LRSC

SHORT COMMUNICATION

Social relationship satisfaction and PTSD: which is the chicken and which is the egg?

Sara A. Freedman*, Moran Gilad, Yael Ankri, Ilan Roziner$ and Arieh Y. Shalev%

Center for Traumatic Stress Studies, Hadassah University Hospital, Jerusalem, Israel

Background: Impaired social relationships are linked with higher levels of posttraumatic stress disorder (PTSD), but the association’s underlying dynamics are unknown. PTSD may impair social relationships, and,

vice versa, poorer relationship quality may interfere with the recovery from PTSD.

Objective: This work longitudinally evaluates the simultaneous progression of PTSD symptoms and social relationship satisfaction (SRS) in a large cohort of recent trauma survivors. It also explores the effect of

cognitive behavior therapy (CBT) on the association between the two.

Method: Consecutive emergency department trauma admissions with qualifying PTSD symptoms (n �501) were assessed 3 weeks and 5 months after trauma admission. The World Health Organization Quality of Life

evaluated SRS and the Clinician Administered PTSD Scale evaluated PTSD symptom severity. Ninety-eight

survivors received CBT between measurement sessions. We used Structural Equation Modeling to evaluate

cross-lagged effects between the SRS and PTSD symptoms.

Results: The cross-lagged effect of SRS on PTSD was statistically significant (b � �0.12, p �0.01) among survivors who did not receive treatment whilst the effect of PTDS on SRS was nil (b� �0.02, p �0.67). Both relationships were non-significant among survivors who received CBT.

Discussion: SRS and PTSD are highly associated, and this study shows that changes in SRS in the early aftermath of traumatic events contribute to changes in PTSD, rather than vice versa. SRS impacts natural

recovery, but not effective treatment. This study suggests that being satisfied with one’s relationships might be

considered as an important factor in natural recovery from trauma, as well as in intervention.

Keywords: Social relationship satisfaction; PTSD; natural recovery

Responsible Editor: Cherie Armour, University of Ulster, UK.

*Correspondence to: Sara A. Freedman, School of Social Work, Bar Ilan University, Ramat Gan, Israel,

Email: [email protected]

For the abstract or full text in other languages, please see Supplementary files under ‘Article Tools’

Received: 16 June 2015; Revised: 2 November 2015; Accepted: 9 November 2015; Published: 16 December 2015

D ifficulties in social relationships, including rela-

tionship quality, satisfaction, intimacy, cohesion,

and sexual satisfaction, have all been associated

with the presence of posttraumatic stress disorder (PTSD)

in one or both partners (Dekel, Enoch, & Solomon, 2008;

Koenen, Stellman, Sommer, & Stellman, 2008; Lunney &

Schnurr, 2007). This association, although well estab-

lished, is not well understood.

Social relationships comprise many different factors and

can be assessed from different standpoints. One aspect is

satisfaction with intimate social relationships, usually marital

partners. Another refers to satisfaction with social roles, such

as parenting. A further factor is related to behavior patterns,

such as within a marriage. Social support is a particular facet

of social relationships, examining perceived readiness of

others to provide help in times of need. Clearly, these

different factors overlap, such that higher perceived social

support from a spouse is likely related to reported satisfac-

tion in that relationship, as well as being related to nurturing

behaviors within that relationship (Cundiff, Smith, Butner,

Critchfield, & Nealey-Moore, 2015). However, most

studies have examined these factors separately.

Two conflicting hypotheses exist regarding the role of

social relationships in PTSD. On the one hand, PTSD

$ Present address: School of Social Work, Bar Ilan University, Ramat Gan 52900, Israel.

% Present address: Department of Psychiatry, New York University School of Medicine, New York, NY, USA.

