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      Editorial: Post-traumatic Stress in the Family

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          Abstract

          Traumatic events may have severe, long-lasting effects on the individual survivor. These include, first and foremost, post-traumatic stress disorder (PTSD)—a chronic, debilitating systemic psychiatric disorder, characterized by symptoms of re-experiencing, avoidance, negative mood and cognitions, and autonomic hyper-arousal (American Psychiatric Association, 2013)—and other comorbid conditions, including major depression, anxiety, substance abuse, and somatization (Galatzer-Levy et al., 2013). During the past few decades, studies have shown that individuals in the trauma survivor's close proximity may also suffer from psychological symptoms associated with his/her experience. Extant research reveals trauma's massive influence on the entire family system, through processes related to parenthood, spousal relationships and household conflict and aggression (Galovski and Lyons, 2004). In addition, trauma was often found to be “contagious,” as manifested in numerous studies of secondary traumatization (e.g., Dekel et al., 2016), i.e., post-traumatic symptoms experienced by those who were only indirectly exposed to trauma, whether by hearing stories about the event, or by witnessing their negative effects on their loved one (Figley, 1995). Nonetheless, major gaps in knowledge still exist regarding trauma's effects on families, couples, and parent-child dyads. This is perhaps most apparent when one considers the relative scarcity of treatment modules directly targeting the post-traumatic family (e.g., Berkowitz et al., 2011), compared to the large variety of evidence-based treatment options offered to the individual survivor (Kar, 2011). In addition, much remains to be understood regarding the underlying mechanisms of post-traumatic distress in the family, and the deep dynamics between family members following traumatic exposure. This Research Topic aims to present readers with new, updated empirical, and theoretical perspectives about post-traumatic stress within the family system. The Topic gathers scholars from around the globe, working in diverse post-traumatic contexts (military and civilian) and age groups (children, adults, and the elderly). The 10 papers published in this Topic may generally be divided into two categories: studies examining trauma's effects on couples, and others looking at the child-parent dyad. We will now present these papers, starting with those focusing on couples. In her clear, concise, opinion piece, Vilchinsky presents a strong and important argument, calling for more family research in the field of cardiac-disease-induced PTSD (CDI-PTSD). More specifically, she notes that although cardiac diseases are highly prevalent, their post-traumatic effects on the patient's spouse have been widely neglected over the years. Studies suggest that 12–15% of all patients who undergo an acute coronary event (ACE) subsequently develop CDI-PTSD. Since one's partner is often the main caregiver, and given the fact that partners often directly or indirectly witness the incidence of ACEs or subsequent hospitalizations, they face an increased risk of suffering from post-traumatic symptoms and emotional distress in general. Thus, there is a need for much more research and clinical work in this field. Two papers in the Topic attempt to disentangle complex questions related to couple dynamics in the face of trauma. In their paper, Misca and Forgey critically review the literature on bidirectional intimate partner violence (IPV) among military and veteran populations, and its association with PTSD. Perhaps unsurprisingly, studies reveal a vicious cycle of mutual aggression between soldiers/veterans and their spouses. However, two main critiques emerge from the review. First, none of the studies reviewed have explored the partner's PTSD and its possible role in the bi-directional nature of violence. Second, the authors highlight the importance of developing a comprehensive measure of IPV, tapping its frequency, physical and emotional impact, and motives. Future studies that would follow these recommendations may enhance our understanding of IPV following trauma. In the second paper, Lahav et al. present novel, even provocative, findings regarding post-traumatic growth (PTG) among ex-POWs and their spouses. They employ a longitudinal study design to show that PTG, traditionally viewed as a positive, salutogenic phenomenon, may in fact predict adverse dyadic outcomes. The authors infer that PTG reflects defensive, illusory beliefs, rather than an authentic process of personal development following trauma. A study by Hershkowitz et al. serves as a possible bridge between the two categories of papers included in this Topic, as it sheds light on processes related to both parenthood and spousal relationships. Its results show that PTSD is negatively associated with parenting behaviors. More importantly, results show that marital satisfaction may buffer the effects of depression on parenting, thus connecting between two areas of family life. As noted, several papers included in this Topic focused on the parent-child dyad. Two of these papers examined parents' potential role as “stress regulators” for their children. Wise and Delahanty's review paper clearly reveals that a parent's post-traumatic symptoms are associated with his/her child's distress following traumatic injury. The review also underscores the importance of discussing, in an emotionally open and supportive manner, the traumatic event within the family. Also, given the impact of moderators such as parent/child gender, and the developmental stage of the child, it is highly unlikely that a singular, one-size-fits-all approach to treatment interventions for parents of injured children will be effective in reducing child symptoms. In another paper, Slone and Shoshani report an interesting gender effect, where the mother's parenting style—but not the father's—moderated the association between exposure to political violence and emotional distress among Israeli adolescents. More specifically, maternal authoritative parenting style and warmth emerged as potent protectors against the child's mental health symptoms. Three studies included in this Topic focus on various aspects of inter-generational transmission of trauma, and the general effect of parental PTSD on the parent-child relationship. Creech and Misca's review paper reveals the vast influence of military-related parental PTSD on the quality of the parent-child bond and on children's well-being, with an emphasis on internalizing-externalizing behaviors. Once again, parental gender issues are discussed, and those seem to merit more research in the future. A study by Shrira et al. focused on a unique sample—aging individuals who are second generation to Holocaust survivors. The study's important findings reveal the far-reaching implications of parents' trauma, as manifested in their offspring's negative aging processes, more than half a century after the Holocaust. Importantly, these effects seem to be associated with the offspring's secondary post-traumatic symptoms. In a highly original study, Kazlauskas et al. explore the concept of “inter-generational transmission of resilience,” as may be seen in sense of coherence among offspring of individuals suffering from post-traumatic symptoms. The idea that salutogenic processes may also be transmitted from one generation to another carries important clinical implications, and we wish to encourage future studies to further explore this area. Finally, one study in this Topic examined another form of directionality, one stemming from the child and influencing the parent. Bitton et al. present findings attesting to parents' distress during their child's participation in ongoing military conflict. The study raises important questions regarding parents' peri-traumatic distress, as well as regarding the overlap between concepts such as parental anxiety, worry, and secondary post-traumatic symptoms. To conclude, we wish to highlight two issues we view as highly important. The first has to do with the “geography” of trauma, and cross-cultural psychology in general. As can be seen in this Topic, and as explicitly noted by several of its authors, a large portion of the evidence regarding post-traumatic stress in the family comes from English speaking countries, most notably the U.S., as well as from Israel, a country continuously troubled by war and terror. We strongly encourage studies from other areas of the world, such as the one from Kazlauskas et al. (Lithuania), noted above. Finally, families are complex systems (Hill, 1949; McCubbin and Patterson, 1983), which, when facing stress or crisis, undergo dramatic changes involving parents, children, spouses, brothers, and their various inter-relations. This field therefore requires studies that would examine the family as a whole, in an attempt to shed light not only on the couple or parent-child post-traumatic dyad, but on the familial gestalt. Such studies would strengthen the existing impressive body of knowledge, and improve family-based interventions following traumatic events. Author contributions DH and AB have equally contributed to all relevant tasks related to this paper. These include editing the research topic and preparing the editorial. Conflict of interest statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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          Most cited references6

