The Role of Emotional Numbing in Sexual Functioning Among Veterans of the Iraq and Afghanistan Wars

Transcription

1 MILITARY MEDICINE, 175, 6:424, 2010 The Role of Emotional Numbing in Sexual Functioning Among Veterans of the Iraq and Afghanistan Wars Sarah E. Nunnink * ; Gali Goldwaser ; Niloofar Afari* ; Caroline M. Nievergelt * ; Dewleen G. Baker * ABSTRACT Post-traumatic stress disorder (PTSD) negatively impacts sexuality, yet few studies have evaluated which component of PTSD contributes to this known association. The present study examined which of four PTSD clusters (numbing, avoidance, intrusiveness, and hyperarousal) was most closely linked to sexual problems in a sample of 197 veterans from the Iraq or Afghanistan wars. Newly registered veterans completed a packet of questionnaires including standardized measures of PTSD and questions regarding sexual functioning. A stepwise logistic regression was performed to examine the relationship between symptom cluster and sexual functioning. As predicted, only the numbing cluster was retained in the regression model. The numbing cluster appears to be intimately tied to sexual functioning, assessment of which should be part of a comprehensive evaluation during the postdeployment readjustment phase. Those exhibiting numbing symptoms should be thoroughly assessed for sexual functioning problems and referred for treatment as necessary. INTRODUCTION Awareness of the deleterious impact of post-traumatic stress disorder (PTSD) on sexual functioning is not new. Research indicates that up to 80% of individuals with PTSD meet criteria for clinically relevant sexual difficulties. 1 This association remains, even after controlling for factors with known relation to sexual complications, including history of smoking, hypertension, diabetes, and prescription medication usage. 1 3 Moreover, PTSD severity appears to exhibit a dose response relationship to sexual dysfunction. 2 Recently, sexual dysfunction in active duty military and veterans with PTSD has been reported, the incidence varying by type: erectile dysfunction 63 85%, 1 3 sexual disinterest 37 44%, 1, 4 and avoidance of sex 48%. 1 One intuitively appealing theory suggests that sexual dysfunction may be a result of the general numbing of responsiveness and affect restriction routinely observed in PTSD. 1 Studies have linked general distress in romantic relationships to emotional numbing, 5 7 and, of the PTSD symptom clusters, emotional numbing has a unique negative effect on relationship functioning. 5 Although research has evaluated numbing within the context of general relationship distress, no study has applied numbing specifically to sexual functioning. Numbing seems particularly relevant to relationship sexual health, given the increased difficulty with intimacy reported by both those with PTSD and their partners. 6 In light of research suggesting *Veterans Affairs Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC 116A, San Diego, CA VA San Diego Healthcare System, 3350 La Jolla Village Drive, MC 116A, San Diego, CA Department of Psychiatry, University of California, San Diego, 9500 Gillman Dr., MC 0603, San Diego, CA This article was presented in poster format at the Veterans Health Administration s Mental Health Conference, Meeting the Diverse Mental Health Needs of Veterans: Implementing the Uniform Services Handbook in Baltimore, MD, July 21 July 23, that optimal sexuality involves an intense emotional connection, 8 the pervasive emotional numbing in those with PTSD is suspect as damaging to sexual health. Emotional numbing is an accepted feature of PTSD; 4 however, currently it is subsumed within the avoidance cluster in DSM-IV-TR.9 Recent literature suggests effortful avoidance and emotional numbing are two independent constructs 10 involving separate mechanisms. 11 This assumption of discreetness is further supported by a number of empirical studies The theoretical and statistical premise of such studies has led some researchers to call for a reformulation of PTSD clusters to reflect numbing as an independent factor. This exploratory study utilized the four-cluster conceptualization of PTSD to evaluate the role of each cluster in sexual functioning. We predicted that, given the intimacy necessitated by a sexual encounter and the emotional detachment reported by those with PTSD, the symptom cluster of emotional numbing would capture the majority of the variance accounting for the relationship between PTSD and sexual functioning. METHODS Study Population This study was part of a larger project screening mental and physical health in veterans newly enrolling for VA care. From April to October of 2006, 445 veterans and reservists were approached at initial registration to complete a battery of questionnaires. Of these veterans, 177 did not meet inclusionary criteria for this study, given they did not endorse prior trauma and/or had not served in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF). There were 268 veterans that did meet inclusion criteria for this study, 197 (44%) of which provided sufficient data. A total of 71 participants had greater than 25% missing data on one or more measures of interest and were excluded from the study. The study was approved by the University of California, San Diego 424 MILITARY MEDICINE, Vol. 175, June 2010

