Couple and family therapies for post-traumatic stress disorder (PTSD).

BACKGROUND: Post-traumatic stress disorder (PTSD) refers to an anxiety or trauma- and stressor-related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include difficulties in intimate and family relationships. A range of couple- and family-based treatments have been suggested as appropriate interventions for families impacted by PTSD. OBJECTIVES: The objectives of this review were to: (1) assess the effects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non-specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative effects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings. SEARCH METHODS: We searched MEDLINE (1950- ), Embase (1980- ) and PsycINFO (1967- ) via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) to 2014, then directly via Ovid after this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018. SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the effects of interventions for dichotomous outcomes, and standardised mean differences (SMD) to summarise post-treatment between-group differences on continuous measures. MAIN RESULTS: We included four trials in the review. Two studies examined the effects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the effects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the effects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in sufficient detail - we did not include it in the meta-analysis. One trial with 40 couples (80 participants) showed that CBCT was more effective than wait list control in reducing PTSD severity (SMD -1.12, 95% CI -1.79 to -0.45; low-quality evidence), anxiety (SMD -0.93, 95% CI -1.58 to -0.27; very low-quality evidence) and depression (SMD -0.66, 95% CI -1.30 to -0.02; very low-quality evidence) at post-treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not differ significantly according to relationship satisfaction (SMD 1.07, 95% CI -0.17 to 2.31; very low-quality evidence); and one study showed no significant differences regarding depression (SMD 0.28, 95% CI -0.35 to 0.90; very low-quality evidence) or anxiety symptoms (SMD 0.15, 95% CI -0.47 to 0.77; very low-quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more effective than PFE in reducing PTSD severity for the primary patient (SMD -1.32, 95% CI -1.90 to -0.74; low-quality evidence) at post-treatment. There was no evidence of differences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI -0.51 to 0.53; very low-quality evidence), depression (SMD 0.21, 95% CI -0.31 to 0.73; very low-quality evidence) and anxiety (SMD -0.16, 95% CI -0.68 to 0.36; very low-quality evidence) for intimate partners; and depression (SMD -0.28, 95% CI -0.81 to 0.24; very low-quality evidence) or anxiety (SMD -0.34, 95% CI -0.87 to 0.18; very low-quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant differences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated 'high'. Two studies had significant amounts of missing information resulting in 'unclear' risk of bias. There were too few studies available to conduct subgroup analyses. AUTHORS' CONCLUSIONS: There are few trials of couple-based therapies for PTSD and evidence is insufficient to determine whether these offer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple-based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and stand-alone interventions with couples or families which target reduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.

Secondary Traumatic Stress in Postdisaster Field Research Interviewers.

Numerous studies show that those involved in disaster response may develop posttraumatic stress disorder or experience secondary traumatic stress (STS). There are few reports about the experiences of postdisaster field research interviewers. We report findings from a follow-up study of researchers who conducted postwildfire field research interviews with residents affected by 5 severe wildfire events in Australia over the period 2009-2014. There were 33 postwildfire research interviewers who reported their experiences, and 18 of them (54.5%) described distressing interviews involving deaths, surviving severe threats to life, and destruction of houses. There were 27 (81.6%) who reported having experienced 1 or more STS symptoms on a 20-item measure. Those who conducted interviews following a multifatality wildfire event reported higher levels of STS symptoms compared with researchers whose interviews followed nonfatal wildfires. There were 21 (63.6%) researchers who reported that their interviewing experiences had positive effects on their lives. This indicates that the researcher role of gathering information so that future wildfire risk could be mitigated may have served a protective function.

Greater severity of depressive symptoms is associated with changes to perceived sweating, preferred ambient temperature, and warmth-seeking behavior.

The thermosensory system is relevant to both the conceptualization and treatment of depression. There is evidence that depression is associated with changes in thermoregulatory functioning, and that thermosensory pathways can be recruited to influence affect and reduce depressive symptoms. In this study, we investigated the relationship between severity of depressive symptoms and changes to measures of subjective experiences associated with thermoregulatory processes as well as the relationship between severity of depressive symptoms and affective responses to warm stimuli, specifically frequency of warmth-seeking behavior. Participants (N = 529) completed measures of depressive symptoms, subjective experiences associated with thermoregulatory processes (i.e., perceived sweating and preferred ambient temperature) and frequency of warmth-seeking behavior (e.g., long hot baths, saunas, etc.). We demonstrate that, controlling for age and gender, greater severity of depressive symptoms is associated with greater perceived sweating and lower preferred ambient temperature. Furthermore, we demonstrate that greater severity of depressive symptoms is associated with more frequent warmth-seeking behavior, and that something other than thermal preference (i.e., stated preference for warmer temperature) is driving this behavior. These data highlight the importance of incorporating the thermoregulatory system in our conceptualization of the pathophysiology of depression and support the potential to recruit thermosensory pathways to target depressive symptoms.

Facilitators and Barriers to Assistance Dog Puppy Raisers' Engagement in Recommended Raising Practices.

