Relationship Functioning in Vietnam Veteran ... - Wiley Online Library

Relationship Functioning in Vietnam Veteran Couples: The Roles of PTSD and Anger Erika M. Roberge,1,3 Nathaniel J. Allen,1 Judith W. Taylor,2 and Craig J. Bryan3 1

Washington DC Veterans Affairs Medical Center Charles George Veterans Affairs Medical Center 3 National Center for Veterans Studies & The University of Utah 2

Objective: Posttraumatic stress disorder (PTSD) and anger have been implicated separately in relationship dysfunction for veterans; however, no studies have simultaneously examined the roles of each of these constructs. Method: This study examined the roles of PTSD and anger in the relationships of Vietnam veterans and their partners (n = 33 couples) with actor–partner interdependence modeling (APIM). Couples in which the veteran was diagnosed with PTSD (PTSD-positive; n = 20) were compared to couples in which the veteran did not have PTSD (PTSD-negative; n = 13) on measures of frequency of anger and relationship functioning. Results: PTSD-positive and PTSD-negative couples reported similar levels of relationship functioning, yet PTSD-positive veterans reported experiencing anger significantly more often than PTSD-negative veterans. Across groups, anger was predictive of relationship functioning, but PTSD severity was not. Conclusions: Trait anger may have a more deleterious effect on relationship functioning than PTSD symptoms. Theoretical and clinical implications C 2016 Wiley Periodicals, Inc. J. Clin. Psychol. 72:966–974, 2016. are discussed. Keywords: posttraumatic stress disorder; Vietnam veteran; couples; relationship functioning; anger; actor–partner interdependence model

Longitudinal research suggests that the fastest rising concern among the most recent cohort of service members is their interpersonal relationship problems (Milliken, Auchterlonie, & Hoge, 2007). Several studies have reported that posttraumatic stress disorder (PTSD) may be the primary cause of relationship dysfunction in veteran couples since the Vietnam era (Lambert, Engh, Hasbun, & Holzer, 2012). Community lifetime prevalence rates of PTSD are estimated to be 8% (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; American Psychiatric Association, 2000); however, among a representative sample of U.S. veterans, the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990) reported higher rates: 30.9% for men and 26.9% for women. The study also found that 11 years after the end of the war, 500,000 Vietnam veterans still met criteria for PTSD. PTSD is associated with a range of negative outcomes and health issues, among which relationship problems are especially well documented. According to the President’s Commission on Mental Health Report (1978), 38% of Vietnam veterans’ marriages dissolved within 6 months of their return from the conflict, and the NVVRS study reported that Vietnam veterans with PTSD were two times more likely than Vietnam veterans without PTSD to have been divorced (as cited by Riggs, Byrne, Weathers, & Litz, 1998). The association between PTSD and relationship dysfunction has been well documented, particularly among the Vietnam veteran cohort. Importantly, Vietnam veterans with PTSD have reported significantly more relationship distress than Vietnam veterans without PTSD in several empirical studies (e.g., Card, 1987; Carroll, Rueger, Foy, & Donohoe, 1985; Caska et al., 2014; Riggs et al., 1998), as have their partners (e.g., Campbell & Renshaw, 2011; Jordan et al., 1992; Riggs et al., 1998). Several theories have been proposed to explain how PTSD may affect relationship functioning. Proposed mechanisms such as secondary traumatization, ambiguous loss,

Please address correspondence to: Erika Roberge, University of Utah, 380 S 1530 E BehS 502 Salt Lake City, UT 84112. E-mail: [email protected] C 2016 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 72(9), 966–974 (2016) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22301 The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