2 Institutional Review Board and the San Diego VA Healthcare System s Research and Development Committee. Data Source Demographics Participants completed a demographic background questionnaire, which provided data on age, gender, ethnicity, rank, and branch of service. Health Screening Given the well-known link between certain medical conditions and sexual functioning problems, veterans completed a 52-item checklist of medical symptoms to serve as a brief screen for medical history. This checklist is similar to those used in previous studies of health symptoms in veterans. 16 Participants responded with positive or negative endorsement as to whether they were currently experiencing a host of medical symptoms including: diabetes, heart disease, hypertension, and depression. Information regarding tobacco use was collected. Sexual Functioning The 52-item checklist of medical symptoms included 1 item regarding impotence or other sexual problems. An additional checklist assessing current medical diagnoses was added specifically for this study and included a question as to whether veterans had a current diagnosis related to diminished sexual desire or function. A positive screen for sexual functioning problems was defined as endorsement of one or both of these items. Participants who did not endorse either item were identified as screening negative. Thus, participants were categorized into one of two groups: sexual functioning problems or no sexual functioning problems. Mental Health Given the potential negative impact of drugs and alcohol on sexual functioning, the well-validated Alcohol Use Disorders Identification Test (AUDIT) 17 and Drug Abuse Screening Test (DAST) 18 were included. Because depression is often linked to sexual functioning problems, included in the packet was a two-item yes/no depression screener that asked: (1) During the past month have you often been bothered by feeling down, depressed, or hopeless? (2) During the past month have you often been bothered by little interest or pleasure in doing things? This two-item screener has been routinely utilized in other studies published on VA populations as a general screen for depression. 19 It has been found to be a psychometrically sound and useful measure for detecting depression in primary care settings and has demonstrated similar test characteristics to other casefinding instruments , 22 The Davidson Trauma Scale (DTS) was used to measure PTSD symptomatology. This study utilized a four-cluster conceptualization of the DTS: Re-experiencing (scale range: 0 40), avoidance (scale range: 0 32), hyperarousal (scale range: 0 40), and numbing (scale range: 0 24). Total scores on the DTS range from 0 to 136. Both Foa 11 and Riggs 6 have argued that the three symptoms most characteristic of numbing include detachment from others, loss of interest, and restricted affect, and have published research utilizing this subscale. For this study, the three numbing items were extracted from the avoidance cluster to represent numbing. All other items were left intact in their original clusters. 21 Items in each cluster were summed to produce a total cluster score. Data Analysis Data analysis was performed using SPSS v Initial analyses examined differences between participants who completed the assessment packet and those who did not using c 2 and t -tests for discrete and continuous variables, respectively. Descriptive statistics were then used to describe the participants. Demographic and health differences, and mean DTS scores between participants with and without sexual problems, were analyzed with c 2 tests including Yates Correction for Continuity (categorical) and ANOVAs (continuous variables). Finally, a stepwise binary logistic regression utilizing the four PTSD clusters to predict membership into positive or negative sexual functioning groups was conducted. All four PTSD clusters were entered into the first block using the forward stepwise method, as a multicollinearity diagnostic showing variance inflation factors (VIFs) <5 for each of these subscales when entered into the model together. In all analyses, p values 0.05 were considered statistically significant. RESULTS Characteristics Initial analyses indicated those who completed the assessment packet did not significantly differ from those who did not complete the packet on demographic and the other variables of interest (where information was provided) ( Table I ). The sample of 197 OEF/OIF veterans was composed of mostly young ( M = 32.3 years, SD = 8.45), males (89%) who had held ranks between E-4 and E-7 (77%) and were separated from Navy (28%), Marines (37%), or Army (25%). Most were Caucasian (46%), Hispanic (27%), or African-American (15%) and were previously deployed as part of OEF (50%), OIF (90%), or