The prevalence of posttraumatic stress disorder (PTSD) in the Veteran population across different war eras is 5% to 30% (Acierno et al., 2017). Individuals with PTSD experience impairing symptoms, such as intrusive thoughts, avoidance, negative alterations in mood, alteration in arousal, and reactivity (Fang et al., 2015). This symptomology negatively influences psychosocial functioning (Fang et al., 2015) and interactions by individuals within their environments, as well as their ability to fulfill roles within environments, such as work, social activities, and relationships (Bosc, 2000).
Rodriguez, Holowka, and Marx (2012) note that PTSD is linked to problems in psychosocial functioning in marital, parental, familial, and occupational domains. For example, patients with PTSD are more likely to miss work and report reduced work productivity. Furthermore, Veterans with PTSD are twice as likely as Veterans without PTSD to divorce and three times as likely to experience multiple divorces (Rodriguez et al., 2012). PTSD may also negatively impact parenting ability, which can lead to impaired attachment with children, child behavioral problems, and family violence (Rodriguez et al., 2012). Veterans with PTSD typically avoid crowds and may abruptly leave social events, creating discomfort for their partners and others. Veterans often have limited friendships because they cannot share feelings, show emotional support, or settle arguments in productive ways (Rodriguez et al., 2012).
Both the United States Department of Veterans Affairs (VA) and the Department of Defense (DOD) recognize the importance of addressing psychosocial functioning in PTSD treatment. The current VA/DOD practice guidelines for management of PTSD accordingly advise clinicians to assess functioning in the aforementioned areas and monitor progress after treatment (Rodriguez et al., 2012). In addition, the guidelines recommend using individual, manualized, trauma-focused psychotherapy as first-line treatment for PTSD, when patient preferred and readily available (Management of Posttraumatic Stress Disorder Work Group, 2017). Treating symptoms that affect psychosocial functioning can improve quality of life for the Veteran population (Schnurr, Hayes, Lunney, McFall, & Uddo, 2006), and improvement in PTSD symptoms may also improve psychosocial functioning (Schnurr et al., 2006).
Despite the recognized importance of addressing psychosocial functioning in PTSD, the impact of evidence-based psychotherapy (EBP) interventions for PTSD on psychosocial functioning has not been adequately investigated. Most PTSD intervention studies focus only on PTSD symptom change, considering psychosocial functioning as a secondary or indirect variable, or these studies fail to address psychosocial functioning (Frueh, Turner, Beidel, & Cahill, 2001). Therefore, an integrative review was conducted to investigate, through the lens of the Socio-Interpersonal Framework Model of PTSD (Maercker & Hecker, 2016; Maercker & Horn, 2013), current research about the content and effectiveness of EBP PTSD interventions to improve psychosocial functioning in the Veteran population. In addition, the current integrative review explored whether specific factors (e.g., age, race, sex) can facilitate such improvement.
The Socio-Interpersonal Framework Model of PTSD (Maercker & Horn, 2013) guided the current integrative review. This model addresses complex relationships within the PTSD structure and emphasizes the socio-interpersonal aspect of PTSD (Maercker & Horn, 2013). For example, family, peers, and society are deemed important and can influence PTSD symptomology (Maercker & Hecker, 2016). For the current review, results were synthesized using the framework's 3-level approach.
The model's 3-level approach includes individual, close relationship, and distant social levels. The individual level addresses the interactive styles of persons with PTSD. For example, the model identifies affective reactions to other people, close friends, or groups as social affects. Anger, shame/guilt, and aggression can lead to interpersonal avoidance, social withdrawal, and partner violence (Maercker & Hecker, 2016). The close relationship level concentrates on intimate relationships, such as romantic and family relationships. The social interaction within this level can be supportive or maladaptive. Finally, the distant social level involves societal and cultural belonging within groups (Maercker & Horn, 2013).
The current integrative review followed the well-established methodological framework for integrative reviews developed by Whittemore and Knafl(2005) using the model's five stages of (a) problem identification, (b) literature search, (c) data evaluation, (d) data analysis, and (e) presentation. Stage 1 involved formulating and stating the question framing the review. Stage 2 was addressed using a systematic literature search. Study quality and level of evidence were then evaluated during Stage 3 using standardized tools. To finalize Stage 4 of the methodological framework, the publications were presented in a table after data reduction. Stage 5 involved synthesis of findings, implications, and discussion of limitations (Whittemore & Knafl, 2015).
