Partners' attributions for service members' symptoms of combat-related posttraumatic stress disorder

Development of a brief support and education intervention for loved ones of veterans with posttraumatic stress disorder

Clinical practice guidelines for managing posttraumatic stress disorder (PTSD) encourage incorporating loved ones into treatment, and supportive relationships can increase engagement in mental health care for veterans with PTSD. This study describes the iterative refinement, feasibility/acceptability testing, and national dissemination of a brief support and psychoeducation intervention for loved ones of veterans with PTSD. Loved ones (n = 181; range:1-11 per group) attended and qualitatively rated "PTSD 101 for Family and Friends: A Support and Education Workshop." Open-ended questions were used to gather data on suggestions for improvement and descriptions of helpful content, and the workshop was refined following participant and operational partner feedback using a quality improvement framework. Rating quantitative items on a 1-5 scale, participants found the overall quality (M = 4.76) and relevance (M = 4.82) to be excellent, noting they learned substantial new information (M = 4.45). Sense of support (M = 4.95), intentions to use the material (M = 4.87), PTSD self-efficacy (M = 4.41), and understanding of PTSD (M = 4.76) were rated favorably. Common themes among helpful elements were a sense of shared experience and optimism and increased knowledge of treatments/resources. Suggestions for improvement referenced logistics. Following continual stakeholder feedback and refinement, the workshop represents a novel method for providing loved ones with empirically supported psychoeducation, coping skills, and community. It is being disseminated by the Family Services Section of the Veterans Health Administration Office of Mental Health and Suicide Prevention.

Effectiveness of cognitive behavioral conjoint therapy for posttraumatic stress disorder (PTSD) in a U.S. Veterans Affairs PTSD clinic

Cognitive behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) is a 15-session conjoint treatment for PTSD designed to improve PTSD symptoms and enhance intimate relationship functioning. Numerous studies of CBCT for PTSD document improvements in patient PTSD and comorbid symptoms, partner mental health, and relationship adjustment. However, little is known about its effectiveness in real-world clinical settings. Using an intention-to-treat sample of couples who participated in CBCT for PTSD in an outpatient U.S. Veterans Affairs (VA) PTSD clinic (N = 113), trajectories of session-by-session reports of veterans' PTSD symptoms and both partners' relationship happiness were examined. Across sessions, there were significant reductions in veteran-rated PTSD symptoms, d = -0.69, and significant increases in veteran- and partner-rated relationship happiness, ds = 0.36 and 0.35, respectively. Partner ratings of veterans' PTSD symptoms increased before significantly decreasing, d = -0.24. Secondary outcomes of veteran and partner relationship satisfaction, ds = 0.30 and 0.42, respectively; veteran and partner depressive symptoms, ds = -0.75 and -0.29, respectively; and partner accommodation of PTSD symptoms, d = -0.44, also significantly improved from pre- to posttreatment. The findings suggest that CBCT for PTSD was effective for decreasing PTSD and comorbid symptoms in veterans, as well as for improving relationship functioning and partners' mental health, among a sample of real-world couples seeking treatment in a VA PTSD specialty clinic.

Trajectories of PTSD and secondary traumatization: A longitudinal study

Ever since the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there has been a controversy around whether the inclusion of indirect exposure as a potential traumatic event for the diagnosis of posttraumatic stress disorder (PTSD) is justified. The aim of the current study was to examine the validity of PTSD resulting from secondary traumatization by evaluating the longitudinal trajectories and clinical picture of PTSD following both direct exposure and indirect exposure to war trauma. One-hundred-and-fifty-five war veterans of the 1973 Yom Kippur War and their spouses filled out self-report questionnaires assessing PTSD, 30 (T1), 38 (T2), and 42 years (T3) after the war. Findings revealed that although PTSD was more prevalent and intense among veterans, the relative distribution of PTSD trajectories was similar among veterans and spouses. In both groups, the most prevalent was the resilient trajectory (43% and 73%, respectively), followed by the recovered trajectory (28% and 15%, respectively), the chronic trajectory (21% and 7%, respectively), and the delayed trajectory (8% and 6%, respectively). In addition, the composition of PTSD symptoms was similar among veterans and spouses at T1 and T2, but not at T3. These findings demonstrate that although PTSD is more prevalent and intense among individuals who were exposed to traumatic events directly as compared to those who were traumatized secondarily, the similarities in the clinical picture support the inclusion of secondary traumatization in PTSD Criterion A.

