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The Association of Veterans' PTSDwith Secondary Trauma Stress amongVeterans' SpousesKhodabakhsh Ahmadi a , Seddigeh Azampoor-Afshar a , GholamrezaKarami a & Arastoo Mokhtari aa Behavioral Sciences Research Center , Baqiyatallah University ofMedical Sciences , Tehran, IranPublished online: 24 Aug 2011.

To cite this article: Khodabakhsh Ahmadi , Seddigeh Azampoor-Afshar , Gholamreza Karami& Arastoo Mokhtari (2011) The Association of Veterans' PTSD with Secondary Trauma Stressamong Veterans' Spouses, Journal of Aggression, Maltreatment & Trauma, 20:6, 636-644, DOI:10.1080/10926771.2011.595761

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Journal of Aggression, Maltreatment & Trauma, 20:636–644, 2011Copyright © Taylor & Francis Group, LLCISSN: 1092-6771 print/1545-083X onlineDOI: 10.1080/10926771.2011.595761

POSTTRAUMATIC STRESS DISORDER (PTSD)RESEARCH

The Association of Veterans’ PTSDwith Secondary Trauma Stress among

Veterans’ Spouses

KHODABAKHSH AHMADI, SEDDIGEH AZAMPOOR-AFSHAR,GHOLAMREZA KARAMI, and ARASTOO MOKHTARIBehavioral Sciences Research Center, Baqiyatallah University of Medical

Sciences, Tehran, Iran

Studies have noted that close relationships with individuals withposttraumatic stress disorder can lead to traumatic stress amongtheir caregivers. This study intended to understand the prevalenceof secondary trauma stress among spouses of veterans and the asso-ciation of the degrees of posttraumatic stress disorder in veteranswith the severity of symptoms in their spouses. One hundred veter-ans and their spouses were studied and data were gathered usingmeasures and questionnaires. The severity of posttraumatic stressdisorder in the veterans group predicted the degree of traumaticstress in the spouses group (p = .0001). Among the demographicfactors, only the duration of posttraumatic stress disorder symp-toms in veterans predicted the severity of secondary trauma stressin spouses (p = .01).

KEYWORDS posttraumatic stress disorder, secondary traumastress, veterans

Posttraumatic stress disorder (PTSD) is one of the major psychiatric problemsamong combat veterans, affecting their social and emotional well-being.

Submitted 9 December 2009; revised 3 March 2010; accepted 18 March 2011.Address correspondence to Khodabakhsh Ahmadi, Behavioral Sciences Research Center,

Baqiyatallah University of Medical Sciences, Mollasadra Ave., Vanak Sq. P.O. Box: 19395–5487,Tehran 14548, I.R. Iran. E-mail: kh_ahmady@yahoo.com

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Their caregivers, who are usually their spouses, also suffer from emo-tional distress and marital maladjustment (Dekel, Solomon, & Bleich, 2005).Moreover, veterans suffer from serious conflicts with their families that harmtheir domestic well-being (Dirkzwager, Bramsan, Ader, & Vander Ploeg,2005; Rosenheck & Nathan, 1985). The veterans’ spouses and childrenobserve numerous disturbing symptoms of PTSD in their PTSD-diagnosedpartner or parent during their everyday lives; the family members copewith sleeplessness, vivid dreams, and absent-mindedness of the veteran(Dekel, Goldblatt, Keider, Solomon, & Polliack, 2005). Various studies havedemonstrated that long-term and close relationships with individuals withsignificant psychiatric disorders could lead to diverse psychological mani-festations such as chronic stress, depressive symptoms, anxiety disorders,and concentration problems (Dekel, Solomon, & Bleich, 2005). The signif-icant prevalence of marital maladjustment among veterans with PTSD andtheir spouses has been cited in previous studies (Ben Arzi, Solomon, &Dekel, 2000; Vogel & Marshall, 2001). Sexual dysfunction leading to maritalmaladjustment has been illustrated by one of the author’s previous stud-ies. In that particular study, the maladjustment rates were as high as 11%among PTSD-diagnosed veterans and their spouses (Ahmadi, Fathi-Ashtiani,Zareir, Arabnia, & Amiri, 2006). Marital maladjustment of PTSD veteransand their partners might be considered to be one of the consequencesof living with a PTSD veteran. Another serious consequence that resultsin significant marital discord is the veteran’s practice of violence against hisspouse (Sherman, Satter, Jackson, Lyons, & Han, 2006). Solomon et al. (1992)believed that PTSD among war veterans leads to impaired social relation-ships with symptoms ranging from inner feelings of loneliness to impairedmarital relationships.

