Longitudinal associations between interpersonal relationship functioning and posttraumatic stress disorder (PTSD) in recently traumatized individuals: differential findings by assessment method.

BACKGROUND: The role of interpersonal relationship functioning in trauma recovery is well-established. However, much of this research has been done with cross-sectional samples, often years after trauma exposure, using self-report methodology only, and is focused on intimate relationship adjustment. METHODS: The current study investigated the longitudinal associations between interpersonal (intimate and non-intimate) relationship functioning and clinician- and self-reported posttraumatic stress disorder (PTSD) symptoms in 151 recently (within the past 6 months) traumatized individuals. Participants were assessed at four time points over 1 year. RESULTS: Approximately 53% of the sample was diagnosed with PTSD at initial assessment, with declining rates of diagnostic status over time to 16%. Latent difference score (LDS) modeling revealed nonlinear declines in both clinician-assessed and self-reported PTSD symptom severity, with faster declines in earlier periods. Likewise, LDS models revealed nonlinear declines in negative (conflict) aspects of interpersonal relationship functioning, but linear declines in positive (support, depth) aspects. The relationship between PTSD and relationship functioning differed for clinician- and self-reported PTSD. Bivariate LDS modeling revealed significant cross-lagged effects from relationship conflict to clinician-assessed PTSD, and significant cross-lagged effects from self-reported PTSD to relationship conflict over time. CONCLUSIONS: These results highlight that the variability in prior results may be related to the method of assessing PTSD symptomatology and different relational constructs. Implications for theory and early intervention are discussed.

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes.

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1-3 and one session from Sessions 4-7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18-0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.

The Diagnostic Assessment Research Tool in action: A preliminary evaluation of a semistructured diagnostic interview for DSM-5 disorders.

This article describes the initial validation of the Diagnostic Assessment Research Tool (DART), a modular semistructured interview to facilitate diagnosis of various disorders among adults corresponding with the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). In this study, the construct, convergent, and discriminant validity of DART modules for anxiety disorders, depressive disorders, obsessive-compulsive disorder, posttraumatic stress disorder, and substance-related and addictive disorders was assessed among a sample of 610 participants in a clinical outpatient setting. The data indicated excellent construct validity among DART modules assessed. Individuals with and without DSM-5 diagnoses identified via the DART had significant between-group differences on self-report measures corresponding to these diagnoses. Follow-up logistic regressions supported convergent validity for all diagnostic categories assessed. Discriminant validity was established for the majority of diagnostic categories assessed. High rates of interrater agreement in a small subsample (n = 15) were observed for the various diagnostic categories of the DART (88% average agreement). The results of the present study provide initial support for the DART as a useful tool to aid in the assessment of several major diagnostic categories corresponding with DSM-5 disorders. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Sensitivity and specificity of the Posttraumatic Stress Disorder Checklist for DSM-5 in a Canadian psychiatric outpatient sample.

The Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) is a widely used, self-report measure that is employed to assess PTSD symptom severity and determine the presence of probable PTSD in various trauma-exposed populations. The PCL-5 is often administered in clinical settings as a screening tool for PTSD, with a suggested cutoff score of 33 indicating a probable PTSD diagnosis. Recent research indicates that a higher cutoff may be required in psychiatric samples. In the present study, we aimed to determine the sensitivity and specificity of the PCL-5 in a Canadian outpatient psychiatric sample and establish an optimal cutoff score for detecting probable PTSD in this sample. Participants were 673 individuals who reported a history of trauma exposure and were assessed using a semistructured interview and self-report measures. Individuals diagnosed with PTSD (N = 193) reported a mean PCL-5 score of 56.57, whereas individuals without PTSD (N = 480) reported a mean score of 33.56. A score of 45 was determined to be the optimal cutoff score in this sample, balancing sensitivity and specificity while detecting a probable diagnosis of PTSD. Consistent with findings in other psychiatric samples, these findings indicate that in an outpatient psychiatric sample with a history of exposure to a variety of trauma types, a higher cutoff score is required to determine probable PTSD. In addition, given the estimated rate of false positives even with a higher cutoff, follow-up diagnostic assessments are recommended.

The relationship between emotion regulation difficulties and PTSD outcomes during group cognitive processing therapy for PTSD.

