The Role of Posttraumatic Growth in a Randomized Controlled Trial of Cognitive–Behavioral Conjoint Therapy for PTSD

Posttraumatic growth (PTG) is defined as a positive psychological change that can emerge following a traumatic life event. Although documented in noninterventional studies of traumatized individuals, there are scant data on the potential for therapy to induce or improve PTG. Thus, the primary goal of this study was to examine changes in PTG in a controlled trial of cognitive–behavioral conjoint therapy for posttraumatic stress disorder versus waitlist (CBCT for PTSD; Monson & Fredman, 2012). We also examined whether pretreatment relationship satisfaction and PTSD symptomatology moderated change in PTG. There were 40 couples (75% with a female partner with PTSD) who were randomized to either immediate CBCT for PTSD or a 3‐month waitlist (WL). Compared to WL, individuals who received treatment immediately demonstrated a significant increase in PTG. There was a moderate effect size between‐group difference (Hedge's g = 0.45). There was a nonsignificant relationship with a moderate effect size (Hedge's g = 0.65) for the positive effect of pretreatment relationship satisfaction on the trajectory of PTG, but no effect of pretreatment PTSD symptoms. Results suggested that CBCT for PTSD facilitated PTG, even with a limited focus on PTG in this conjoint intervention. Future research should target PTG as a treatment goal and further examine the role of close others in facilitating development of PTG.     

Couple Treatment for Alcohol Use Disorder and Posttraumatic Stress Disorder: Pilot Results From U.S. Military Veterans and Their Partners

We studied 13 U.S. male military veterans and their female partners who consented to participate in an uncontrolled trial of couple treatment for alcohol use disorder and posttraumatic stress disorder (CTAP). CTAP is a 15‐session, manualized therapy, integrating behavioral couples therapy for alcohol use disorder (AUD) with cognitive–behavioral conjoint therapy for posttraumatic stress disorder (PTSD). Due to ineligibility (n = 1) and attrition (n = 3), 9 couples completed the study, and 7 completed 12 or more sessions. There were 8 veterans who showed clinically reliable pre‐ to posttreatment reduction of PTSD outcomes. There were also significant group‐level reductions in clinician‐, veteran‐, and partner‐rated PTSD symptoms (d = 0.94 to 1.71). Most veterans showed clinically reliable reductions in percentage days of heavy drinking. Group‐level reduction in veterans’ percentage days of heavy drinking was significant (d = 1.01). There were 4 veterans and 3 partners with clinically reliable reductions in depression, and group‐level change was significant for veterans (d = 0.93) and partners (d = 1.06). On relationship satisfaction, 3 veterans and 4 partners had reliable improvements, and 2 veterans and 1 partner had reliable deterioration. Group‐level findings were nonsignificant for veteran relationship satisfaction (d = 0.26) and for partners (d = 0.52). These findings indicate that CTAP may be a promising intervention for individuals with comorbid PTSD and AUD who have relationship partners.     

Effects of Cognitive–Behavioral Conjoint Therapy for PTSD on Partners’ Psychological Functioning

A number of studies have documented that posttraumatic stress disorder (PTSD) symptoms in “one” partner are negatively associated with their intimate partner's psychological functioning. The present study investigated intimate partners’ mental health outcomes (i.e., depression, anxiety, and anger) in a sample of 40 partners of individuals with PTSD within a randomized waitlist controlled trial of cognitive–behavioral conjoint therapy for PTSD (Monson & Fredman, 2012 ). There were no significant differences between active treatment and waitlist in intimate partners’ psychological functioning at posttreatment. Subgroup analyses, however, of partners exhibiting clinical levels of distress at pretreatment on several measures showed reliable and clinically significant improvements in their psychological functioning at posttreatment and no evidence of worsening. Results suggest that cognitive–behavioral conjoint therapy for PTSD may have additional benefits for partners presenting with psychological distress.     

