What's love got to do with it? Relationship quality appraisals and quality of life in couples facing cardiovascular disease.

Objective: Changes in couples' relationship quality are common post-cardiac event but it is unclear how relationship quality is linked to patients' and spouses' quality of life (QoL). The purpose of the present study was to examine the association between relationship quality on QoL in patient-spouse dyads within six months of a cardiac event. Methods: Participants (N = 181 dyads; 25.9% female patients), recruited from a large cardiac hospital, completed validated questionnaires measuring demographic, relationship (Dyadic Adjustment Scale; DAS) and QoL variables (Heart-QoL & Quality of life of Cardiac Spouses Questionnaire). An Actor-Partner Interdependence Model was used to investigate actor (i.e. responses influencing their own outcome) and partner effects (responses influencing their partner's outcome) of relationship quality and QoL. Results: Patients' and spouses' perceptions of relationship quality were in the satisfied range (DAS > 108; 65% of sample) and, as expected, patients reported lower general physical QoL than did their spouse (t(180) = -10.635, p < .001). Patient and spouse relationship quality appraisals were positively associated with their own physical (patient ß = .25; spouse ß = .05) and emotional/social (patient ß = .21; spouse ß = .04) QoL. No partner effects were identified. Conclusion: High quality relationship appraisals appear to matter for patients' and spouses' QoL after the onset of CVD.

Dyadic patterns of mental health and quality of life change in partners and patients during three months of cardiac rehabilitation.

The effects of mental health on quality of life (QoL) over the course of a couple's recovery from a patient's cardiac event are unknown as partner outcomes are rarely considered within cardiac rehabilitation. To capture the transactional nature of recovery from a cardiac event, this research investigated the link between longitudinal changes in the mental health of couples in which at least one of the partners had cardiac disease and changes in their QoL during cardiac rehabilitation. Participants (N = 184 dyads) completed questionnaires measuring anxiety, depression, and QoL at baseline (enrollment) and 3 months (discharge). Dyadic data were analyzed using the Actor-Partner Interdependence Model with integrated latent change scores. The results indicated that improved anxiety was associated with significant positive changes in physical and emotional QoL for both the patient and partner (actor effects). A reduction in depression in both partners from baseline to follow-up predicted an increase in emotional QoL for patients and partners, and an increase in physical QoL for partners (actor effects). Patients whose depression decreased from enrollment to the completion of cardiac rehabilitation were associated with partners' greater positive changes in emotional QoL than were patients whose depression did not decrease, and reductions in partners' anxiety over time predicted positive changes in patients' physical QoL (partner effects). Findings underscore the need to screen for and attend to patients' and partners' mental health outcomes postcardiac event, as positive changes in mental health symptoms may optimize changes in patients' and partners' emotional and physical QoL. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Better together: Relationship quality and mental health among cardiac patients and spouses.

Reductions in marital relationship quality are pervasive post-cardiac event. It is not yet understood how relationship quality is linked to mental health outcomes in couples where one member has established cardiovascular disease (CVD) and the interdependence within dyads is seldom measured. This research is required as psychological distress has been independently linked to CVD incidence, morbidity, and mortality. This study assessed associations of relationship quality with depression and anxiety among patients with CVD and their spouses. Participants completed questionnaires measuring four dimensions of relationship quality and mental health. Data were analyzed using an Actor-Partner Interdependence Model with hierarchical moderation analyses. 181 dyads (N = 362 participants) comprised the study sample. Most patients had coronary artery disease (66.3%) and 25.9% were female. Patients reported higher relationship satisfaction and fewer anxiety symptoms than did spouses. Patients and spouses with high dyadic consensus and affectional expression reported fewer mental health symptoms, but only when the other partner also perceived high levels of consensus and affectional expression in the relationship. Patients and spouses with low dyadic cohesion reported worse mental health symptoms (actor effects), but those effects were no longer significant when both the patient and the spouse appraised the relationship as having high levels of dyadic cohesion. Taken together, relationship quality is linked to mental health symptoms in patients with CVD and their spouses. Longitudinal and experimental studies are now warranted to further substantiate the cross-sectional findings of this study.

Efficacy of Emotionally Focused Therapy among Spanish-speaking couples: study protocol of a randomized clinical trial in Argentina, Costa Rica, Guatemala, Mexico, and Spain.