To develop an effective literature search strategy for the current integrative review, a medical reference librarian was consulted, and the PRISMA statement was applied to guide the conduction and reporting of the search process (Figure 1) (Moher, Liberati, Tetzlaff, & Altman, 2009). The search was conducted using CINAHL, MEDLINE, and PsycINFO electronic databases and included Boolean operators. In addition, bibliographies of publications included in the sample were examined manually to identify any articles that were not captured in the electronic database search.
PRISMA flow diagram (Moher et al., 2009).
Note. EBP = evidence-based psychotherapy; PTSD = posttraumatic stress disorder.
The following key terms were used to conduct the search: interpersonal functioning, psychosocial functioning, social adjustment, social cognition, social competence, social outcomes, social skills, social functioning, marriage functioning, marriage satisfaction, romantic relationships, work functioning, work satisfaction, employment, parenting, education, school functioning, family functioning, family members, friendship, friendship satisfaction, relationship quality, close relationships, posttraumatic stress disorder, PTSD, veteran, soldier, military, veterans, evidence-based interventions, therapy, and intervention. The search terms moderator, mediator, and predictor were included to explore the conditions under which PTSD treatment is effective as it related to psychosocial functioning. Inclusion criteria were studies:
- that investigated psychosocial functioning as a primary or secondary outcome;
- conducted with Veterans diagnosed with PTSD;
- that tested EBP interventions (e.g., prolonged exposure [PE], cognitive-behavioral therapy [CBT], cognitive processing therapy [CPT]);
- examining predictors, moderators, and mediators of treatment; and research conducted with adults (age >18 years).
Exclusion criteria were:
- non-English articles;
- articles not published in peer-reviewed journals;
- pharmaceutical interventions;
- traumatic brain injury diagnosis;
- dissertations; and
- literature reviews.
Furthermore, because the primary interest is in the most recent research studies and evidence, a 10-year limit was applied.
The literature search in MEDLINE, CINAHL, and PsycINFO resulted in 18 articles, none of which were relevant manuscripts. To expand the search, the search terms predictor, moderator, and mediator were removed. The revised search resulted in 738 publications with no duplicates. All 738 articles were screened for eligibility by reading titles and abstracts, leaving 70 full-text articles for additional review. Sixty-four articles were removed because they did not meet inclusion criteria. Five articles presented reports of studies in which researchers investigated various domains of psychosocial functioning. There was limited discussion on the conditions of effective PTSD treatment to improve psychosocial functioning; therefore, one article in which the researchers evaluated PTSD symptom improvement and aspects of psychosocial functioning as associated factors was retained. Six articles were selected, and an additional article was added from manual reviews of the bibliographies. A total of seven articles were included in the current integrative review (Figure 1).
Relevant publications were arranged in a matrix as follows: author and year, intervention and population, study method/design, relevant outcomes and measures, relevant findings, and level of evidence (Table 1). The Critical Appraisal Skills Programme (CASP) criteria were used to evaluate the quality of the studies, and level of evidence was evaluated using the Oxford Center for Evidence-Based Medicine (2011) criteria. The sample studies varied in quality and level of evidence. However, overall, studies met criteria for most of the required components of the chosen appraisal tools. Table 2 presents the Socio-Interpersonal Framework Model of PTSD levels included in each of the sample studies.
Evidence from Selected Studies
Socio-Interpersonal Framework Model of PTSD Levels Included in Studies
Socio-Interpersonal Framework Model of PTSD
None of the studies in the sample used the Socio-Interpersonal Framework model of PTSD. Only one study, the exploratory chart review, described using a theoretical framework: the Anderson Behavioral model. The formulation of the distant social relationship level of the Socio-Interpersonal Framework Model of PTSD was expanded to include work-related functioning, student status, social activities, and social detachment, because each factor was applicable to the third level of societal and cultural sphere (Maercker & Hecker, 2016). Factors at the distant social level were most commonly addressed (Table 2).
Individual Level. The Clinician Administered PTSD Scale (CAPS) four-item subset was administered to measure social and emotional functioning in one of the sampled studies; two items on the CAPS subset addressed the individual level, including range of affect and anger control. In addition, written self-reports were used to record and measure the number and severity of anger, rage, and anxiety episodes (Beidel, Frueh, Uhde, Wong, & Mentrikoski, 2011). In the study by Beidel et al. (2011), Veterans received PE alone or trauma management therapy (TMT), which incorporates PE and social emotional rehabilitation training. Participants in both groups had lower PTSD symptomology after treatment and showed a reduction in self-reported weekly episodes of verbal rage. Furthermore, participants in both treatment groups showed improvement in emotional functioning as measured by CAPS (Beidel et al., 2011).
