اختلال استرس پس از حادثه و رضایت زناشویی در اعضای خدمت نظام: بررسی نقش همزمان سوء استفاده جنسی دوران کودکی و مواجهه با جنگ

Childhood sexual abuse (CSA) is relatively common and is associated with a multitude of negative outcomes in adulthood, including posttraumatic stress disorder (PTSD) and lower marital satisfaction. However, CSA has been understudied in military samples. The purpose of the present study was to examine the relative contributions of CSA and combat exposure to PTSD and marital satisfaction. Two hundred eighteen National Guard/Reserve veterans who deployed overseas between 2001 and 2008 completed self-report measures of CSA, marital satisfaction, combat exposure, and PTSD symptom severity. Data were analyzed using linear regression and path analysis to evaluate a comprehensive model including all variables. CSA accounted for unique variance in PTSD symptom severity independent of combat exposure. CSA also had a negative direct association with marital satisfaction, independent of combat exposure and PTSD symptom severity. In contrast, combat exposure had only a negative indirect association with marital satisfaction via PTSD when all variables were examined simultaneously. CSA accounted for unique variance in both PTSD symptom severity and marital satisfaction in this sample of combat veterans. Clinically, results suggest that assessment and treatment of CSA is indicated for military veterans suffering from PTSD. Further, treatment of CSA may improve marital satisfaction, which may positively affect psychological functioning in the veteran.

Over the past decade, more than two million military service members have deployed to combat zones in Afghanistan, Iraq, and related areas (Institute of Medicine, 2010). Over 90% of these service members report being exposed to potentially traumatic events, such as being fired upon while deployed (e.g., Hoge et al., 2004), with rates of PTSD generally estimated between 10% and 20% (e.g., Hoge et al., 2004 and Milliken et al., 2007). In addition, a great deal of research over the past decade has focused on interpersonal distress in this population, with reports of increased family and marital strain related to high rates of deployment (e.g., Allen, Rhoades, Stanley, & Markman, 2011) and, particularly, to symptoms of combat-related PTSD (meta-analysis by Taft, Watkins, Stafford, Street, & Monson, 2011). To date, a significant amount of research has focused on actual combat experiences as the primary predictor of PTSD symptoms in this population, with recent research beginning to investigate other deployment-related risk factors (e.g., pre-deployment preparedness; post-deployment social support; Goldmann et al., 2012, Renshaw, 2011 and Vogt and Tanner, 2007). Despite research on such military-related risk factors before, during, and after deployments (Goldmann et al., 2012), fewer studies have examined non-military related risk factors for PTSD severity among combat veterans. One particular risk factor for PTSD severity and poor relationship satisfaction that has only rarely been investigated in this population is the experience of childhood sexual abuse (CSA; Lapp et al., 2005). Summarizing data across multiple epidemiological surveys in the United States, Finkelhor (2011) reports that rates of CSA in the general population range from 1.12 to 10.5 per 1,000, based on self/caretaker reports and/or agency reports. With regard to the military population, a review of the literature on trauma among female veterans revealed that between 27% and 49% report experiencing CSA (Zinzow, Grubaugh, Monnier, Suffoletta-Maierle, & Frueh, 2007). Comparatively, rates of CSA among male veterans have not been well established. In one study of 133 male veterans being treated for PTSD in a psychiatric inpatient unit of a veterans hospital, the rate of reported CSA was quite high, at 41% (Lapp et al., 2005). In another study of 64 male veterans (38 of who were being treated for PTSD on a psychiatric inpatient unit), the rate of reported CSA was 8% (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993). Notably, only individuals from the PTSD treatment group versus individuals being treated for medical problems reported a history of CSA. Thus, CSA does appear to be a relevant, albeit highly understudied, factor in military population. Childhood abuse in general (i.e., physical, sexual, and psychological abuse, as well as neglect) has been linked with significant maladjustment and psychological difficulties later in life (e.g., Briere and Elliott, 2003 and Tyler, 2002), including PTSD (Briere and Elliott, 2003, Larsen et al., 2011 and Molnar et al., 2001). Childhood abuse has also been linked to PTSD severity specifically in military veterans. An early study by Engel et al. (1993) found that childhood abuse