BACKGROUND: Couple relationship distress is common and associated with poor physical, psychological, and relational outcomes for both partners. Emotionally Focused Therapy for couples (EFT) is a short-term structured approach based on attachment theory that integrates a humanistic, experiential approach to restructuring emotional experience and a systemic structural approach to restructuring interactions. This model has been shown to be an effective treatment for couple distress. The supporting research, however, has only been conducted with English-speaking couples. Despite Spanish being the second-most spoken language and meaningful cultural differences between English- and Spanish-speaking countries, the efficacy of EFT has not been examined in this cultural context. This study will examine the efficacy of EFT in this particular context and advance the understanding of potential mechanisms of change. METHODS: We will use a multicenter randomized wait-list controlled design to examine the efficacy of EFT in a Spanish-speaking sample of moderately distressed couples. One hundred forty individuals in 70 couples in Argentina, Costa Rica, Guatemala, Mexico, and Spain will be randomly assigned to receive 19-21 sessions of EFT or be placed on a waitlist. Outcomes on a range of relational and individual mental health variables will be assessed prior to random assignment, throughout treatment, and at the conclusion of treatment. Primary outcomes will include dyadic adjustment, couple satisfaction, and attachment. Secondary variables, such as loneliness, parenting, affective communication, and sexual satisfaction, will be included as potential mediators of the treatment effect. Couples in the treatment group will also be assessed at 3-, 6-, 12-, 18-, and 24-month follow-ups. Process variables such as the therapeutic alliance will also be assessed routinely in couples assigned to the treatment group. Couples in the waitlist will receive a psycho-educational program based on EFT after completing the study. DISCUSSION: This study will be the first RCT of Emotionally Focused Therapy in a Spanish-speaking context. The results of the study will inform researchers interested in whether treatments developed and tested in the USA and Canada can be effective in differing cultural contexts. It may also point researchers and clinicians to areas where cultural adaptation is needed to improve efficacy. TRIAL REGISTRATION: ClinicalTrials.gov NCT04277325. Registered on February 20, 2020.

Attachment insecurities, caregiver burden, and psychological distress among partners of patients with heart disease.

Caregiver psychological distress (i.e., depression and anxiety) is harmful to both caregiver and patient. Different affect-regulation strategies associated with attachment orientations may impact a caregiver's perception of their caregiving role as a burden, thereby contributing to their psychological distress. The aim of the present investigation was to examine the links among attachment orientations, caregiver burden, and psychological distress in a cardiac context. Participants (N = 181, Mage = 61.79, SD = 10.49; males = 24.7%) were romantic partners of patients with heart disease (i.e., informal caregivers) who completed validated questionnaires. The majority of caregivers had partners with coronary artery disease (n = 127, 70. 2%). 66.3% of caregivers reported low burden, 87.6% reported low levels of depression and 89.9% reported low levels of anxiety. The mean anxious attachment score was 2.74 (SD = 1.37) and the mean avoidant attachment score was 2.95 (SD = 1.26). Four mediation analyses were run using PROCESS macro for IBM SPSS (version 26). Statistical models showed that the relationships between attachment anxiety and psychological distress were mediated by caregiver burden [abanxiety= 0.15, 95% C.I. (0.04, 0.29); abdepression = 0.15, 95% C.I. (0.05, 0.28)] and that attachment avoidance was not a significant covariate (cvanxiety = -0.02, p>0.05; cvdepression = 0.40, p>0.05). The relationships between attachment avoidance and psychological distress were also mediated by caregiver burden [abanxiety = 0.23, 95% C.I. (0.10, 0.42); abdepression = 0.21, 95% C.I. (0.09, 0.37]with attachment anxiety as a significant covariate (cvanxiety = 1.09, p<0.001; cvdepression = 1.09, p<0.001). Interventions for caregivers reporting attachment insecurity and burden should be explored to potentially lessen caregiver distress as they support their partners with heart disease.

Emotionally focused therapy: Attachment, connection, and health.