Roles of PTSD and Anger in Relationships

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and couple adaptation have received limited empirical support, whereas caregiver burden models have received limited scientific attention (Dekel & Monson, 2010). The cognitive-behavioral interpersonal model (CBIM), in contrast, has gained the most empirical support. The CBIM suggests that individual and interpersonal cognitive and behavioral factors overlap to create a reciprocal relationship between PTSD and relationship dysfunction (Dekel & Monson, 2010). According to the CBIM, avoidance of trauma-related cues maintains the symptoms of PTSD and negatively affects couple communication, which may cause escalating aggression. Anger and aggression, perhaps the most disruptive symptoms for couples affected by PTSD (Galovski & Lyons, 2004; Monson, Guthrie, & Stevens, 2003; Riggs et al., 1998), have been consistently reported in samples of male veterans with PTSD (i.e., Carroll et al., 1985; Dekel & Soloman, 2006; Glenn et al., 2002; Jordan et al., 1992). In an experimental study of 65 Iraq and Afghanistan veterans and their partners, veterans with PTSD reported and demonstrated significantly more anger in response to experimentally induced stress than veterans without PTSD (Caska et al., 2014). Furthermore, veterans with PTSD have demonstrated an increased rate of physical aggression toward their partners (Gerlock, Grimesey, & Sayre, 2014), with some estimates suggesting that over 60% of partners of male combat veterans with PTSD have been assaulted by the veteran (Manguno-Mire et al., 2007). Severity of PTSD symptoms has been associated with more frequent and severe conflicts (Caska et al., 2014), suggesting that anger may play a mediating role between PTSD and poor relationship functioning. Although veterans with PTSD often experience a range of problems that affect their relationships, including PTSD symptoms, physical disabilities, substance abuse, and aggression (Gerlock et al., 2014), anger may play a particularly important role in the emergence of relationship dysfunction because irritability and anger affect both the individual with PTSD and the partner. Specifically, PTSD creates stress for the partner individually and within the relationship more generally because the partner may feel the need to “walk on eggshells” to avoid upsetting the individual with PTSD (Maloney, 1988). However, few studies have attended to the individual contributions of PTSD and anger to relationship dysfunction in both partners simultaneously. Unfortunately, extant literature addressing the association between PTSD and relationship functioning in Vietnam veterans and their partners has several notable methodological limitations, including limited racial diversity (e.g., Caska et al., 2014; Hendrix & Anelli, 1993; Riggs et al., 1998), PTSD “diagnoses” made via self-report instruments without collateral informants (e.g., Card, 1987; Carroll et al., 1985; Riggs et al., 1998), the absence of partners’ reports of relationship functioning (e.g., Carroll et al., 1985; Hendrix & Anelli, 1993), and the absence of designs that explicitly consider actor–partner effects (e.g., Carroll et al., 1985; Hendrix & Anelli, 1993; Riggs et al., 1998). Additional research that accounts for each of these limitations is therefore needed to clarify the relationships between PTSD, anger, and relationship functioning in Vietnam veterans. Such research could uncover important clues about the long-term effect of PTSD on relationship among military veterans, which could in turn yield useful information relevant to our most recent cohort of service members. The primary aim of the present study was to evaluate the roles of PTSD and trait anger on the relationship functioning in two groups of Vietnam veterans and their partners: couples in which the veteran met diagnostic criteria for PTSD (PTSD-positive; n = 20 couples) and couples in which the veteran did not (PTSD-negative; n = 13 couples). To achieve this aim, the present study used actor–partner interdependent models (APIMs; Kenny, Kashy, & Cook, 2006), to examine the effects of PTSD severity and trait anger on relationship quality. We hypothesized that the veteran’s PTSD severity would be significantly associated with relationship dysfunction within themselves (i.e., actor effect) and with their partner (i.e., partner effect). We additionally hypothesized that each partner’s trait anger would be significantly associated with relationship dysfunction within themselves (i.e., actor effects) and with their partners (i.e., partner effects). Finally, we hypothesized that veterans and couples in the PTSD-positive group would report significantly more relationship dysfunction and trait anger than the PTSD-negative group.