Close Relationship Level. Two instruments were used to assess psychosocial functioning at the close relationship level. The Social Adjustment Scale (SAS) was used to measure overall social adjustment, which assesses multiple domains, including spouse (i.e., role as a spouse), family (i.e., being a member of a family unit), extended family (i.e., relationship with extended family members), housework, school-work, work, social and leisure activities, parenting, and income (Monson et al., 2012). The Sheehan Disability Scale measures impairment in various psychosocial functioning domains; a portion of the scale measures second-level factors by assessing family life and home life (Ehlers et al., 2014).
In one study, clients who received CPT showed improvement in overall social adjustment compared to those on a wait list to receive treatment (Monson et al., 2012). In addition to improvements in overall social adjustment, improvements in extended family relationships and housework scores were also noted. When standard CBT and intensive 7-day CBT were compared, both treatments were effective in improving overall psychosocial functioning–related disability as measured by the Sheehan Disability Scale (Ehlers et al., 2014).
Distant Social Level. The following instruments were used to assess psychosocial functioning at this level: CAPS, investigator-designed self-reports, Quality of life Inventory (QOLI); Sheehan Disability Scale; and the Short Form 36 Health Survey (SF36).
Social functioning, defined as interest in social activities and social detachment, was measured by a subset of questions on the CAPS tool. Participants completed self-reports to record information related to social activities. Occupation-related outcomes were measured via clinician-rated occupational impairment with CAPS and by the occupational satisfaction item on the QOLI. The Sheehan Disability Scale assesses work, leisure activities, and the social life of participants (Ehlers et al., 2014). The SF36 assesses psychosocial and health functioning domains, such as social functioning, work, and social and daily activities (Holliday, Williams, Bird, Mullen, & Surís, 2015).
Improvement in social functioning occurred with PE and TMT interventions (Beidel et al., 2011). However, the group that received TMT demonstrated greater improvements in self-reported frequency and duration of social activities. Occupational impairment improved following PE and present centered therapy (PCT); however, occupational satisfaction showed no improvement with these treatments (Schnurr & Lunney, 2012). CBT was effective in improving overall work and social life (Ehlers et al., 2014). CPT and PCT improved functioning in the psychosocial domains related to problems with social, work, and daily activities as measured by the SF36 (Holliday et al., 2015).
Conditions for Symptom Change
CPT improved the core PTSD symptom emotional numbing (individual level factor), which was associated with improvements in overall social, extended family, and housework adjustment (Monson et al., 2012). Furthermore, participants who received CPT demonstrated improvements in the core PTSD symptom effortful avoidance (individual level factor), which was associated with an improvement in housework adjustment, but with a decline in extended family adjustment (Monson et al., 2012). Improvements in various aspects of psychosocial functioning, such as occupational impairments, were reported when participants no longer met PTSD diagnostic criteria (Schnurr & Lunney, 2012, 2016). Veterans who identified as students (distant social level factor) and completed EBP, PE, or PCT had greater PTSD symptom reduction compared to non-students (Myers, Haller, Angkaw, Harik, & Norman, 2018). In addition, experiencing problems with family members or significant others was associated with completion of EBP treatment. Therefore, the relationship between social and treatment success may be bidirectional. Predisposing factors (e.g., sex, race, ethnicity, military sexual trauma) were not associated with improvements in PTSD or completion of EBP treatment.
The current integrative review had several aims. The first aim was to gain a better understanding of EBP interventions and their effect on psychosocial functioning among Veterans with PTSD. The second aim was to explore factors that may facilitate improvement in this area. In addition, the Socio-Interpersonal Framework Model of PTSD was used to synthesize and organize findings.
All sampled studies used quantitative methods; three studies were randomized controlled trials (RCTs), three studies were secondary analyses of RCTs conducted by the author of the current integrative review, and one was an exploratory chart review. Six studies were conducted in the United States, and one study was conducted in the United Kingdom.
Psychosocial functioning was not always mentioned directly, and terminology associated with this concept varied. Studies examined multiple domains of psychosocial functioning. For example, in one study, researchers measured psychosocial functioning related to disability (Ehlers et al., 2014), whereas in another study, researchers assessed occupational satisfaction and impairment (Schnurr & Lunney, 2012). Other studies investigated domains including social adjustment and psychosocial and health functioning (Beidel et al., 2011; Holliday et al., 2015; Monson et al., 2012). Researchers in one study explored the association among PTSD symptom improvement, status as a student, and family relationship status (Myers et al., 2018). In addition, sampled studies explored conditions in which aspects of psychosocial functioning showed the greatest improvement (Monson et al., 2012; Schnurr & Lunney, 2016). Most studies also measured additional variables such as quality of life, depression, and anxiety. EBP interventions included CPT, PE, CBT for PTSD, and PCT (Table 3).
