Thursday, October 23, 2008

What are common problems in relationships with PTSD-diagnosed veterans?

Our problems are not new or news. We've stood by their sides for over thirty years. In my case, it's been 26 years since the day I met my husband. The years, well they haven't been easy. Seeing him change as mild PTSD carried him away, helpless to stop any of it from getting worse, took me down many paths. As I was reaching out to his friends to get help, he wouldn't listen. PTSD got worse and our marriage suffered more and more. What I knew about PTSD helped me to cope but did not end the heartache. It just helped me find hope that one day he would go for help. He finally did and then the knowledge I had was supported by a renewed hope that our marriage could survive. 24 years later, we're still married, in a crazy marriage without a boring moment.

Wives of veterans have a job on our hands. Too bad they don't have uniforms for us so that people would know we serve the military as well because we are the ones who take care of the veterans after the military is finished with them. We make sure they find reasons to get up every morning and keep trying. When they can't find it in themselves to fight, we fight for them. We take on the government to make sure their wounds are taken care of and they are compensated for the incomes their wounds prevent them from earning, but we also have to fight them. They want to give up. Too many times they win on this one and take their own lives, walk out of marriages or simply wait to die. They turn to drugs and alcohol instead of the love we feel for them because they can no longer believe in it. They wonder how we could possibly love them when they are such a mess inside. They have forgotten who they still are and all that we see in them becomes invisible.

The wives of Iraq and Afghanistan veterans have a lot more than we did when they came back from Vietnam. There are support groups all over the country and that is a good thing. One thing that support groups are doing is opening up their arms to us so that they can learn from what we know works and avoid making the same mistakes we did. There is hope in our experiences and marriages that have stood beyond where anyone ever thought their marriage would be tested by.

Emails come in from wives across the US and many other nations because of the book I wrote, For the Love of Jack, and the videos I've done. Their stories, oh so very familiar, and they wonder how their life could be the same as mine. Soon they discover that while the wars may be different, our husband's hair grayer and our children have grown, there is really no difference between us. War is still war and wives, well, were still picking up the pieces of what war did to them.

Here is one more way to get there from here. kc
Partners of Veterans with PTSD: Caregiver Burden and Related Problems
Jennifer L. Price, Ph.D. & Susan P. Stevens, Psy.D.
A number of studies have found that veterans' PTSD symptoms can negatively impact family relationships and that family relationships may exacerbate or ameliorate a veteran's PTSD and comorbid conditions. This fact sheet provides information about the common problems experienced in relationships in which one (or both) of the partners has PTSD. This sheet also provides recommendations for how one can cope with these difficulties. The majority of this research involved female partners (typically wives) of male veterans; however, there is much clinical and anecdotal evidence to suggest that these problems also exist for couples where the identified PTSD patient is female.

What are common problems in relationships with PTSD-diagnosed veterans?
Research that has examined the effect of PTSD on intimate relationships reveals severe and pervasive negative effects on marital adjustment, general family functioning, and the mental health of partners. These negative effects result in such problems as compromised parenting, family violence, divorce, sexual problems, aggression, and caregiver burden. 1, 2, 3, 4, 5

Marital adjustment and divorce rates
Male veterans with PTSD are more likely to report marital or relationship problems, higher levels of parenting problems, and generally poorer family adjustment than veterans without PTSD. 2, 6, 7 Research has shown that veterans with PTSD are less self-disclosing and expressive with their partners than veterans without PTSD. 8 PTSD veterans and their wives have also reported a greater sense of anxiety around intimacy. 7 Sexual dysfunction also tends to be higher in combat veterans with PTSD than in veterans without PTSD. 9 It has been posited that diminished sexual interest contributes to decreased couple satisfaction and adjustment. 10

Related to impaired relationship functioning, a high rate of separation and divorce exists in the veteran population (those with PTSD and those without PTSD). Approximately 38% of Vietnam veteran marriages failed within six months of the veteran's return from Southeast Asia. 11 The overall divorce rate among Vietnam veterans is significantly higher than for the general population, and rates of divorce are even higher for veterans with PTSD. The National Vietnam Veterans Readjustment Study (NVVRS) found that both male and female veterans without PTSD tended to have longer-lasting relationships with their partners than their counterparts with PTSD. 3 Rates of divorce for veterans with PTSD were two times greater than for veterans without PTSD. Moreover, veterans with PTSD were three times more likely than veterans without PTSD to divorce two or more times.