In this review, we suggest attachment science as a framework for understanding the negative impact of loneliness and social disconnection on mental and physical health and for guiding the interventions of clinicians. We provide an overview of current findings linking loneliness and social isolation to mental health problems such as depression and anxiety, as well as to physical illnesses such as heart disease. We propose emotionally focused therapy for couples, families, and individuals to enhance the quality of people's emotional ties to significant others and their subjective sense of social connectedness. We conclude by suggesting that the strengthening of emotional, interpersonal bonds, which is the primary focus of all forms of emotionally focused therapy, can help restore emotional balance, thereby protecting people from chronic feelings of isolation and the host of health problems that they can cause.

Canadian French Translation and Preliminary Validation of the Conformity to Masculine Norms Inventory: A Pilot Study.

Conformity to masculine norms has been linked to poor mental and physical health outcomes. Its valid assessment among subgroups of the population is therefore a crucial step in the investigation of intercultural variability in the enactment of masculinity, as well as its causes, costs, and benefits. The present pilot study aimed to adapt and conduct a preliminary validation of a French version of the Conformity to Masculine Norms Inventory (CMNI-22), a self-report questionnaire designed to assess overall conformity to male gender standards. The French adaptation of the CMNI-22 (CanFr-CMNI-22) was developed using a forward-backward translation process. The data from a sample of 57 Canadian French men (23-81 years old), collected at two time points 2 weeks apart, were then analyzed to investigate the psychometric properties and factor structure of the CanFr-CMNI-22. Findings indicated adequate internal reliability of the global scores and highly satisfactory test-retest reliability. Correlations with the Male Role Norms Inventory-Short Form (MRNI-SF) at both time points also showed strong convergent validity. Overall, the CanFr-CMNI-22 appears to be a reliable and valid instrument to assess conformity to traditional masculine gender norms in French-speaking men from the general population. This study is a key step in a research process aiming to validate the Canadian French version of the CMNI and contributes to enhance inclusive research and clinical care to foster men's health.

Dyadic effects of anxiety and depression on quality of life among couples facing cardiovascular disease.

OBJECTIVE: Anxiety and depression are frequently comorbid in patients with cardiovascular disease (CVD) and a patient's poor mental health may implicate the quality of life (QoL) of a partner. The bidirectional effects of comorbid anxiety and depression on patient and partner outcomes are inadequately understood. The aim of this study was to investigate associations of the combined role of depression and anxiety on patients' and partners' QoL. METHOD: In this cross-sectional study, patients with CVD and their partners completed questionnaires measuring anxiety, depression, and QoL. Dyadic data was analyzed using the Actor-Partner Interdependence Model and polynomial interaction for examining the synergistic and dysergistic effects of anxiety and depression (i.e., in combination). RESULTS: 181 dyads comprised the study sample (66.3% coronary artery disease; 25.9% female patients). Anxiety and depression, in synergy was associated with poorer QoL in patients and partners (actor effects). Patients that are more anxious than depressed have greater physical QoL whereas partners that are more depressed than anxious have greater emotional QoL (dysergistic actor effects). Patients' more severe symptoms of anxiety and depression, in synergy, was associated with partners' poorer QoL (partner effect). CONCLUSION: Anxiety and depression are comorbid and associated with poor QoL in patients and their partners. The results may have implications for secondary prevention programming but future longitudinal studies are warranted to substantiate the cross-sectional findings.

The Healing Hearts Together Randomized Controlled Trial and the COVID-19 Pandemic: A Tutorial for Transitioning From an In-Person to a Web-Based Intervention.

Supportive couple relationships are associated with reduced risk of chronic illness development, such as cardiovascular disease, as well as improved secondary prevention. Healing Hearts Together (HHT) is an 8-week couples-based intervention designed to improve relationship quality, mental health, quality of life, and cardiovascular health among couples in which one partner has experienced a cardiac event. A randomized controlled trial began in October 2019 to test the efficacy of the in-person, group-based HHT program as compared to usual care. In March of 2020, all recruitment, assessments, and interventions halted due to the COVID-19 pandemic. Guided by optimal virtual care principles, as well as by Hom and colleagues' four-stage framework-consultation, adaptation, pilot-testing, and test launch-this paper is a tutorial for the step-by-step transition planning and implementation of a clinical research intervention from an in-person to a web-based format, using the HHT program as an example. Clinical and research considerations are reviewed, including (1) privacy, (2) therapeutic aspects of the intervention, (3) group cohesion, (4) research ethics, (5) participant recruitment, (6) assessment measures, (7) data collection, and (8) data analyses. This tutorial can assist clinical researchers in transitioning their research programs to a web-based format during the pandemic and beyond.