Lower Sexual Satisfaction and Function Mediate the Association of Assault Military Sexual Trauma and Relationship Satisfaction in Partnered Female Service Members/Veterans

Little is known about the association of military sexual trauma (MST) and relationship satisfaction among partnered female service members/veterans (SM/Vs). Extant civilian literature shows a strong association between sexual trauma and poorer relationship outcomes, and theory suggests that sexual function and satisfaction may mediate this association. Given that as many as 40% of female SM/Vs report MST and roughly half of female veterans are partnered and in their peak sexual years, it is critical to understand the association of MST, relationship satisfaction, sexual function, and sexual satisfaction in this population. Female SM/Vs (N = 817) completed a demographic inventory, self-report measures of MST, relationship satisfaction, sexual function, and sexual satisfaction. One hundred fifty-one (18.48%) participants did not experience MST. Three hundred eighty-eight (47.49%) reported that they experienced harassment-only MST, and 278 (34.03%) reported assault MST. At the bivariate level, lower relationship satisfaction was associated with lower sexual function and satisfaction with large effect sizes. Assault MST was associated with lower relationship satisfaction and sexual function and satisfaction with small-to-medium effect sizes. No differences in relationship satisfaction, sexual satisfaction, and function between those with harassment-only and no MST were observed. Mediation analyses demonstrated that lower sexual function and satisfaction mediated the association of assault MST and relationship satisfaction. Couples' therapy offered to SM/Vs with MST should screen for type of MST, sexual function, and satisfaction. Addressing the sequelae of MST and increasing sexual function and satisfaction in these partnerships may be critical treatment targets.

Partners' motivations for accommodating posttraumatic stress disorder symptoms in service members: The reasons for accommodation of PTSD scale

Emerging research reinforces the importance of partner accommodation in the interpersonal context of posttraumatic stress disorder (PTSD). A better understanding of partners' motivations for accommodation is needed to help refine or design interventions that target accommodation. To explore partners' motivations, we created the Reasons for Accommodation of PTSD Scale (RAPS) and evaluated it in 263 female partners of male Army soldiers who had returned from a deployment within the past 2 years. Soldiers completed a measure of military-related PTSD, and partners completed a measure of accommodation and the newly created RAPS. Factor analysis of the RAPS yielded a clear, 3-factor solution suggesting the following reasons for accommodating: (1) Relationship & Obligation, or a desire for positive relationship outcomes and a sense of duty or responsibility; (2) Helping Recovery, or a belief that avoidance was helpful for the service member; and (3) Conflict Avoidance/Helplessness, or a desire to avoid conflict or simply not knowing what else to do. Analyses of these factors in relation to soldiers' PTSD clusters indicated that hyperarousal symptoms were uniquely associated with relationship and obligation motivations, re-experiencing symptoms were uniquely associated with helping recovery motivations, and emotional numbing symptoms were uniquely associated with conflict avoidance and helplessness motivations. Furthermore, conflict avoidance and helplessness accounted for the greatest variance in partners' accommodation frequency and distress. Assessment of partners' accommodative behaviors, as well as their motivations for engaging in accommodation, may aid in treatment planning and enhance outcomes for couples in which one individual has PTSD.

Supporting a Spouse With Military Posttraumatic Stress: Daily Associations With Partners' Affect

Service members and veterans (SM/Vs) with posttraumatic stress disorder (PTSD) can receive significant benefits from social support by a spouse or romantic partner. However, little is known about how providing support impacts partners. This study sought to identify (a) how provision of support is associated with partners' daily negative and positive affect and (b) how SM/Vs' PTSD symptom severity might moderate such associations. In a 14-day daily-diary study that assessed 64 couples in which one member was an SM/V with PTSD symptoms, partners reported nightly on whether or not they provided instrumental support and/or emotional support that day as well as their current negative and positive affect. Multilevel modeling showed that the provision of emotional and instrumental support were both significantly related to partners' lower levels of negative affect, f ² = 0.09, and higher levels of positive affect, f ² = 0.03, on that same day but not the next day. The positive same-day effects were seen if any support was given, with no additive effects when both types of support were provided. Severity of SM/V PTSD moderated the association between provision of emotional support and lower same-day negative affect such that the association was significant only when PTSD symptoms were more severe. Overall, these findings indicate that support provision to a partner with PTSD is associated with improved affect for the romantic partner providing support. However, given that only same-day affect was associated with support, the findings may also suggest that positive affect increases the provision of support.