PSYCHOTRAUMATOLOGY EUROPEAN JOURNAL OF

�

European Journal of Psychotraumatology 2015. # 2015 Sara A. Freedman et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format, and to remix, transform, and build upon the material, for any purpose, even commercially, under the condition that appropriate credit is given, that a link to the license is provided, and that you indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

1

Citation: European Journal of Psychotraumatology 2015, 6: 28864 - http://dx.doi.org/10.3402/ejpt.v6.28864 (page number not for citation purpose)

may lead to poorer social relationships. There is some

support for this notion. First, studies have shown that its

particularly numbing symptoms have been shown to be

negatively related to relationship satisfaction (Campbell

& Renshaw, 2013). Second, two prospective studies with

military populations have examined the association of

relationships and PTSD, one showing that PTSD results

in poorer relationships (Campbell & Renshaw, 2013), and

the other that increases in PTSD results in a detrimental

effect on marital relationships and parenting (Gewirtz,

Polusny, DeGarmo, Khaylis, & Erbes, 2010).

Third, studies examining PTSD and social support have

shown that initial PTSD levels predict later social support

in military populations (e.g., King, Taft, King, Hammond,

& Stone, 2006; Solomon & Mikulincer, 1990).

These studies seem to indicate therefore that PTSD has

detrimental effects on social relationships. The opposing

hypothesis that poorer social relationships, which in-

crease the likelihood of developing PTSD, also has some

support in the literature, because the social support in

general has been shown to be a consistent predictor of

PTSD (Andrews, Brewin, & Rose, 2003). Studies that

have examined PTSD and relationship and role satisfac-

tion, and behavior, have not, to our knowledge, examined

the possibility that poorer relationships may lead to

PTSD. Indeed, the studies described above that examined

relationship satisfaction rather than social support, assessed

relationship satisfaction only at the second time point,

and therefore the hypothesis that PTSD might be sub-

sequent to poorer relationships could not be tested.

One longitudinal study has shown that both these

opposing hypotheses may be correct, such that perceived

social support amongst family members is a predictive

factor of PTSD soon after a traumatic event, but over

time, this relationship is reversed, and PTSD levels then

predict social support (Kaniasty & Norris, 1993).

A related area of research is the effect that social rela-

tionships have on recovery from PTSD. A small number

of studies have shown that greater social support (Thrasher,

Power, Morant, Marks, & Dalgleish, 2010) and lower ex-

pressed emotion (Tarrier, Sommerfield, & Pilgrim, 1999)

are related to recovery from chronic PTSD. However, the

impact of social relationships has not been considered as

a potential factor in early recovery. The first months after

trauma exposure are critically important for the devel-

opment of persistent PTSD. Indeed, most survivors who

meet initial PTSD diagnostic criteria recover from PTSD

within 1 year (Freedman, Brandes, Peri, & Shalev, 1999;

Kessler, 2000). It is plausible that qualities of interper-

sonal relationships may critically affect the likelihood

of recovery early after a traumatic event, either sponta-

neously or with treatment. To our knowledge, no study

has previously examined this relationship.

To address this gap, we here present a novel analysis of

data from a randomized control study, in which patients

were evaluated at multiple time points during the months

that followed trauma exposure (Shalev et al., 2011, 2012).

In addition to symptom levels at all time points, subjects’

perceptions of their social relationships were also as-

sessed. This measure assesses three of the social relation-

ship factors described above: perceived social support,

perceived satisfaction with social relationships in general,

and perceived satisfaction with intimate relationships.

Specifically, we use these data to address two alternative

hypotheses: decreased social relationship satisfaction

(SRS) would be associated with subsequent higher levels

of PTSD, and that increased PTSD would be associated

with subsequent poorer SRS, in both cases controlling for

treatment type.

Method

Participants Participants were 501 individuals who had attended the

emergency room following a civilian trauma meeting

Criterion A of DSM (American Psychiatric Association,

2000). Women were 49.7% of the sample, men were 50.3%.

The mean participants’ age was 36.22 (SD �11.84) and it ranged from 20 to 69. SES was measured on a 5-point

scale, ranging from very low (1) to very high (5); the mean

SES was 2.4 (SD �1.1).

Measures

Clinical interviews

Clinician Administered PTSD Scale (CAPS; Blake

et al., 1995): PTSD was assessed at both time points using

the CAPS. The CAPS gives a score for both frequency

and intensity of the 17 PTSD symptoms (DSM IV), and

a continuous score is calculated by summing all these.

In this study, Cronbach’s a was 0.93 at Time I and 0.96 at Time II.