An attachment-based intervention for patients with cardiovascular disease and their partners: A proof-of-concept study.

Couple distress is associated with cardiovascular disease (CVD) risk factors, whereas support is associated with heart-healthy behaviors and better CVD outcomes. OBJECTIVE: To assess the clinical benefit of the Healing Hearts Together (HHT) intervention, an attachment-based relationship enhancement program for couples in which 1 partner has CVD, on relationship quality, mental health, and quality of life (QoL). METHOD: Patients from a tertiary cardiac care center and their partners (N = 78; 39 couples) attended the 8-session HHT group. Participants completed validated, self-report questionnaires pre- and postintervention, including the Dyadic Adjustment Scale (DAS), Couple Satisfaction Index (CSI), Hospital Anxiety and Depression Scale (HADS), and the SF-36 (QoL). At intervention completion, participants completed a satisfaction survey. Between-groups comparisons (patient/partner) were examined with analysis of variance. Paired-sample t tests were used to assess changes over time with HHT participation for the complete sample and for patients and partners separately. RESULTS: Many participants reported relationship and psychological distress at baseline. Clinically and statistically significant changes from pre to postintervention were observed for relationship distress (DAS: +7.8 points; p < .001; CSI changes [+3.6] were clinically significant) and depression (-1.8; p < .001), whereas statistically significant changes occurred for anxiety (-1.5; p < .001), and physical (+2.1; p = .047) and mental (+3.3; p < .001) QoL. Patients, but not partners, reported statistically significant changes in QoL-mental component summary. Clinically and statistically significant changes were observed for anxiety for partners, but not patients. CONCLUSIONS: The HHT intervention was beneficial for patients' and partners' relationship quality, mental health, and QoL. A larger randomized controlled trial evaluating the impact of this intervention on relationship quality, mental health and QoL is warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Prevalence of Symptoms of Anxiety Disorders and Depression in Cardiac Rehabilitation Patients in an Academic Hospital: a Case Study.

The relationship between body and mind is increasingly recognized in the occurrence and prognosis of cardiac disease. Based on reports detailing the potential (and the influence of certain risk factors) of developing depression and anxiety following cardiovascular disease, or a cardiac event, most notably acute coronary syndrome (ACS), we investigated whether such symptoms also existed in patient cases found at the cardiac rehabilitation unit of an academic hospital of Eastern Ontario. We examined data from charts during a 6-year period (2012-2017). The Hospital Anxiety and Depression Scale cumulated data within a retrospective cross-sectional study, was used to estimate the prevalence of anxious and depressive symptoms that might reflect the presence of psychological distress. Overall, our sample included 1178 patient files, 81.3% of which were diagnosed with ACS and 69.6% were male. 63.1% of the patients were between 60 and 79 years old at the time of diagnosis. Most patients were Caucasian (81.1%), married (60.3%), and living with their family (74.3%), and 49.7% were recorded as overweight or obese. We found that 29.3% of patients reported symptoms of psychological distress. Regression analyses revealed strong negative correlations between the proportion of symptoms of psychological distress and factors like age and functional capacity as measured by metabolic equivalents. Significant associations were also established between symptoms of psychological distress and factors such as obesity, sedentary lifestyle, smoking, and sex (female). This study was undertaken as part of a business case to implement a new cardiac rehabilitation programme in an academic hospital of Eastern Ontario and illustrate to the managers and decision-makers, the important factors to consider and to target when developing a stepped-care program for patients in cardiac rehabilitation in order to prevent psychological distress and how such a program was relevant to their institution.

Traumatic Stress, Attachment Style, and Health Outcomes in Cardiac Rehabilitation Patients.