Posttraumatic stress disorder and relationship functioning: A comprehensive review and organizational framework

Posttraumatic stress disorder (PTSD) is associated with impairments in relationship functioning. Beyond the abundance of research that has demonstrated this basic link, more recent research has begun to explore possible mediators and moderators of this association. The present paper reviews and synthesizes existing literature in the context of an overarching organizational framework of potential ways in which PTSD impacts relationship functioning. The framework organizes findings in terms of specific elements of PTSD and comorbid conditions, mediators (factors that are posited to explain or account for the association), and moderators (factors that are posited to alter the strength of the association). Specific symptoms of PTSD, comorbid symptoms, and many of the potential mediators explored have extensive overlap, raising questions of possible tautology and redundancy in findings. Some findings suggest that non-specific symptoms, such as depression or anger, account for more variance in relationship impairments than trauma-specific symptoms, such as re-experiencing. Moderators, which are characterized as individual, relational, or environmental in nature, have been the subject of far less research in comparison to other factors. Recommendations for future research and clinical implications of the findings reviewed are also presented.

Trauma Symptoms, Communication, and Relationship Satisfaction in Military Couples

Trauma symptoms are negatively correlated with couple relationship satisfaction, which is of particular importance in the relationships of military personnel who are often exposed to trauma whilst on overseas deployment. This study tested a model in which communication mediated an association between trauma symptoms and low relationship satisfaction. Thirty-one Australian military couples were observationally assessed during a communication task, and assessed on their relationship satisfaction and individual functioning. As expected, trauma symptoms in the male military spouse were associated with low satisfaction in both spouses. Females' low positive communication fully mediated the relationship between males' trauma symptoms and low female satisfaction, but not male relationship satisfaction. Unexpectedly, males' negative communication behaviors were associated with high male relationship satisfaction, and partially mediated the association between trauma symptoms and male satisfaction. Discussion focused on how some communication usually thought of as negative might be associated with relationship satisfaction in military couples.

A Review of Military Health Research Using a Social–Ecological Framework

Objective:

We aim to contextualize the growing body of research on the sequelae of military service in the wars in Afghanistan and Iraq. We employ a social–ecological (SE) framework for the taxonomy of military health research and classify risk as arising from the individual, family, community, and the institutional levels. We intend for this review to inform enhanced health promotion efforts in military communities.

Data Source:

Articles reviewed were extracted from Web of Science, PubMed, and Scopus.

Inclusion and Exclusion Criteria:

Research focused on somatic and psychological sequelae of combat deployment published from 2001—the year the war in Afghanistan began—through the end of 2014. We excluded studies of non-US military personnel, other systematic reviews, meta-analyses, book chapters, and theoretical papers.

Data Extraction:

We examined and summarized the aims, participants, methods, study design, SE framework tier, risk factors, and health outcomes.

Data Synthesis:

Studies were categorized according to SE tier, whether they focused on somatic, behavioral, or psychological outcomes, and by risk factor.

Results:

Of the 352 peer-reviewed papers, 84% focused on war’s sequelae on the index military personnel, and 75% focused on mental or behavioral health outcomes—mostly on post-traumatic stress disorder. We find comparatively little research focusing on the family, community, or institutional tiers.

Conclusions:

We know relatively little about how family and community respond to the return of personnel from combat deployment; how family resources affect the health of returning military personnel; and how a war’s persistence presents challenges for federal, state, and local agencies to meet military health-care needs. Such work is especially salient as US troops return home from war—particularly in communities where there are substantial military populations.

Posttraumatic Stress Disorder Symptoms, Intimate Partner Violence, and Relationship Functioning: A Meta-Analytic Review

This meta-analysis was the first study of which we are aware to investigate the association between Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) PTSD symptom clusters and parent, child, family, and marital/partner functioning problems (e.g., intimate partner violence [IPV] and intimacy). Of the 23 studies that met inclusion criteria, the sample was predominantly male (83.8%), Caucasian (65.0%), and from the military (98.9%). The average age was 43.65 years old (SD = 6.27); the average sample size was 397.4 (SD = 416.9; total N = 9,935). PTSD symptom clusters were assessed primarily by self-report (87.0%), with 8.7% using a rating by a clinician. We used fixed analysis following Fisher's r to z transformation and an unbiased weighing and summing of effect sizes within samples and across studies. We found a small association between hyperarousal and IPV (z = .20). We also found two moderate associations for the emotional numbing and avoidance symptom clusters: (a) with parent, child, and family functioning (z = .32, z = .28, respectively); and (b) with intimacy problems (z = .35, z = .42, respectively). We found two large associations for emotional numbing: marital and parent problems (z = .47) and parent, child, and family functioning problems (z = .32, respectively). Our findings suggested that treatments aim to lessen the effect on those who have close relationships with the individual with PTSD.

