Posttraumatic stress disorder and attachment among Croatian War veterans and their wives : doctoral dissertation

Šeremet, Ana (avtor), Gostečnik, Christian (mentor), Knežević, Martina (komentor), Knežević, Martina (komentor)

One of the most common problems for veterans suffering from PTSD is the disturbance of interpersonal relationships or attachments. These types of interpersonal impairments in abilities to love and feel loved (unable to have loving feelings, feelings of detachment or estrangement from others, and a sense of foreshortened future) result in significant problems in social, family, sexual, and work functioning. The wives of war veterans are the most vulnerable group after their return from war, and marital relations often become damaged. The interactive nature of the marital relationship, cultural norms, expectations, and a sense of obligation are just some factors that contribute to the wife's increased sensitivity to the stress experienced by her. In addition, wives often "take over" the symptoms of the traumatized person as a result of close emotional connection with and care for that person, thus resulting in the so-called process of secondary traumatization. The main aim of doctoral research was to investigate the relationships between PTSD symptoms, marital relationship quality, and partner attachment in Croatian veterans and their wives. Specifically, we want to investigate the answer to the following research questions: (1) Do veterans with PTSD and their wives have lower marital quality than veterans without PTSD and their wives? (2) Do anxious and avoidant attachment contribute to PTSD symptom levels in veterans and their spouses? Does veterans' anxious and avoidant attachment contribute to their wives' PTSD symptom levels, or does veterans' spouses' anxious and avoidant attachment contribute to veterans' PTSD symptom levels? (3) Are anxious and avoidant attachments a transmission mechanism of PTSD symptoms between the veterans and their spouses? Methodology The sample consisted of two groups: (1) 75 veterans diagnosed with PTSD and their wives and (2) 75 veterans without PTSD diagnosis and their wives. They have answered questions from several questionnaires: The Cognitive non-verbal test (CNT; Sučević et al., 2004), The Combat Exposure Questionnaire (CES; Keane et al., 1989), Posttraumatic Stress Disorder Checklist for DSM-5 -PCL-5 (Weathers et al., 2013), Experiences in close relationship scale (ECR-12; Lafontaine et al., 2015). They also fulfill a sociodemographic questionnaire. Using t-test for independent samples we tested if two groups of veterans and two groups of their wives differ in marital quality. Using dyadic methodology, we have tested four separate actor-partner inderdependence models with anxious/avoidant attachment as a predictor, and symptoms of PTSD as a criteria. At the end, we conducted eight mediation analytes to test direct and indirect effects of anxious and avoidant attachment of an individual partner on the relationship between PTSD symptoms of veterans' wives and PTSD symptoms of veterans, and vice versa. Results and discussion Wives of veterans diagnosed with PTSD report higher levels of PTSD symptoms, higher levels of anxious attachment, and higher levels of marital cohesion than wives of veterans without PTSD diagnosis did. Veterans diagnosed with PTSD report higher levels of PTSD symptoms and higher levels of marital cohesion than veterans without PTSD diagnosis. Although 25 years have passed between the end of the war and our study, and other postwar stressful events may have influenced PTSD, the results of high levels of PTSD symptoms among veterans diagnosed with PTSD, and their wives suggest long-term consequences of war trauma and the existence of chronic PTSD Taking