OBJECTIVE: Research on psychosocial risk factors in cardiovascular disease (CVD) has identified traumatic stress and attachment style as independent risk factors for the development of CVD and poor prognosis for those with established CVD. Exploring the interrelationships between these variables will inform psychosocial risk factor modeling and potential avenues for intervention. Therefore, the hypothesis that attachment style is related to health outcomes among CR patients and that traumatic stress mediates this relationship was tested. METHODS: Patients in a cardiac rehabilitation program (n = 201) completed validated self-report measures of traumatic stress and attachment style at baseline (program intake). Health outcomes were assessed at baseline and 3 months, including anxiety, depression, quality of life, fasting blood glucose, glycated hemoglobin (HbA1c), and cholesterol (HDL ratio). Multivariate structural equation modeling was used to fit the data. RESULTS: Of the 201 participants, 42 (21%) had trauma scores indicating the probable presence of posttraumatic stress disorder. Via greater levels of traumatic stress, greater attachment anxiety at baseline was indirectly related to greater anxiety, depression, fasting blood glucose, and HbA1c, and poorer physical and mental quality of life. There were no significant indirect effects on HDL ratios. CONCLUSION: Greater attachment anxiety predicted greater traumatic stress; this, in turn, predicted poorer health outcomes. Screening and treatment for these constructs in CVD patients is warranted.

Short-Term and Long-Term Effects of Training in EFT: A Multinational Study in Spanish-speaking Countries.

This study seeks to validate the cross-cultural effectiveness of emotionally focused couple therapy (EFT) training in a sample of Spanish-speaking clinicians. The 28-hr formalized training for EFT was offered in six different Spanish-speaking countries, covering Europe, North America, Central America, and South America. Two hundred and seven therapists of 14 different Spanish-speaking nationalities completed pre-training assessments, 153 of them completed post-training assessments, and 92 therapists also completed the follow-up assessment. Using multilevel growth modeling (MLM), results indicated that therapists experienced significant and positive changes in terms of EFT competence (knowledge and skill acquisition), mature empathy, self-compassion, and attachment over time. Implications for transnational EFT training, specifically in Spanish-speaking countries, are discussed.

Reducing Caregiver Distress and Cardiovascular Risk: A Focus on Caregiver-Patient Relationship Quality.

Spouses report elevated levels of distress upon assuming a caregiver role; this role and related distress might, ironically, increase the cardiovascular risk of spousal caregivers of patients with cardiovascular disease (CVD). Physiological, behavioural, and emotional factors experienced by caregivers can contribute to enhanced CVD risk. Despite an appreciation of these established associations few approaches have shown effectiveness in reducing a caregiver's stress. It is known that CVD can produce additional strain on a caregiver-patient relationship, in turn accentuating caregiver distress. Poor relationships are known to be a detriment to cardiovascular health and negatively influence behaviours affecting CVD risk and outcomes. In light of these findings, we argue in this nonsystematic narrative review that enhancing caregiver-patient relationship quality in secondary prevention programs might afford an appropriate and timely opportunity to reduce caregiver distress and improve the cardiovascular health of the patient and their spousal caregiver. Evaluations of the effect of couples-based interventions on patient and caregiver CVD risk and health outcomes are required.

Of Sound Heart and Mind: A Scoping Review of Risk and Protective Factors for Symptoms of Depression, Anxiety, and Posttraumatic Stress in People With Heart Disease.

BACKGROUND: Heart disease is related to the etiology of mental health problems such as depression, anxiety, and posttraumatic stress. OBJECTIVE: The goal of this scoping review was to determine which factors pose a significant risk for the onset of symptoms of depression, anxiety, and posttraumatic stress in patients with heart disease, as well as to identify what might protect them from these afflictions. METHOD: We conducted a thorough search of relevant medical and psychological databases (Scopus, PsycARTICLES, Psychology and Behavioral Sciences Collection, Sage Journals, and MEDLINE) and identified 41 studies that met inclusion criteria, which included all types of heart disease. RESULTS: The results of our review indicate that mental health history, the tendency to stifle negative emotional experiences (known as "type D personality"), and social support in patients with heart disease are related to the onset of or protection from depression, anxiety, and posttraumatic stress. These factors, along with gender and younger age, seem to be relatively consistent predictors of mental health problems in this population. CONCLUSIONS: As per our results, it is important for clinicians to attend to the mental health history, type D personality, and presence and quality of social support in patients with heart disease. More research into prevention and gender differences is necessary to hone the detection and treatment of these problems in people with heart disease. CLINICAL IMPLICATIONS: Attention to their mental health history, their ability to express and regulate affect, their age, and their gender will most likely assist in identifying symptoms of depression, anxiety, and posttraumatic stress in people with cardiac disease. Gender differences, particularly in the manifestation of depression, ought to be taken into account.

