PTSD and the Social Support of the Interpersonal Environment: The Development of Social Cognitive Behavior Therapy

Involving a Significant Other in Treatment of Patients With PTSD Symptoms: A Systematic Review of Treatment Interventions

Previous studies have called for the inclusion of social support in the treatment of PTSD. The current review identifies interventions for adults with PTSD symptoms, which include a significant other as a source of social support. 11 articles focusing on eight interventions were found, including a total of 495 participants who had experienced trauma. These interventions were divided according to level of involvement of the significant other in treatment. Significant others were either passively or actively involved in the treatment. Preliminary results show that interventions actively involving a significant other in the treatment of the patient with posttraumatic stress symptoms were most effective in reducing PTSD symptoms. The current review provides recommendations for future research and suggests that significant others should be actively involved in the treatment of PTSD symptoms.

Avoidance behaviour generalizes to eye processing in posttraumatic stress disorder

BACKGROUND

Avoidance describes any action designed to prevent an uncomfortable situation or emotion from occurring. Although it is a common reaction to trauma, avoidance becomes problematic when it is the primary coping strategy, and plays a major role in the development and maintenance of posttraumatic stress disorder (PTSD). Avoidance in PTSD may generalize to non-harmful environmental cues that are perceived to be unsafe.

OBJECTIVE

We tested whether avoidance extends to social cues (i.e. emotional gazes) that are unrelated to trauma.

METHOD

A total of 159 participants (103 who had been exposed to the 2015 Paris terrorist attacks and 56 who had not) performed a gaze-cueing task featuring sad, happy and neutral faces. Attention to the eye area was recorded using an eyetracker. Of the exposed participants, 52 had been diagnosed with PTSD (PTSD+) and 51 had not developed PTSD (PTSD-). As a result of the preprocessing stages, 52 PTSD+ (29 women), 50 PTSD- (20 women) and 53 nonexposed (31 women) participants were included in the final analyses.

RESULTS

PTSD+ participants looked at sad eyes for significantly less time than PTSD- and nonexposed individuals. This effect was negatively correlated with the intensity of avoidance symptoms. No difference was found for neutral and happy faces.

CONCLUSIONS

These findings suggest that maladaptive avoidance in PTSD extends to social processing, in terms of eye contact and others' emotions that are unrelated to trauma. New therapeutic directions could include targeting sociocognitive deficits. Our findings open up new and indirect avenues for overcoming maladaptive avoidance behaviours by remediating eye processing.Trial registration: ClinicalTrials.gov identifier: NCT02810197.

HIGHLIGHTS

Avoidance is a key symptom of posttraumatic stress disorder (PTSD).Avoidance is often viewed as limited to reminders linked to the trauma.Results show that attention to the eyes of sad faces is also affected by PTSD. This effect is correlated with avoidance symptoms in PTSD.

A systematic review of interventions for supporting partners of military Veterans with PTSD

Introduction: Partners of military Veterans with post-traumatic stress disorder (PTSD) and other mental health difficulties can themselves develop difficulties with stress, well-being, and secondary trauma. Various interventions exist which involve partners of military personnel, but very few with an explicit focus on the partners’ well-being. This article aims to conduct a systematic review of these interventions and outline the range of interventions and the outcomes measured. Methods: We conducted a systematic literature search, from which 25 papers were reviewed. Papers were included if they described any form of intervention in which a partner was involved, where the Veteran was described as having PTSD, and where the aim of the intervention was aimed at least partly at improving the well-being of partners. Results: We found various types of interventions, such as group-based interventions, residential retreats, couples therapies, Internet-based interventions, and family-based interventions. Of the 25 studies reviewed, 21 reported on well-being outcomes, either via randomized controlled trials (RCTs), evaluations, or case studies. In most cases, interventions reported improvements in the well-being of partners, although there were very few controlled studies. Only a small number of interventions were aimed solely at partners. The most common feature of interventions was psychoeducation on topics such as communication, problem solving, and emotion regulation. Many papers described the advantages of group processes such as social support and normalization, gained from partners sharing experiences with one another. Discussion: A wide range of formats exist of interventions for improving the well-being of military partners. The literature would benefit from more robust experimental research into their effectiveness, and exploration of interventions aimed directly at the well-being of partners.

Anger and Aggression in UK Treatment-Seeking Veterans with PTSD

Prevalence rates of anger and aggression are often higher in military personnel. Therefore, it is important to understand more about why this is, and the factors with which it is associated. Despite this, there is little evidence relating to anger and aggression in UK veterans who are seeking treatment for mental health difficulties such as post-traumatic stress disorder (PTSD). This study investigated the prevalence rates of anger and aggression in this population, as well as the associations between anger and aggression, and various sociodemographic, functioning and mental health variables. A cross-sectional design was used, with participants completing a battery of self-report questionnaires. Prevalence rates for significant anger and aggression were 74% and 28% respectively. Both women and those over 55 were less likely to report difficulties. Those with high levels of PTSD and other mental health difficulties were more likely to report anger and aggression. Other factors related to anger and aggression included unemployment due to ill health, and a perceived lack of family support. Findings showed that veterans who are seeking support for mental health are likely to be experiencing significant difficulties with anger and aggression, especially if they have comorbid mental health difficulties. The associations between anger, aggression, and other variables, has implications for the assessment and treatment of military veterans.

