Design of a randomized clinical trial of brief couple therapy for PTSD augmented with intranasal oxytocin

BACKGROUND

Leveraging military veterans' intimate relationships during treatment has the potential to concurrently improve posttraumatic stress disorder (PTSD) symptoms and relationship quality. Cognitive-Behavioral Conjoint Therapy (CBCT) and an 8-session Brief Cognitive-Behavioral Conjoint Therapy (bCBCT) are manualized treatments designed to simultaneously improve PTSD and relationship functioning for couples in which one partner has PTSD. Although efficacious in improving PTSD, the effects of CBCT on relationship satisfaction are small, especially among veterans. Intranasal oxytocin, which targets mechanisms of PTSD and relationship quality, may enhance the efficacy of bCBCT.

METHOD/DESIGN

The purpose of this 4-year clinical trial is to compare the outcomes of bCBCT augmented with intranasal oxytocin versus bCBCT plus placebo. We will also explore potential mechanisms of action: self-reported communication skills, empathy, and trust. We will recruit 120 dyads (i.e., veteran with PTSD and their intimate partner) from the VA San Diego Healthcare System. Veterans will be administered 40 international units of oxytocin (n = 60) or placebo (n = 60) 30 min before each of 8 bCBCT sessions delivered via telehealth. Clinical and functioning outcomes will be assessed at five timepoints (baseline, mid-treatment, post-treatment, and 3- and 6-month follow-up).

CONCLUSION

Study findings will reveal the efficacy of oxytocin-assisted brief couple therapy for PTSD, which could serve as highly scalable option for couples coping with PTSD, as well as provide preliminary evidence of interpersonal mechanisms of change.

CLINICALTRIALS

govIdentifier:NCT06194851.

An examination of relationship satisfaction as a predictor of outcomes of brief couple therapy for posttraumatic stress disorder

The pretreatment quality of intimate relationships can promote or interfere with couple therapy for posttraumatic stress disorder (PTSD) treatment response. We tested whether baseline relationship satisfaction predicted clinical and process outcomes in two dyadic treatments for PTSD. Using data from a randomized trial comparing brief cognitive behavioral conjoint therapy (bCBCT) for PTSD to PTSD family education (PFE) among 137 military veterans and their partners (N = 274, Mage = 42.3 years, 46.7% White, 81.0% male veteran partner), we examined whether baseline relationship satisfaction (Couples Satisfaction Index; CSI-32) predicted change in PTSD symptom severity (Clinician Administered PTSD Scale for DSM-5; CAPS-5), psychosocial functioning (Brief Inventory of Psychosocial Functioning; B-IPF), and relationship satisfaction at posttreatment and 6-month follow-up. We also explored associations with process outcomes (working alliance, treatment satisfaction, dropout). In both treatment conditions, neither partner's baseline CSI-32 score moderated change in veteran CAPS-5 or B-IPF score or any process variable. However, baseline CSI-32 scores moderated both partners' CSI-32 score change during bCBCT and PFE; participants who scored in the distressed range at baseline (n = 123) experienced significant improvements in relationship satisfaction, β = .199, whereas there was no change among those in the nondistressed range at baseline (n = 151), β = .025. Results suggest bCBCT and PFE are effective in improving PTSD symptoms and psychosocial functioning regardless of whether a couple is experiencing clinically significant relationship distress; further, these treatments improve relationship satisfaction for the most distressed individuals.