Emotional Activation and Habituation During Imaginal Exposure for PTSD Among Women With Borderline Personality Disorder

The current study examined patterns and outcomes of emotional activation and habituation during imaginal exposure for posttraumatic stress disorder (PTSD). Participants were 16 women with borderline personality disorder (BPD), PTSD, and recent suicidal and/or self‐injurious behavior who received imaginal exposure for PTSD concurrently with dialectical behavior therapy. The intensity of global distress and 6 specific emotions were assessed before and after imaginal exposure trials. Results indicated that significant within‐session habituation (WSH) occurred for global distress (Hedge's g effect size = ?2.52) and fear (g = ?0.80), whereas significant between‐session habituation (BSH) occurred for global distress (g = ?2.18), fear (g = ?1.89), guilt (g = ?1.14), shame (g = ?0.74), and disgust (g = ?0.41). BSH significantly predicted PTSD diagnostic status at posttreatment, whereas activation and WSH were unrelated to outcome. Clients who remitted from PTSD showed significantly more BSH in global distress than nonremitters (η² = .39). In addition, remitters reported reductions in sadness and anger across trials, whereas sadness and anger increased for those who did not remit (η² = .54 and .40, respectively). Overall, BPD clients exhibited patterns of activation and habituation during imaginal exposure comparable to other client populations, and there was no evidence of persistent emotional engagement or habituation problems.     

Social Information Processing in Anger Expression and Partner Violence in Returning U.S. Veterans

We examined social information processing factors that could represent pathways through which posttraumatic stress disorder (PTSD) symptoms relate to anger expression and intimate partner violence (IPV) perpetration in returning U.S. veterans. The sample included 92 male Operation Enduring Freedom/Operation Iraqi Freedom veterans, primarily Caucasian (77.4%), with smaller numbers of African American, Asian, Hispanic or Latino, American Indian or Alaskan Native, and other minority participants (9.7%, 2.2%, 2.2%, 3.2%, and 5.3% respectively). The average age was 40.37 (SD = 9.63) years. Data were collected through self‐report questionnaires (PTSD Checklist, State‐Trait Anger Expression Scale, Revised Conflict Tactics Scales) and the Articulated Thoughts in Simulated Situations experimental protocol. Laboratory‐based assessment of cognitive biases and hostile attributions were tested as mediators of associations between PTSD symptoms and anger expression and IPV. Among the PTSD symptom clusters, hyperarousal symptoms were most strongly associated with anger expression (r = .50) and IPV perpetration (r = .27). Cognitive biases mediated associations between PTSD total scores and 3 of 4 PTSD cluster scores as well as anger expression. Hostile attribution biases were also associated with IPV perpetration (r = .23). We discuss the implications of these findings for understanding social information processing mechanisms for the relationship between PTSD symptoms and aggression.     

Emotional Reactivity,Emotion Regulation Capacity,and Posttraumatic Stress Disorder in Traumatized Refugees: An Experimental Investigation

Refugees who suffer from posttraumatic stress disorder (PTSD) often react with strong emotions when confronted with trauma reminders. In this study, we aimed to investigate the associations between low emotion regulation capacity (as indexed by low heart rate variability [HRV]), probable PTSD diagnosis, and fear and anger reaction and recovery to trauma‐related stimuli. Participants were 81 trauma‐exposed refugees (probable PTSD, n = 23; trauma‐exposed controls, n = 58). The experiment comprised three 5‐min phases: a resting phase (baseline); an exposition phase, during which participants were exposed to trauma‐related images (stimulus); and another resting phase (recovery). We assessed HRV at baseline, and fear and anger were rated at the end of each phase. Linear mixed model analyses were used to investigate the associations between baseline HRV and probable DSM‐5 PTSD diagnosis in influencing anger and fear responses both immediately after viewing trauma‐related stimuli and at the end of the recovery phase. Compared to controls, participants with probable PTSD showed a greater increase in fear from baseline to stimulus presentation, d = 0.606. Compared to participants with low emotion regulation capacity, participants with high emotion regulation capacity showed a smaller reduction in anger from stimulus presentation to recovery, d = 0.548. Our findings indicated that following exposure to trauma‐related stimuli, probable PTSD diagnosis predicted increased fear reactivity, and low emotion regulation capacity predicted decreased anger recovery. Impaired anger recovery following trauma reminders in the context of low emotion regulation capacity might contribute to the increased levels of anger found in postconflict samples.     