Secondary trauma stress (STS) is known to have similar components toPTSD, with the exception that the person experiencing the symptoms hasnot had exposure to the traumatic event, but has developed them as a resultof close contact with someone diagnosed with PTSD (Lev-Wiesel & Amir,2001). Figley (1995) has defined this condition as vicarious trauma stress orcompassion fatigue. Mason (1990) described details of her own life, livingwith her husband diagnosed with PTSD, along with her own PTSD symp-toms. In her book, she explains her sense of “walking on eggshells” andher fear of her husband’s erratic explosions. Maloney (1988) discusses sixspouses of Vietnam veterans who experienced PTSD symptoms similar totheir husbands, including dreams of the war and panic attacks triggered bythe same stimuli that aroused the symptoms of their husbands, such as thebuzzing of helicopters, loud noises, and the smell and sound of rain. It isalso partly believed that STS is a consequence of empathy with the PTSDpatient (Figley, 1998). Williams (1980) described the “spread of effect” forthe PTSD symptoms, as well as the distancing and violence of the husbandas the major causes of the distress felt by the spouse. There are also stud-ies that give an etiologic role to the demands of living with a symptomatic

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PTSD person, rather than the empathic elements (Lev-Wiesel & Amir, 2001).Hankin, Abueg, Gallagher-Thomson, and Murphy (1992) described PTSD asa long-term condition that places a heavy burden on the caregiver’s partner.Regardless of the mechanism that might lead to STS, the general manifes-tations are the same as PTSD, which include symptoms such as insomnia,nightmares, loss of interest, irritability, chronic fatigue, and changes in self-perception (Figley, 1998). A previous study performed among wives ofKuwaiti veterans of the first Gulf War revealed that almost 28% of thespouses of PTSD veterans met criteria for PTSD without experiencing thewar. (Al-Turkait & Ohaeri, 2008).

Another study described that almost 30% of PTSD veterans’ spousessuffer from STS (Francikovic’ et al., 2007). In Francikovic’ et al.’s study onCroatian combat veterans, marital age and unemployment of spouses werethe two significant predictors of spouses’ traumatic stress. They concludedthat the role of these two factors is the result of longer exposure to PTSDsymptoms of their husbands. The association of demographic issues suchas age, ethnicity, and educational level with partner’s psychological dis-tress has not been supported by previous research (Calhoun, Beckham, &Bosworth, 2002).

Although several studies have been conducted on STS, there is a lack ofstudies among populations in Islamic and Middle Eastern countries due totheir complicated belief and value systems. In Iran, for example, there is nosingle study about STS or its symptoms. Furthermore, Iranian psychiatristsand psychologists working in veterans’ clinics were reporting that based ontheir everyday clinical experience, the prevalence of STS might be muchhigher than what the literature and other studies have previously indicated.Thus, we planned to study the occurrence of STS among spouses of PTSD-diagnosed veterans and also consider the association of various demographicparameters with STS of the veterans’ spouses. In fact, we hypothesized thatthe severity of PTSD in veterans might be associated with presence anddegree of STS in their spouses.

METHOD

The study was conducted among veterans of the war between Iraq andIran (1980–1988) and their spouses who had psychiatric records in Tehran’sthree major veteran clinics including Baquiatallah, Khatam, and Sasan hos-pitals. The veterans and their spouses were asked by their psychiatrists toparticipate in the study while attending their routine visits. All the veteranshad been diagnosed with PTSD by a psychiatrist according to the criteriaof the Diagnostic and Statistical Manual of Mental Disorders (4th ed., textrevision [DSM–IV–TR]; American Psychiatric Association, 2000) and had psy-chiatric records in the veterans’ clinics. In most of the cases, the spousesoften accompany the veterans to the clinic because of the veterans’ physical

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Secondary Trauma Stress in Spouses of PTSD Veterans 639

disabilities. The spouses also organize most of their husbands’ visits, espe-cially in psychiatric clinics. Of all the cases of PTSD veterans who attendedour clinics from spring 2007 until 2008, 120 veterans and their spouses(240 individuals) were selected. The sampling method was simple randomsampling.

The ages of the participants were between 34 and 59 years, with theaverage of 46.5 in the veteran group, and an average of 41.35 in the spousegroup. Moreover, 31% of the veterans had not obtained a high schooldiploma, 28% had high school diplomas, and 41% had achieved a post-secondary degree. The figures were 35%, 47%, and 18% among the spousegroup, respectively. Of the families, 4% had no children, 74% had one tothree children, and 22% had four or more children.