A case study of social cognitive treatment of PTSD in a South African rape survivor: the central role of case formulation

This is a systematic case study of the psychological assessment and treatment of Zinhle (19), a Black South African student with posttraumatic stress disorder, following a rape at age 10. Treatment was based on Ehlers and Clark's (2000) cognitive therapy, a flexible formulation driven model. The study documented the secondary trauma experienced by families following child sexual abuse and showed how treatment not only needed to target the trauma memory but also the ruptured relationships within and outside the family. This was done within the framework of Tarrier and Humphreys's (2004) social cognitive model. At the end of treatment Zinhle no longer met criteria for PTSD, and the narrative supports Ehlers and Clark's model as well as the social cognitive model.

Perceived social support buffers the impact of PTSD symptoms on suicidal behavior: implications into suicide resilience research

BACKGROUND

A growing body of research has highlighted the importance of identifying resilience factors against suicidal behavior. However, no previous study has investigated potential resilience factors among individuals with Posttraumatic Stress Disorder (PTSD). The aim of this study was to examine whether perceived social support buffered the impact of PTSD symptoms on suicidal behavior.

METHODS

Fifty-six individuals who had previously been exposed to a traumatic event and reported PTSD symptoms in the past month (n = 34, 60.7% participants met the full criteria for a current PTSD diagnosis) completed a range of self-report measures assessing PTSD symptoms, perceived social support and suicidal behavior. Hierarchical regression analyses were conducted to examine whether perceived social support moderates the effects of PTSD symptoms on suicidal behavior.

RESULTS

The results showed that perceived social support moderated the impact of the number and severity of PTSD symptoms on suicidal behavior. For those who perceived themselves as having high levels of social support, an increased number and severity of PTSD symptoms were less likely to lead to suicidal behavior.

CONCLUSIONS

The current findings suggest that perceived social support might confer resilience to individuals with PTSD and counter the development of suicidal thoughts and behaviors. The milieu of social support potentially provides an area of further research and an important aspect to incorporate into clinical interventions for suicidal behavior in PTSD or trauma populations.

A multi-site single blind clinical study to compare the effects of prolonged exposure, eye movement desensitization and reprocessing and waiting list on patients with a current diagnosis of psychosis and co morbid post traumatic stress disorder: study protocol for the randomized controlled trial Treating Trauma in Psychosis

BACKGROUND

Trauma contributes to psychosis and in psychotic disorders post-traumatic stress disorder (PTSD) is often a comorbid disorder. A problem is that PTSD is underdiagnosed and undertreated in people with psychotic disorders. This study's primary goal is to examine the efficacy and safety of prolonged exposure and eye movement desensitization and reprocessing (EMDR) for PTSD in patients with both psychotic disorders and PTSD, as compared to a waiting list. Secondly, the effects of both treatments are determined on (a) symptoms of psychosis, in particular verbal hallucinations, (b) depression and social performance, and (c) economic costs. Thirdly, goals concern links between trauma exposure and psychotic symptomatology and the prevalence of exposure to traumatic events, and of PTSD. Fourthly predictors, moderators, and mediators for treatment success will be explored. These include cognitions and experiences concerning treatment harm, credibility and burden in both participants and therapists.

METHODS/DESIGN

A short PTSD-screener assesses the possible presence of PTSD in adult patients (21- to 65- years old) with psychotic disorders, while the Clinician Administered PTSD Scale interview will be used for the diagnosis of current PTSD. The M.I.N.I. Plus interview will be used for diagnosing lifetime psychotic disorders and mood disorders with psychotic features. The purpose is to include consenting participants (N = 240) in a multi-site single blind randomized clinical trial. Patients will be allocated to one of three treatment conditions (N = 80 each): prolonged exposure or EMDR (both consisting of eight weekly sessions of 90 minutes each) or a six-month waiting list. All participants are subjected to blind assessments at pre-treatment, two months post treatment, and six months post treatment. In addition, participants in the experimental conditions will have assessments at mid treatment and at 12 months follow-up.

DISCUSSION

The results from the post treatment measurement can be considered strong empirical indicators of the safety and effectiveness of prolonged exposure and EMDR. The six-month and twelve-month follow-up data have the potential of reliably providing documentation of the long-term effects of both treatments on the various outcome variables. Data from pre-treatment and midtreatment can be used to reveal possible pathways of change.

TRIAL REGISTRATION

Trial registration: ISRCTN79584912.

How Do Social Interactions with a Significant Other Affect PTSD Symptoms? An Empirical Investigation with a Clinical Sample

Social support and coping are both related to posttraumatic stress disorder (PTSD) symptoms, but the mechanisms underlying their relationships remain unclear. This study explores these relationships by examining the perceived frequency of supportive and countersupportive interactions with a significant other in PTSD patients. Ninety-six participants with PTSD were recruited and completed questionnaires assessing social interactions, ways of coping, and PTSD symptoms. Associations of social interactions (r² = 4.1%-7.9%, p < .05) and coping (r² = 15.9%-16.5%, p < .001) with symptoms were independent, and suggested a direct association between social interactions and PTSD. Countersupportive interactions were more associated to symptoms than supportive interactions. Our findings suggest the development of psychotherapies that integrate social support interventions.