Weathering the storm? The impact of trauma on romantic relationships

The current paper reviews the recent literature examining the impact of trauma on romantic relationships. We introduce the Dyadic Responses to Trauma (DRT) Model as a framework for organizing existing research and guiding future research. A traumatic event affects romantic relationships for the better or for the worse depending on the diverse trauma-related experiences people can have, influencing the way partners interact with each other and ultimately the quality of the relationship. In addition, recent research demonstrates how romantic partners can demonstrate resiliency in spite of a negative trauma experience depending on how they interpret and cope with the experience individually and as a couple.

PREP for Strong Bonds: A review of outcomes from a randomized clinical trial

To help address the relationship needs of service members, there have been a number of programs offered within active duty and veteran contexts. One program, offered within the Strong Bonds portfolio delivered by Army Chaplains, is PREP for Strong Bonds (PREP = the Prevention and Relationship Education Program). PREP has a number of empirically based and tested variants. This article reviews the disseminated research regarding results from a large randomized clinical trial designed to test the effectiveness of PREP for Strong Bonds. From a sample of 662 Army couples drawn from two sites, outcome papers have focused on different subsamples, marital outcomes, follow up time points, and moderators. Reviewing these disseminated outcomes, we conclude that PREP for Strong Bonds has significant divorce reduction effects at one site; these divorce effects were found at both one and two years post intervention, and were moderated by factors such as minority status, economic strain, and cohabitation history of the couple. In terms of marital quality outcomes, some modest overall effects were found pre to post intervention, but there were no overall marital quality outcome effects two years post intervention. However, marital quality outcomes are significantly moderated by infidelity and cohabitation history, with couples reporting these risk factors showing greater positive marital quality outcomes. These results to date are discussed in terms of clinical and research implications as well as directions for future work, such as examining longer term preventative effects.

Gender differences in the associations of PTSD symptom clusters with relationship distress in U.S. Vietnam veterans and their partners

Research has consistently linked symptoms of posttraumatic stress disorder (PTSD) with relationship distress in combat veterans and their partners. Studies of specific clusters of PTSD symptoms indicate that symptoms of emotional numbing/withdrawal (now referred to as negative alterations in cognition and mood) are more strongly linked with relationship distress than other symptom clusters. These findings, however, are based predominantly on samples of male veterans. Given the increasing numbers of female veterans, research on potential gender differences in these associations is needed. The present study examined gender differences in the multivariate associations of PTSD symptom clusters with relationship distress in 465 opposite-sex couples (375 with male veterans and 90 with female veterans) from the National Vietnam Veterans Readjustment Study. Comparisons of nested path models revealed that emotional numbing/withdrawal symptoms were associated with relationship distress in both types of couples. The strength of this association, however, was stronger for female veterans (b = .46) and female partners (b = .28), compared to male veterans (b = .38) and male partners (b = .26). Results suggest that couples-based interventions (e.g., psychoeducation regarding emotional numbing symptoms as part of PTSD) are particularly important for both female partners of male veterans and female veterans themselves.

Partner accommodation in posttraumatic stress disorder: initial testing of the Significant Others' Responses to Trauma Scale (SORTS)

Posttraumatic stress disorder (PTSD) is associated with myriad relationship problems and psychological distress in partners of individuals with PTSD. This study sought to develop a self-report measure of partner accommodation to PTSD (i.e., ways in which partners alter their behavior in response to patient PTSD symptoms), the Significant Others' Responses to Trauma Scale (SORTS), and to investigate its reliability and construct validity in 46 treatment-seeking couples. The SORTS demonstrated strong internal consistency and associations with individual and relationship distress. Accommodation was positively correlated with partners' ratings of patients' PTSD symptoms, patient self-reported depressive and trait anger severity, and partner self-reported depressive and state anger severity. Accommodation was negatively correlated with patient and partner relationship satisfaction and partners' perceived social support received from patients. Findings suggest that accommodation may be an attempt to adapt to living with a partner with PTSD but may have negative implications for patient and partner well-being.