Emotion regulation difficulties (difficulty regulating the experience, occurrence, and expression of emotions) are associated with the severity of posttraumatic stress disorder (PTSD) symptoms across trauma types (e.g., childhood abuse, sexual assault, combat trauma). Despite emerging research suggesting that evidence-based treatments for PTSD, including cognitive processing therapy (CPT), are effective in improving emotion regulation difficulties, some have argued that these therapies may not be as safe or acceptable to patients compared to non-trauma focused treatments. Accordingly, the current study sought to determine the impact of pre-treatment emotion regulation difficulties on PTSD treatment outcomes and dropout, as well as whether emotion regulation difficulties improve over the course of treatment with group CPT among individuals with PTSD. One hundred and one individuals with PTSD participated in group CPT. Repeated measures t-tests found significant pre- to post-treatment improvements for emotion regulation difficulties (d = .79). Further, hierarchical linear modeling and logistic regression analyses revealed that pre-treatment emotion regulation difficulties were neither significantly associated with changes in PTSD symptoms over the course of treatment (d = -.07) nor with treatment dropout (OR = 1.00). These findings suggest that CPT delivered in a group setting to individuals with PTSD can lead to significant improvement in emotion regulation and that emotion regulation difficulties do not negatively impact treatment outcome or patient retention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Sexual Dysfunction in Male Canadian Armed Forces Members and Veterans Seeking Mental Health Treatment.

INTRODUCTION: There is mixed evidence regarding how posttraumatic stress disorder (PTSD) symptom clusters are associated with sexual dysfunction (SD), and most studies to date have failed to account for potentially confounding variables. Our study sought to explore the unique contribution of PTSD symptom clusters on (a) lack of sexual desire or pleasure, and (b) pain or problems during sexual intercourse, after adjusting for comorbidities and medication usage. MATERIALS AND METHODS: Participants included 543 male treatment-seeking veterans and Canadian Armed Forces (CAF) personnel (aged <65 years), referred for treatment between September 2006 and September 2014. Each participant completed self-report measures of demographic variables, depressive symptom severity, chronic pain, alcohol misuse, and psychotropic medication usage as part of a standard clinical intake protocol. Hierarchical ordinal logistic regression analyses were used to determine the incremental contribution of PTSD symptom clusters on sexual dysfunction. RESULTS: Nearly three-quarters (71.5%) of participants reported a lack of sexual desire or pleasure and 40.0% reported pain or problems during intercourse. Regression analyses suggested that avoidant/numbing symptoms were the only symptoms to be independently associated with lacking sexual desire or pleasure (AOR = 1.10; 95% CI 1.05-1.15). None of the PTSD symptom clusters were independently associated with pain or problems during intercourse. CONCLUSIONS: Sexual dysfunction is prevalent among male treatment-seeking CAF personnel and veterans. Results suggest that PTSD symptoms are differentially associated with sexual desire or pleasure concerns. Assessing sexual function among CAF personnel and veterans seeking treatment for PTSD is critical in order to treat both conditions and improve overall functioning.

Comorbidity Patterns of Psychiatric Conditions in Canadian Armed Forces Personnel.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is often accompanied by other mental health conditions, including major depressive disorder (MDD), substance misuse disorders, and anxiety disorders. The objective of the current study is to delineate classes of comorbidity and investigate predictors of comorbidity classes amongst a sample of Canadian Armed Forces (CAF) Regular Force personnel. METHODS: Latent class analyses (LCAs) were applied to cross-sectional data obtained between April and August 2013 from a nationally representative random sample of 6700 CAF Regular Force personnel who deployed to the mission in Afghanistan. RESULTS: MDD was the most common diagnosis (8.0%), followed by PTSD (5.3%) and generalized anxiety disorder (4.7%). Of those with a mental health condition, LCA revealed 3 classes of comorbidity: a highly comorbid class (8.3%), a depressed-only class (4.6%), and an alcohol use-only class (3.1%). Multinomial logit regression showed that women (adjusted relative risk ratio [ARRR] = 2.77; 95% CI, 2.13 to 3.60; P < 0.01) and personnel reporting higher trauma exposure (ARRR = 4.18; 95% CI, 3.13 to 5.57; P < 0.01) were at increased risk of membership in the comorbid class compared to those without a mental health condition. When compared to those with no mental health condition, experiencing childhood abuse increased the risk of being in any comorbidity class. CONCLUSIONS: Results provide further evidence to support screening for and treatment of comorbid mental health conditions. The role of sex, childhood abuse, and combat deployment in determining class membership may also prove valuable for clinicians treating military-related mental health conditions.

A randomized controlled effectiveness trial of training strategies in cognitive processing therapy for posttraumatic stress disorder: Impact on patient outcomes.