Many assistance dog providers use volunteer raisers to manage each puppy's learning and daily experiences, which partly determines the puppy's behavioural development. Therefore, it is important that raisers engage in recommended practices. Three common recommendations from the literature include frequent socialisation and consistent training for the puppies, and effective training for the raisers. However, what facilitates or hinders raisers' engagement in these practices remains unclear. To understand this, we interviewed eight raisers (three men and five women) every month during their year-long puppy raising program, and pseudo-randomly selected 16 from 48 interviews for data analysis. Thematic analyses revealed several facilitating and/or hindering factors corresponding to each of the three recommended practices. Frequent socialisation was influenced by the raisers' availability, sharing of puppy raising responsibility with others, support from their workplace, and the puppy's behaviours (e.g., soiling indoors, jumping). Consistent training was challenged by the presence of everyday distractors, accessibility to timely advice, perceived judgement from others, and the puppy's undesirable behaviours. Effective learning was facilitated by having information available in raisers' preferred learning modality, opportunities for peer-learning, and willingness to seek help. Future research should examine these factors quantitatively, which will enable more robust evaluation of programs aimed at supporting puppy raisers.

Family functioning predicts outcomes for veterans in treatment for chronic posttraumatic stress disorder.

A longitudinal framework was used to examine the competing hypotheses of (a) whether family functioning predicts changes in posttraumatic stress disorder (PTSD) symptoms or (b) whether PTSD symptoms predict changes in family functioning. Veterans (N = 311) admitted to a treatment program completed a series of questionnaires at 3 time points: at intake, from intake to completion of a treatment program, and at the 6-month follow-up. Alcohol use and general mental health symptoms were also measured at intake. A cross-lagged panel model using structural equation modeling analyses indicated that family functioning was a moderate predictor of PTSD symptoms at posttreatment and at the 6-month follow-up. PTSD was not a significant predictor of family functioning across time and alcohol use, and general mental health symptoms did not affect the overall findings. Further analyses of PTSD symptom clusters indicated that the avoidance symptom cluster was most strongly related to family functioning. Targeting family relationships for treatment may be important in the future for veterans with PTSD.

Adverse relationship processes: the attempts of women with bulimia nervosa symptoms to fit the perceived ideal of intimate partners.

OBJECTIVE: This study drew together research on anxious attachment, self-silencing, self-consciousness during sexual activity and bulimic symptoms. METHOD: A mixed community/university sample of 225 women aged 18-63 (M = 30.24, SD = 10.44) and involved in an intimate relationship completed questionnaires. RESULTS: Adverse relationship processes were significantly associated and each was also associated with bulimic symptoms. Self-consciousness during sexual activity was the best predictor of bulimic symptoms, followed by anxious attachment. Self-silencing was redundant when the other relationship processes were included in the regression. General psychopathology mediated the association between self-silencing and bulimic symptoms, and partially mediated associations between bulimic symptoms and both anxious attachment and self-consciousness during sexual activity. DISCUSSION: Women with bulimic symptoms attempt to change themselves by engaging in adverse processes in intimate relationships to meet the perceived expectations of their partners. Targeting these relationship processes in therapy might further add to the success of relationship-oriented treatments (e.g. interpersonal therapy).

Appearance feedback in intimate relationships: the role of self-verification and self-enhancement.

To better understand how body image operates within the context of intimate relationships, we investigated women's responses to appearance feedback from an intimate partner. Participants (N=192) imagined receiving feedback from their partner that was either consistent with their own appearance self-view (i.e., self-verifying), more positive (i.e., self-enhancing), or less positive (i.e., devaluing), and then provided their affective and cognitive reactions. As expected, women's perceptions of their own appearance moderated their reactions. Women with more negative self-views felt happier with enhancing feedback, but thought that it meant their partner understood them less well. They also felt less happy when they received verifying feedback, but felt more understood by their partners. Thus, women with body image dissatisfaction may find themselves stuck in the "cognitive-affective crossfire" reacting ambivalently whether their partner enhances their appearance or confirms their negative self-views. Further examination of partners' actual feedback is needed.

Predicting posttraumatic stress disorder symptoms and pain intensity following severe injury: the role of catastrophizing.

BACKGROUND: A number of theories have proposed possible mechanisms that may explain the high rates of comorbidity between posttraumatic stress disorder (PTSD) and persistent pain; however, there has been limited research investigating these factors. OBJECTIVE: The present study sought to prospectively examine whether catastrophizing predicted the development of PTSD symptoms and persistent pain following physical injury. DESIGN: Participants (N=208) completed measures of PTSD symptomatology, pain intensity and catastrophizing during hospitalization following severe injury, and 3 and 12 months postinjury. Cross-lagged path analysis explored the longitudinal relationship between these variables. RESULTS: Acute catastrophizing significantly predicted PTSD symptoms but not pain intensity 3 months postinjury. In turn, 3-month catastrophizing predicted pain intensity, but not PTSD symptoms 12 months postinjury. Indirect relations were also found between acute catastrophizing and 12-month PTSD symptoms and pain intensity. Relations were mediated via 3-month PTSD symptoms and 3-month catastrophizing, respectively. Acute symptoms did not predict 3-month catastrophizing and catastrophizing did not fully account for the relationship between PTSD symptoms and pain intensity. CONCLUSIONS: Findings partially support theories that propose a role for catastrophizing processes in understanding vulnerability to pain and posttrauma symptomatology and, thus, a possible mechanism for comorbidity between these conditions.