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Journal of Clinical Psychology, September 2016

Methods Procedures Veterans were recruited from the Washington D.C. Veterans Affairs Medical Center (DC VAMC) and local Community-Based Outpatient Clinics (CBOCs). Veterans were either referred by a DC VAMC provider or identified through a review of the electronic medical records (EMR), and they were invited to participate in a DC VAMC institutional review board-approved research study assessing relationship functioning in veterans and their partners. Eligible couples were given the option to complete the questionnaires at the DC VAMC or at home. Partners and veterans completed identical questionnaires, except partners were not given a measure of PTSD severity. Couples who completed the questionnaires at the DC VAMC were physically separated and unable to communicate during the study. Couples who were recruited from CBOCs did not live within a reasonable driving distance to the DC VAMC for study participation and completed the study materials from home. To minimize the risk that questions were answered incorrectly due to misunderstanding, a study staff member called each couple when they received their questionnaires to ask if either partner had any questions. If questionnaires were returned with missing data, a staff member attempted to gather the missing data from the appropriate participant over the phone. Couples agreed to complete their packets separately and were reminded by an instruction sheet to do so. Completed questionnaires were mailed back in separate and sealed envelopes to avoid viewing of each other’s responses. Veterans and their partners signed informed consent forms and were reimbursed for their participation.

Participants Recruited veterans were eligible for participation if they were Vietnam veterans and either married or had been cohabitating with a partner for at least one year. Veterans were excluded if they endorsed substance abuse, psychosis, or suicidal ideation in the past 6 months. Additionally, veterans that provided for or received significant amounts of care (e.g., medical care) from their partners were excluded. Eligible veterans then verbally consented that the research team could contact their partners to complete screening procedures. Partners were screened by the same parameters but were not asked about veteran status or PTSD diagnosis. A total of 35 couples were eligible to participate in this study. Couples included male Vietnam veterans and their female partners. Veterans were assigned to the PTSD-positive group if they endorsed having PTSD, had a documented PTSD diagnosis from a mental health clinician in their EMR, and met criteria on a measure of PTSD severity. Veterans who did not endorse PTSD and did not have a diagnosis in their record were assigned to the PTSD-negative group.

PTSD-positive group. A total of 20 couples were identified as PTSD-positive, 85% (n = 17) of which were married and the remaining were cohabitating. Of these male veterans, 65% (n = 13) served in the Army, 10% (n = 2) the Navy, and 25% (n = 5) the Marine Corps. A total of 18 of these veterans were service connected for PTSD. Of the two veterans not service connected for PTSD, one veteran’s PTSD diagnosis was confirmed by the Clinician Administered PTSD Scale (Blake et al., 1995), and the other was receiving treatment for PTSD at the time of study participation. PTSD severity scores ranged from 48 to 76, with two veterans scoring below 50. PTSD-negative group. A total of 15 couples were identified as PTSD-negative. However, two veterans scored greater than 50 on a measure of PTSD severity, suggesting that they may have PTSD; as a result, these veterans’ and their partners’ responses were excluded from data analyses. Of the remaining veterans (n = 13), the highest reported PTSD severity score was 34, well below the screening threshold of 50 (Blanchard, Jones-Alexander, Bukley, & Forneris, 1996). Each of the included couples was married. Of the veterans, 62% (n = 8) served in the Army, 15% (n = 2) the Air Force, 15% (n = 2), and the Navy, and 8% (n = 1) served in the Marine Corps.


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Table 1 Veteran Demographics

Age African American Caucasian Years served active duty More than high school education Number of divorces Number of children Ever received mental health treatment

PTSD+ n = 20

PTSD− n = 13

t test or x2 statistic

63.1 (4.4) 60% 30% 4.25 (4.22) 25% 0.85 (0.88) 1.8 (1.5) 50%

68.4 (3.9) 31% 62% 9.46 (8.72) 46% 0.92 (0.64) 2.2 (0.9) 25%

3.6** 2.7 3.2 2.01* 1.59 −0.28 −0.86 0.18

Note. PTSD = posttraumatic stress disorder. For continuous variables, means and standard deviations (in parentheses) are presented. For dichotomous variables, percentages are presented. *p < .05. **p < .01. ***p < .001.

Overall, our groups of veterans were fairly similar, reporting similar amounts of education, number of divorces, children, and history of receiving mental health treatment (Table 1). However, the PTSD-positive veterans were significantly younger and served fewer years on active duty than PTSD-negative veterans. Age was not correlated to relationship quality (r = .03, p = .87) but was negatively correlated with anger (r = −.46, p = .008). Additionally, time served on active duty was not correlated with relationship quality (r = .20, p = .30) or trait anger (r = −.28, p = .11). Therefore, age was included as a covariate in models including veteran trait anger.