The age inclusion criteria was between 35 and 50 years old in additionto being married for at least five years with the spouses living together in thesame household. Substance abuse by both veterans and their spouses was anexclusion criterion. Spouses with diagnosed psychiatric disorders (includingPTSD) were excluded. After explaining the terms and conditions of the studyto the veterans and their spouses and eliminating subjects based on theinclusion and exclusion criteria, 100 couples (200 individuals) were selectedto participate in the study. The medical ethics committee of BaquiatallahUniversity of Medical Sciences approved the research and the veterans andtheir spouses gave informed consent.

Data were obtained by questionnaires, which each veteran and his wifefilled out individually. The questionnaires for the spouses included two sec-tions, with one for demographic data inquiring about the age, marital age,educational level, employment status, number of children, and the dura-tion of PTSD symptoms in their husbands. The second section included thespousal version of the Mississippi Scale for Combat-Related PTSD (Keane,Caddell, & Taylor, 1988). The scale consists of 39 questions, each ques-tion with a possible score of 5, for a possible total score of 195. Scoresless than 65 refer to mild traumatic stress, 65 to 130 represent moderatestress, and above 130 describe severe traumatic stress. The questionnairewas validated in previous studies with a Cronbach’s alpha calculated at .94(Keane et al., 1988). Translation of the scale was validated by an experimenton 266 individuals (including normal individuals, and patients with PTSD,depression, and obsessive–compulsive disorder) and the Cronbach’s alphawas calculated at .92.

Veterans were administered another test for the severity of PTSD, thePTSD Checklist–Military (PCL–90; Weathers, Litz, Herman, Huska, & Keane,1993). The checklist includes 17 questions: Five questions are associatedwith the reexperiencing of trauma, seven questions are related to avoidancesymptoms, and the rest belong to the arousal component of PTSD. Scoresbetween 0 and 17, 18 and 34, and 35 and 51 represent mild, moderate, andsevere symptoms, respectively. The Cronbach’s alpha has been calculated at.939 for this questionnaire (Blanchard, Jones-Alexander, Buckley, & Forneris,

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1996). The checklist has been validated between .93 and .94 in previousIranian studies. The veterans also filled out a demographic section similarto the one given to the spouses, in addition to other questions related tocombat, such as the duration of war-front attendance (i.e., total number ofmonths a veteran has spent in a war location) and concomitant physicalwar injuries. The statistical analysis was performed with SPSS the correlationcoefficients were used for the analysis and examination of the hypotheses.

RESULTS

Of the veterans, 75.6% suffered from physical disabilities. The average dura-tion of PTSD symptoms was 22.4 years among the veterans. The meanmarital age was 22.7 years with a standard deviation of about five years.The veterans’ actual combat exposure ranged between nine months and56 months. The average PCL–90 score of veterans who had symptoms ofreexperiencing was M = 7.66 (out of 15), avoidance M = 12.23 (out of 21),and hyperarousal was M = 9.01 (out of 15). See Table 1. A total of 13% ofveterans suffered from mild PTSD, 57% demonstrated moderate symptoms,and 30% showed severe symptoms. According to the Mississippi Scale forCombat-Related PTSD, all of the spouses reported STS symptoms: 49% ofthe spouses expressed moderate symptoms, and 51% demonstrated severesymptoms. The average score for reexperiencing of stressful events wasM = 39 (out of 50), hyperarousal was M = 31 (out of 50), depression wasM = 34 (out of 45), and interpersonal relationship impairments was M = 29(out of 50). See Table 2.

TABLE 1 The Severity of Posttraumatic Stress Disorder in Veterans Accordingto the PTSD Checklist–Military Scale

Variable Total potential score M SD

Reexperience score 15 7.6 2.4Avoidance score 21 12.2 4.1Hyperarousal score 15 9.0 2.7Total 51 28.8 9.2

TABLE 2 The Severity of Secondary Trauma Stress Among Spouses of VeteransAccording to the Mississippi Scale for Combat-Related PTSD

Variable Total potential score M SD

Reexperiencing stressful events 50 39.21 4.8Depression 45 34.6 4.4Hyperarousal 50 31.3 4.5Interpersonal relationship impairments 50 29.7 3.3Total score 195 131.9 14.1

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The Pearson correlation coefficient for the severity of the veterans’ PTSDas measured by the PCL–90 score and Mississippi Scale for Combat-RelatedPTSD of spouses revealed that the degree of PTSD in veterans signifi-cantly predicts the level of STS symptoms among spouses (r = .371, p= .0001). Among the various demographic factors including age, maritalage (i.e., length of marriage), the duration of PTSD symptoms, duration ofactual combat exposure, concomitant physical injury, employment status,and the number of children, only the duration of veterans’ PTSD symp-toms was a significant predictor of STS in veterans’ spouses (r = .284,p = .01).

