خشم، تفکیک و PTSD در جانبازان مرد ورود به درمان PTSD

Prior research suggests that dissociation and anger are risk factors for the development of posttraumatic stress disorder (PTSD). Research found that trauma survivors with higher levels of anger also report more severe PTSD overall. Studies also support a relationship between PTSD severity and dissociation. Only one prior study of sexual assault survivors by Feeny, Zoellner, and Foa (2000) examined the relationships among dissociation, anger, and PTSD. While Veterans have been found to report high levels of anger and dissociation, the relationship between these factors and PTSD has not been examined among Veterans. This paper examines the relationship among anger, dissociation, and PTSD in treatment-seeking Veterans who presented for evaluation at the PTSD Clinic in the VA Ann Arbor Healthcare System during a four year period. Anger and dissociation predicted PTSD, hyperarousal, and avoidance/numbing severity while dissociation predicted intrusive severity. The implications of these results for clinical practice are discussed.

Posttraumatic stress disorder (PTSD) among military Veterans remains a significant concern with estimated prevalence rates of 15% among Vietnam-era Veterans (Schlenger et al., 1992), 2–10% among the first Persian Gulf War Veterans (Iowa Persian Gulf Study Group, 1997 and Kang et al., 2003), and 11–22% among active duty soldiers and Veterans from the Afghanistan and Iraq conflicts (Hoge et al., 2004, Hoge et al., 2006 and Seal et al., 2009). These rates coupled with the well-documented, multidimensional impairment associated with this disorder create an immediate need to better understand and treat PTSD in this population (e.g., Kulka et al., 1990 and Maguen et al., 2009; Shea, Vujanovic, Mansfield, Sevin, and Liu, 2010). Given the hallmark symptoms of this disorder (e.g., reexperiencing, emotional numbing, distress in response to triggers, exaggerated startle response, emotional detachment), research has begun to explore emotion processing and regulation difficulties that may be risk factors for the development and maintenance of PTSD. Two hallmark, emotion-related symptoms of PTSD – anger and dissociation – are known risk factors for the development and maintenance of PTSD and significant problems among Veterans with PTSD (e.g., Bremner et al., 1992 and Jakupcak et al., 2007). 1.1. Anger and PTSD Anger is associated with numerous negative consequences, including impulsive aggression (Teten et al., 2010), poorer treatment outcomes (Forbes et al., 2003, Forbes et al., 2005 and Forbes et al., 2008), substance misuse (Seedat, Stein, & Forde, 2003) and increased aggression (e.g., Taft, Street, Marshall, Dowdall, & Riggs, 2007). Among both Veteran and civilian populations, trauma survivors who report higher levels of anger are more likely to meet criteria for PTSD (e.g., Chemtob et al., 1994 and Taft et al., 2007). In addition, among combat Veterans level of anger differentiated those Veterans with and without PTSD (e.g., Frueh et al., 1997 and Jakupcak et al., 2007), even after controlling for level of combat exposure (e.g., Chemtob et al., 1994). Additionally, higher levels of anger are associated with more severe PTSD overall (e.g., Chemtob et al., 1994 and Taft et al., 2007), even after PTSD items relating to anger are removed (e.g., Novaco & Chemtob, 2002). In a meta-analysis, Orth and Wieland (2006) found that the strength of the relationship between PTSD and anger was significant overall across trauma types but that it was strongest among military combat Veterans. 1.2. Dissociation and PTSD Dissociation is commonly defined as difficulty integrating thoughts, feelings and experiences into consciousness and memory (Bernstein & Putnam, 1986). Peritraumatic and trait dissociation, in particular, have been examined as potential predictors of PTSD with mixed results (McCaslin et al., 2008; for full review of peritraumatic dissociation, see van der Velden & Wittmann, 2008). Increased dissociative symptoms both during and after trauma exposure are related to higher prevalence and increased severity of PTSD in military and civilian participants (e.g., Bremner and Brett, 1997 and Dancu et al., 1996). Additionally, the relationship between dissociation during the event and the later emergence of PTSD has been shown prospectively (Holen, 1993). In fact, a meta-analysis examining potential predictors of PTSD reported that dissociation at the time of the trauma (peritraumatic dissociation) had the largest effect size (weighted r = .35) relative to other risk factors, such as prior trauma history, family history of psychopathology, perceived life threat during the trauma, post-trauma social support, and prior psychological adjustment ( Ozer, Best, Lipsey, & Weiss, 2003). Among Veterans, higher levels of dissociation both during and following the trauma were found among those with PTSD than without PTSD ( Bremner and Brett, 1997 and Bremner et al., 1992) and were predictive of PTSD status even after controlling for level of combat exposure ( Marmar et al., 1994). The relationships between dissociation and the three specific PTSD symptom clusters (intrusion, avoidance/numbing, and hyperarousal) are less clear. For instance, in a study of female Veterans who served in Vietnam, dissociation significantly predicted intrusive symptoms and avoidance symptoms ( Tichenor, Marmar, Weiss, Metzler, & Ronfeldt, 1996). However, increased dissociation was only related to arousal symptoms in a sample of male Australian Vietnam Veterans ( Tampke & Irwin, 1999). 1.3. Anger and dissociation Taken together, the results of the previous studies suggest that anger and dissociation are important factors in the development and maintenance of PTSD. However, to date, only one study of sexual assault survivors has examined the concurrent relationships between dissociation, anger, and PTSD (Feeny, Zoellner, & Foa, 2000). In this study, higher anger was related to more dissociation in female-assault survivors at 12 weeks post-assault, even after controlling for PTSD severity. In addition, higher anger and dissociation were related to worse mental health outcomes (i.e., PTSD and social impairment), and higher anger at four weeks post-assault predicted PTSD at 3 months post-assault while dissociation at four weeks post-assault predicted social impairment at 3 months post-assault. Based on these results, Feeny and colleagues suggested anger and dissociation are complimentary methods of emotional disengagement from the traumatic event that comprise problematic coping styles consistent with emotional avoidance. While these results are compelling, replication and extension is necessary to understand the relationship between anger, dissociation, and PTSD among combat Veterans. The current study examines the relationships between PTSD, dissociation, and anger in treatment-seeking Veterans who presented for evaluation at the PTSD clinic in the Veterans Affairs Ann Arbor Healthcare System between November 2003 and November 2007.

In summary, anger and dissociation are apparent in treatment-seeking Veterans with PTSD. These factors are significantly related to PTSD severity in both overall and specific symptoms clusters. Identifying anger and dissociation as avoidance and maladaptive coping strategies involved in the maintenance of PTSD symptoms can be a critical part of effective treatment for PTSD.