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          Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review

          Background: Post-traumatic stress disorder (PTSD) is a psychiatric sequel to a stressful event or situation of an exceptionally threatening or catastrophic nature. Cognitive behavioral therapy (CBT) has been used in the management of PTSD for many years. This paper reviews the effectiveness of CBT for the treatment of PTSD following various types of trauma, its potential to prevent PTSD, methods used in CBT, and reflects on the mechanisms of action of CBT in PTSD. Methods: Electronic databases, including PubMed, were searched for articles on CBT and PTSD. Manual searches were conducted for cross-references in the relevant journal sites. Results: The current literature reveals robust evidence that CBT is a safe and effective intervention for both acute and chronic PTSD following a range of traumatic experiences in adults, children, and adolescents. However, nonresponse to CBT by PTSD can be as high as 50%, contributed to by various factors, including comorbidity and the nature of the study population. CBT has been validated and used across many cultures, and has been used successfully by community therapists following brief training in individual and group settings. There has been effective use of Internet-based CBT in PTSD. CBT has been found to have a preventive role in some studies, but evidence for definitive recommendations is inadequate. The effect of CBT has been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD. Many studies also report physiological, functional neuroimaging, and electroencephalographic changes correlating with response to CBT. Conclusion: There is scope for further research on implementation of CBT following major disasters, its preventive potential following various traumas, and the neuropsychological mechanisms of action.
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            The Child and Family Traumatic Stress Intervention: secondary prevention for youth at risk of developing PTSD.