Supporting a Spouse With Military Posttraumatic Stress: Daily Associations With Partners’ Affect

Service members and veterans (SM/Vs) with posttraumatic stress disorder (PTSD) can receive significant benefits from social support by a spouse or romantic partner. However, little is known about how providing support impacts partners. This study sought to identify (a) how provision of support is associated with partners’ daily negative and positive affect and (b) how SM/Vs’ PTSD symptom severity might moderate such associations. In a 14‐day daily‐diary study that assessed 64 couples in which one member was an SM/V with PTSD symptoms, partners reported nightly on whether or not they provided instrumental support and/or emotional support that day as well as their current negative and positive affect. Multilevel modeling showed that the provision of emotional and instrumental support were both significantly related to partners’ lower levels of negative affect, f ² = 0.09, and higher levels of positive affect, f ² = 0.03, on that same day but not the next day. The positive same‐day effects were seen if any support was given, with no additive effects when both types of support were provided. Severity of SM/V PTSD moderated the association between provision of emotional support and lower same‐day negative affect such that the association was significant only when PTSD symptoms were more severe. Overall, these findings indicate that support provision to a partner with PTSD is associated with improved affect for the romantic partner providing support. However, given that only same‐day affect was associated with support, the findings may also suggest that positive affect increases the provision of support.     

Cognitive–Behavioral Couple's Treatment for Posttraumatic Stress Disorder: Initial Findings

This pilot study was an initial investigation of Cognitive-Behavioral Couple's Treatment (CBCT) for posttraumatic stress disorder (PTSD). Seven couples in which the husband was diagnosed with PTSD secondary to Vietnam combat experiences completed the treatment. According to independent clinician assessment and partner report, the veterans had substantial improvements in their PTSD symptoms. The veterans reported less dramatic improvements in their PTSD symptoms, but endorsed significant improvements in their depression and anxiety. The partners reported improved relationship satisfaction, whereas the veterans' relationship satisfaction was unchanged across treatment. The current findings are compared with findings on other forms of empirically validated treatment for PTSD and previous studies of CBCT for various individual problems. Theoretical implications and future directions are offered.     

Trauma‐Exposed Community‐Dwelling Women and Men Respond Similarly to the DAR‐5 Anger Scale: Factor Structure Invariance and Differential Item Functioning

Anger is associated with the development of posttraumatic stress disorder (PTSD) and with poor treatment outcomes. The Dimensions of Anger Reactions Scale‐5 (DAR‐5) has demonstrated preliminary evidence of unitary factor structure and sound psychometric properties. Gender‐based differences in psychometric properties have not been explored. The current study examined gender‐based factor structure invariance and differential item functioning of the DAR‐5 and gender differences in PTSD symptoms as a function of anger severity using a community sample of adults who had been exposed to trauma. Data were collected from 512 trauma‐exposed community‐dwelling adults (47.9% women). Confirmatory factor analyses, Mantel‐Haenszel χ² tests and a comparison of characteristic curves, and 2‐way analyses of variance, respectively, were used to assess gender‐based factor structure invariance, gender‐based response patterns to DAR‐5 items, and gender differences in PTSD symptoms as a function of anger. The unitary DAR‐5 factor structure did not differ between men and women. Significant gender differences in the response pattern to the DAR‐5 items were not present. Trauma‐exposed individuals with high anger reported greater overall PTSD symptoms (p < .001), regardless of gender. The DAR‐5 can be used to assess anger in trauma‐exposed individuals without concern of gender biases influencing factor structure or item functioning. Findings further suggested that the established relationship between anger and PTSD severity did not differ by gender.     

Using Interpretation Bias Modification to Reduce Anger in Veterans with Posttraumatic Stress Disorder: A Pilot Study

Difficulty controlling anger is the most commonly reported reintegration concern among veterans with posttraumatic stress disorder (PTSD). One of the mechanisms associated with problematic anger is a tendency to interpret ambiguous interpersonal situations as hostile, known as the hostile interpretation bias (HIB). A computer-based interpretation bias modification (IBM) intervention has been shown to successfully reduce HIB and anger but has not been tested in veterans with PTSD. The current study was a pilot trial of this IBM intervention modified to address problematic anger among veterans with PTSD. Veterans with PTSD and a high level of anger (N = 7) completed eight sessions of IBM treatment over the course of 4 weeks. Participants completed self-report questionnaires at pre- and posttreatment assessment visits, as well as a treatment acceptability interview at posttreatment. Veterans experienced large reductions in hostile interpretation bias and anger from pre- to posttreatment, ds = 1.03–1.96, although these estimates may be unstable due to the small sample size. The feasibility for recruitment, retention, and treatment completion were high. Questionnaire and interview data demonstrated that most participants were satisfied with the treatment and found it helpful and easy to use. Overall, IBM for anger was feasible and acceptable to veterans with PTSD and was associated with reductions in hostile interpretations and self-reported anger outcomes. Further research examining this approach is warranted.     