DISCUSSION

In this study, all of the partners of known PTSD veterans reported moderateto severe degrees of STS. Our results were remarkably different from theoutcome of previous studies. Studies among war veterans have shown that30% of spouses meet the criteria for STS (Francikovic’ et al., 2007; Koic,Francikovic, Masle, Dordevic, & Vindracek, 2002) reported the rate of STSamong veterans’ spouses was 39%.

The high percentage of STS among Iranian veterans’ spouses could beexplained by means of social, cultural, and religious differences betweenWestern and Middle Eastern countries. It is a generally accepted fact thatliving with a PTSD patient affects all family members. Their reexperi-ence, avoidance, and hyperarousal symptoms can substantially influence theeveryday life of their families. Such symptoms would affect their spouses,as they are typically the first-line and closest contacts before anyone else.Along with experiencing a stressful life, the spouses are confronted withnew responsibilities and duties known as “spouse’s role” (Matsakis, 1996).The impact of Middle Eastern, Islamic, and especially Iranian culture mani-fests itself by burdening the spouse with the cumbersome role of carrying aholy responsibility, demanding that she care for her husband, who, accord-ing to their culture is considered to be injured for a divine purpose. Thespouses are considered ungrateful if they neglect their obligations. In suchan atmosphere the wife attempts to devote herself to her husband, in thehopes of “changing him for a better life” (Lyons, 2001, p. 77). Becausethe veterans are unable to fulfill their expected role in the family, thespouses are deemed responsible for compensating, which is a redistribu-tion of roles (Harkness & Zador, 2001). They might have feelings of guilt,suspecting that they are not being competent caregivers, and at the sametime they might feel indignant, assuming the veterans to be the main causeof the hardships in their life, the condition known as “the empathy trap”(Harkness & Zador, 2001, p. 335). It is our belief that the empathy trap

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coupled with cultural and religious factors likely cause more distress amongspouses.

The fact that this study has evaluated the spouse’s symptoms by meansof subjective methods should not be overlooked, as only questionnaires andmeasures were used (no interviews) and the spouses were not diagnosedwith STS. Another important limitation is that veterans and their familieshave many social, financial, and cultural privileges according to public law,and although the veterans and their spouses have been assured that theresults of our study would not be used for legal decisions or benefits,they might have overreported their symptoms for secondary gains. We alsobelieve that the high prevalence of physical injuries and disabilities amongIranian veterans (75.6%) might play a crucial role in the pathogenesis ofSTS symptoms. It is expected that living with a veteran who suffers bothfrom a diagnosis of PTSD and a physical disability can generate more stressand this could lead to higher rates of psychological manifestations suchas STS.

Among the demographic factors considered in the study, only the dura-tion of PTSD symptoms in veterans was a significant predictor of STS amongspouses. This can be explained by the fact that a longer history of vet-erans’ PTSD symptoms means longer exposure of spouses to PTSD. TheCroatian study (Francikovic’ et al., 2007) revealed a correlation betweenSTS of spouses and length of marriage, but in our study there was no sig-nificant association between these two factors. We can postulate that theduration of the spouses’ exposure to the PTSD symptoms of their husbandsdoes not correlate to marital age; presumably there would be couples whowere married before and during the war, before the husbands began todevelop PTSD. Taking such facts into account, the duration of the spouse’sexposure to PTSD symptoms might be more reliable than the length ofmarriage.

In our settings of PTSD management (i.e., treatment of the patientplus treatment for persons around him or her and preventive measures),the spouses are neglected subjects of the management plan. Unfortunatelythe veterans’ clinics do not give sufficient attention to the spouses unless theveterans complain of marital conflicts. Due to the lack of studies undertakenin Middle Eastern and Islamic countries, this research can help draw atten-tion to the spouses of PTSD veterans. Our results show that spouses shouldbe focused on more in the treatment of veterans with PTSD. This studyalso indicates that trauma has long-lasting psychological outcomes, even 20years after war. Along with impacting spouses, traumatic stress might alsohave other tertiary family victims, such as children. Future studies could takeother populations into consideration when examining the effect of PTSD onfamily members.

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