Cultural differences in personal identity in post-traumatic stress disorder

OBJECTIVES

This study investigated cultural differences in goals, self-defining memories, and self-cognitions in those with and without post-traumatic stress disorder (PTSD).

METHOD

Trauma survivors with and without PTSD, from independent and interdependent cultures (N=106) provided major personal goals, self-defining memories, and self-cognitions.

RESULTS

Trauma survivors with PTSD from independent cultures reported more goals, self-defining memories, and self-cognitions that were trauma-related than non-PTSD trauma survivors from independent cultures. In contrast, for those from interdependent cultures, there was no difference between trauma survivors with and without PTSD in terms of trauma-centred goals, self-defining memories, and self-cognitions.

CONCLUSIONS

The results suggest cultural variability in the impact of trauma on memory and identity, and highlight the need for contemporary models of PTSD to more explicitly consider culture in their accounts of PTSD. Clinical implications of these findings, such as cultural considerations in assessment and treating trauma relevant self-schema in cognitive therapy for PTSD, are discussed.

Social support moderates outcome in a randomized controlled trial of exposure therapy and (or) cognitive restructuring for chronic posttraumatic stress disorder

OBJECTIVE

To understand what predicts good outcome in psychiatric treatments, thus creating a pathway to improving efficacy.

METHOD

Our study investigated relations between predictor variables and outcome (on the Clinician Administered Posttraumatic Stress Disorder [PTSD] Scale [CAPS]) at posttreatment for 77 treatment completers in a randomized controlled trial of exposure therapy and (or) cognitive restructuring, compared with relaxation, for chronic PTSD in adults.

RESULTS

More social support on the Significant Others Scale significantly predicted better outcome on the CAPS, even after controlling for the effects of treatment group and of pretreatment severity. Importantly, social support was only a significant predictor of outcome for participants receiving cognitive restructuring and (or) exposure therapy and not for participants in the relaxation condition.

CONCLUSIONS

Better social support is associated with significantly greater gain following cognitive restructuring and (or) exposure therapy for PTSD. Future interventions should consider augmenting social support as an adjunct to treatment.

Psychological and relationship distress among partners of civilian PTSD patients

Significant others of individuals with posttraumatic stress disorder (PTSD) may experience both intrapersonal and interpersonal distress as caregivers. The aim of the present study is 3-fold: (1) to examine symptoms of psychological and relationship distress (anxiety, depression, and dyadic adjustment) among partners of civilian patients with PTSD, (2) to investigate the links between partners' distress and PTSD patients' symptoms (severity; intrusion, avoidance, and arousal subscales), and (3) to explore the perception of mental and physical health, types of trauma and compare partners and PTSD patients' measures. Fifty-seven PTSD patients and their partners filled out 4 questionnaires: Marital Adjustment Test, Beck Anxiety Inventory, Beck Depression Inventory-II, and Medical Outcome Survey-Short Form-12. Results showed that only a minority of partners presented clinical levels of depression (16.7%), anxiety (14.8%), and relationship distress (37%). Pearson correlations analyses revealed an absence of statistically significant relationship between partners' distress and PTSD patients' symptoms. In conclusion, although our study is not a direct validation of the secondary traumatic stress model, our findings fail to provide strong support to the secondary traumatic stress hypothesis among partners of civilian PTSD patients.

Posttraumatic Stress Disorder and Social Support in Female Victims of Sexual Assault

The goal of this study is to enhance the efficacy of CBT with victims of sexual assault suffering from PTSD by getting the spouse involved. Thus, in addition to attempting to reduce PTSD symptoms, the therapy focuses on improving the support offered by the spouse and favors management of the impact of the traumatic event within the couple. A single-case, multiple-baseline across-subjects design is used. Three victims of sexual assault with a diagnosis of PTSD participated in the study. Results at posttreatment and at 3-month follow-up are promising. None of the participants presents a diagnosis of PTSD, and all report a significant improvement in their satisfaction with the support received from their spouses.

Exploring the links between posttraumatic stress disorder and social support: processes and potential research avenues

Social support after a traumatic event is linked to posttraumatic stress disorder (PTSD). However, little is known about the ways in which social support influences the adaptation to trauma and development of PTSD. The aim of the present article is threefold: to outline the various processes by which social support is linked to PTSD, to review the most relevant research in the field, and to suggest potential future research.

Psychotherapy and social support: unsettling questions

There is an extensive body of research that documents the importance of social support as an independent factor in physical health and longevity. This article reviews published research that addresses the effects of psychotherapy on social connection and social support. The assumption of most psychotherapists that psychotherapy generally improves social connection is unsupported by research data except in very specific diagnostic categories. Evidence that otherwise beneficial psychotherapy can inadvertently damage social connections is also considered. The implications of these findings for further research and current practice are discussed.