SCID Structured Clinical Interview for DSM-IV,

(First, Spitzer, Gibbon, & Williams, 1997): This was used

to screen for all current and past Axis I disorders. In this

data set, past depression was measured using the SCID at

Clinical Interview I. It was dummy-coded with 1 �yes. SRS was measured using the World Health Organiza-

tion Quality of Life-BREF (Group, 1998): This is the

26-item version of the original questionnaire and mea-

sures subjective quality of life, in four dimensions: phys-

ical health, psychological health, social relationships,

and environment. Responses are measured on a 5-point

scale, with a higher number indicating a better perceived

quality of life. In this study, the three questions from the

social relationships section were included: How satisfied

are you with your personal relationships?; How satisfied

are you with your sex life?; and How satisfied are you

with the support you get from your friends? In this study,

Sara A. Freedman et al.

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Citation: European Journal of Psychotraumatology 2015, 6: 28864 - http://dx.doi.org/10.3402/ejpt.v6.28864

Cronbach’s a was 0.75 at Clinical Interview I and 0.81 at Clinical Interview II.

Negative life events (NLE) were measured using the

Stressful Life Events Screening Questionnaire*SLESQ (Goodman, Corcoran, Turner, Yuan, & Green, 1998);

this is the Hebrew version of the SLESQ, used in several

previous studies. A total number of endorsed events were

used.

Sociodemographic variables were (1) sex (dummy-

coded, with male �1); (2) age in years; (3) schooling years; (4) marital status (dummy-coded, with married �1 and otherwise �0); (5) number of children (0�9); (6) household density (defined as the number of household

members divided by the number of rooms in the house-

hold); and (7) self-reported income (based on partici-

pants’ responses to a 5-point scale ranging from 1 �way below average to 5 �way above average).

Trauma type, with two types (MVA and Terror) as

the dummy-coded variables, and other types serving as

the base.

Randomized control trial (RCT) condition was ex-

pressed as two dummy-codes of WL and PE/CT, with

non-RCT serving as the base.

Procedure This study examined data collected as part of the

Jerusalem Trauma Outreach and Prevention Study

(J-TOPS; ClinicaltrialsGov Identifier: NCT0014690);

the study included systematic outreach and follow-up of

recent trauma survivors, as well as an embedded rando-

mized controlled study examining the effects of early

interventions for preventing chronic PTSD. The study’s

procedures have been fully described previously (Shalev

et al., 2011) and will be briefly described here.

Subjects were adults aged 18�70 who were consecu- tive trauma survivors attending the emergency room of

a level I trauma center. Traumatic events were mixed

civilian events, with the majority (80%) being motor

vehicle accidents. Eligible participants were recruited

via a telephone interview 10 days following the event

(N �4,743) and gave verbal informed consent. During this initial telephone interview, participants who had

experienced a traumatic event according to criteria A1

and A2, and met other study criteria (N �1,996) were assessed for initial symptoms of acute stress disorder.

Participants with acute PTSD symptoms (N �1,502) were invited to attend a clinical interview 3 weeks post

trauma, of which 756 attended. At this clinical interview

(Clinical Interview I), subjects signed written informed

consent and were assessed for current and lifetime psy-

chiatric disorders using the SCID, and for the presence of

PTSD symptoms. Three hundred ninety-seven subjects

showed sufficient symptoms (acute PTSD minus the time

criterion) and were invited to participate in the rando-

mized controlled trial. Two hundred ninety-six subjects

agreed to enter the trial and were randomized using

equipoise stratified randomization to one of five treat-

ment arms: prolonged exposure (PE, N �63), cognitive therapy (CT, N �40), SSRI (N �23), placebo (N �23), and waiting list control (N �93). Results indicated that PE and CT showed similar effectiveness, and for the pur-

poses of these analyses are considered one group, namely

PE/CT. All patients received 12 weeks of treatment.

As described above, the RCT was embedded in a

follow-up study of all subjects, and as such partici-

pants (N �756) who attended the first clinical interview were reassessed 5 months after the trauma (N �604, Clinical Interview II), regardless of participation in the

RCT. Assessors were blind to participation in the RCT.