into account the weaknesses and vulnerabilities of their husbands, women alternate between the roles they take on in the family. Family dynamics are generally such that women are careful not to anger them with their behavior, monitor their mood, and take on all responsibilities. It is possible, therefore, that due to the woman's great adaptability to his wishes and activities, veterans with PTSD estimate the degree of cohesion with their spouse higher than veterans without a diagnosis of PTSD. Results from two models which test anxious attachment as a predictor of PTSD symptoms shows a significant dyadic “only actor” pattern for veterans. On the other hand, when it comes to veterans’ wives without PTSD diagnosis, we found significant partner effect. In other words, women's anxious attachment significantly positively predicts their level of PTSD symptoms and their partner's level of PTSD symptoms. Results from two models which test avoidant attachment as a predictor of PTSD symptoms shows a significant dyadic “only actor” pattern for veterans and their wives. Difficulties in emotional regulation during and immediately after a traumatic event are potential mechanisms through which anxious and avoidant attachments can influence the development and maintenance of PTSD symptoms (Mikulincer & Shaver 2012, 13). An indirect effect of veterans' PTSD symptoms on women's PTSD symptoms and an indirect effect of wives’ PTSD symptoms on veterans' PTSD symptoms via wives’ anxious attachment were obtained. Specifically, higher PTSD symptoms in veterans indirectly—through a positive effect on wives’ anxious attachment—contribute to higher PTSD symptoms in wives. That is higher levels of PTSD symptoms in veteran spouses indirectly—through a positive effect on veteran spouses' anxious attachment—contribute to higher PTSD symptoms in veterans. Mediation models that tested the avoidant attachment of veterans or their wives and the anxious attachment of veterans as mediators did not prove to be statistically significant; that is, only direct effects of PTSD symptoms of veterans on PTSD symptoms of their wives were obtained, and vice versa. Significant mediation effect of wives’ anxious attachment could be due to the socialization process and social roles that emphasize women's focus on the relationships, which makes them more empathetic and more sensitive to their partner's behaviour and interpersonal skills behaviour which enables the transmission of PTSD symptoms between herself and her husband. Conclusion The results of our research also provide valuable implications for counseling and psychotherapy work with traumatized individuals. Although 25 years have passed since the war's end, veterans diagnosed with PTSD in the post-war period are currently experiencing very high levels of post-traumatic stress disorder symptoms. The combination of the complex clinical picture of PTSD and high comorbidity with other psychiatric and somatic disorders requires a complex or integrative treatment approach that includes biological, psychological, and social dimensions. Moreover, it is essential to include in the therapeutic work with traumatized individuals the spouses and working on the attachment to the partner. Integrating the concept of partner attachment into the treatment of PTSD can enable positive change in mental models of self and others. Therefore, it is important to pay special attention to the anxious attachment of wife and, in therapeutic work with anxiously attached individuals, to focus on her feeling of helplessness and fear of abandonment, to strengthen more effective emotional regulation, which will then lead to the reduction in the level of PTSD symptoms at the individual level, that is, to the reduction of secondary traumatization of the partner.