both (41%). Although all participants had been exposed to a trauma, 122 participants (62%) had a DTS total score of greater than or equal to 40, and thus qualified as a positive screen for PTSD. Regarding PTSD symptom severity, the DTS total scores for the entire sample ranged from 0 to 136 ( M = 57.58, SD = 38.26). DTS total scores on each of the four clusters ranged as follows: re-experiencing ( M = 16.37, SD = 11.19, range = 0 40), avoidance ( M = 11.03, SD = 9.50, range = 0 32), hyperarousal ( M = 20.36, SD = 12.51, range = 0 40), and emotional numbing ( M = 9.83, SD = 8.32, range = 0 24). Type of trauma experienced by participants varied widely; however, the most common traumas reported were combat exposure (24%) and witnessing combat-related violence (19%), including dismembered, disfigured, mutilated, and/or dead bodies. MILITARY MEDICINE, Vol. 175, June

3 TABLE I. Demographic and Psychological Characteristics of Those With Complete vs. Those With Incomplete Data on Variables of Interest Characteristics Complete Data Total N Incomplete Data Total N P Value Gender Male (%) Female (%) Ethnicity Caucasian (%) African-American (%) Asian (%) Hispanic (%) American Indian (%) Other (%) Branch Army (%) Air Force (%) Marines (%) National Guard (%) Navy (%) Rank High Rank/Leadership (%) (E-7 to E-9 and Officer) Middle Rank/Leadership (%) (E-4 to E-6) Junior Rank/Leadership (%) (E-1 to E-3) Characteristic Complete Data M (SD) Total N Incomplete Data M (SD) Total N Age (8.45) (6.76) 69 AUDIT 5.53 (5.80) (7.49) 63 DAST 1.18 (1.39) (1.72) 47, no significant difference; AUDIT, Alcohol Use Disorders Identification Test; DAST, Drug Abuse Screening Test. Screening Positive for Sexual Problems Of the 197 participants, 60 (30.5%) screened positive for sexual problems, with 36 (18%) participants endorsing diminished sexual desire/function and 32 (16%) endorsing impotence or other sexual problems. Table II presents the demographic and health-related characteristics of veterans with and without sexual problems; many of these characteristics have been previously recognized as potentially detrimental to sexual functioning. 2 Overall, those with and without sexual problems did not differ significantly in terms of their demographic characteristics, endorsement of diabetes, heart disease, hypertension, and depression, and there were no differences in terms of their cigarette usage, alcohol consumption, or drug use. It was therefore not necessary to statistically control for any of these factors in the main analysis. PTSD and Sexual Problems As a first step in examining the relationship between PTSD and sexual problems, the mean DTS total scores in the two sexual functioning groups were compared. Findings indicated significantly greater PTSD symptom severity in those screening positive for sexual problems ( M = 66.23, SD = 38.05) than in those screening negative for sexual problems ( M = 53.80, SD = 37.87), F (1,195) = 4.49, p < Next, an exploratory multivariate analysis was undertaken to better understand the relative contribution of each PTSD cluster to this overall association. A correlation analysis showed that all of the predictor variables were significantly intercorrelated ( p < 0.1), with correlations ranging from r (195) = 0.73 between re-experiencing and emotional numbing to r (195) = 0.84 between hyperarousal and emotional numbing, respectively (Pearson correlation, two tailed). Results from the stepwise binary logistic regression using the four PTSD clusters to predict positive or negative sexual functioning found that only the numbing cluster was a significant predictor of sexual functioning (Table III ). Table IV provides mean values for the four PTSD clusters as a function of sexual functioning status. Consistent with the multivariate analysis findings, veterans with sexual problems had higher scores in the numbing cluster ( M = 11.86, SD = 8.38) than those without sexual problems ( M = 8.93, SD =8.16), F (1,195) = 5.29, p < DISCUSSION The current study examined the relationship between PTSD symptoms and sexual problems among OEF and OIF veterans. We found that veterans with sexual problems had significantly higher PTSD symptom scores than veterans without sexual problems. Of particular interest was the collection of PTSD symptoms conceptualized as numbing, which includes detachment from others, loss of interest, and restricted range of affect. Our study is the first to find that emotional numbing was the only significant predictor of sexual problems when compared with the three other PTSD clusters. These findings highlight the significance of emotional numbing in PTSDrelated sexual functioning among young OEF/OIF veterans. 426 MILITARY MEDICINE, Vol. 175, June 2010