was related to more severe PTSD, although only among female veterans. More recently, two studies have examined the moderating effect of combat exposure on the relationship between childhood abuse and PTSD symptom severity (Owens et al., 2009 and Stein et al., 2005). In both studies, at low levels of combat exposure, a higher degree of childhood abuse was associated with increased PTSD severity. Surprisingly, at high levels of combat exposure, a higher degree of childhood abuse was associated with lower PTSD severity. One explanation offered by these researchers is that the experience of significant childhood abuse provides opportunities for individuals to develop adaptive coping skills, which may protect them when facing future traumatic events. In another set of studies, the experience of childhood abuse was shown to predict PTSD in military veterans, even when accounting for severity of combat exposure (Bremner et al., 1993, Brown et al., 2005 and Van Voorhees et al., 2012). Thus, initial evidence demonstrates that childhood abuse is a relevant factor in understanding PTSD severity in military samples. However, in all of the prior studies we identified, only the broad construct of general childhood abuse was examined, with no separate examination of CSA in particular. Thus, the specific relationships among CSA, combat exposure, and PTSD symptom severity have yet to be fully evaluated empirically. Importantly, PTSD is not the only negative outcome to arise from either CSA or military combat experiences. As noted above, another primary focus in current research on military service members is relationship distress. Results of a meta-analysis of 31 studies of the association between PTSD and intimate relationship problems, 19 of which were conducted in military samples, revealed medium-sized effects of PTSD on intimate relationship discord, physical aggression perpetration, and psychological aggression perpetration (Taft et al., 2011). Moreover, the association of symptoms of PTSD with intimate relationship problems was stronger in the 19 military samples than in the 12 civilian samples included in the meta-analysis. In a review of the literature of the psychological sequelae of combat violence, Galovski and Lyons (2004) conclude that exposure to combat increases the likelihood of developing PTSD, which in turn affects social and psychological functioning, particularly in intimate relationships within the family. This suggests that PTSD symptom severity mediates the association of combat exposure with relationship distress, which has been supported in empirical studies of veterans of the recent conflicts in Iraq and Afghanistan (e.g., Allen, Rhoades, Stanley, & Markman, 2010). Despite the handful of studies reviewed above on history of childhood abuse in general and PTSD symptom severity in combat veterans, we were unable to identify any studies examining the effects of CSA and combat-related PTSD symptoms on marital satisfaction in combat veterans. In the general population, a history of CSA has been related to lower relationship satisfaction in adulthood (Friesen, Woodward, Horwood, & Fergusson, 2009). Similar to studies of relationship satisfaction and PTSD in military populations, some studies have found that the association of CSA with adult relationship distress is mediated by other factors, such as greater social and economic disadvantage, lower family living standards, higher rates of parental adjustment problems, more frequent parent changes (Friesen et al., 2009), partner aggression, and partner sexual risk behavior (Testa, VanZile-Tamsen, & Livingston, 2005). However, we identified no studies that examined PTSD symptom severity as a potential mediator of the link between history of CSA and relationship distress in adults. Moreover, we identified no study of CSA, combat experiences, PTSD symptom severity, and relationship distress in combat veterans. Our goal in the current study was to address these gaps in the literature. First, we aimed to examine the relative contributions of CSA and combat exposure to PTSD symptom severity in National Guard/Reserve combat veterans and to extend prior research that has found that childhood abuse in general adds to the prediction of PTSD symptom severity in this population. Second, we aimed to examine the relative contributions of all three of these variables to relationship distress in combat veterans. Our hypotheses were: (1) CSA would be associated with unique variance in PTSD symptom severity independent of combat exposure, and (2) CSA and combat exposure would be indirectly (via PTSD symptom severity) associated with lower marital satisfaction. We hypothesized that CSA and combat exposure would not be directly associated with marital satisfaction while controlling for the effects of PTSD.