Hadassah University Hospital’s Institutional Review

Board approved and monitored the study.

The data used in this analysis concentrate on 501

individuals who have available data at the pre- and post-

early treatment clinical assessments; that is, at 3 weeks

and 5 months post trauma, Clinical Interviews I and II.

Three groups were included: those who received either PE

or CT (PE/CT, N �98); those who were in the waiting list control group (WL, N �90); and those who did not enter the RCT and therefore did not receive any treatment

(non-RCT, N �313). It is important to include this non- treatment group, because it represents an understudied

population, and it is rare to have data that allow for

comparison of subjects who did and did not enter an

RCT. The SSRI/Placebo group was small and had in-

sufficient numbers at follow-up to be included in the

present analyses. SRS and PTSD symptom levels were

assessed at both time points.

Data analytic plan The main analysis approach was Structural Equation

Modeling, done with the Mplus 7.11 program (Muthén &

Muthén, 2012). The minimal covariance coverage in the

variance�covariance matrix used in the analyses was 0.83. To take advantage of all the available data, models were

fit using full-information maximum likelihood estimation

with robust standard errors (Little & Rubin, 2003).

Following recommendations of Hu and Bentler (1999),

we report fit indexes of two types: the Tucker�Lewis index (TLI) and the Comparative Fit Index (CFI), and

two indexes of misfit: root mean-square error of approx-

imation (RMSEA) and standardized root mean-square

residual (SRMR). NNFI and CFI close to or above 0.95,

combined with RMSEA below 0.06 and SRMR below

0.08, are considered indicative of acceptable fit. SRS was

specified as a latent variable, indicated by its three items.

PTSD was also specified as a latent variable, measured

with three indicators, each created as a random third of

the scale items using the accepted approach of parceling

(Bandalos, 2002; Stacy, Bentler, & Flay, 1994). To test for

reciprocal causal associations between SRS and PTSD,

Social relationship satisfaction and PTSD

Citation: European Journal of Psychotraumatology 2015, 6: 28864 - http://dx.doi.org/10.3402/ejpt.v6.28864 3 (page number not for citation purpose)

we fit, within the SEM framework, a cross-lagged panel

model (Finkel, 1995). Such models allow for testing the

causal associations of two variables while considering

for their stabilities and controlling for measuring issues.

For this, we allowed for measurement errors of the same

indicators to correlate over time in autoregressive paths

and fixed factor loadings to equality over time.

Results Descriptive statistics of observed research variables and

their correlations with relationship satisfaction and PTSD

measures are provided in Table 1.

As can be seen in Table 1, PTSD symptoms are nega-

tively correlated with SRS, at both time points. Higher

frequency of NLE and higher levels of past depression

are associated with lower SRS at both time points. In

addition, age is negatively correlated with SRS and posi-

tively correlated with PTSD, both at T2. Participants

who reported higher income also reported better RS and

lower PTSD at T1, but not at T2.

As the first stage of the main analyses, we tested

the measurement model. It yielded acceptable results: x 2

(46, N �501) �66.26, p �0.03, TLI �0.995, CFI �0.996, SRMR �0.030, RMSEA �0.030 (90% CI�0.010; 0.045). We proceeded then to test the cross-lagged panel model.

To this model, we added the two dummy variables ex-

pressing membership in the two RCT experimental groups

as predictors of both T1 and T2 relationship satisfaction

and PTSD. Parceling out the group membership from

T1 measures allowed us to account for the initial im-

balance in the groups’ composition. The group member-

ship effects upon the T2 measures controlled for T1

measures allow us to estimate the RCT impact upon the

change over time in these measures. We also added to the

model, as predictors of each of the four content variables,

those sociodemographic and background variables that

were correlated with any of the content research variables

(Table 1). This structural model fit the data well, with

x 2

(114, N�501)�208.80, pB0.0001, TLI�0.978, CFI� 0.983, SRMR �0.039, and RMSEA �0.041 (90% CI � 0.032; 0.049). In this model, all the paths emitted from

two control variables, number of children and self-

reported income, were not statistically significant. These

variables were deleted from the model. The paths from

NLE to relationship satisfaction and PTSD at T2 were

also non-significant and were therefore fixed to zero.