Measures PTSD Checklist, Military Version (PCL-M). The PCL-M (Weathers, Litz, Herman, Huska, & Keane, 1993) assessed veterans’ PTSD symptoms. The PCL-M is a 17-item measure of PTSD symptom severity related to a military experience. Scores range from 17 to 85, with higher scores indicating more intense PTSD symptom severity. This measure has demonstrated internal consistency and reliability with an alpha coefficient of .96 for all items (Weathers et al., 1993). Dyadic Adjustment Scale (DAS). The DAS (Spanier, 1976) was selected as a measure of relationship functioning. This measure is a 32-item self-report questionnaire. Total scores range from 0 to 151, with higher scores indicating higher relationship functioning. We defined dyadic distress as DAS scores lower than 98, as suggested by Spanier (1989). The DAS total score has a high level of internal consistency (coefficient alpha = .95) and high construct validity as evidenced by a .86 correlation between the DAS and the Locke-Wallace Marital Adjustment Scale (Spanier, 1976). State–Trait Anger Expression Inventory-2 (STAXI-2), Trait Anger Subscale. The STAXI-2 (Spielberger, 1999) is a self-report measure of anger severity and frequency. Internal consistencies range from .73 to .93, and support for validity comes from relationships with other measures of anger and hostility (Spielberger, 1999). Only the Trait Anger subscale was used to measure anger in this study because it assessed how frequent feelings of anger were experienced, while the State Anger subscale assessed the respondent’s current feelings of anger (Spielberger, 1999). Normal males aged 30 years and older scoring above 19 on this subscale are in the 75th percentile (two standard deviations) and above of trait anger. Male psychiatric patients aged 18 years and older scoring above 23 on this subscale are in the 75th percentile (two standard deviations) and above of trait anger (Spielberger, 1999). Veterans scoring above the 75th percentile were considered to have reported clinically significant anger.

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Table 2 Means, Standard Deviations, and Correlations of Posttraumatic Stress, Trait Anger, and Relationship Functioning Correlations

Veteran PCL-M Veteran STAXI Partner STAXI Veteran DAS Partner DAS

PTSD+ M (SD)

PTSD− M (SD)

t test

59.9 (8.43) 22.70 (6.64) 14.32 (1.38) 108.78 (18.57) 111.56 (18.86)

25.6 (9.27) 12.85 (3.36) 14.00 (3.54) 107.92 (20.59) 113.92 (12.35)

−10.76** −5.62*** 0.24 0.12 −0.44

1

2

1.00 0.77*** 1.00

3

4

−0.01 −.09 0.10 −0.46* 1.00 0.13 1.00

5 −.25 −0.42* −0.11 0.66*** 1.00

Note. PTSD = posttraumatic stress disorder. M = mean; SD = standard deviation; PCL-M = Posttraumatic Stress Disorder Checklist-Military Version; STAXI = State-Trait Anger Expression Inventory; DAS = Dyadic Adjustment Scale. Anger was measured by State-Trait Anger Expression Inventory-2. *p < .05. **p < .01. ***p < .001.

Overview of Data Analyses Descriptive statistics were completed with R Studio (version 0.98). Two-tailed t tests of difference of means were used to determine if averaged responses varied between PTSD-positive and PTSD-negative couples. Because of a violation of the homoscedasticity assumption, t statistics not assuming homoscedasticity were reported. Two-tailed t tests and chi-square analyses were used to compare the demographic and clinical characteristics of the two veteran groups. PTSD severity scores were only obtained from the veterans. Therefore, veterans’ PTSD severity scores were used to predict partners’ trait anger and relationship functioning. A correlation procedure was used to measure the strength of the association between relationship dysfunction, PTSD symptom severity, and trait anger variables. Questionnaires with missing data were excluded from analyses unless the questionnaire had established procedures to address missing data. We have used the term “veterans” to refer to all veterans (PTSD-positive and PTSD-negative veterans) and “partners” to refer to all partners, irrespective of their partners’ PTSD diagnosis. To evaluate the unique contributions of PTSD severity and trait anger on relationship dysfunction among couples, we used two-intercept, two-level models to fit APIMs. These models were computed with SAS version 9.4. Two-intercept APIMs allow for the estimation of separate, simultaneous effects of each member of the couple on themselves as well as each other while controlling for cross-partner associations. Models were constructed with all participants included. The moderating effect of veteran’s PTSD diagnosis was tested for each model, but in all cases the effect was nonsignificant, indicating that patterns of findings were comparable across both groups of couples.