The role of veterans' PTSD symptoms in veteran couples' insomnia

Insomnia contributes to individual mental and physical health and relationship well-being. Veterans' PTSD symptoms are associated with their own insomnia. However, research has not explored whether and how veterans' PTSD symptoms are associated with their partners' insomnia. The present study examined the association between veterans' PTSD symptom severity and veterans' and partners' insomnia. Veterans (n = 192) and their partners (n = 192; total N = 384) completed baseline assessments in a PTSD treatment study for veterans with PTSD and their partners. Path analysis was used to examine the relation between veterans' PTSD symptom severity, as measured by the PTSD symptom checklist-5 (PCL-5) and veterans' and partners' insomnia, as measured by the Insomnia Severity Index (ISI). Veterans' full-scale PCL-5 was positively related to veterans' and partners' insomnia. For veterans, intrusion and arousal symptoms were positively related to their own insomnia severity, while veterans' negative alterations in cognition and mood were associated with partners' insomnia severity. In exploratory analyses, partners' depressive symptoms fully mediated the relation between veterans' negative cognitions and mood and partners' insomnia. PTSD symptoms impact both veterans' and partners' insomnia. However, different PTSD symptom clusters were related to insomnia for each partner, and the link for partners was explained by their own depression symptoms. PTSD, insomnia, and integrated treatments should consider strategies for including partners in treatment to address these interconnected problems.

Pilot test of intranasal oxytocin as an enhancer of brief couples therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) negatively impacts military veterans and their intimate partners. Cognitive-Behavioral Conjoint Therapy (CBCT) was developed to address both PTSD and relationship satisfaction among couples. Although efficacious in improving PTSD, the effects of CBCT and the 8-session brief CBCT (bCBCT) on relationship satisfaction among veteran patients with PTSD are modest. Pharmacological augmentation with the neuropeptide oxytocin is promising for enhancing bCBCT's potency due to its effects on mechanisms of trauma recovery (e.g., extinction learning) and relationship functioning (e.g., trust, communication). The goal of this pilot uncontrolled clinical trial was to examine the feasibility and preliminary efficacy of bCBCT augmented with intranasal oxytocin for improving PTSD and relationship satisfaction among 10 U.S. veterans with PTSD and their intimate partners. Veterans self-administered 40 international units of intranasal oxytocin 30 min before each bCBCT session delivered to the couple via telehealth. Both partners completed pre-assessment, weekly, post, and 3-month follow-up assessments of PTSD symptoms and relationship satisfaction. Couples also provided qualitative feedback related to feasibility and engagement. Nine dyads completed the treatment. There were no serious adverse events. Veterans and partners reported moderate to large effect size improvements in relationship satisfaction (Hedge's g = 0.55 and 1.01, respectively). Veterans reported large effect size reductions in PTSD severity (Hedge's g = 1.87). These results suggest that virtual oxytocin-assisted bCBCT is feasible, scalable, potentially efficacious, and should be tested with a placebo-controlled randomized controlled trial.

Adverse childhood experiences, mental health, and relationship satisfaction in military couples

Adverse Childhood Experiences (ACEs) have been found to influence one's own mental health and relationship satisfaction in adulthood; however, the association between one's own ACEs and their partner's individual and relationship functioning has not been explored. Veterans (n = 103) and their significant others (S-O; total N = 206) completed assessments on ACEs, depression, relationship satisfaction, and Posttraumatic Stress Disorder (PTSD) symptom severity as part of a baseline assessment in a treatment outcome study for veterans with PTSD and their S-Os. Actor Partner Interdependence Moderation Modeling (APIMoM) was conducted. Higher ACE score was positively related to PTSD for all participants. Female S-O's ACE score was positively related to their own depression, and male S-Os reported higher depression and lower relationship satisfaction when their partners reported a higher ACE score. Surprisingly, female veterans experienced higher relationship satisfaction when their S-Os reported a higher ACE score. ACEs are related differently to one's own and one's partner's mental health and relationship satisfaction and should be assessed when conducting couple's interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A randomized trial of brief couple therapy for PTSD and relationship satisfaction

OBJECTIVE

This three-arm randomized trial tested a brief version of cognitive-behavioral conjoint therapy (bCBCT) delivered in two modalities compared to couples' psychoeducation in a sample of U.S. veterans with posttraumatic stress disorder (PTSD) and their intimate partners.

