Post-traumatic Stress Disorder and Interpersonal Violence Relationship

Psychological and Social Research: Review, Evaluation and Design

Abstract

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Post-traumatic stress disorder (PTSD) was a serious mental health condition that affected veterans from all conflict eras and many, due to witnessing such extreme violence and suffering with the symptoms of PTSD, turned to commit interpersonal violence (IPV). This review concentrated on providing evidence to prove that there was a significant link between PTSD and IPV. A systematic search was conducted using three databases for academic journals and an overall total of 10 papers were reviewed and discussed. There appeared to be a link between PTSD and IPV based on the papers reviewed but there was limited research on females and no research on homosexual relationships; reasons for this were mentioned. To prevent the perpetration of IPV; interventions should be looked at to help the veterans understand PTSD and how it could be linked to IPV.

A Systematic Review on Veterans’ PTSD and Intimate Partner Violence as a consequence of war

Definition and prevalence of PTSD

Jones and Wessely (2009) stated that being exposed to a war related situation increased the risk of being diagnosed with post-traumatic stress disorder (PTSD) (as cited in Sundin, Fear, Iversen, Rona and Wessely, p.367). PTSD was originally known as “shell shock” during the first world war (Loughran, 2012) and continued to be called this until the end of the Vietnam war. In 1980, the mental illness that many veterans suffered with was finally given an official name (Brown, 2017) PTSD, this led it to being added to the third edition of the DSM and was finally recognised as a serious mental health condition (Van Der Kolk, 2007). According to the current edition of the DSM (DSM-V), a few of the symptoms associated with PTSD are: intrusive memories, recurrent distressing dreams and flashbacks, as well as depression and anxiety (Comer, 2015). The highest rates of PTSD were found in post-conflict settings (Atwali, Stein, Koenen, and McLaughlin, 2015), which could be explained by the older populations, who were either inadvertently or advertently involved in a war (Burri and Maercker, 2014), such as World War 2. Concentrating on a study conducted on UK military, only 4.8% of Iraqi veterans were found to have or be experiencing PTSD symptoms (Iversen et al, 2009). The percentage was small due to the stigma associated with PTSD, some of the troops might have chosen not to come forward and declare that they were suffering with symptoms of the condition (Buchanan, Kemppainen, Smith, MacKain, Wilson-Cox, 2011). In comparison to the UK, a study conducted in the USA found that 18% of troops returning from Iraq suffered with PTSD symptoms (Hoge, Castro, Messer, McGurk, Cotting and Koffman, 2004). A more recent study found that 23% of veterans who were involved in both Operations Iraqi Freedom and Enduring Freedom (OIF/OEF), were believed to be experiencing symptoms of PTSD (Fulton, Calhoun, Wagner, Schry, Hair, Feeling…Beckham, 2015). The percentage could be explained by the difficulty in obtaining treatment and care in westernised countries, including both the UK and USA (Langston, Gould and Greenberg, 2007).

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Self-Perception theory

Veterans who experienced war zones and combat-deployment often suffered with PTSD as already discussed. The key issue here was whether their own self-perception was altered after experiencing a traumatic event. Self-perception theory involved an individual learning about their own emotions and attitudes by observing their own behaviour, much like they did with others (Baumeister and Bushman, 2011). People who suffered with PTSD including veterans, often suffered with changes in their self-perception. Veterans with PTSD often felt feelings of guilt and shame (Singer, 2004), as well as experiencing self-blame and isolation (Regehr and Roberts, 2010). It was important that they understood the meaning of a traumatic event and had schemas in place to re-correct their perceptions (Lee, Scragg and Turner, 2001).

Definition and prevalence of IPV

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There were several terms that could be used to define intimate partner violence (IPV) such as; partner abuse, spouse abuse (Aronson, Perkins and Olson, 2014) or domestic violence (Garcia-Moreno, Jansen, Ellsberg, Heise and Watts, 2005). IPV was defined as:

“IPV is a pattern of coercive behaviours that can result in physical injury, psychological abuse, sexual assault and social isolation…three types of violence that constitute IPV: psychological/emotional abuse, physical and sexual abuse.” (Daigle, Scherer, Fisher and Azini, 2016, as cited in Cuevas and Rennison, p.374).

Regarding the rates of IPV many studies found that more violent IPV was committed by military samples in comparison to civilian samples (Rentz, Martin, Gibbs, Clinton-Sherrod, Hardison and Marshall, 2006; Aronson et al., 2014). It was also discovered that both genders appeared to commit similar acts of IPV at the same rates. However, men were more inclined to commit both physical and sexual abuse compared to women; whereas, both genders committed emotional abuse at the same rates. A study conducted by LaMotte, Taft, Scott and Eckhardt (2015) found that out of their sample of 63 veterans 27.7% had committed physical abuse on their partner at least once. These studies help confirm the notion that IPV was more likely to be committed by military personnel.