This randomized controlled hybrid implementation/effectiveness trial aimed to compare the impact of three different models of training and consultation by examining the PTSD treatment outcomes achieved by therapists who were learning a front-line recommended psychotherapy for posttraumatic stress disorder (PTSD), Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017). Therapists (N = 134) were randomized into one of three conditions after attending a standard CPT training workshop: No Consultation with delayed feedback on CPT fidelity, Standard Consultation involving discussion and conceptualization of cases without session audio review, and Consultation Including Audio Review, which included a review of segments of audiorecorded CPT sessions. Across all training conditions, the patients treated by these therapists (N = 188) evidenced statistically significant reductions in PTSD symptoms, (d = -0.95 to -1.78), comorbid symptoms and functioning (d = -0.27 to -0.51). However, patients of therapists in the Standard Consultation condition (ΔPTSD = - 19.64, d = -1.78) experienced significantly greater improvement than those in the No Consultation condition (ΔPTSD = - 10.54, d = -0.95, ΔDEV = 6.30, ΔParms = 2, p = .043). This study demonstrates that patients who receive evidence-based psychotherapy for PTSD in routine care settings can experience significant symptom improvement. Our findings also suggest that to maximize patient benefit, therapist training should include consultation, but that audio review of sessions during consultation may not be necessary, at least for structured protocols. Implications for implementation, including the reduction of burden and cost of post-workshop support, are discussed.

Depression and the relationship between sleep disturbances, nightmares, and suicidal ideation in treatment-seeking Canadian Armed Forces members and veterans.

BACKGROUND: Research on the relationship between insomnia and nightmares, and suicidal ideation (SI) has produced variable findings, especially with regard to military samples. This study investigates whether depression mediated the relationship between: 1) sleep disturbances and SI, and 2) trauma-related nightmares and SI, in a sample of treatment-seeking Canadian Armed Forces (CAF) personnel and veterans (N = 663). METHOD: Regression analyses were used to investigate associations between sleep disturbances or trauma-related nightmares and SI while controlling for depressive symptom severity, posttraumatic stress disorder (PTSD) symptom severity, anxiety symptom severity, and alcohol use severity. Bootstrapped resampling analyses were used to investigate the mediating effect of depression. RESULTS: Approximately two-thirds of the sample (68%; N = 400) endorsed sleep disturbances and 88% (N = 516) reported experiencing trauma-related nightmares. Although sleep disturbances and trauma-related nightmares were both significantly associated with SI on their own, these relationships were no longer significant when other psychiatric conditions were included in the models. Instead, depressive symptom severity emerged as the only variable significantly associated with SI in both equations. Bootstrap resampling analyses confirmed a significant mediating role of depression for sleep disturbances. CONCLUSIONS: The findings suggest that sleep disturbances and trauma-related nightmares are associated with SI as a function of depressive symptoms in treatment-seeking CAF personnel and veterans. Treating depression in patients who present with sleep difficulties may subsequently help mitigate suicide risk.

The Role of Social Support in Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder.

The current study examined the effect of total, as well as different sources (i.e., family, friends, significant other) of, pretreatment/baseline social support on posttraumatic stress disorder (PTSD) severity and treatment response to cognitive-behavioral conjoint therapy (CBCT) for PTSD. Thirty-six patients were randomized to receive treatment immediately or to a waitlist condition. Those in the treatment condition were offered CBCT for PTSD, a couple-based therapy aimed at reducing PTSD symptoms and improving relationship functioning. PTSD symptoms were assessed at pre-/baseline, mid-/4 weeks of waiting, and posttreatment/12 weeks of waiting using the Clinician-Administered PTSD Scale, and patients self-reported on their levels of pretreatment/baseline social support using the Multidimensional Scale of Perceived Social Support. Total support, as well as social support from family and friends, was not associated with initial PTSD severity or treatment response. However, there was a significant positive association between social support from a significant other and initial PTSD severity (g = .92). Additionally, significant other social support moderated treatment outcomes, such that higher initial significant other support was associated with larger decreases in PTSD severity for those in the treatment condition (g = -1.14) but not the waitlist condition (g = -.04). Social support from a significant other may influence PTSD treatment outcomes within couple therapy for PTSD. The inclusion of intimate partners and other family members may be a fruitful avenue for improving PTSD treatment outcomes; however, future studies are needed to examine whether support can be increased with treatment and whether those improvements lead to greater PTSD symptom response.