4 TABLE II. Demographic and Health-Related Characteristics of Veterans With and Without Sexual Problems Characteristics That Have Been Linked to Sexual Functioning Problems Characteristics Sexual Dysfunction ( N = 60) No Sexual Dysfunction ( N = 137) P value Diabetes (%) Heart Disease (%) 0 0 Hypertension (%) Depression (%) Current No. of Cigarettes Smoked per Day, Mean (SD) 0.20 (0.40) 0.23 (0.42) Age, Mean (SD) (8.75) (8.35) AUDIT Score, Mean (SD) 5.71 (6.01) 5.45 (5.73) DAST Score, Mean (SD) 1.35 (1.31) 1.12 (1.43) General Characteristics Characteristics Sexual Dysfunction ( N = 60) No Sexual Dysfunction ( N = 137) P Value Gender Male (%) Female (%) Ethnicity Caucasian (%) African-American (%) Asian (%) Hispanic (%) American-Indian (%) Other (%) Branch Army (%) Air Force (%) Marines (%) National Guard (%) Navy (%) Rank High Rank/Leadership (%) (E-7 to E-9 and Officer) Middle Rank/Leadership (%) (E-4 to E-6) Junior Rank/Leadership (%) (E-1 to E-3) , no significant difference; AUDIT; Alcohol Use Disorders Identification Test; DAST, Drug Abuse Screening Test. TABLE III. Summary of Stepwise Binary Logistic Regression Analysis Predicting Sexual Functioning Problems Variables in the Equation 95% Confidence Interval Variable B SE Wald Odds Ratio Lower Upper Numbing * Variables Not in the Equation Variable Score df Significant Avoidance Hyperarousal Re-experiencing * p < Research has established that PTSD is associated with interpersonal and relationship problems, including attachment, intimacy, and sexuality. 24 Current findings corroborate previous reports that veterans with PTSD symptoms are more susceptible to a range of sexual health challenges. 2, 4, 25 Findings underscore the importance of clinician assessment of PTSD-related numbing as part of a comprehensive TABLE IV. Mean and Standard Deviation Values for Predictor Variables as a Function of Sexual Functioning Status Sexual Dysfunction ( n = 60) M (SD) No Sexual Dysfunction ( n = 137) M (SD) t (195) Variable Emotional (8.38) 8.93 (8.16) 2.30 * Numbing Avoidance (9.68) (9.36) 1.62 Hyperarousal (11.97) (12.61) 1.97 Re-experiencing (11.48) (10.94) 1.94 * p < evaluation during the postdeployment readjustment phase. Clinicians providing treatment to veterans with PTSD should consider frank discussion about sexual health or intimacy issues if emotional numbing is reported, followed by thorough assessment of current sexual functioning. In symptomatic cases, additional resources (e.g., literature about sexual health issues common to veterans) or referral to particular treatments (e.g., couples or sex therapy) may be indicated. This study has several limitations. First, findings are based on self-report of medical and mental health history. Next, no information related to use of prescription medications was MILITARY MEDICINE, Vol. 175, June

5 collected, therefore we cannot determine the extent to which sexual problems may have been the result of medication side effects.26 It is important to note that our sample was relatively young (mean age: 32) and was composed of newly registering veterans at the VA. A recent study indicated that in the general population, individuals in the 18- to 34-year-old age group report roughly half the antidepressant drug usage when compared to those in age groups 35 49, 50 64, and 65 or older. 27 In light of these factors, it is likely that the sample was healthier and probably had fewer prescribed medications in comparison to an older sample with established VA care. Future studies of emotional numbing in PTSD and sexual health should include a comprehensive review of medications and control for medication side effects. Finally, given this study was part of a larger-scale project designed to screen veterans at their entry point into the VA system, we did not obtain detailed data on sexual functioning. We included just two brief (and thus more sensitive than specific) screening items. Future studies will benefit from including a thorough standardized measure of sexual functioning and may want to explore whether particular PTSD clusters relate to specific sexual disorders. Findings from this study suggest that OEF/OIF veterans with sexual health problems endorsed more severe PTSD symptomatology; the numbing cluster was most predictive of sexual problems. Further, understanding of the insidious consequences of military-related trauma, such as emotional numbing, and its effects on the sexual health of veterans, should be advanced. ACKNOWLEDGMENTS We acknowledge Michael Kilmer and Clay King, chief of Social Work Service at VA San Diego Healthcare System; Glenn White and his staff at the VA San Diego Healthcare System Member Services Department; and Jodi Orcutt for their efforts in support of this project. Dr. Baker is supported in part by the VA Research Grants (Merit, HSR&D, and Cooperative Studies). Dr. Afari is supported in part by the National Institutes of Health (R01AR and U01DK082325). Drs. Nunnink, Goldwaser, Baker, and Afari are supported, in part, by the VA Center of Excellence for Stress and Mental Health (CESAMH). REFERENCES 1. Letourneau EJ, Schewe PA, Frueh BC : Preliminary evaluation of sexual problems in combat veterans with PTSD. J Trauma Stress 1997 ; 10 (1) : Cosgrove DJ, Gordon Z, Bernie JE, et al : Sexual dysfunction in combat veterans with post-traumatic stress disorder. 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