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Many clinicians are aware of the painful impact of posttraumatic stress disorder (PTSD) on individuals' lives, including disrupting sleep, interfering with work and hobbies, and damaging self-worth. A growing body of research shows that PTSD is also harmful for some of the most important relationships in people's lives, including relationships with family and intimate partners (Lambert et al., 2012). This tends to be especially true for military veterans (Taft et al., 2011). However, one important limitation of this research is a reliance on samples of predominantly male veterans with PTSD and their female intimate partners.
Research shows women and men can experience trauma and PTSD differently. Women tend to experience higher rates of trauma and PTSD overall (Christiansen & Elklit, 2012), and women and men are differentially likely to develop PTSD following different trauma types (Luxton et al., 2010). Women express more internalizing symptoms on average (e.g., withdrawing, depression), while men tend to externalize more (e.g., substance abuse). Some research has shown men’s trauma impacts relationship functioning more than women’s trauma (Gallagher et al., 2017), and one study with veterans suggested that PTSD symptoms impact family functioning more for veteran men and work functioning more for veteran women (Vogt et al., 2017).
Given gender differences in both PTSD and relationship roles, might the link between PTSD and relationship functioning look different for female veterans and male veterans?
In the current study, our research team examined differences between female-veteran couples and male-veteran couples in associations between PTSD and several domains of relationship functioning. Participants were 197 mixed-gender couples including a veteran patient and their intimate partner who were recruited to a treatment study of Cognitive-Behavioral Conjoint Therapy for PTSD (CBCT; Monson & Fredman, 2012) at the VA San Diego medical center. Data were drawn from the baseline assessment, including demographic information; the veteran’s self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5); the partner's perception of the veteran’s PTSD using a collateral-report adaptation of the PCL-5; and relationship functioning domains including satisfaction, communication, aggression, and sexual functioning. We used actor-partner interdependence models (APIMs) to test associations between PTSD symptoms and relationship functioning as reported by veterans and partners, and we tested whether the APIM pathways were moderated by gender.
Although the APIMs produced numerous complex findings, there were two main patterns to our results. First, the majority of significant links were with partners' collateral PTSD reports: partner-reported PTSD symptom severity was associated with partners' own ratings of relationship satisfaction, constructive negotiation, psychological aggression, sexual pleasure, and sexual desire frequency, and with veterans' ratings of negotiation and sexual desire frequency. In contrast, veterans' self-reported PTSD symptoms were only associated with their own ratings of psychological aggression.
Second, many of these results were moderated by gender, such that links between PTSD symptoms and relationship functioning were generally more maladaptive for male-veteran couples and more neutral or even helpful for female-veteran couples. For example, in male-veteran couples, higher partner-reported PTSD was negatively linked to sexual desire, whereas in female-veteran couples, higher partner-reported PTSD had no association with desire and was linked with less sexual coercion.
These results tell us that the experience of intimate partners matters when it comes to how PTSD impacts veterans' relationships. Our findings also suggest that the well-established links between PTSD and worse relationship functioning may not always apply to couples with a female veteran. Although our data do not provide an explanation as to why, it is possible that female veterans may feel more understood or male intimate partners may be more effective at providing support when they perceive more of her PTSD symptoms (or correctly attribute symptoms to PTSD; see Renshaw et al., 2014).
Clinically, our findings encourage therapists to consider the perspective of romantic partners when providing PTSD treatment. Incorporating loved ones may be crucial to improving the psychosocial functioning and overall wellbeing of PTSD patients. Clinicians should also be aware of possible gender differences in the impact of partners' perspectives and should include gender and gender roles into biopsychosocial case conceptualizations. Finally, this study highlights a need for more research on female veterans with PTSD and their intimate relationships, as well as on veterans in same-gender relationships.

Target Article

Knopp K, Wrape ER, McInnis R, Khalifian CE, Rashkovsky K, Glynn SM, Morland LA. Posttraumatic stress disorder and relationship functioning: Examining gender differences in treatment-seeking veteran couples. J Trauma Stress. 2022 Apr;35(2):484-495. doi: 10.1002/jts.22761. Epub 2021 Nov 20. PMID: 34800061.

Discussion Questions

  1. Because these data were cross-sectional, they don't tell us about causation or direction of effects. How have you seen PTSD impact relationships? How have you seen relationships impact PTSD?
  2. Why do you think partners' perceptions of veterans' PTSD is related to relationship functioning – perhaps even more than veterans' own reports of PTSD symptoms?
  3. How do you think gender socialization might impact people's experiences of trauma, PTSD, and relationships?
  4. What could studying same-gender relationships add to our understanding of gender and gender roles in PTSD and relationship functioning?