Interpersonal violence
Studies have found that, in addition to more general relationship problems, families of veterans with PTSD have more family violence, more physical and verbal aggression, and more instances of violence against a partner. 12, 2, 3 In these studies, female partners of veterans with PTSD also self-reported higher rates of perpetrating family violence than did the partners of veterans without PTSD. In fact, these female partners of veterans with PTSD reported perpetrating more acts of family violence during the previous year than did their partner veteran with PTSD. 2

Similarly, Byrne and Riggs 12 found that 42% of the 50 Vietnam veterans in their study had engaged in at least one act of violence against their partner during the preceding year, and 92% had committed at least one act of verbal aggression in the preceding year. The severity of the veteran's PTSD symptoms was directly related to the severity of relationship problems and physical and verbal aggression against the partner.

Mental health of partners
PTSD can also affect the mental health and life satisfaction of a veteran's partner. Numerous studies have found that partners of veterans with PTSD or other combat stress reactions have a greater likelihood of developing their own mental health problems compared to partners of veterans without these stress reactions. 10 For example, wives of Israeli veterans with PTSD have been found to report more mental health symptoms and more impaired and unsatisfying social relations compared to wives of veterans without PTSD. 5 In at least two studies, including the NVVRS study noted above, partners of Vietnam veterans with PTSD reported lower levels of happiness, markedly reduced satisfaction in their lives, and more demoralization compared to partners of Vietnam veterans not diagnosed with PTSD. 2 About half of the partners of veterans with PTSD indicated that they had felt "on the verge of a nervous breakdown". In addition, male partners of female Vietnam veterans with PTSD reported poorer subjective well being and more social isolation than partners of female veterans without PTSD.

Nelson and Wright 13 indicate that partners of PTSD-diagnosed veterans often describe difficulty coping with their partner's PTSD symptoms, describe stress because their needs are unmet, and describe experiences of physical and emotional violence. These difficulties may be explained as secondary traumatization, which is the indirect impact of trauma on those in close contact with victims. Alternatively, the partner's mental health symptoms may be a result of his or her own experiences of trauma, related to living with a veteran with PTSD (e.g., increased risk of domestic violence) or related to a prior trauma.

Caregiver burden
Limited empirical research exists that details the specific relationship challenges that couples must face when one of the partners has PTSD. However, clinical reports indicate that significant others are presented with a wide variety of challenges related to their veteran partner's PTSD. Wives of PTSD-diagnosed veterans tend to assume greater responsibility for household tasks (e.g., finances, time management, house up-keep) and the maintenance of relationships (e.g., children, extended family). 13, 14 Partners feel compelled to care for the veteran and to attend closely to the veteran's problems. Partners are keenly aware of cues that precipitate symptoms of PTSD, and partners take an active role in managing and minimizing the effects of these precipitants. Caregiver burden is one construct used to categorize the types of difficulties associated with caring for someone with a chronic illness, such as PTSD. Caregiver burden includes the objective difficulties of this work (e.g., financial strain) as well as the subjective problems associated with caregiver demands (e.g., emotional strain).

Beckham, Lytle, and Feldman 15 examined the relationship between PTSD severity and the experience of caregiver burden in female partners of Vietnam veterans with PTSD. As expected, high levels of caregiver burden included psychological distress, dysphoria, and anxiety. More recently, Calhoun, Beckham, and Bosworth 1 expanded this understanding of caregiver burden among partners of veterans with PTSD by including a comparison group of partners of help-seeking veterans who do not have PTSD. They reported that partners of veterans with PTSD experienced greater burden and had poorer psychological adjustment than partners of veterans without PTSD. Across both studies, caregiver burden increased with PTSD symptom severity. That is, the worse the veteran's PTSD symptoms, the more severe the caregiver burden.

Why are these problems so common?
Because of the dearth of research that examines the connection between PTSD symptoms and intimate-relationship problems, it is difficult to discern the exact correspondence between them. 7, 16 Some symptoms, like anger, irritability, and emotional numbing, may be direct pathways to relationship dissatisfaction. For example, a veteran who cannot feel love or happiness (emotional numbing) may have difficulty feeling lovingly toward a spouse. Alternatively, the relationship discord itself may facilitate the development or exacerbate the course of PTSD. Perhaps the lack of communication, or combative communication, in discordant relationships impedes self-disclosure and the emotional processing of traumatic material, which leads to the onset or maintenance of PTSD.

Riggs, Byrne, Weathers, and Litz 7 did examine the connection between PTSD symptom clusters and the relationship condition. The study examined the connection between the cluster of avoidance symptoms and the decreased ability of the person diagnosed with PTSD to express emotion in the relationship. The results of the study suggest that avoidance symptoms, specifically emotional numbing, interfere with intimacy (for which the expression of emotions is required) and contribute to problems in building and maintaining positive intimate relationships.
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