Date of Award

2020

Embargo Period

1-4-2021

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College

College of Nursing

First Advisor

Lynne S. Nemeth

Second Advisor

Martina Mueller

Third Advisor

Ron Acierno

Fourth Advisor

Lisa Marie Sternke

Abstract

Purpose: This dissertation compendium includes an integrative literature review, an evolutionary concept analysis, and findings from a secondary data analysis. The literature review explores the effects of evidence-based interventions on psychosocial functioning in veterans with combat-related Post Traumatic Stress Disorder (PTSD). The concept analysis examines psychosocial functioning comprehensively to develop a clear understanding of this concept and its relationship to veterans with combat-related PTSD. The secondary analysis study compares the impact of Prolonged Exposure (PE) on psychosocial functioning outcomes in two groups: PTSD diagnosed, treatment seeking combat veterans who receive PE in-person compared to those receiving PE via homebased telehealth. Additional aims in that study were as follows: determine whether race, type of war conflict and service connection disability rating (SC%) moderate and whether PTSD, anxiety, and depression mediate the effect of PE on psychosocial functioning.

Problem: PTSD is linked to maladaptive or impaired psychosocial functioning, including functioning in the following domains: romantic relationships with spouse or partner, family, work, friendships, parenting, and education. Many combat veterans are unemployed, are divorced, or express dissatisfaction with their interpersonal relationships. Some research has demonstrated that treating PTSD symptoms can improve psychosocial functioning as well, yet the focus of PTSD treatment remains primarily on PTSD symptomology itself. Veterans with combat-related PTSD are being treated via telehealth modality at higher rates; however, this modality may contribute to isolation and, in turn, result in poor outcomes in functioning.

Aims: To evaluate treatment and delivery methods for improving psychosocial functioning in veterans with combat-related PTSD. We completed the following studies: first, an integrative review evaluated evidence-based therapies (EBT) and their treatment effects on psychological functioning. Second, an evolutionary concept analysis examined the phenomenon of psychosocial functioning in this population. Finally, a secondary analysis investigated whether PE was associated with improvement in psychosocial functioning, and whether the telehealth treatment modality may be an acceptable alternative to in-person treatment modality.

Design: Whittemore and Knafl’s (2005) framework informed the integrative review, while Rodger’s (2000) framework guided the evolutionary concept analysis. Using a correlational design for the secondary analysis, we investigated relationships between PE treatment delivery methods and potential reduction in psychosocial functioning symptoms. The socio-interpersonal framework of PTSD was used throughout the dissertation, guiding the conceptualization and analysis of psychosocial functioning in relation to veterans with combat-related PTSD.

Findings: The integrative review produced several important results. We found that literature in this area is limited and more research is warranted. We concluded that treating avoidance and numbing can improve functioning; furthermore, treating veterans until they no longer qualify for a PTSD diagnosis can be beneficial in functional improvement. However, the terminology and assessment tools used to assess x psychosocial functioning lacked consistency and therefore may produce confusion for treating providers.

The evolutionary concept analysis identified combat exposure as well as PTSD symptoms such as emotional numbing and withdrawal as main antecedents. Psychosocial functioning environments/domain and psychosocial functioning status were the leading attributes associated with this concept. Social support emerged as an influencing factor in alleviating PTSD symptoms, thus improving functioning. Discussion in the literature mainly focused on functioning in the romantic partnership domain, and further research is necessary to address functioning in other important domains.

The results from the secondary analysis illustrate that race, type of war conflict, and SC% did not moderate the effect of PE on psychosocial functioning. Likewise, PTSD, depression, and anxiety did not mediate the effects of PE on psychosocial functioning. However, we observed a positive correlation between depression, PTSD, and anxiety mean scores in relation to psychosocial functioning mean scores. This finding demonstrates that as depression, PTSD, and anxiety improved, so did psychosocial functioning.

The parent study’s main purpose was to investigate PTSD outcomes with a noninferiority design, the current study used a standard superiority design, therefore a conclusion of no difference between the modalities cannot be drawn at this time. The findings do provide an indication and preliminary evidence that both treatment delivery methods may be acceptable options related to psychosocial functioning outcomes. Similarly, it is too soon to formulate conclusions on the effects of PE on psychosocial functioning based on our results. Although some improvement post-treatment was xi evident, most results were not statistically significant, and mean scores mostly remained in the same functional impairment category. Nevertheless, we remain encouraged based on some promising findings that were identified. Notably, the family domain showed possible clinically significant improvement across treatment groups, and in the homebased telehealth group, the parenting domain results had a similar pattern. Moreover, the family domain in home-based telehealth group had statistically significant improvement as well.

Conclusion: Veterans with combat-related PTSD struggle in various social environments. Impairment in work, romantic partnerships, parenting, and education domains are debilitating consequences for veterans with combat-related PTSD. Although the overall results of this dissertation indicate that some evidence-based therapies (EBTs) may improve psychosocial functioning, and both modalities may be used, more research is warranted to confirm those promising preliminary findings. In conclusion, psychosocial functioning is a multidimensional concept that may affect the quality of life of veterans with combat-related PTSD, thus requiring more attention in the scientific community.

Rights

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