The resulting model (Fig. 1) showed good fit to the data,

with x 2

(92, N �501) �158.92, pB0.0001, TLI �0.984, CFI �0.988, SRMR �0.037, and RMSEA �0.037 (90% CI �0.027; 0.047).

As seen in Fig. 1, both SRS and PTSD exhibited some

stability across time (with stability coefficients of 0.62 and

0.56, accordingly). The correlations between them were

rather high, both at T1 (r � �0.42) and T2 (r � �0.50). Importantly, the cross-lagged effect of PTSD upon SRS

was close to zero (b � �0.02, p �0.67), whereas the parallel effect of SRS upon PTSD was small in magni-

tude, but statistically significant (b� �0.12, p �0.01).

Table 1. Means and standard deviations for the research variables and their correlations with SRS and PTSD

Variable Mean SD

Social relationship

satisfaction

T1

Social relationship

satisfaction

T2

PTSD

T1

PTSD

T2

RCT group: waiting lista 0.18 0.38 �0.09 �0.18*** 0.22*** 0.29***

RCT group: PE/CTa 0.20 0.40 �0.16*** �0.02 0.24*** �0.01

Sex: malea 0.50 0.50 0.02 0.06 0.02 �0.05

Age (in years) 36.22 11.84 �0.06 �0.16*** �0.04 0.11*

Education (in years) 13.19 2.67 0.00 0.00 0.00 0.04

Marital status: marrieda 0.51 0.50 0.00 �0.05 0.02 0.06

Number of children 1.60 1.98 �0.04 �0.08 0.06 0.11*

Household density 1.05 0.59 �0.02 �0.06 �0.07 �0.06

Income 2.40 1.10 0.09* 0.08 �0.13** �0.01

Negative life events 1.80 1.77 �0.13** �0.17*** 0.05 0.07

Past depressiona 0.27 0.44 �0.10* �0.16*** 0.13** 0.05

Trauma type: terrora 0.13 0.33 �0.01 0.02 0.09* 0.05

Trauma type: MVAa 0.83 0.37 �0.01 �0.02 �0.06 �0.02

Social relations T1 3.29 0.96 *

Social relations T2 3.50 0.97 0.58*** *

PTSD T1 1.58 0.73 �0.40*** �0.29*** *

PTSD T2 0.81 0.74 �0.32*** �0.52*** 0.57*** *

MVA, motor vehicle accident; Terror, terrorist attack.

*pB0.05; **pB0.01; ***pB0.001. aDummy-coded variable, 1 �the value specified in the variable name, 0 �other.

Sara A. Freedman et al.

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This pattern of results is consistent with the hypothesis

that initial levels of SRS are the driving force in the

development of PTSD.

At the next step, we added to the model the interactive

effects of RCT group membership, WL, or PE/CT, and the

initial level of each of the focal research variables, SRS or

PTSD, upon the other variable at T2. To obtain a clear

picture, we tested each of these effects within separate

models. Three out of four interactive effects failed to reach

statistical significance (for WL �PTSD, p �0.66; for PE/CT �PTSD, p �0.63; and for WL �SRS, p �0.11). The interaction of WL �SRS was significant, b �0.19, p �0.02. To illustrate the form of this interaction, the cross-lagged model was fit separately for the three experi-

mental groups. The path from T1 relationship satisfaction

to T2 PTSD was negative and significant in two groups,

non-RCT (b � �0.18, pB0.05) and WL (b ��0.26, pB0.05), but was not significant in the PE/CT group

(b �0.12, p�0.30).

Discussion To the best of our knowledge, this is the first prospec-

tive analysis examining SRS, PTSD, and treatment re-

sponse in a civilian population. The results indicate that

increased PTSD symptoms are correlated with decreased

SRS, and this corroborates previous studies (Campbell &

Renshaw, 2013; Gewirtz et al., 2010).