Results Approximately 24% of PTSD-positive and 20% of PTSD-negative couples scored in the dyadic distress range of the relationship functioning measure. A total of 40% (n = 8) of PTSD-positive and 8% (n = 1) of PTSD-negative veterans scored above the 75th percentile of trait anger. Means, standard deviations, and intercorrelations of study variables are presented in Table 2. As expected, PTSD symptom severity and trait anger were significantly higher among PTSDpositive veterans, but relationship functioning did not differ between the two groups (PTSDpositive M = 110.24, SD = 12.06; PTSD-negative M = 111.04, SD = 16.73; t = −0.18, p = .86). PTSD severity was also positively associated with trait anger and trait anger was positively associated with relationship functioning, but PTSD severity was not significantly associated with relationship functioning (see Table 2). We next constructed a series of APIMs to test the associations among PTSD severity, trait anger, and relationship functioning. Results of each model are summarized in Table 3. In the first


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Table 3 Regression Coefficients From Three APIM Models PCL-M Predicts DAS Effect Veteran Intercept Veteran Partner Partner Intercept Partner Veteran

B

SE

114.56*** −0.14 –

9.20 0.19 –

122.39*** – −0.22

7.38 – 0.15

PCL-M Predicts STAXI B

STAXI Predicts DAS

SE

B

SE

5.24** 0.29*** –

2.18 0.05 –

136.53*** −1.25* 1.41

12.41 0.52 1.43

14.58*** – −0.02

1.72 – 0.04

156.38*** −1.09** −0.43

12.41 0.41 0.67

Note. APIM = actor–partner interdependence modeling; SE = standard error; PCL-M = Posttraumatic Stress Disorder Checklist-Military Version; DAS = Dyadic Adjustment Scale; STAXI = State–Trait Anger Expression Inventory-2. Age was included as a covariate for models including STAXI. Only veteran PCL-M scores were obtained. *p < .05. **p < .01. ***p < .001.

APIM, we examined the effects of veteran PTSD symptom severity on relationship functioning in both partners. Results indicated that veteran PTSD symptoms were not significantly associated with relationship functioning for either the veteran or the partner. In the second APIM, we examined the effects of veteran PTSD symptom severity on trait anger in both partners while controlling for veteran age. Results indicated that veteran PTSD symptoms were associated with significantly higher trait anger for the veteran but not for the partner. In the third APIM, we examined the effects of each partner’s trait anger on relationship functioning in both partners, again controlling for the effects of veteran age. Results indicated that the veteran’s trait anger was significantly associated with lower relationship functioning in the veteran but not the partner. The partner’s trait anger was significantly associated with lower relationship functioning in the partner but not the veteran. To determine if these relationships differed according to PTSD diagnostic groups, each model was repeated with interaction effects added. None of the interaction effects were statistically significant, suggesting that patterns of results did not differ across the two groups.

Discussion Consistent with our hypotheses and prior research, veterans’ PTSD severity was significantly associated with higher self-reported trait anger, and veterans’ trait anger was significantly associated with their own reports of lower relationship functioning. These results are consistent with previously published findings (e.g., Byrne & Riggs, 1996; Caska et al., 2014; Carroll et al., 1985; Dekel & Soloman, 2006). Veteran PTSD severity did not predict their partner’s report of relationship functioning or trait anger. In addition, veterans’ anger was not correlated with their partner’s anger. Therefore, there was no crossover effect of veterans’ PTSD severity or anger symptoms on the partner. The absence of a relationship between PTSD severity and relationship dysfunction observed in the present study diverges from previous findings suggesting a crossover effect of the veteran’s PTSD symptoms on their partner’s relationship functioning (i.e., Riggs et al., 1998). In this earlier study, PTSD-positive veterans reported comparable scores on the PCL-M to the veterans in our sample, ruling out the possibility that differences are attributable to differing levels of pathology. Because Riggs et al. did not measure anger in their study, it is not possible to determine if there are differences with respect to this construct that might explain our differential findings. An alternative perspective is that the nature of the disorder’s effect on important relationship