METHOD

Couples were randomized to receive (a) in-person, office-based bCBCT (OB-bCBCT), (b) bCBCT delivered via home-based telehealth (HB-bCBCT), or (c) an in-person psychoeducation comparison condition (PTSD family education [OB-PFE]). Primary outcomes were clinician-assessed PTSD severity (Clinician Administered PTSD Scale), self-reported psychosocial functioning (Brief Inventory of Psychosocial Functioning), and relationship satisfaction (Couples Satisfaction Index) at posttreatment and through 6-month follow-up.

RESULTS

PTSD symptoms significantly decreased by posttreatment with all three treatments, but compared to PFE, PTSD symptoms declined significantly more for veterans in OB-bCBCT (between-group d = 0.59 [0.17, 1.01]) and HB-bCBCT (between-group d = 0.76 [0.33, 1.19]) treatments. There were no significant differences between OB-bCBCT and HB-bCBCT. Psychosocial functioning and relationship satisfaction showed significant small to moderate improvements, with no differences between treatments. All changes were maintained through 6-month follow-up.

CONCLUSIONS

A briefer, more scalable version of CBCT showed sustained effectiveness relative to an active control for improving PTSD symptoms when delivered in-person or via telehealth. Both bCBCT and couples' psychoeducation improved psychosocial and relational outcomes. These results could have a major impact on PTSD treatment delivery within large systems of care where access to brief, evidence-based PTSD treatments incorporating family members are needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Posttraumatic stress disorder and relationship functioning: Examining gender differences in treatment-seeking veteran couples

Posttraumatic stress disorder (PTSD) symptoms are robustly associated with intimate relationship dysfunction among veterans, but most existing research has focused on male veterans and their female partners. Links between PTSD and relationship functioning may differ between female-veteran couples and male-veteran couples. The current study used actor-partner interdependence models (APIMs) to test the associations between PTSD symptoms (i.e., veteran self-report or significant others' collateral-report) and each partner's reports of six domains of relationship functioning, as well as whether these links were moderated by the gender composition of the couple. Data were from 197 mixed-gender couples (N = 394 individuals) who completed baseline assessments for a larger randomized controlled trial of a couple-based PTSD treatment. Significant others' collateral PTSD reports were associated with their own ratings of relationship satisfaction, negotiation, psychological aggression, sexual pleasure, and sexual desire frequency, |β|s = .19-.67, and with veterans' ratings of negotiation and sexual desire frequency, |β|s = .20-.48. In contrast, veterans' self-reported PTSD symptoms were only associated with their own ratings of psychological aggression, β = .16. Gender moderated the associations between significant others' collateral PTSD reports and five of the six outcome variables; findings from exploratory subgroup analyses suggested links between reported PTSD symptoms and relationship functioning were generally more maladaptive for male-veteran couples, whereas female veterans showed more neutral or even helpful impacts of higher partner-perceived PTSD symptoms. These findings have implications for clinicians treating relational impacts of PTSD and emphasize the need for further research with female-veteran couples.

Utilizing the couple relationship to prevent suicide: A preliminary examination of Treatment for Relationships and Safety Together

OBJECTIVE

To evaluate the feasibility, preliminary effects, and acceptability of the first comprehensive couple-based treatment for suicide, called Treatment for Relationships and Safety Together (TR&ST).

METHOD

In a preliminary examination, five couples (N = 10) participated in 10 weekly sessions of TR&ST. All couples included a veteran who reported active suicidal ideation at baseline and their partner. Couples completed measures of relationship functioning, perceived burdensomeness, thwarted belonging, and suicidal ideation at baseline, mid-treatment, and posttreatment.

RESULTS

TR&ST was feasible to deliver. Veteran and partner relationship functioning improved and veteran perceived burdensomeness, thwarted belonging, and suicidal ideation decreased. There were no suicide related behaviors, hospitalizations, or crisis line calls during the study. TR&ST seemed acceptable to couples (100% retention and high satisfaction ratings).

CONCLUSION

Couple-based suicide prevention may provide an additional avenue for suicide prevention in veterans.

