82 Chapter Six: Conclusion.92 References.95 Appendix.113 PTSD and Veterans’ Relationships 1 Abstract When veterans return home from war with PTSD, the disorder can have detrimental effects on their close family relationships. Researchers have proposed different mechanisms underlying the distress experienced by partners and children of veterans with PTSD in the hopes that these mechanisms can be targeted in treatment. The purpose of this project is to review and synthesize the current literature on these mechanisms of distress, as well as the treatments that have been designed to address them. This review examines several key factors that account for veterans’ relationship distress, including the important factors of intimacy and aggression. Due to the emotional numbing symptoms of PTSD, veterans have a difficult time experiencing emotions and communicating them to their partners, which can hinder the development of intimacy in the relationship. Through an increased propensity to perceive threat and a loss of self-monitoring, the hyperarousal symptoms of PTSD can lead to intimate partner aggression. A number of couple-based treatments have been developed for veterans with PTSD and their partners, referred to as Behavioral Conjoint Therapies. These interventions are currently only in their pilot stages, but address some of the key mechanisms of distress for veterans and their partners, including intimacy and communication.When veterans return home from war with PTSD, the disorder can have detrimental effects on their close family relationships. Researchers have proposed different mechanisms underlying the distress experienced by partners and children of veterans with PTSD in the hopes that these mechanisms can be targeted in treatment. The purpose of this project is to review and synthesize the current literature on these mechanisms of distress, as well as the treatments that have been designed to address them. This review examines several key factors that account for veterans’ relationship distress, including the important factors of intimacy and aggression. Due to the emotional numbing symptoms of PTSD, veterans have a difficult time experiencing emotions and communicating them to their partners, which can hinder the development of intimacy in the relationship. Through an increased propensity to perceive threat and a loss of self-monitoring, the hyperarousal symptoms of PTSD can lead to intimate partner aggression. A number of couple-based treatments have been developed for veterans with PTSD and their partners, referred to as Behavioral Conjoint Therapies. These interventions are currently only in their pilot stages, but address some of the key mechanisms of distress for veterans and their partners, including intimacy and communication. PTSD and Veterans’ Relationships 2 Chapter One: Introduction Combat-related Posttraumatic Stress Disorder (PTSD) has been of interest to psychologists since long before a consistent conceptualization of the disorder had been established. During the American Civil War, it was labeled as “irritable heart,” and in the postwar period as “soldier’s heart. ” Around the time of World War I, the condition had received several names, including “war neurosis,” “combat fatigue,” and “shell shock. ” While some scientific studies of psychological disturbances in combatants, prisoners of war, and survivors of concentration camps were done around the World War II era, researchers had not yet made a connection between combat and other types of trauma. It was only after the Vietnam War that advocates of Vietnam veterans and rape survivors joined with scholars to create the budding scientific literature that led to the conceptualization of PTSD (Keane & Barlow, 2002, p. 419420). Since then, the first Gulf War and particularly the wars in Iraq and Afghanistan have brought record numbers of veterans reporting PTSD. Between 1999 and 2004 alone, the number of veterans reporting PTSD rose from 120,265 to 215,871, which is a 79.5% increase (Rosenheck & Fontana, 2007). Some of the rise in rates of PTSD during Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) is thought to result from the fact that there are no sanctuaries in these wars, and death could come at any moment (Paulson & Krippner, 2007, p. 19). Along with this dramatic rise in rates of PTSD among combat veterans comes a new wealth of scientific literature studying the disorder within the military population. While there is a vast literature covering diverse aspects of combat-related PTSD, an issue of particular importance is the disorder’s manifold effects on the returning veteran’s family life. Within previous generations of war veterans, PTSD has been linked to relationship distress, poor communication, sexual dysfunction, lower levels of intimacy, and intimate partner violence PTSD and Veterans’ Relationships 3 (Galovski & Lyons, 2004; Monson, Taft, & Fredman, 2009). Recent studies with veterans returning from Iraq and Afghanistan have found similar relationship impairment (Goff, Crow, Reisbig, & Hamilton, 2007; Erbes, Meis, Polusny, & Compton, 2011). In a large-scale, longitudinal study of over 88,000 soldiers returning from Iraq, veterans’ concerns about interpersonal conflict increased fourfold within 6 months (Milliken, Auchterlonie, & Hoge, 2007). From these studies showing a connection between combat-related PTSD and relationship impairment, it is clear that the disorder can have interpersonal as well as intrapersonal consequences. PTSD Symptoms In order to gain a better understanding of the influence of PTSD on veterans’ interpersonal relationships, it is beneficial to review the symptoms of the disorder itself. In the current edition of the DSM (DSM IV-TR; American Psychiatric Association, 2000), a diagnosis of PTSD consists of three distinct symptom clusters, which reflect (a) reexperiencing of the traumatic event (e.g. flashbacks, nightmares), (b) avoidance of reminders of the event and emotional numbing (e.g. feelings of detachment from others), and (c) hyperarousal (e.g. hypervigilance; for a more detailed description of the PTSD symptoms, please refer to the Appendix). It is important to note that the proposed revision to the PTSD criteria in the DSM-V involves separating the active avoidance and emotional numbing symptoms into two distinct clusters, which may help reduce spurious diagnoses of PTSD due to comorbidity with depression (Forbes et al., 2011). These distinct symptom clusters have been shown to differentially affect the trajectory of the disorder as a whole (Schell, Marshall, & Jaycox, 2004), as well as the PTSD and Veterans’ Relationships 4 relationship adjustment of the person with the disorder (Taft, Schumm, Panuzio, & Proctor, 2008). Purpose and Scope of Project Addressing the issue of how PTSD affects veterans’ family relationships is of critical importance. Not only will it provide a better understanding of the extensive negative effects of facing combat trauma, but it also holds practical implications for veterans’ care upon returning home. The quality of veterans’ family functioning has been shown to predict their response to PTSD treatment (Evans, Cowlishaw, Forbes, Parslow, & Lewis, 2010), and so addressing the veteran’s family environment as a part of treatment is beneficial. Currently, treatments are being developed that target the PTSD symptoms and relationship distress in tandem (e.g. cognitivebehavioral conjoint therapy; Monson & Fredman, 2012). Treatments aimed at alleviating the relationship distress of veterans with PTSD will be maximally effective when they target the specific mechanisms underlying that distress. Because of this, the current project endeavors to identify the mechanisms of distress in relationships of veterans with PTSD, and to explicate the current research on these mechanisms. The scope and structure of the project are dictated by three research questions: (1) Through what specific mechan