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factors change as PTSD becomes more chronic. Because the present study was conducted nearly 17 years after Riggs et al., it is possible, for instance, that partners have adapted to the veteran’s PTSD and anger such that they no longer influence their relationship functioning. Our results further indicate that veterans’ trait anger is a better predictor of relationship dysfunction than PTSD severity. To our knowledge, this has not been previously reported, although multiple studies have shown that hyperarousal symptoms (Hendrix, Erdmann, & Briggs, 1998) and anger (Galovski & Lyons, 2004; Monson et al., 2003) have significant negative effect on relationships. From a clinical perspective, these results suggest that anger may be an important treatment target for couples affected by PTSD. For example, cognitive-behavioral conjoint therapy for PTSD (Monson & Fredman, 2012), the only treatment specifically designed to reduce PTSD symptoms and enrich relationship functioning (Monson, Taft, & Fredman, 2009), includes conflict management as a treatment target and has been shown to be associated with improvements in relationship functioning and trait anger for the partner diagnosed with PTSD (Monson & Fredman, 2012). Although couples reporting significant dyadic distress may benefit from this therapy, the present findings suggest that couples’ therapy may not be necessary and treating the veteran’s anger individually may be sufficient. Our results align with the CBIM (Dekel & Monson, 2010) framework, because individuals who are frequently angry are more likely to be unhappy and negatively affect those close to them. This anger then reciprocally affects other relationship factors, such as communication and intimacy, and when coupled with insufficient conflict management, creates dysfunction within relationships.

Strengths and Limitations This study has several strengths including the implementation of a control group, reports from both members of the dyad, clinician-confirmed PTSD diagnoses documented in the medical record, and actor–partner interdependence modeling. However, several limitations also exist. First, we relied solely on the use of self-report questionnaires, which are subjective measurements vulnerable to response bias. Namely, this study could have been strengthened if it had used an interview to confirm the presence or absence of PTSD diagnoses. However, the multiple sources of information (i.e., documentation in veteran’s chart by a mental health clinician, service-connection, and meeting criteria on the PCL) provide strong support for the assignment of veterans to their respective groups. Second, a number of participants completed the study questionnaires at home and were therefore not supervised by study staff, making it difficult for participants to obtain clarification when needed. Although we used procedures to reduce the risk of these potentially compromising factors, the differences in data collection settings nonetheless could have affected response patterns. Further, we did not record which couples completed the questionnaires at home, limiting our ability to analyze potential differences between couples that completed the study in person versus home. A potential third limitation of this study is the small sample size, which comprised 20 PTSD-positive couples and 13 PTSD-negative couples. Fortunately, APIM is robust to the limitations of small sample sizes often obtained when analyzing couples (Tambling, Johnson, & Johnson, 2011). Nonetheless, the present study should be replicated in a larger sample to confirm these findings. Fourth, the PTSD-positive and PTSD-negative veterans differed in age and years served on active duty, consistent with previous research that has also reported that PTSD-positive veterans tend to be younger than PTSD-negative veterans (Jordan et al., 1992; Riggs et al., 1998). Finally, our results may not generalize to other veteran cohorts, female service members, civilians, or same-sex couples. Additional studies are needed to determine the applicability of our conclusions to these other groups.

Conclusions These results provide more specific insight to mechanisms of disruption in the relationships of Vietnam veterans with PTSD. Overall, our PTSD-positive couples reported relationship functioning comparable to PTSD-negative couples and trait anger was a better indicator of


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relationship dysfunction than PTSD severity. Future research should seek to better extrapolate the role of anger in relationship dysfunction and examine how PTSD evolves to affect couples over time. Clinicians working with couples in which one partner has PTSD may also consider assessing the effect of anger within the relationship and making it a treatment target.

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