            This pilot study evaluated the effectiveness of a four-session, caregiver-child Intervention, the Child and Family Traumatic Stress Intervention (CFTSI), to prevent the development of chronic posttraumatic stress disorder (PTSD) provided within 30 days of exposure to a potentially traumatic event (PTE). One-hundred seventy-six 7 to 17-year-old youth were recruited through telephone screening based on report of one new distressing posttraumatic stress symptom after a PTE. Of those, 106 youth were randomly assigned to the Intervention (n = 53) or a four-session supportive Comparison condition (N = 53). Group differences in symptom severity were assessed using repeated measures with mixed effects models of intervention group, time, and the interaction of intervention and time. Logistic regression analyses were performed to assess treatment condition and any subsequent traumas experienced as predictors for full and partial PTSD diagnosis at 3-month follow-up. An exploratory chi-square analysis was performed to examine the differences in PTSD symptom criteria B, C, and D at follow-up. At baseline, youth in both groups had similar demographics, past trauma exposures and symptom severity. At follow-up, the Intervention group demonstrated significantly fewer full and partial PTSD diagnoses than the Comparison group on a standardized diagnostic measure of PTSD. Also, there was a significant group by time interaction for Trauma Symptom Checklist for Children's Posttraumatic Stress and Anxiety Indices as the CFTSI group had significantly lower posttraumatic and anxiety scores than the Comparison group. The results suggest that a caregiver-youth, brief preventative early intervention for youth exposed to a PTE is a promising approach to preventing chronic PTSD. © 2010 The Authors. Journal of Child Psychology and Psychiatry. © 2010 Association for Child and Adolescent Mental Health.
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              Patterns of lifetime PTSD comorbidity: a latent class analysis.

              Posttraumatic stress disorder (PTSD) is associated with high rates of psychiatric comorbidity, most notably substance use disorders, major depression, and other anxiety disorders. However, little is known about how these disorders cluster together among people with PTSD, if disorder clusters have distinct etiologies in terms of trauma type, and if they confer greater burden over and above PTSD alone. Utilizing Latent Class Analysis, we tested for discrete patterns of lifetime comorbidity with PTSD following trauma exposure (n = 409). Diagnoses were based on the Structured Clinical Interview for DSM-IV (SCID). Next, we examined if gender, trauma type, symptom frequency, severity, and interference with everyday life were associated with the latent classes. Three patterns of lifetime comorbidity with PTSD emerged: a class characterized by predominantly comorbid mood and anxiety disorders; a class characterized by predominantly comorbid mood, anxiety, and substance dependence; and a relatively pure low-comorbidity PTSD class. Individuals in both high comorbid classes had nearly two and a half times the rates of suicidal ideation, endorsed more PTSD symptom severity, and demonstrated a greater likelihood of intimate partner abuse compared to the low comorbidity class. Men were most likely to fall into the substance dependent class. PTSD comorbidity clusters into a small number of common patterns. These patterns may represent an important area of study, as they confer distinct differences in risk and possibly etiology. Implications for research and treatment are discussed. © 2012 Wiley Periodicals, Inc.
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                Author and article information

                Contributors
                Journal
                Front Psychol
                Front Psychol
                Front. Psychol.
                Frontiers in Psychology
                Frontiers Media S.A.
                1664-1078
                06 February 2018
                2018
                : 9
                : 40
                Affiliations
                [1] 1Department of Psychology, Bar-Ilan University , Ramat Gan, Israel
                [2] 2Department of Psychiatry, New York University , New York City, NY, United States
                [3] 3Department of Psychology, Sarah Lawrence College , Bronxville, NY, United States
                Author notes

                Edited and reviewed by: Antoine Bechara, University of Southern California, United States

                *Correspondence: Danny Horesh Danny.Horesh@ 123456biu.ac.il

                This article was submitted to Psychopathology, a section of the journal Frontiers in Psychology

                †Shared first authorship.

                Article
                10.3389/fpsyg.2018.00040
                5808160
                29467688
                dd7028df-491b-44ff-aca8-15113da1a4f3
                Copyright © 2018 Horesh and Brown.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 15 December 2017
                : 11 January 2018
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 9, Pages: 3, Words: 1793
                Categories
                Psychology
                Editorial

                Clinical Psychology & Psychiatry
                traumatology,family,intergenerational transmission,ptsd,parenthood,marriage

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