The role of attachment in current and future parent caregiving.

Few studies have investigated how attachment bonds between older parents and their adult children influence adult children's provision of care and older parents' seeking of support from kin. The aim of this study was to investigate how the attachment orientations of adult children (N = 119) and older parents (N = 148) predict family caregiving and perceptions of carer burden. Across both samples (that were unrelated), attachment dimensions were associated with current and future caregiving and care receiving and perceptions of carer burden, even when accounting for demographic variables, parental dependence and filial obligation. Specifically, attachment avoidance was associated negatively with adult children's future care of parents and positively with burden. In contrast, attachment anxiety was positively associated with older parents' seeking current support, perceptions of carer burden, and intentions to seek future support.

Longitudinal analyses of family functioning in veterans and their partners across treatment.

OBJECTIVE: This study evaluated the relations between posttraumatic stress disorder (PTSD) symptoms and poor family functioning in veterans and their partners. METHOD: Data were collected from Caucasian veterans with PTSD (N = 1,822) and their partners (N = 702); mean age = 53.9 years, SD = 7.36. Veterans completed the Posttraumatic Checklist Military Version (PCL-M) and, along with their partners, completed the McMaster Family Assessment Device (FAD-12). Assessments were conducted at intake into a treatment program at 3 months and 9 months posttreatment. RESULTS: Structural equation models (SEMs) were developed for veterans as well as for veterans and their partners. Poor family functioning for veterans at intake predicted intrusion (ß = .08), hyperarousal (ß = .07), and avoidance (ß = .09) at 3 months posttreatment. At 3 months posttreatment, family functioning predicted hyperarousal (ß = .09) and avoidance (ß = .10) at 9 months. For veterans and their partners, family functioning at intake predicted avoidance (ß = .07) at 3 months, and poor family functioning at 3 months predicted intrusion (ß = .09) and hyperarousal (ß = .14) at 9 months. The reverse pathways, with PTSD symptoms predicting poor family functioning, were only evident with avoidance (ß = .06). CONCLUSION: Family functioning may play a role in treatment for veterans.

An examination of willingness to self-disclose in women with bulimic symptoms considering the context of disclosure and negative affect levels.

OBJECTIVE: This study explored the relationship between bulimic symptoms and self-disclosure. It examined whether women who reported greater bulimic symptomatology were generally less willing to self-disclose in intimate relationships or whether reluctance to disclose was confined to eating and weight concerns. METHOD: Women with high and low scores on the Bulimia Test Revised (BULIT-R) were compared on self-disclosure about three topics (daily activities, eating, and weight) and sexual and relationship issues to three targets (mother, friend, and partner). RESULTS: There were significant main and interaction effects for BULIT-R score, target, and topic of self-disclosure. When depression was controlled for, it partially explained the association between bulimic behavior and self-disclosure. DISCUSSION: Results supported a contextual model of self-disclosure. Compared with nonbulimic women, women with bulimic symptoms were less willing to self-disclose certain topics to particular targets. Levels of depression explained low willingness to disclose on topics unrelated to eating and weight to some targets.

Chronic posttraumatic stress disorder and family functioning of Vietnam veterans and their partners.

OBJECTIVE: This study examines the association between posttraumatic stress disorder (PTSD), in terms of the three main symptom clusters (intrusion, avoidance and arousal), and the self-report of family functioning of Vietnam veterans and the self-report of family functioning of their partners. A second objective was to determine if depression, anger and alcohol abuse mediated between PTSD symptoms and family functioning. METHOD: Vietnam veterans and their partners completed a series of questionnaires as part of their participation in the inpatient and outpatient PTSD treatment program, in the Veterans Psychiatry Unit, at the Austin and Repatriation Hospital. RESULTS: Data from 270 veterans and partners were used in the final analyses. The PTSD subscales were initially correlated with family functioning for veterans and family functioning for partners. Then two path diagrams were constructed and analyzed using the statistical program AMOS to test for mediating effects between PTSD symptoms and family functioning. For veterans there were significant initial correlations with all three subscales of the PTSD measure. In the path analysis when the mediating variables were included only the avoidance subscale of the PTSD measure remained directly associated with family functioning. The arousal PTSD subscale was mediated by anger. The measures of depression and anger were significantly associated with poor family functioning and the anger and the avoidance subscales were significantly associated with depression. In the second set of analyses conducted on data from partners, the PTSD symptoms of avoidance and arousal were initially correlated with family functioning. When the test for mediation was conducted none of the PTSD subscales remained associated with partners' self-report of family functioning. Posttraumatic stress disorder arousal and alcohol abuse were mediated by anger for partners' self-report of family functioning. CONCLUSIONS: Posttraumatic stress disorder symptoms of avoidance for veterans, and comorbid symptoms of anger and depression for veterans, and anger on its own for partners appear to be important in the self-report of family functioning. These findings suggest that veterans and their partners have similar difficulties as couples with distressed relationships in the community.