Longitudinal Associations Between PTSD Symptoms and Dyadic Conflict Communication Following a Severe Motor Vehicle Accident.

There are well-documented associations between posttraumatic stress disorder (PTSD) symptoms and intimate relationship impairments, including dysfunctional communication at times of relationship conflict. To date, the extant research on the associations between PTSD symptom severity and conflict communication has been cross-sectional and focused on military and veteran couples. No published work has evaluated the extent to which PTSD symptom severity and communication at times of relationship conflict influence each other over time or in civilian samples. The current study examined the prospective bidirectional associations between PTSD symptom severity and dyadic conflict communication in a sample of 114 severe motor vehicle accident (MVA) survivors in a committed intimate relationship at the time of the accident. PTSD symptom severity and dyadic conflict communication were assessed at 4 and 16weeks post-MVA, and prospective associations were examined using path analysis. Total PTSD symptom severity at 4weeks prospectively predicted greater dysfunctional communication at 16weeks post-MVA but not vice versa. Examination at the level of PTSD symptom clusters revealed that effortful avoidance at 4weeks prospectively predicted greater dysfunctional communication at 16weeks, whereas dysfunctional communication 4weeks after the MVA predicted more severe emotional numbing at 16weeks. Findings highlight the role of PTSD symptoms in contributing to dysfunctional communication and the importance of considering PTSD symptom clusters separately when investigating the dynamic interplay between PTSD symptoms and relationship functioning over time, particularly during the early posttrauma period. Clinical implications for the prevention of chronic PTSD and associated relationship problems are discussed.

Social Anxiety and the Accuracy of Memory for Childhood Teasing Frequency.

Adults' recollections of how often they were teased as children are positively associated with their social anxiety symptoms. It has therefore been suggested that childhood teasing may play a role in the development of social anxiety disorder (SAD). However, existing studies have not determined whether adults with SAD were actually teased more as children or whether their current symptoms have distorted their memories of childhood events. This study examined reports of childhood teasing in adults with SAD before and after cognitive behavioral therapy (CBT). If recollections of childhood teasing are colored by SAD symptoms, then reported frequency of teasing might be more likely to decrease as symptoms improve after CBT. However, if individuals' memories of teasing are unbiased, they should not substantially change with the reduction of symptoms after CBT. Ninety-one participants with SAD completed the Teasing Questionnaire-Revised (TQ-R) before and after 12 sessions of group CBT. CBT was effective in reducing SAD symptoms, whereas recollections of the frequency of childhood teasing did not change significantly after treatment. These results are consistent with the possibility that recollections of childhood teasing are not substantially biased by symptoms of SAD, and they lend support to previous studies which suggest that adults with SAD endured higher frequencies of teasing as children compared to controls.

An uncontrolled trial of a present-focused cognitive-behavioral conjoint therapy for posttraumatic stress disorder.

OBJECTIVE: The efficacy of a present-focused version of cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD) was examined in a community sample. METHOD: Seven couples completed pretreatment assessments, including measures of clinician-, self- and partner-rated PTSD symptoms and relationship satisfaction. Six couples completed present-focused CBCT for PTSD and all posttreatment assessments. A seventh couple terminated their relationship prior to completing treatment; therefore, they completed posttreatment symptom measures, but not ratings of relationship satisfaction. RESULTS: Results revealed significant decreases in PTSD symptoms that were associated with medium-to-large effect sizes. Medium effect sizes for changes in relationship satisfaction were found, though were only significant for partners. CONCLUSION: Results from this pilot study suggest that present-focused CBCT for PTSD may be a promising alternative for individuals who are unwilling to engage in a trauma-focused treatment.

A Preliminary Examination of the Effects of Pretreatment Relationship Satisfaction on Treatment Outcomes in Cognitive-Behavioral Conjoint Therapy for PTSD.

