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
Overview
• PTSD Overview
• Neurobiology of PTSD
• PTSD and General Family
Functioning
• PTSD and Partner Violence
• Strength at Home Program
6 Criteria for PTSD Diagnosis
1. Stressor- A threatening event accompanied by
fear, helplessness, or horror
2. Reexperiencing
3. Avoidance
4. Arousal
5. Duration (> 1 month)
6. Distress or Impairment
Avoidance
Reexperiencing
Flashbacks
Intrusive memories
Post
Traumatic
Stress
Thoughts & feelings
Activities/Places/People
Amnesia
Loss of interest
Detachment
3
Restricted affect
Foreshortened
future
Dreams
Psychological distress
w/ reminders
Physiological
reactivity
1
PTSD
2
Disorder
Sleep difficulties
Hypervigilance
Irritability & anger
Startle
Concentration
Arousal
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
Identifying Biomarkers of PTSD
Gray Matter
Volumetry
Functional Brain
Changes [fMRI]
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
PTSD participants viewing fearful facial
expressions during fMRI
R amygdala
PTSD>Control, Fear vs. Happy
Shin et al., 2005 Arch Gen Psychiatry
Imaging of Treatment
Bryant et al., 2008 Psychological Medicine
How well do treatments work?
Results from Meta-Analysis
Effect Size (d)
0
0.5
Prolonged Exposure
Other Exposure
Other CBT
1
1.5
Psychotherapies
shown in green
Stress Inoculation
EMDR
Group therapy
Drugs shown in
yellow
SSRIs
TCAs
Other Antidepressants
Alpha blockers
MAO-Is
Cognitivebehavioral
therapy is most
effective
Atypical Antipsychotics
Benzodiazepines
Note. Effect sizes are computed from the difference
between groups in individual studies at posttreatment
Watts et al., 2007
PTSD and General
Family Functioning
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
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.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
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%)
PTSD and Relationship Quality
• In veterans, PTSD associated with:
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More relationship distress
Less cohesion
Less emotional expressiveness and engagement
More intimacy difficulties
More areas of relationship conflict
Domestic violence and problems with anger
PTSD and Relationship Satisfaction
Reexperiencing
Avoidance/
Numbing
Emotional
Numbing
Effortful
Avoidance
Hyperarousal
Other Mechanisms
• Secondary traumatization
• Caregiver burden
• Changes in family roles
Secondary Traumatization
“The natural consequent behaviors and
emotions resulting from knowledge about a
stressful event experienced by a significant
other” (Figley, 1998).
Secondary Traumatization in
Peacekeepers’ Partners
14
Symptom Severity
12
10
8
No PTSD
PTSD
6
4
2
0
Intrusions
Avoidance
Dirkzwager, Bramsen, Ader, & van der Ploeg, 2005
Hyperarousal
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
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Crisis management
Symptom management
Social isolation
Financial problems
Family strain
Emotional Cycles of Deployment
Stage 1: Pre-deployment
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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
Emotional Cycles of Deployment
Stage 2: Deployment
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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
Emotional Cycles of Deployment
Stage 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
Emotional Cycles of Deployment
Stage 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
Emotional Cycles of Deployment
Stage 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
PTSD and Partner Violence
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
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
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%
PTSD and Partner Violence
Reexperiencing
Avoidance/
Numbing
Hyperarousal
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
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
Other Contributing Factors
1. Depression
2. Alcohol use problems
3. Traumatic brain injury
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
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)
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
Core Themes
1. Trust
2. Self- and Other-Esteem
3. Power Conflicts
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
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
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)
Strength at Home Program
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
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
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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
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
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
www.StrengthAtHome.com
Contact Sarah Krill
(857) 364-4173
Sarah.Krill@va.gov