夫妻疗法可改善PTSD症状和夫妻感情

《美国医学会杂志》(JAMA)8月15日发表的一项最新研究显示，专门针对创伤后应激障碍(PTSD)的认知-行为夫妻疗法有助于改善症状和提高夫妻关系满意度(JAMA 2012;308:700-9)。

在这项研究中，加拿大瑞尔森大学的Candice M. Monson博士及其同事将40对夫妻随机分成2组：3个月PTSD治疗组和对照(等待名单)组。主要终点为CAPS(临床医生发放的PTSD量表)的评分改变。次要终点包括PTSD检查表、DAS(婚姻适应量表)、BDI(贝克抑郁问卷)和状态-特质焦虑问卷的评分改变。

受试者的平均年龄为40岁，结婚时间为5~8年。PTSD原因包括成人或儿童性创伤、非战斗性冲突、机动车辆碰撞、目睹或了解死亡或疾病、战斗相关问题等。创伤后的时间介于12个月以下至44年。许多PTSD患者还患有至少1种合并症，包括情绪障碍(90％)、焦虑症(50％)和物质滥用或依赖(45％)。

治疗内容包括15次会议，涉及3个心理社会领域，每周举行2次会议。第1阶段重点学习了解PTSD及其对感情关系的影响；第2阶段重点在于加强沟通；第3阶段通过促使夫妻双方应用这些新技能来积极改善关系。此外，还对受试夫妻额外随访3个月，观察改善效果是否得以维持。

治疗期结束时，治疗组PTSD症状严重程度的降幅约为对照组的3倍，夫妻关系满意度是对照组的4倍多。此外，治疗组在抑郁、愤怒和焦虑等次要终点方面也获得改善。3个月随访期结束后，81%的夫妻报告PTSD症状缓解得以维持，81%不再符合PTSD诊断标准。所有夫妻均报告对感情关系满意。

研究者承认，基线时报告的夫妻关系满意度相对较高，可能对结果有影响。治疗组夫妻报告的关系满意度与对照组基本无差别，并且夫妻对PTSD症状改善的评价结果与临床医生的评价结果不一致。

随刊述评：夫妻治疗可能有益但难以普及

波士顿大学精神病学教授Lisa M. Najavits博士指出，治疗组和对照组纳入的夫妻都经过了仔细选择，并且基线时均较为健康(例如无严重合并症)，同时还有愿意参与治疗的配偶支持，因此比临床上的典型患者更易治疗。此外，受试者主要为白人且均有工作，而临床上遇到的患者夫妻则可能缺乏这种工作稳定性。综上所述，虽然该研究观察到夫妻行为疗法能够改善配偶的症状及对感情关系的满意度，但研究结果不具有普遍意义(JAMA 2012;308:714-6)。

该研究获美国国立精神卫生研究所资助。研究者和Najavits博士均声明无经济利益冲突。

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By: MICHELE G. SULLIVAN, Internal Medicine News Digital Network

A cognitive-behavioral couples therapy specially targeted at posttraumatic stress disorder helped improve symptoms and increased patient satisfaction within the relationship.

"There is increasing recognition that intimate relationships play a potent role in recovery from PTSD, its comorbid symptoms, and the psychosocial impairments that accompany it," Candice M. Monson, Ph.D., and her colleagues wrote in the Aug. 15 issue of JAMA. "Cognitive behavioral conjoint therapy may be used to efficiently address individual and relational dimensions of traumatization and might be indicated for individuals with PTSD who have stable relationships and partners who are willing to engage in treatment with them."
 
Dr. Monson, professor of psychology at Ryerson University in Toronto, examined the efficacy of an intervention called cognitive-behavioral conjoint therapy, which stressed education, communication, and conflict resolution. She and her associates randomized 40 couples to either the 3-month PTSD program or a wait list. The primary end point was change on the CAPS (Clinician-Administered PTSD Scale). Secondary end points included change on the PTSD Checklist, the DAS (Dyadic Adjustment Scale), the BDI (Beck Depression Inventory), and the State-Trait Anxiety Inventory (JAMA 2012;308:700-9).

The participants were a mean of 40 years old and had been married for 5-8 years. Causes of PTSD included adult or childhood sexual trauma, noncombat physical assault, motor vehicle collision, witnessing or learning about death or illness, and combat-related issues. Time since the trauma ranged from 44 years to fewer than 12 months. Many of the partners with PTSD also had at least one comorbid condition, including mood disorder (up to 90%), anxiety disorder (50%), and substance abuse or dependence (45%).

The intervention consisted of 15 sessions covering three psychosocial realms; the sessions were held twice a week. Phase 1 targeted learning about PTSD and its relational effects. Phase 2 focused on enhanced communication. Phase 3 challenged couples to actively improve their relationships by putting these new skills to work. Couples also were followed for an additional 3 months to determine whether improvements could be maintained.

At the conclusion of the treatment period, PTSD symptom severity had decreased almost three times as much as it did in the control arm. Partner relationship satisfaction had improved four times more. There were also gains in the secondary end points of depression, anger, and anxiety.

After the 3-month follow-up period, 81% of couples reported sustained gains in PTSD symptoms and 81% no longer met the criteria for a PTSD diagnosis. All of the couples reported satisfaction with their relationship.

The investigators cautioned, however, that the relatively high partner satisfaction reported at baseline might have skewed the results somewhat. There was "little evidence of differences between the [intervention group] and the wait list in partner-reported relationship satisfaction, and partners’ ratings of PTSD symptom improvements were not as consistent with the clinicians’ ratings," they said.

Past research in this area yielded more partner-rated benefits, which were similar to those observed by clinicians, wrote Dr. Monson and her coauthors.

The study was sponsored by the National Institute of Mental Health. Dr. Monson had no financial declarations. Dr. Najavits reported no financial disclosures.

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Couples Therapy Might Help - But Whom?

Although the couples therapy program described in Dr. Monson’s paper did improve patients’ symptoms and their perspectives on their intimate relationships, it’s hard to fit those changes into the context of other research data, Lisa M. Najavits, Ph.D., said in an accompanying editorial (JAMA 2012;308:714-6).

Couples in both the active and investigational groups were carefully selected and were already somewhat healthy at baseline, noted Dr. Najavits.

"From a clinical perspective, the study sample appeared ‘easier to treat’ than is typical in community settings, as indicated by baseline measurements of relationship satisfaction, a general lack of severe comorbidities and the support of an intimate partner who was willing to participate in the treatment," she wrote.

The groups also were mostly white and employed, which added a measure of stability that many struggling couples lack, she noted.

"Although the results of this trial were positive, study participants were carefully selected and thus, the applicability of this intervention to a wide range of clinical settings and patients characteristics remains unclear."

Because of this, it’s hard to generalize the results to other couples, who might have already experienced more stresses resulting from PTSD. The trial "cannot be interpreted as being applicable to couples with these additional challenges," who may be the couples in greatest need of help, she said.

DR. NAJAVITS is professor of psychiatry at Boston University, a lecturer at Harvard Medical School in Boston, a clinical psychologist at the Veterans Affairs Boston Healthcare System, and a clinical associate at McLean Hospital in Belmont, Mass. She reported no financial disclosures.