• Jezik: Angleški jezik
• Ključne besede: veterans, combat PTSD, veterans’ wives, attachment, secondary traumatization, marital quality
• Vrsta gradiva: Doktorsko delo/naloga
• Tipologija: 2.08 - Doktorska disertacija
• Organizacija: TEOF - Teološka fakulteta
• Kraj izida: Ljubljana
• Založnik: [A. Šeremet]
• Leto izida: 2023
• Št. strani: X, 237, II str.
• PID: 20.500.12556/RUL-145653
• UDK: 159.97:355.1-057.36-057.75(497.5)
• COBISS.SI-ID: 152072963
• Datum objave v RUL: 04.05.2023

Sekundarni jezik

• Jezik: Slovenski jezik
• Naslov: Posttravmatska stresna motnja in navezanost med hrvaškimi vojnimi veterani in njihovimi ženami

Izvleček

Ena najpogostejših težav veteranov s posttravmatsko stresno motnjo je motnja medosebnih odnosov oziroma navezanosti. Te vrste medosebnih motenj v sposobnosti ljubiti in čutiti ljubljenega (nezmožnost čutiti ljubeče občutke, občutke ločenosti ali odtujenosti od drugih in občutek skrajšane prihodnosti) povzročijo znatne težave v socialnem, družinskem, spolnem in delovnem delovanju. Žene vojnih veteranov so po vrnitvi iz vojne najbolj ranljiva skupina, zakonski odnosi pa se pogosto skrhajo. Interaktivna narava zakonskega odnosa, kulturne norme, pričakovanja in občutek obveznosti so le nekateri dejavniki, ki prispevajo k povečani občutljivosti žene na stres, ki ga doživlja. Poleg tega žene pogosto »prevzamejo« simptome travmatizirane osebe zaradi tesne čustvene povezanosti in skrbi za to osebo, kar povzroči tako imenovani proces sekundarne travmatizacije. Glavni cilj doktorske raziskave je bil raziskati povezave med simptomi PTSM, kakovostjo zakonskih odnosov in navezanostjo na partnerja pri hrvaških veteranih in njihovih ženah. Natančneje, želimo raziskati odgovor na naslednja raziskovalna vprašanja: (1) Ali imajo veterani s PTSM in njihove žene slabšo zakonsko kakovost kot veterani brez PTSM in njihove žene? (2) Ali tesnobna in izogibajoča navezanost prispevata k ravni simptomov PTSM pri veteranih in njihovih ženah? Ali anksiozna in izogibajoča navezanost veteranov prispeva k stopnji simptomov posttravmatske stresne motnje pri njihovih ženah ali tesnobna in izogibajoča se navezanost ženah veterana prispeva k ravni simptomov posttravmatske stresne motnje pri veteranih? (3) Ali so anksiozna in izogibajoča navezanost mehanizem prenosa simptomov PTSM med veterani in njihovimi ženami? Metodologija Vzorec sta sestavljali dve skupini: (1) 75 veteranov z diagnozo PTSM in njihove žene ter (2) 75 veteranov brez diagnoze PTSM in njihove žene. Odgovorili so na vprašanja iz več vprašalnikov: The Cognitive non-verbal Test (CNT; Sučević et al., 2004), The Combat Exposure Questionnaire (CES; Keane et al., 1989), Posttraumatic Stress Disorder Checklist for DSM-5 -PCL -5 (Weathers et al., 2013), Experiences in close relationship scale (ECR-12; Lafontaine et al., 2015). Izpolnili su tudi sociodemografski vprašalnik. S t-testom za neodvisne vzorce smo testirali, ali se dve skupini veteranov in dve skupini njihovih žena razlikujeta v kakovosti zakonske zveze. Z diadično metodologijo smo testirali štiri ločene modele neodvisnosti med akterjem in partnerjem z anksiozno/izogibno navezanostjo kot napovednikom in simptomi PTSM kot merilom. Na koncu smo izvedli osem mediacijskih analiza za testiranje neposrednih in posrednih učinkov anksiozne in izogibajoče se navezanosti posameznega partnerja na razmerje med simptomi PTSP žena veteranov in simptomi PTSM veteranov in obratno. Rezultati in razprava Žene veteranov z diagnozo PTSD poročajo o višjih stopnjah simptomov PTSM, višjih stopnjah anksiozne navezanosti in višjih stopnjah zakonske kohezije kot žene veteranov brez diagnoze PTSM. Veterani z diagnozo PTSD poročajo o višjih stopnjah simptomov PTSM in višjih stopnjah zakonske kohezije kot veterani brez diagnoze PTSM. Čeprav je med koncem vojne in našo študijo minilo 25 let in so drugi povojni stresni dogodki morda vplivali na PTSP, rezultati visokih stopenj simptomov PTSP med veterani z diagnozo PTSD in