Frustration-Aggression theory and the coming of the General Aggression Model

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This provided a theoretical framework for IPV and it postulated that an individual who was frustrated could experience many ways to respond to the feeling, however, the normal response was anger or aggression (Mitchell and Vanya, 2009; as cited in Mitchell and Anglin, p.41) especially in males, as this was a prominent masculine trait (Klein, 2008). The impact of aggression on relationships often led to a negative effect (Bookwala, Frieze and Grote, 1994). Although the frustration-aggression theory provided a starting point for why IPV occurred, the general aggression model (GAM) was more expansive and provided a conceptual framework that included the frustration-aggression theory (DeWall and Anderson, 2001). There were a number of situations that increased the likelihood of aggression, such as: mental exhaustion. When this occurred, they were less likely to control their levels of aggression, more so if they felt provoked or were experiencing communication problems, as said by Medeiros and Straus (2007, as cited in Hamels and Nicholls, pp. 77-78). Those who experienced PTSD often felt mentally drained. During a relationship altercation those experiencing PTSD attacked their partner because they misperceived the level of threat (Bell and Orcutt, 2009) and due to them experiencing this mental exhaustion. It was discovered that PTSD had a role in the development of a chronic fatigue like illness in veterans (Kang, Natelson, Mahan, Lee and Murphy, 2003).

Attachment theory

To begin with attachment theory was initially created to understand children’s attachments; it now included attachments for adults regarding their relationships with others. There were 4 attachment styles or patterns to which adults could be categorised: secure attachment, preoccupied, dismissive and fearful-avoidant (Gibson and Gibson, 2016).

Attachments have been researched in the area of PTSD and IPV to see if there was a relationship between the type of attachment and how that affected PTSD development and committing of IPV. According to Scott and Babcock (2010) experiencing a high dependency and anxiety attachment (preoccupied) strengthened the relationship between PTSD and IPV as it made emotional connections more difficult (Knox and Schacht, 2015). Whereas, having low dependency and anxiety attachments (dismissive) decreased the rates of IPV and PTSD (Scott and Babcock, 2010). These results implied that a preoccupied attachment style led to high PTSD and IPV rates and having a dismissive attachment was associated with rejecting intimate relationships and experiencing less symptoms of PTSD. As many veterans experienced elevated levels of PTSD and committed IPV then their attachment style would be more related to the preoccupied attachment, based on this study.

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The importance of this review

A review of PTSD and IPV was important to establish whether there was a link, as many studies found conflicting results. There appeared to be a lack of homosexual relationships involved in this research area, as there was discriminating attitudes towards them (Sinclair, 2009), so it would be interesting to see if they were included in more recent research.

Regarding the research conducted on veterans and PTSD, this review would be considering samples from deployment in Iraq. The review itself would provide clinicians with what to look out for regarding the treatment of PTSD and the committing of IPV, as well as providing the veterans with a better understanding of the implications of war. PTSD and IPV have only been researched relatively recently (Bell and Orcutt, 2009; Sullivan and Elbogen, 2014; Finley, Baker, Pugh and Peterson, 2010) and there was a lack of research that solely concentrated on the veterans from the OIF/ OEF eras (Aronson et al., 2014; LaMotte,Taft, Weatherill, Scott and Eckhardt, 2014). Due to the length of the Iraq war and due to advanced research more studies could now be conducted on the effects of combat deployment and IPV (Link and Palinkas, 2013).

Method- Literature search

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To begin the initial search, it was decided that the [email protected], Ebsco and Proquest Central should be used as they included articles within their databases that were both scholarly and peer-reviewed, both considered as important for this systematic search. It was decided that 2006-2017 would be the years looked at.

The scope of the review originally concentrated on Cognitive Behavioural Therapy (CBT) and PTSD using the search terms: cognitive behavioural therapy, cognitive behaviour therapy, post-traumatic stress disorder, post traumatic stress disorder and posttraumatic stress disorder. After finding 76,242 articles on one website (Ebsco) and only managing to narrow that down to 8527, it was concluded that this search was too broad. That was when IPV was considered alongside PTSD regarding Iraqi war veterans which yielded a much better search. There was a variety of abbreviations that could be used, as established in the original search. It was important to concentrate on only a few so the search would be more narrow and specific. The search criteria finally used was: PTSD, IPV and Iraqi war veterans and the years remained the same as in the first search. Due to the difficulties in the initial search 70 articles was given as a cut-off point. Studies conducted in the UK or USA were used as they were both involved in the Iraq war and it was thought that anything before 2006 would be outdated and not as relevant as more modern research. Only English papers were looked at due to a language barrier which did not affect the final search as all of them were in English. A specific sample size was not required for this review as long as the participants were veterans from the OEF/OIF eras.

Both [email protected] and Ebsco found 65 relevant articles and Proquest Central found 15; of these articles, 10, 5 and 7 titles contained the relevant key words; 4, 1 and 2 titles were considered irrelevant and were removed. That left 6, 2 and 5 relevant titles for the reading stage of the search. However, 1 was removed via abstract and 2 were removed due to duplication. This left an overall count of 10 papers for review (see Figure 1).