Evidence-Based Psychotherapy Interventions
The main purpose was to explore conditions that may facilitate improvements related to psychosocial functioning after EBP. However, identifying these conditions was challenging due to limited available literature. Despite the scarcity of data, results indicated that addressing the core PTSD symptoms of emotional numbing and effortful avoidance can improve select psychosocial functioning domains, such as social and extended family adjustment. These findings are in line with other research studies that report that emotional numbing is negatively associated with psychosocial functioning related to relationship satisfaction (Campbell & Renshaw, 2013).
Loss of PTSD diagnosis can improve psychosocial functioning as well, and researchers suggest that treating Veterans until they no longer meet diagnostic criteria for PTSD is beneficial. Myers et al. (2018) suggested that being a student can be helpful and produces a better response because students are familiar with homework and following instructions. This study (Myers et al., 2018) also determined that experiencing an issue with family or significant others is associated with EBP treatment completion, suggesting that this factor is an important motivator to improve. Although predisposing factors such as gender and ethnicity did not contribute to treatment outcomes, it is important to mention that the authors evaluated only one such study.
Although most of the framework factors were explored across the sample studies, factors associated with the individual and close relationship level are under-investigated in the literature. Factors at the distant social level were dominant among the sample studies. Parenting and marital functioning domains were not thoroughly evaluated in any of the studies. Current evidence shows these two domains are affected by PTSD symptomology, suggesting a crucial area for future research (Rodriguez et al., 2012). Consequently, sample study results suggest PTSD symptoms improve following EBP, which can lead to improvement in certain aspects of psychosocial functioning.
The current integrative review had several limitations. The articles selected may not include all available published studies because of the 10-year search limit and did not include grey literature. Therefore, as a future direction, a similar review may be conducted without a limit to capture a more comprehensive representation of literature. In addition, the current integrative review was conducted by a single reviewer. To enhance validity of the current integrative review, an additional reviewer would have been beneficial. Few studies addressed the conditions under which psychosocial functioning symptom improved after EBP in the Veteran population, which limits possible recommendations and conclusions. Studies exploring improvement in psychosocial functioning domains following EBP are similarly promising but limited in number. None of the studies integrated the complete Socio-Interpersonal Framework Model of PTSD. To minimize limitations, a medical reference librarian was consulted to assist with the search strategy. In addition, a methodological and theoretical framework was used to perform the current integrative review.
Another limitation was the lack of consistency associated with the measuring tools and terminology researchers used to assess psychosocial functioning. The CAPS measuring tool was frequently used in various ways to measure multiple psychosocial functioning factors. However, the CAPS tool only provides a general assessment of occupational and social domains (Rodriguez et al., 2012). Only one study used a comprehensive measuring tool (i.e., SAS) to evaluate multiple factors simultaneously (Monson et al., 2012). Other research has demonstrated the benefits of a comprehensive approach that evaluates multiple domains of psychosocial functioning (Rodriguez et al., 2012).
Implications and Conclusion
The diagnosis of PTSD and associated symptoms places Veterans at risk for impaired psychosocial functioning in various domains (Fang et al., 2015; Rodriguez et al., 2012). The results supported the theory that EBP can improve psychosocial functioning resulting from PTSD. In addition, it was determined that this area is neglected in the current literature. Thus, further research into improvements in psychosocial functioning following EBP is necessary.
The current integrative review explored conditions that facilitate improved psychosocial functioning, providing support for addressing core PTSD symptoms and treating Veterans until they no longer exhibit PTSD symptoms (Monson et al., 2012; Schnurr & Lunney, 2012, 2016). In addition, more research is necessary to determine the best psychosocial functioning instrument that can present more uniform and comprehensive results (Fang et al., 2015; Rodriguez et al., 2012).
Although impaired marital functioning, parenting, and parent-child relationships are associated with PTSD, a limited number of studies were identified in these areas, warranting further research (Rodriguez et al., 2012). Additional research should thus focus on parenting and marital domains at the individual and close relationship levels. The Socio-Interpersonal Framework Model of PTSD provides an effective guide and can be applied in subsequent studies related to psychosocial functioning. EBP demonstrated effectiveness in improving various aspects of psychosocial functioning.