In sickness and in health: relationship quality and cardiovascular risk and management.

PURPOSE OF REVIEW: To review the link between couple relationships and cardiovascular health, the plausible mechanisms by which relationship quality affects heart health, and to provide an overview of couple-based interventions aimed at improving cardiovascular health. RECENT FINDINGS: Marriage and the quality of the couple relationship bond are robust predictors of long-term health outcomes. Chronic relationship conflict and disconnection can be deadly. There are direct and indirect pathways by which couple relationship quality affect cardiovascular health. Direct pathways include effects of relationship quality on cardiovascular, neuroendocrine, and immune functioning. Indirect pathways include effects of emotional, cognitive and behavioural factors that impact lifestyle choices and adherence to treatment regimens. Effects of couple-based interventions addressing traditional cardiovascular risk factors have been null to modest and there is only one couple-based intervention that addressed relationship quality and heart health. On the basis of the literature, this is major oversight. We propose attachment-based interventions, such as our Healing Hearts Together program, for patients with heart disease and their partners. SUMMARY: Previous research indicates that couple-based interventions are promising. Large randomized controlled trials that aim to improve relationship quality among patients with CVD and their partners, as well as study mechanistic, surrogate, and clinical outcomes, are required to appropriately assess their impact.

Post-Traumatic Stress Disorder among Cardiac Patients: Prevalence, Risk Factors, and Considerations for Assessment and Treatment.

There is increasing awareness of the impact of post-traumatic stress disorder (PTSD) on physical health, particularly cardiovascular disease. We review the literature on the role of trauma in the development of cardiovascular risk factors and disease, aftermath of a cardiac event, and risk for recurrence in cardiac patients. We explore possible mechanisms to explain these relationships, as well as appropriate assessment and treatment strategies for this population. Our main conclusion is that screening and referral for appropriate treatments are important given the high prevalence rates of PTSD in cardiac populations and the associated impact on morbidity and mortality.

Soothing the threatened brain: leveraging contact comfort with emotionally focused therapy.

Social relationships are tightly linked to health and well-being. Recent work suggests that social relationships can even serve vital emotion regulation functions by minimizing threat-related neural activity. But relationship distress remains a significant public health problem in North America and elsewhere. A promising approach to helping couples both resolve relationship distress and nurture effective interpersonal functioning is Emotionally Focused Therapy for couples (EFT), a manualized, empirically supported therapy that is strongly focused on repairing adult attachment bonds. We sought to examine a neural index of social emotion regulation as a potential mediator of the effects of EFT. Specifically, we examined the effectiveness of EFT for modifying the social regulation of neural threat responding using an fMRI-based handholding procedure. Results suggest that EFT altered the brain's representation of threat cues in the presence of a romantic partner. EFT-related changes during stranger handholding were also observed, but stranger effects were dependent upon self-reported relationship quality. EFT also appeared to increase threat-related brain activity in regions associated with self-regulation during the no-handholding condition. These findings provide a critical window into the regulatory mechanisms of close relationships in general and EFT in particular.

Process research on Emotionally Focused Therapy (EFT) for couples: linking theory to practice.

The focus of this article is on the link among theory, process, and outcome in the practice of Emotionally Focused Therapy (EFT) for couples. We describe the EFT model of change and the EFT perspective on adult love as the reflection of underlying attachment processes. We outline the manner in which theory and research inform EFT interventions. This leads into a detailed review of the literature on the processes of change in EFT. We highlight the client responses and therapist operations that have emerged from process research and their relation to treatment outcomes. We discuss the implications of this body of research for clinical practice and training.

United we stand: emotionally focused therapy for couples in the treatment of posttraumatic stress disorder.

We present emotionally focused therapy (EFT) for couples as a viable treatment option for posttraumatic stress disorder (PTSD). We outline the empirical evidence of a link between interpersonal relationships and posttraumatic stress, with an emphasis on social support as a buffer for the development of PTSD symptoms. This leads into a discussion of the usefulness of attachment theory in the conceptualization and treatment of PTSD, followed by a description of the EFT approach and its empirical evidence. We present a clinical case with excerpts from EFT couple therapy sessions in which one partner was diagnosed with PTSD. The article concludes with clinical recommendations for helping people confront and overcome the pain and the fear that PTSD provokes.