The relation between mindfulness and perceived partner responsiveness during couples' vulnerability discussions

Intimacy develops when a person discloses vulnerability and perceives their partner's response as supportive. However, a published experimental study found that individuals report their partners as less supportive in response to disclosures of specific examples of vulnerability that involve the partner (i.e., partner-inclusive) compared to disclosures that do not involve the partner (i.e., partner-exclusive). This research is an extension of findings from that experimental study and examines how individual differences in mindfulness and disclosure specificity are associated with perceived partner responsiveness during disclosures of partner-inclusive and partner-exclusive vulnerabilities. Cohabiting couples (N = 82) were randomly assigned to engage in either partner-inclusive or -exclusive vulnerability discussions. Each couple engaged in 2 video-recorded discussions so that each person took a turn as discloser and responder. Trained coders rated disclosures for specificity (i.e., whether or not the discloser used specific examples). Following each discussion, couples rated perceived partner responsiveness. Hypotheses were tested with multilevel modeling. Findings suggest that individuals perceived their partners' reactions as less responsive when they disclosed specific, partner-inclusive vulnerabilities and their partners had lower mindfulness. When partners had higher mindfulness, individuals perceived their partners as similarly responsive when disclosing partner-inclusive and -exclusive vulnerabilities, regardless of specificity. Mindfulness may enable couples to remain engaged during partner-inclusive vulnerability discussions leading to higher perceived responsiveness-an integral component of intimacy development. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Association Between Sexual Functioning and Suicide Risk in U.S. Military Veteran Couples Seeking Treatment for Post-Traumatic Stress Disorder

Intimate relationship distress has been identified as one of the most common precipitants of suicidal thoughts for U.S. military populations. Sexual functioning is associated with relationship distress and has recently been identified as a predictor of suicidal ideation with female military personnel; however, no studies have examined this association among a treatment-seeking sample of male and female veterans and their partners. Couples (N = 138) completed baseline assessments of sexual functioning, relationship functioning, suicidal ideation, and mental health prior to evaluation for engagement in a couples-based PTSD treatment study. Analyses revealed that decreased sexual pleasure and decreased frequency of sexual intercourse were associated with more recent suicidal ideation for male veterans, whereas increased sexual frequency was marginally associated with increased suicidal ideation for female veterans, controlling for PTSD and depression symptoms, relationship satisfaction, and medications. These findings stress the importance of assessing sexual functioning as a risk factor for suicide and taking into consideration the possibility that sexual functioning may be protective or predictive of suicidality depending on the person and context.

Skills for Healthy Adult Relationships at the University of Maryland, Baltimore County: Program Development and Preliminary Data

The present study examines the development and preliminary pilot findings of Skills for Healthy Adult Relationships at the University of Maryland, Baltimore County (SHARe@UMBC)-an intimate partner violence prevention program for college students. SHARe@UMBC is based on an integrative cognitive-behavioral model of communication and emotion regulation in close interpersonal relationships. There were four aims of the present study: first, to describe program development; second, to examine program acceptability and participant satisfaction; third, to examine the extent to which participants acquired relationship skills and their level of confidence in using those skills; and fourth, to examine perpetration and victimization of physical, sexual, and psychological aggression. These aims utilized data collected before program initiation, immediately after program completion, and at a follow-up 9 to 15 months after program completion. Findings from two pilot groups (15 students in total; eight women and seven men) indicated high ratings of program acceptability and satisfaction, reductions in negative communication, improvements in confidence using conflict management strategies with romantic partners and peers, and confidence initiating new romantic relationships. In addition, large effect sizes were observed for confidence providing emotional support to a romantic partner and self-disclosure with peers. Participants reported no incidents of physical, sexual, or psychological aggression perpetration or victimization at follow-up. Pilot implementation and initial uncontrolled results are encouraging and provide support for initiating a more extensive controlled investigation of program efficacy.