A Dyadic Analysis of the Influence of Trauma Exposure and Posttraumatic Stress Disorder Severity on Intimate Partner Aggression

This study used structural equation modeling to evaluate a mediation model of the relationship between trauma exposure, posttraumatic stress disorder (PTSD) symptoms, and perpetration of intimate partner physical and psychological aggression in trauma‐exposed veterans and their cohabitating spouses (n = 286 couples; 88% male veteran and female spouse, 80.8% White, non‐Hispanic). Dyadic data analyses were used to simultaneously evaluate actor and partner effects using the actor–partner interdependence model (Kashy & Kenny, 2000). The primary hypothesis was that PTSD would mediate the association between trauma exposure and intimate partner physical and psychological aggression with these effects evident both within and across members of a couple (i.e., actor and partner effects). The best‐fitting model included (a) equivalent actor and partner direct effects of trauma on veterans’ acts of psychological aggression (β = .17 to .20, p = .001), and (b) equivalent actor and partner indirect effects via PTSD on veterans’ acts of physical aggression (β = .08 to .10, p < .001). There were no direct or indirect effects predicting the spouses’ aggression. Results suggest it is important to consider the trauma histories and possible presence of PTSD in both partners as this may be a point of intervention when treating distressed couples.     

Impact of Coping Style and PTSD on Family Functioning After Deployment in Operation Desert Shield/Storm Returnees

The relationship between military combat and postdeployment family functioning difficulties has been frequently investigated in the literature, as has the relationship between types of coping and posttraumatic stress disorder (PTSD). Few studies, however, have examined these variables together, and no studies of which we are aware have examined the effect of coping on family functioning after combat exposure. This study examined coping style measured immediately after return from deployment, and PTSD symptoms and family functioning 18–24 months after return from deployment in a sample of Operation Desert Shield/Storm veterans (N = 2,949). Structural equation models suggested that the relationships between distinct coping styles on family functioning were differentially mediated by postdeployment PTSD symptoms. Results are consistent with full mediation for avoidant coping (β_direct = ?.09, p = .07; β_indirect = ?.17, p < .001) and partial mediation for approach coping (β_direct = .16, p < .001; β_indirect = .09, p < .001). Results suggest that the strategies used to cope with a combat stress event may impact both PTSD and family functioning outcomes, and highlight the potential utility of pre‐ and postdeployment coping skills training.     

Associations Between Functioning and PTSD Symptom Clusters in a Dismantling Trial of Cognitive Processing Therapy in Female Interpersonal Violence Survivors

This study conducted secondary analyses of a published trial and sought to determine if different domains of psychosocial functioning (e.g., daily living, work, nonfamily relationships) improved following trauma‐focused treatment for posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT), an empirically supported treatment that involves evaluating trauma‐related beliefs and written trauma accounts, was compared to its components: CPT without the written accounts or written accounts only in a sample of 78 women with PTSD secondary to interpersonal violence. Overall and individual domains of functioning significantly improved with treatment and results were similar across treatment groups, Fs (2, 150) ≥ 11.87, ps < .001. Additionally, we investigated whether changes in different PTSD symptom clusters were associated with outcomes in domains of psychosocial functioning, after collapsing across treatment condition. Multiple hierarchical linear regression analyses revealed that overall clinician‐assessed PTSD symptom reduction was associated with outcomes in all domains of functioning, βs = .44 to .68, ps < .001. Additionally, improvements in the emotional numbing symptom cluster were associated with outcomes in the nonfamily relationships domain, β = .42, p < .001, and improvements in the hyperarousal symptom cluster were associated with outcomes in the overall, daily living, and household tasks domains, βs = .34 to .39, ps < .01. Results suggest that it may be important to monitor improvements in emotional numbing and hyperarousal symptoms throughout treatment to increase the likelihood of changes in psychosocial functioning.     

