Psychological sequelae of combat violence: A review of the impact of PTSD on the veteran's family and possible interventions

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Abstract

This review of the literature reveals that veterans' posttraumatic stress disorder (PTSD) following exposure to combat violence affects veterans' familial relationships and the psychological adjustment of family members. Previous study within other trauma populations has conceptualized the negative impact of an individual's traumatic stress on his/her family members as “secondary traumatization.” This review examines the processes by which secondary traumatization occurs within combat veterans' families. Research has identified PTSD as mediating the effect of veterans' combat experience on the family. Veterans' numbing/arousal symptoms are especially predictive of family distress; while, to a lesser extent, veterans' anger is also associated with troubled family relationships and secondary traumatization among family members. Empirical modeling of additional factors involved in secondary traumatization is needed. Marital/family interventions have largely focused on improving relationships and reducing veterans' symptoms, rather than targeting improvements in the psychological well-being of the spouse and children. Interventions directly addressing the needs of significant others, especially spouses, are advocated. The potential for increased effectiveness of PTSD interventions and possible cost-savings attained by improving relationships and reducing caregiver burden are also discussed.

Introduction

Recent research (Kessler, 2000) estimates that 12% of the American population develops posttraumatic stress disorder (PTSD) at some point in their life. Within this diagnostic group, multiple episodes of PTSD (each averaging several years in duration) appear to be the norm. PTSD severely impacts functioning across major domains, increasing the odds of unemployment by 150% and marital instability by 60%. The risk of suicide associated with PTSD exceeds that of any other anxiety disorder.

While the direct impact of experiencing psychological trauma has been studied extensively over the past century, the secondary impact of living with an individual suffering from PTSD is a far less developed field of inquiry. Early investigations focused on families of survivors of the Holocaust Bergmann & Jucovy, 1982, Epstein, 1979 as well as studies of veterans' families. Figley (1983) coined the phrase “secondary traumatization” to describe the finding that individuals living in close proximity to victims of violent trauma can themselves become indirect victims of that trauma. An examination of the literature reveals two applications of the phrase secondary traumatization. First, some authors have equated secondary traumatization with vicarious traumatization. In this application, an individual who has not been directly exposed to a trauma develops trauma symptoms (nightmares, intrusive thoughts, flashbacks) after learning of an event indirectly through someone who actually experienced the event. Second, the phrase has been used more broadly to refer to any transmission of distress from someone who experienced a trauma to those around the traumatized individual. In this broader sense, the phrase includes a wide range of manifestations of distress, not merely those that mimic PTSD.

In this paper, we use the phrase secondary traumatization in the latter, more inclusive definition. We review the literature that has developed regarding how the veteran's combat exposure and PTSD impact the family. There is a relative paucity of literature available on the impact of traumatization within female veterans' families. The literature is primarily focused on male veterans and their female partners, with some studies addressing effects on children. In particular, the sequelae of the veteran's anger/violence and avoidance/numbing are highlighted. We also provide an overview of the available treatment literature for these families and summarize the need for continued development in this area.

To adequately review the available literature, a search was conducted on the following terms: combat exposure, PTSD and veterans, intergenerational transmission, familial PTSD, vicarious traumatization, combat veterans and PTSD, and combat disorders. From this search and from additional related terms, 141 relevant articles were reviewed. Approximately 100 papers were included in the review from this original pool. The vast majority of papers reviewed were published in peer-reviewed journals.

Section snippets

Impact of combat trauma and PTSD on the couple

The President's Commission on Mental Health Report (1978) indicated that 38% of the marriages of Vietnam veterans dissolved within 6 months of the return of the veteran from Southeast Asia. Several studies have explored factors contributing to these break-ups, and tried to tease out the relative contributions of combat, PTSD, and other background variables.

In one of the earliest efforts to identify variables contributing to postwar marital distress (studying the trauma of capture rather than of

Impact of combat exposure and PTSD on parenting

In a clinical report, Haley (1984) described the experience of child-rearing as a delayed stressor for combat veterans. She theorized that the veterans may have some difficulty identifying the age-appropriate aggressiveness of a toddler as separate from their own violent behavior during wartime. Lack of differentiation can result in an unwillingness to interact with the child (avoidance) or an overreaction and overprotectiveness. Harkness (1993) similarly reported veterans' parenting to be

Treatment

Riggs (2000) reviewed PTSD-related family and marital treatments for the International Society for Traumatic Stress Studies' practice guidelines. There is a large literature on the treatment of childhood PTSD, focused on children who have directly experienced school shootings, war-zone violence, sexual abuse, or other trauma. However, neither Riggs' literature search nor our own identified any empirical studies specifically focused on treatment of children of traumatized parents or systematic

Discussion

The literature clearly demonstrates that when the violence of combat leads to PTSD in the veteran, it can dramatically impact the veteran's loved ones in a broad range of ways. PTSD-related emotional numbing and emotional/behavioral withdrawal are identified as particularly damaging to relationships. Anger outbursts are also cited as problematic, especially in early studies (when the average age of veterans was younger and when the combat exposure was more recent). Controlling for comorbid

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    This paper is the result of work supported with resources and the use of facilities at the G.V. (“Sonny”) Montgomery VA Medical Center, Jackson, MS, with additional support from VA South Central (VISN 16) Mental Illness Research, Education and Clinical Center (MIRECC). The views expressed here represent those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the University of Mississippi Medical Center.

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