OBJECTIVE: The primary goal of the present study was to investigate whether pre-treatment relationship satisfaction predicted treatment drop-out and posttraumatic stress disorder (PTSD) symptom outcomes within a trial of cognitive-behavioral conjoint therapy (CBCT) for PTSD (Monson & Fredman, 2012). Additionally, we examined the influence of pre-treatment relationship distress on relationship outcomes. METHOD: Thirty-seven patients and their intimate partners who participated in a course of CBCT for PTSD were assessed for PTSD symptoms with the Clinician-Administered PTSD Scale and PTSD Checklist, and for intimate relationship functioning with the Dyadic Adjustment Scale. CBCT for PTSD is a conjoint therapy designed to improve PTSD symptoms and enhance relationship functioning. Patients had to meet diagnostic criteria for PTSD to be included in the study; however, couples were not required to be in distressed relationships to receive treatment. RESULTS: Neither patients' nor partners' pre-treatment relationship satisfaction, nor their interaction, predicted treatment drop-out (ORs = .97-1.01) or completing patients' post-treatment PTSD symptom severity (sr2 ≤ .03). However, participants who were in distressed relationships prior to treatment made greater gains in relationship satisfaction compared with those who began treatment in more satisfied relationships (g = 1.02). CONCLUSIONS: Among patients receiving CBCT for PTSD, treatment drop-out and improvements in PTSD symptoms may be independent of pre-treatment relationship functioning, whereas improvements in relational functioning may be greater among those distressed prior to treatment.

Associations between functioning and PTSD symptom clusters in a dismantling trial of cognitive processing therapy in female interpersonal violence survivors.

This study conducted secondary analyses of a published trial and sought to determine if different domains of psychosocial functioning (e.g., daily living, work, nonfamily relationships) improved following trauma-focused treatment for posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT), an empirically supported treatment that involves evaluating trauma-related beliefs and written trauma accounts, was compared to its components: CPT without the written accounts or written accounts only in a sample of 78 women with PTSD secondary to interpersonal violence. Overall and individual domains of functioning significantly improved with treatment and results were similar across treatment groups, Fs (2, 150) ≥ 11.87, ps < .001. Additionally, we investigated whether changes in different PTSD symptom clusters were associated with outcomes in domains of psychosocial functioning, after collapsing across treatment condition. Multiple hierarchical linear regression analyses revealed that overall clinician-assessed PTSD symptom reduction was associated with outcomes in all domains of functioning, ßs = .44 to .68, ps < .001. Additionally, improvements in the emotional numbing symptom cluster were associated with outcomes in the nonfamily relationships domain, ß = .42, p < .001, and improvements in the hyperarousal symptom cluster were associated with outcomes in the overall, daily living, and household tasks domains, ßs = .34 to .39, ps < .01. Results suggest that it may be important to monitor improvements in emotional numbing and hyperarousal symptoms throughout treatment to increase the likelihood of changes in psychosocial functioning.

Effects of cognitive-behavioral conjoint therapy for PTSD on partners' psychological functioning.

A number of studies have documented that posttraumatic stress disorder (PTSD) symptoms in "one" partner are negatively associated with their intimate partner's psychological functioning. The present study investigated intimate partners' mental health outcomes (i.e., depression, anxiety, and anger) in a sample of 40 partners of individuals with PTSD within a randomized waitlist controlled trial of cognitive-behavioral conjoint therapy for PTSD (Monson & Fredman, 2012). There were no significant differences between active treatment and waitlist in intimate partners' psychological functioning at posttreatment. Subgroup analyses, however, of partners exhibiting clinical levels of distress at pretreatment on several measures showed reliable and clinically significant improvements in their psychological functioning at posttreatment and no evidence of worsening. Results suggest that cognitive-behavioral conjoint therapy for PTSD may have additional benefits for partners presenting with psychological distress.

Changes in social adjustment with cognitive processing therapy: effects of treatment and association with PTSD symptom change.

The current study sought to determine if different spheres of social adjustment, social and leisure, family, and work and income improved immediately following a course of cognitive processing therapy (CPT) when compared with those on a waiting list in a sample of 46 U.S. veterans diagnosed with posttraumatic stress disorder (PTSD). We also sought to determine whether changes in different PTSD symptom clusters were associated with changes in these spheres of social adjustment. Overall social adjustment, extended family relationships, and housework completion significantly improved in the CPT versus waiting-list condition, η(2) = .08 to .11. Hierarchical multiple regression analyses revealed that improvements in total clinician-rated PTSD symptoms were associated with improvements in overall social and housework adjustment. When changes in reexperiencing, avoidance, emotional numbing, and hyperarousal were all in the model accounting for changes in total social adjustment, improvements in emotional numbing symptoms were associated with improvements in overall social, extended family, and housework adjustment (ß = .38 to .55). In addition, improvements in avoidance symptoms were associated with improvements in housework adjustment (ß = .30), but associated with declines in extended family adjustment (ß = -.34). Results suggest that it is important to consider the extent to which PTSD treatments effectively reduce specific types of symptoms, particularly emotional numbing and avoidance, to generally improve social adjustment.