The Moderating Effect of State Anger on Treatment Outcome in Female Adolescents With PTSD*

Trauma experienced in childhood and adolescence negatively affects the development of adaptive regulation of emotions and is associated with greater symptoms of anger. Prior research has suggested that high levels of anger may impede the outcome of treatment in adults with posttraumatic stress disorder (PTSD). The current study investigated whether high levels of anger resulted in poorer treatment outcomes in adolescent girls with PTSD. Participants included 61 female adolescent survivors of sexual abuse or assault who were randomized to either prolonged exposure for adolescents (PE‐A) or client‐centered therapy (CCT) for traumatized children for 8–14 weekly sessions. Participants were followed for 12 months posttreatment. High levels of state anger at baseline were associated with less improvement in PTSD symptoms in the CCT group than the PE‐A group (d = 0.62). The moderating effects of state anger on improvement in PTSD symptoms was significant with emotion regulation difficulties, which may underlie anger symptoms (d = 0.58) in the model. The results of this study suggessted that high state anger was less of an impediment to treatment of PTSD for those receiving PE‐A than those receiving less differentiated approaches such as CCT.     

Feasibility,acceptability, and preliminary efficacy of cognitive processing therapy in Japanese patients with posttraumatic stress disorder

Cognitive processing therapy (CPT) is one of the most widely tested evidence-based treatments for posttraumatic stress disorder (PTSD). However, most studies on CPT have been conducted in Western cultural settings. This open-label, single-arm trial investigated the feasibility, acceptability, and preliminary efficacy of CPT for treating Japanese patients with PTSD. A total of 25 outpatients underwent 12 CPT sessions. The primary outcome was the assessment of PTSD symptoms using the Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV); secondary outcomes included the assessment of subjective PTSD severity, depressive and anxiety symptoms, trauma-related cognitions, and subjective quality of life. All outcomes were evaluated at pretreatment (i.e., baseline), posttreatment, and 6- and 12-month follow-ups. On average, participants attended 13 sessions of CPT (SD = 1.38), with a completion rate of 96.0%. One serious adverse event (hospitalization) occurred. Significant within-subjects standardized mean differences in CAPS-IV scores were found from baseline to treatment completion, g = −2.28, 95% CI [−3.00, −1.56]; 6-month follow-up, g = −2.95, 95% CI [−3.79, −2.12]; and 12-month follow-up, g = −2.15, 95% CI [−2.89, −1.41]. Moderate-to-large effects, gs = −0.77 to −2.45, were found on secondary outcomes. These findings support the feasibility, acceptability, and preliminary efficacy of CPT in a Japanese clinical setting.     

Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: A cause for cautious optimism?

This study investigated treatment outcome in combat-related posttraumatic stress disorder (PTSD). Participants were 419 Australian Vietnam veterans who completed a 12-week hospital-based program. A comprehensive protocol assessed PTSD, comorbidity, and social functioning at admission and at 3 and 9 months posttreatment. Overall, the group showed significant improvements in core PTSD symptoms, anxiety, depression, alcohol abuse, social dysfunction, and anger. Changes occurred mostly between admission and 3 months posttreatment, with gains maintained at 9 months. Ratings by patients and their partners indicated perceived improvement and strong satisfaction with treatment. Nevertheless, treatment gains were variable and, for most veterans, considerable pathology remained following the programs. The current study provides grounds for cautious optimism in the treatment of combat-related PTSD.     

PTSD and Romantic Relationship Satisfaction: Cluster‐ and Symptom‐Level Analyses

Previous studies have demonstrated bidirectional associations between posttraumatric stress disorder (PTSD) and romantic relationship dissatisfaction. Most of these studies were focused at the level of the disorder, examining the association between relationship dissatisfaction and having a diagnosis of PTSD or the total of PTSD symptoms endorsed. This disorder‐level approach is problematic for trauma theorists who posit symptom‐level mechanisms for these effects. In the present study, we examined the prospective, bidirectional associations between PTSD symptom clusters (e.g., reexperiencing) and relationship satisfaction using the data from 101 previously studied individuals who had had a recent motor vehicle accident. We also conducted exploratory analyses examining the prospective, bidirectional associations between individual PTSD symptoms and relationship satisfaction. Participants had completed the PTSD Checklist‐Civilian Version and the Relationship Assessment Scale at 4, 10, and 16 weeks after the MVA. We performed time‐lagged mixed‐effects regressions to examine the effect of lagged relationship satisfaction on PTSD clusters and symptoms, and vice versa. No cluster effects were significant after controlling for a false discovery rate. Relationship satisfaction predicted prospective decreases in reliving the trauma (d = 0.42), emotional numbness (d = 0.46), and irritability (d = 0.49). These findings were consistent with the position that relationship satisfaction affects PTSD through symptom‐level mechanisms.     