njihovimi ženami kažejo na dolgoročne posledice vojne travme in obstoj kronične posttravmatske stresne motnje. Ob upoštevanju slabosti in ranljivosti svojih mož ženske izmenjujejo vloge, ki jih prevzemajo v družini. Družinska dinamika je na splošno taka, da ženske pazijo, da jih ne razjezijo s svojim vedenjem, spremljajo njihovo razpoloženje in prevzemajo vse odgovornosti. Možno je torej, da veterani s posttravmatsko stresno motnjo zaradi velike prilagodljivosti ženske njegovim željam in dejavnostim ocenjujejo stopnjo kohezije z zakoncem višje kot veterani brez diagnoze posttravmatske stresne motnje. Rezultati dveh modelov, ki preizkušata anksiozno navezanost kot napovedovalec simptomov posttravmatske stresne motnje, kažejo pomemben diadičen vzorec „only actor“ za veterane. Po drugi strani pa, ko gre za žene veteranov brez diagnoze PTSP, smo ugotovili pomemben „partner effect“. Z drugimi besedami, anksiozna navezanost žensk pomembno pozitivno napoveduje njihovo raven simptomov PTSM in raven simptomov PTSM pri njihovem partnerju. Rezultati dveh modelov, ki preizkušata izogibajočo se navezanost kot napovedovalec simptomov posttravmatske stresne motnje, kažejo pomemben diadičen vzorec »only actor« za veterane in njihove žene. Težave pri čustveni regulaciji med travmatičnim dogodkom in takoj po njem so možni mehanizmi, prek katerih lahko anksiozna in izogibajoča se navezanost vplivata na razvoj in vzdrževanje simptomov PTSP (Mikulincer & Shaver 2012, 13). Dobljen je bil posredni učinek simptomov PTSD veteranov na simptome PTSD pri ženskah in posredni učinek simptomov PTSD pri ženah na simptome PTSD veteranov prek anksiozne navezanosti žena. Natančneje, višji simptomi PTSM pri veteranih posredno – s pozitivnim učinkom na anksiozno navezanost žena – prispevajo k večjim simptomom PTSM pri ženah. To pomeni, da višje ravni simptomov PTSM pri zakoncih veteranih posredno – s pozitivnim učinkom na anksiozno navezanost zakoncev veteranov – prispevajo k višjim simptomom PTSM pri veteranih. Modeli mediacije, ki so testirali izogibajočo se navezanost veteranov ali njihovih žena in anksiozno navezanost veteranov kot mediatorjev, se niso izkazali za statistično značilne; to pomeni, da so bili pridobljeni samo neposredni učinki simptomov PTSM veteranov na simptome PTSM žena in obratno. Pomemben mediacijski učinek anksiozne navezanosti žena je lahko posledica socializacijskega procesa in družbenih vlog, ki poudarjajo osredotočenost žensk na odnose, zaradi česar postanejo bolj empatične in bolj občutljive na partnerjevo vedenje in vedenje medosebnih veščin, kar omogoča prenos simptomov PTSP med sebe in svojega moža. Zaključek Rezultati naše raziskave dajejo tudi dragocene implikacije za svetovalno in psihoterapevtsko delo s travmatiziranimi posamezniki. Čeprav je od konca vojne minilo že 25 let, veterani, ki so jim v povojnem obdobju diagnosticirali PTSD, trenutno doživljajo zelo visoke stopnje simptomov posttravmatske stresne motnje. Kombinacija kompleksne klinične slike PTSM in visoke komorbidnosti z drugimi psihiatričnimi in somatskimi motnjami zahteva kompleksen ali integrativen pristop k zdravljenju, ki vključuje biološke, psihološke in socialne razsežnosti. Poleg tega je nujno, da v terapevtsko delo s travmatiziranimi posamezniki vključimo zakonca in delo na navezanosti na partnerja. Vključevanje koncepta navezanosti na partnerja v zdravljenje posttravmatske stresne motnje lahko omogoči pozitivne spremembe v mentalnih modelih sebe in drugih. Zato je pomembno, da posebno pozornost posvetimo anksiozni navezanosti žene in se pri terapevtskem delu z anksiozno navezanimi posamezniki osredotočimo na njen občutek nemoči in strahu pred zapuščenostjo, da okrepimo učinkovitejšo čustveno regulacijo, ki bo nato privedla do zmanjšanje stopnje simptomov PTSM na individualni ravni, to je do zmanjšanja sekundarne travmatizacije partnerja.

• Ključne besede: veterani, bojna PTSM, žene veteranov, navezanost, sekundarna travmatizacija, zakonska kakovost