However, the results of the path analysis indicate that

poorer SRS may drive PTSD symptoms, rather than the

reverse. Previous studies (Campbell & Renshaw, 2013;

Gewirtz et al., 2010) have shown that PTSD results in

decreased satisfaction, but as noted above, these studies

did not examine initial relationship satisfaction. These

results imply that patients who present with trauma

exposure and relationship difficulties may be particularly

vulnerable to PTSD development. It is possible that the

discrepancy with previous studies arises from the differ-

ent populations studied*civilian as opposed to military. As has been noted (De Burgh, White, Fear, & Iversen,

2011), the marital relationship is placed under particular

strain in military families, due in part to long absences

and frequent moving, and therefore it may not be rele-

vant to compare these populations.

In survivors who received treatment, the significant

relationship between decreased satisfaction with relation-

ships and elevated PTSD is not apparent, whereas it

remains significant in those groups who did not receive

treatment, either within the RCT (waiting list) or those

Fig. 1. Structural equation model of cross-lagged relationship satisfaction and PTSD effects with standardized parameters.

x 2

(92, N �501) �158.92, pB0.0001, TLI �0.984, CFI �0.988, SRMR �0.037, and RMSEA �0.037. The solid lines indicate paths statistically significant at pB0.05. The dotted lines indicate non-significant paths. NLE, negative life effects; SRS, social

relationship satisfaction; WL, waiting list; PE/CT, prolonged exposure/cognitive therapy.

Social relationship satisfaction and PTSD

Citation: European Journal of Psychotraumatology 2015, 6: 28864 - http://dx.doi.org/10.3402/ejpt.v6.28864 5 (page number not for citation purpose)

who did not enter the treatment trial. These results do

not support previous studies showing that greater social

support is related to better treatment response (Thrasher

et al., 2010). This may be explained by the timing of

assessments in the current study. Previous studies have

all examined the treatment or effects of chronic PTSD,

rather than preventative treatment early after a traumatic

event. Patients in the current study had suffered from

symptoms for a relatively short period of time (5 weeks)

before beginning treatment. This may not be long enough

for the adverse effects of PTSD on previously satisfying

relationships to be felt, and therefore effects on treatment

response may not be seen.

The current results may indicate that the process of

natural recovery is enhanced when the individual reports

satisfaction with relationships, but impaired with poorer

satisfaction. Treatment appears to amend this relation-

ship, perhaps showing that when an intervention is

successful at impacting PTSD levels, the levels of

relationship satisfaction is immaterial to outcome. This

may also be attributed to a therapeutic relationship that

compensates for the lack of satisfying social relationships

(Beutler, Forrester, Holt, & Stein, 2013).

Taken together, these results indicate that relationship

satisfaction may play a part in the development of PTSD,

and natural recovery from it. Chronic PTSD is associated

with marital difficulties and parenting problems (Dekel &

Monson, 2010) which in themselves can lead to trauma-

tization of other family members (Berz, Taft, & Watkins,

2008). The results presented here may show that even

though early treatment has little long-term benefit over

later treatment (Shalev et al., 2012) it may positively

impact family relationships and this has beneficial effect

beyond PTSD symptoms.

This study is limited first by the measurement of

relationship satisfaction. Recent studies examining family

interactions have preferred to use multiple assessments,

thus gaining input, for example, from both partners in

a relationship (Holmbeck, Li, Schurman, Friedman, &

Coakley, 2002) as opposed to self-report measures of

one partner. The second limitation regards the sample,

consisting of one-time traumatic events in a civilian

population. This analysis should be replicated in other

trauma populations.

Conclusions These novel results indicate that the impact of PTSD and

social relationships on each other needs to be more fully

explored. Recent clinical trials have shown the impor-

tance of including significant others in PTSD treatment

(Monson et al., 2012), and these results support this

approach. Future studies might systematically assess

social relationships, their impact on treatment, and the

impact that treatment (or lack of it) has on them.

Conflict of interest and funding

Dr. Shalev received an investigator-initiated grant from

Lundbeck Pharmaceuticals Ltd. (Denmark) for this

study and for an ongoing collaborative study (PI Dr.

Joseph Zohar) entitled ‘‘Prevention of PTSD by Escita-

lopram.’’ Other co-authors have no conflicts of interest to

declare. This study was supported by a research grant #

MH071651 from the NIMH.

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