Intimate Relationship Distress and Combat-related Posttraumatic Stress Disorder

Waiting to Phone Home, MSG Henrietta Snowden, courtesy of the Army Art Collection, US Army Center of Military History.

Decades of research spanning generations of war have firmly established that veterans with posttraumatic stress disorder (PTSD) and their romantic partners suffer significant relationship and psychological distress compared to civilian and veteran populations without PTSD [1]. World War II prisoners of war with PTSD reported more adjustment, communication, and intimacy problems in their relationships compared to prisoners of war without PTSD [2]. Similarly, Vietnam War veterans with PTSD, compared to Vietnam veterans without PTSD, were more likely to report marital and family adjustment problems, parenting difficulty, violence [3], significant relationship distress, intimacy problems, and thoughts or actions toward separation or divorce [4].

Several studies have shown that veterans from Operation Enduring Freedom and Operation Iraqi Freedom (OIF) have significant mental health risk and intimate relationship discord. Soldiers deployed to Iraq are at significant risk of developing PTSD [5] and reported a fourfold increase in interpersonal problems [6]. Developing a greater understanding of the impact and complex interplay of combat-related PTSD on intimate relationships can be of great benefit to the mental health providers, the veterans, their intimate partners, and the family system.

25.1 Case Presentation

Julia is a 28-year-old female spouse of a veteran who presented to a military behavioral health clinic for an urgent walk-in. Her chief complaint was “My husband is driving me crazy and I can’t take it anymore!”

She reported being upset and overwhelmed almost daily in the context of worsening problems with her husband. He is a combat veteran with multiple deployments to Iraq and had been diagnosed with PTSD. He was a different person after his deployments and their marriage had become more difficult to the point where she is now thinking of divorcing him. She was more irritable with the children, had difficulty sleeping, reported being angry with him, and felt sad that their family was dissolving before her eyes. She even admitted to fleeting and passive suicidal thoughts but never with any intention or plan.

She was extremely dissatisfied in the marriage and felt her husband’s PTSD was to blame. She knew he had seen combat but she did not know the details. He would not talk to her about his deployments, in fact, he did not communicate at all. He was like a stranger in their home and frequently isolated himself in the basement from her and the kids. When she tried to talk to him about his experiences he just brushed her off. She felt so lonely in the marriage. She could not remember the last time they had been intimate. She wondered what was wrong with her that he did not trust her or could not let her in.

Besides the emotional and physical distance, he was always on edge. When they did talk, more often than not he would explode with unpredictable anger, triggered by everyday stressors. In response to his anger, sometimes she would get angry and it escalated quickly. He had destroyed furniture and punched holes in the walls. He had never hurt her or the kids but there were times when she was afraid he could. More recently she simply avoided him.

He did not sleep much. When he did, he thrashed about while dreaming, yelling and kicking. One night he jumped on top of her and started to choke her in a crazed state. She slapped him awake and he appeared mortified. After that he preferred to sleep on the living room couch. He liked it because he could “have a visual on all the doors, windows, and rooms.” Sometimes he even slept with his firearm because “I have to be ready just in case.” Some of these behaviors made sense to her because “It was like he was still in Iraq.”

His insomnia and mood swings had affected his work performance. He had been counseled several times by his employer for tardiness and irritable behavior. At home he was often too overwhelmed or withdrawn to manage the kids. He had difficulty with other general household tasks. Julia had to assume responsibility for childcare, chores, home maintenance, and finances. In addition, she had to make sure he attended his medical appointments and took his medications. She felt extremely burdened with all these responsibilities which added to her loneliness, frustration, and hopelessness. Lately, she had been so overwhelmed that she was having more difficulty organizing and managing the household. Ironically, she felt the family worked better when he was deployed.

This was Julia’s first behavioral health treatment. She had wanted to seek care earlier but was afraid that if she saw behavioral health it might have a negative effect on her husband’s career. He had been initially resistant to seeing a psychiatrist because he did not want his friends or coworkers to think he was “weak or crazy” but she eventually persuaded him. She had no family history or previous personal history of mental illness, depression, anxiety, psychosis, or mania. She denied substance use or medical problems.

Julia was raised by a loving family in a small town in the Pacific Northwest. She met all her developmental milestones. She denied abuse. She excelled in academics and sports. She met her husband when they were in high school. He enlisted in the Army after graduation and she went to college for prelaw. He proposed when she was a junior and she gave up her dream to go to law school to be a stay-at-home wife and mother. Together, they have two young school-age children. They have some financial debt but no legal problems. They attend a Christian church on the weekends.

On exam, Julia was a well-groomed white female who appeared emotionally distressed. She was cooperative, coherent, and articulate. Her speech was at a normal rate but sometimes she raised her voice when upset. She reported some depressive and anxious feelings. Her affect was constricted but appropriate to content. Her thought process was linear and logical. She admitted to rare, passive suicidal thoughts in the past without any intent, plan, or attempt. She denied current suicidal or homicidal ideation. There was no evidence of psychosis or paranoia. She was oriented and appeared to be of above average intelligence. She had good insight and judgment.

25.2 Diagnosis and Assessment

25.2.1 Relationship Distress with Spouse or Intimate Partner (DSM-5)

While the patient presents with mild symptoms of depression, anxiety, and stress, it’s clear that the primary problem is relational. Her husband’s combat-related PTSD is having a tremendous impact on her own mental health, causing significant psychological distress and functional impairment. In general, partners who perceive greater levels of PTSD symptom severity also report greater individual and marital distress [7]. In this case, Julia’s relationship distress is associated with impaired functioning in behavioral, cognitive, and affective domains, specifically reactive to her husband’s PTSD symptoms. There is a growing body of research literature examining how the specific symptom clusters of PTSD—intrusions, avoidance, negative alterations of cognition and mood, and hyperarousal—affect the intimate partner. Further, studies are exploring how the behavioral, cognitive, and affective reactions of the intimate partner feedback to the veteran to either alleviate, maintain, or even worsen the PTSD.

Several studies have shown that the degree of relationship distress is particularly correlated with the severity of emotional numbing [2, 4]. In DSM-5, PTSD emotional numbing symptoms have been reorganized primarily into the new negative cognitions and mood cluster. Julia described several ways in which her spouse engaged in these symptoms to include his inability to communicate his experience, both in the present and in the past; his physical withdrawal into the basement, his estrangement from family participation, and marked lack of physical intimacy. In response to these symptoms, Julia developed cognitive, affective, and behavioral reactions. She felt terribly alone in the marriage. Spouses report that loneliness is the hardest thing to cope with while their partners are deployed. Ironically, PTSD reintroduces that loneliness and isolation despite the physical return of their veteran spouse. Julia wondered, “What’s wrong with me? Why can’t he trust me?”

Using an attributional cognitive model [7], Julia may be misinterpreting her husband’s emotional numbing and withdrawal as reflective of her or the relationship itself, instead of being a function of the disorder. She internalized his avoiding behavior and developed reactionary negative cognitions, that is, “Something is wrong with me or he doesn’t trust me.” This reinforces clinically significant depressive feelings and symptoms. Behaviorally, she initially tried to engage but after being rebuffed so many times she has little option but to reciprocate the emotional withdrawal. The lack of communication and disclosure is inherently isolating to the veteran and their partner, thus feeding back into the couple’s relational dysfunction.

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