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Evidence from Selected Studies
|Study||Intervention and Population||Study Design||Relevant Outcomes and Measures||Relevant Findingsa||CASPb/LOEc|
|Beidel, Frueh, Uhde, Wong, & Mentrikoski (2011)||PE vs TMT
N= 49 (male)||RCT||Social and emotional functioning
Patient ratings CAPS subset of 4-item subset||PE and TMT showed decrease in weekly episodes of verbal rage (p< 0.01) and improved social and emotional functioning (p< 0.001)||8/1b|
|Ehlers et al. (2014)||7-day CBT vs CBT vs emotion-focused supportive therapy
N = 121||RCT||Psychosocial-related disability (difficulty in work, social life, leisure activities, family life, and home)
Sheehan Disability Scale||Intensive 7-day CBT (d = 1.60, p< 0.002) and standard CBT (d = 1.50, p< 0.002) delivered over 3 months, improved psychosocial functioning||10/1b|
|Holliday, Williams, Bird, Mullen, & Surís (2015)||CPT vs PCT
N= 45||RCT||Psychosocial and health functioning domains
SF36||CPT and PCT improved social functioning domain (symptoms interfere with social activities) (p= 0.025) and role emotional domain (work and daily activities issue due to emotional problems) (p= 0.050)||9/1b|
|Monson et al. (2012)||CPT vs wait list
N= 46||Retrospective cohort||Social adjustment (spouse, family, extended family, housework, work, and social/leisure activities domains)
PTSD symptom clusters associations with changes in social adjustment domains
SAS||CPT improved extended family relationships, and housework completion (range, η2= 0.08 to 0.11)
Improvements in emotional numbing were associated with improvement in overall, extended family, and housework adjustment (ß = 0.35 to 0.55)
Improvement in avoidance was associated with decline in extended family adjustment (ß = −0.34), but improvement in housework (ß = 0.30)||12/1b|
|Myers, Haller, Angkaw, Harik, & Norman (2018)||CPT individual vs CPT group vs PE
N= 82 (male)||Retrospective chart review||Predisposing characteristics (sex, age, race)
Enabling resources (treatment format, student status, distance to the VA)
Needs factors (reporting problems to their provider about work, family or significant others, sleep, anger) as predictors of PTSD symptom improvement and treatment completion||CPT or PE individual therapy showed significant improvement in PTSD symptoms with treatment completion (d = 0.64)
Veterans who completed evidence-based psychotherapy and identified as students showed greater reduction in PTSD symptoms compared to Veterans who were not students (ηp2 = 0.06, p = 0.024)
Veterans who reported problems with family members or significant others were more likely to complete treatment (OR = 3.8, 95% CI [1.32, 10.97], p = 0.014)
Age, gender, ethnicity, race did not predict treatment response||12/2b|
|Schnurr & Lunney (2012)||PE vs PCT
N= 218 (female)||Secondary analysis
Retrospective cohort||Occupational impairment
CAPS QOLI||PE and PCT showed no significant change in occupational satisfaction but significant reduction in work impairment (PE: d = −0.33, p < 0.01) (PCT: d = −0.29, p <0.01)
Participants who no longer met PTSD criteria had greater improvements (range, d = 0.16 to −0.84, p < 0.01)||12/2b|
|Schnurr & Lunney (2016)||PE vs PCT
N=235 (female)||Secondary analysis Retrospective cohort||PTSD symptom change groups: no response, response, loss of diagnosis, and remission
Clinician-rated social and occupational impairment, self-reported functional impairment (role emotional, role physical, social functioning scale)
CAPS||No differences were found between PE and PCT on outcome
Loss of PTSD diagnosis vs response is associated with improvement in clinician-rated social (OR = 4.65, 95% CI [1.75, 12.36], p< 0.01) and occupational impairment (OR = 3.54, 95% CI [1.44, 8.73], p< 0.01)
PTSD symptom change showed improvement between groups; improvement from no change to remission, suggesting as PTSD symptoms decreased psychosocial functioning improved||11/2b|
Socio-Interpersonal Framework Model of PTSD Levels Included in Studies
|Study||Individual Level||Close Relationship Level||Distant Social Level|
|Beidel et al. (2011)||X||X|
|Ehlers et al. (2014)||X||X|
|Holliday et al. (2015)||X|
|Monson et al. (2012)||X||X|
|Myers et al. (2018)||X|
|Schnurr & Lunney (2012)||X|
|Schnurr & Lunney (2016)||X|
Evidence-Based Psychotherapy Interventions
|Prolonged exposure||Concentrates on repetitive imagined and/or in vivo exposure to the traumatic event|
|Cognitive processing therapy||Involves modifying maladaptive cognitive coping strategies related to traumatic events|
|Cognitive-behavioral therapy for PTSD||Works on restructuring negative cognitions to decrease the ongoing sense of threat; based on Ehlers and Clark's model of PTSD|
|Present centered therapy||Focuses on issues experienced by the Veteran at the time of treatment as a result of PTSD|