Presenting Concerns of Veterans Entering Treatment for Posttraumatic Stress Disorder

Patient‐centered care involves engaging patients as partners in establishing treatment priorities. No prior studies have examined what specific problems veterans hope to address when they enter posttraumatic stress disorder (PTSD) treatment. Veterans starting outpatient (n = 216) and residential (n = 812) PTSD treatment in 2 multisite care management trials specified (open‐ended) the 2 or 3 problems that they most wanted to improve through treatment. Over 80% mentioned PTSD‐symptom‐related concerns including PTSD or trauma (19.2% to 19.9% of patients), anger (31.0% to 36.7%), sleep problems (14.3% to 27.3%), nightmares (12.3% to 19.4%), and estrangement/isolation (7.9% to 20.8%). Other common problems involved depression (23.1% to 36.5%), anxiety not specific to PTSD (23.9% to 27.8%), relationships (20.4% to 24.5%), and improving coping or functioning (19.2% to 20.4%). Veterans’ treatment goals varied significantly by outpatient versus residential setting, gender, and period of military service. Our findings confirm the importance of educating patients about how available efficacious treatments relate to clients’ personal goals. Our results also suggest that clinicians should be prepared to offer interventions or provide referrals for common problems such as anger, nightmares, sleep, depression, or relationship difficulties if these problems do not remit with trauma‐focused psychotherapy or if patients are unwilling to undergo trauma‐focused treatment.     

The Role of Gender in the Associations Among Posttraumatic Stress Symptoms,Anger, and Aggression in Russian Adolescents

Symptoms of posttraumatic stress disorder (PTSD) have been linked to anger and aggressive behavior in adult and veteran populations. However, research on the associations among anger, aggression, and PTSD in adolescents is lacking, particularly regarding differences between the sexes. To address this research gap, we used self-report data from Russian adolescents (N = 2,810; age range: 13–17 years) to perform a full path analysis examining the associations between PTSD symptoms and the emotional (anger traits) and cognitive (rumination) components of anger as well as physical/verbal and social aggression, after adjusting for depressive symptoms. We also examined the interaction effects between PTSD symptoms and sex on anger and aggression. The results indicated that girls scored higher on measures of anger and PTSD symptoms, ds = 0.20–0.32, whereas boys scored higher on measures of physical and verbal aggression, d = 0.54. Clinical levels of PTSD symptoms were associated with anger rumination, β = .16, and trait anger, β = .06, and an interaction effect for PTSD symptoms and sex was found for aggression, whereby boys with clinical levels of PTSD symptoms reported more physical/verbal and social aggression, βs = .05 and .20, respectively. Our findings suggest that PTSD symptoms may have an important impact on anger, anger rumination, and aggression during adolescence. In particular, boys seem to have an increased risk for aggressive behavior in the presence of PTSD symptoms. The present results highlight the importance of taking anger and aggression into account when evaluating PTSD.     

The Association Between PTSD and Functional Outcome Is Mediated by Perception of Cognitive Problems Rather Than Objective Neuropsychological Test Performance

Posttraumatic stress disorder (PTSD) has been consistently linked to poorer functional outcomes, including quality of life, health problems, and social and occupational functioning. Less is known about the potential mechanisms by which PTSD leads to poorer functional outcomes. We hypothesized that neurocognitive functioning and perception of cognitive problems would both mediate the relationship between PTSD diagnosis and functioning. In a sample of 140 veterans of the recent wars and conflicts in Iraq and Afghanistan, we assessed PTSD symptoms, history of traumatic brain injury (TBI), depression, self‐report measures of quality of life, social and occupational functioning, and reintegration to civilian life, as well as perception of cognitive problems. Veterans also completed a comprehensive neuropsychological battery of tests. Structural equation modeling revealed that perception of cognitive problems, but not objective neuropsychological performance, mediated the relationship between PTSD diagnosis and functional outcomes after controlling for TBI, depression, education, and a premorbid IQ estimate, b = −6.29, 95% bias‐corrected bootstrapped confidence interval [−11.03, −2.88], showing a large effect size. These results highlight the importance of addressing appraisals of posttrauma cognitive functioning in treatment as a means of improving functional outcomes.