About the Authors

Kayla Knopp
, Ph.D. is a postdoctoral research fellow in the Advanced Fellowship for Women's Health at VA San Diego. Her research interests are in the development and functioning of intimate relationship, links between relationships and physical/mental health, and relationship functioning among diverse populations (e.g., non-monogamous relationships, LGBTQ+ folks). Clinically, she loves working with couples in her small private practice, and along with coauthor Dr. Chandra Khalifian, she provides research-based relationship education on Instagram @the.CLIC.online. She would love to talk with you about these interests and can be contacted at kayla.knopp@va.gov.
Elizabeth Wrape
, Ph.D. is the clinic coordinator for the Family Mental Health Program at VA San Diego and Assistant Professor at University of California, San Diego. Her interests lie in family service provision and supervision, particularly training individual therapists in effectively including loved ones in mental health care. She can be contacted at ewrape@ucsd.edu.
Chandra Khalifian
, Ph.D. is a Research Psychologist and Assistant Professor of Psychiatry at the University of California, San Diego (UCSD). Her research interests include examining contributors to and expression of suicidal thoughts and behaviors, relationship distress, and comorbid psychopathology. She is currently implementing a Career Development Award focused on developing and evaluating a couple-based intervention for suicide: Treatment for Relationships and Safety Together (TR&ST). She enjoys discussing all aspects of relationships and can be contacted at chandra.khalifian@va.gov.
Katerine Rashkovsky
, B.S. earned her bachelor’s degree in clinical psychology at UC San Diego and now serves as the research coordinator of a couple-based suicide intervention trial at the San Diego VA under coauthor Dr. Chandra Khalifian. Currently, Katerine’s research interests are related to investigating maladaptive psychological responses to traumatic experiences, particularly sexual assault, and evaluating and developing interventions for trauma-related psychiatric concerns, such as posttraumatic stress disorder (PTSD) and suicidality. She is particularly interested in focusing on traumatic stress in LGBTQ+ individuals and the application of evidence-based techniques to treating psychiatric concerns in gender and sexually minoritized populations.
Leslie Morland
, PsyD. is the Director of Telemental Health at the Department of Veterans Affairs San Diego Healthcare System, and a Professor of Psychiatry at the University of California, San Diego (UCSD). Dr. Morland devotes time to local and national leadership roles focused on the strategic planning and implementation of the use of technology to increase access to posttraumatic stress disorder (PTSD) specialty care in the Veterans Health Administration. Dr. Morland is also a researcher with the National Center for PTSD-Pacific Islands Division where she designs and implements multiple federally funded research projects examining the use of technology to provide evidence-based PTSD services for Veteran populations. In addition, Dr. Morland provides research consultation and mentorship on multiple research projects and national initiatives.

References Cited

Christiansen, D. M., & Elklit, A. (2012). Sex differences in PTSD. In E. Ovuga (Ed.), Post traumatic stress disorders in a global context (pp. 113-142). InTechOpen. https://doi.org/10.5772/1281

Gallagher, H. C., Lusher, D., Gibbs, L., Pattison, P., Forbes, D., Block, K., Harms, L., MacDougall, C., Kellett, C., Ireton, G., & Bryant, R. A. (2017). Dyadic effects of attachment on mental health: Couples in a postdisaster context. Journal of Family Psychology31(2), 192–202. https://doi.org/10.1037/fam0000256

Lambert, J. E., Engh, R., Hasbun, A., & Holzer, J. (2012). Impact of posttraumatic stress disorder on the relationship quality and psychological distress of intimate partners: A meta-analytic review. Journal of Family Psychology, 26(5), 729–737. https://doi.org/10.1037/a0029341

Luxton, D. D., Skopp, N. A., & Maguen, S. (2010). Gender differences in depression and PTSD symptoms following combat exposure. Depression and Anxiety, 27(11), 1027–1033. https://doi.org/10.1002/da.20730

Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Therapist’s manual. New York, NY: Guilford.

Renshaw, K. D., & Campbell, S. B. (2011). Combat veterans' symptoms of PTSD and partners' distress: The role of partners' perceptions of veterans' deployment experiences. Journal of Family Psychology25(6), 953.

Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., & Monson, C. M. (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology79(1), 22–33. https://doi.org/10.1037/a0022196

Vogt, D., Smith, B. N., Fox, A. B., Amoroso, T., Taverna, E., & Schnurr, P. P. (2017). Consequences of PTSD for the work and family quality of life of female and male US Afghanistan and Iraq war veterans. Social Psychiatry and Psychiatric Epidemiology, 52(3), 341–352. https://doi.org/10.1007/s00127-016-1321-