More or less: Newlyweds' preferred and received social support, affect, and relationship satisfaction

Matching theories of social support suggest that receiving the amount and type of support one prefers from one's romantic partner promotes more favorable affect and higher relationship satisfaction. Individuals who feel they are provided with less support from their partner than they desire (underprovision) generally experience less positive affect, more negative affect, and tend to be less satisfied in their relationships. However, research findings are mixed with regard to whether receiving more of a particular type of support from one's partner than one desires (overprovision) is associated with more favorable affect and higher relationship satisfaction. The purpose of the present study was to examine whether underprovision and overprovision of two theoretically important types of social support from spouses-emotional or informational support-were associated with more favorable affect and higher relationship satisfaction in a sample of newlywed couples. Participants were 114 newlywed couples. Data were analyzed using Actor-Partner Interdependence Moderation Models. Results suggested that receiving more emotional support was associated with more favorable affect and higher relationship satisfaction regardless of support preferences. Also, wives who received more informational support from their husbands had higher relationship satisfaction regardless of support preferences. In contrast to findings for relationship satisfaction, the association between informational support and affect were consistent with matching hypotheses. Husbands who experienced underprovision of informational support from their wives, experienced less favorable affect. In contrast, wives who experienced overprovision of informational support from their husbands experienced higher depressive symptoms. Implications for research, theory, and practice are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Newlyweds' perceptions of partner conflict behaviors and change in intimate safety over time

The aim of this study was to examine hypotheses from Cordova and Scott's (2001) behavioral conceptualization of intimacy. This theory defines intimacy as a process that involves exhibiting interpersonally vulnerable behavior (i.e., behavior that is at risk of censure or punishment by another person) that is reinforced rather than punished by the other person's response. Over time, as more vulnerable behaviors are reinforced than are punished by a relationship partner, one develops feelings of intimate safety (i.e., a sense of comfort and safety in being vulnerable with one's partner). The current study investigated whether individuals' perceptions of how frequently their partner engages in reinforcing and punishing behaviors during conflict are associated with change in intimate safety. Ninety one newlywed couples completed assessments of intimate safety at Time 1 and Time 2 (1 year later), and completed assessments of their perceptions of partners' positive conflict behaviors (e.g., understanding one another's viewpoint) and negative conflict behaviors (e.g., criticizing, blaming) at Time 2 (reporting on the previous 6 months). Results indicated that individuals who reported that their partners engaged in high levels of negative conflict behaviors experienced decreased intimate safety from Time 1 to Time 2. Further, wives who reported that their husbands engaged in high levels of positive conflict behaviors experienced increased intimate safety from Time 1 to Time 2. This study is the first to test a key hypothesis of the behavioral conceptualization of intimacy, and findings are generally consistent with the theory. This line of research has important implications for couple interventions, which often target intimacy. (PsycINFO Database Record

Trust, attachment, and mindfulness influence intimacy and disengagement during newlyweds' discussions of relationship transgressions

Discussions of relationship transgressions-violations of relationship norms-are often difficult for couples to successfully navigate. Nevertheless, engaging in and resolving these discussions should promote intimacy. Drawing on the risk regulation model, individuals' experiences of disengagement and intimacy during transgression discussions should depend on their trust in their partner regarding the transgression and how they regulate distress related to lower trust. Attachment style represents individual differences in emotion regulation in close relationship contexts and is indicated by the risk regulation model. In contrast, mindfulness also improves interpersonal emotion regulation but is not reflected in the model. The present study proposed that the effect of trust on the experience of intimacy and disengagement during transgression discussions would depend on individuals' attachment style or mindfulness. Hypotheses were tested in a sample of 81 heterosexual newlywed couples. Trust was positively associated with intimacy for individuals with higher attachment avoidance, but not for individuals with lower attachment avoidance. Trust was negatively associated with disengagement for individuals with either lower mindfulness or higher attachment avoidance. Trust was not associated with disengagement for individuals with higher mindfulness or lower attachment avoidance. Implications for theory and clinical interventions focused on increasing intimacy and decreasing disengagement in couple relationships are discussed. (PsycINFO Database Record