A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault

Coping responses in the midst of terror: the July 22 terror attack at Utøya Island in Norway

This study examined the peri-trauma coping responses of 325 survivors, mostly youth, after the July 22, 2011 terror attack on Utøya Island in Norway. The aim was to understand peri-trauma coping responses and their relation to subsequent post-traumatic stress (PTS) reactions. Respondents were interviewed face-to-face 4-5 months after the shooting, and most were interviewed at their homes. Peri-trauma coping was assessed using ten selected items from the "How I Cope Under Pressure Scale" (HICUPS), covering the dimensions of problem solving, positive cognitive restructuring, avoidance, support seeking, seeking understanding, and religious coping. PTS reactions were assessed with the UCLA PTSD Reaction Index. The participants reported using a wide variety of coping strategies. Problem solving, positive cognitive restructuring, and seeking understanding strategies were reported most often. Men reported using more problem-solving strategies, whereas women reported more emotion-focused strategies. There were no significant associations between age and the use of coping strategies. Problem solving and positive cognitive restructuring were significantly associated with fewer PTS reactions. The results are discussed in light of previous research and may help to inform early intervention efforts for survivors of traumatic events.

Patterns of victimization, suicide attempt, and posttraumatic stress disorder in Greenlandic adolescents: a latent class analysis

AIM

The current study had two main aims. The first was to identify groups of adolescents based on their similarity of responding across a number of victimizing and potentially traumatic events (PTEs). In doing so, we employed the statistical technique of Latent Class Analysis (LCA). The second aim was to assess the relationship between our resultant classes and the covariates of gender, suicide attempt, and PTSD.

METHODS

Two hundred and sixty-nine Greenlandic school students, aged 12-18 (M = 15.4, SD = 1.84) were assessed for their level of exposure to PTEs. In addition, adolescents were assessed for the psychological impact of these events. A LCA was performed on seven binary indicators representing PTEs. Logistic regression was subsequently implemented to ascertain the relationships between latent classes and covariates.

RESULTS

Three distinct classes were uncovered: a violence, neglect, and bullying class (class 1), a wide-ranging multiple PTE class (class 2), and a normative/baseline class (class 3). Notably, classes 1 and 2 were largely separated by the presence or absence of sexual PTEs. Individuals who reported having previously attempted suicide were almost six times more likely to be members of class 1 (OR = 5.97) and almost four times more likely to be members of class 2 (OR = 3.87) compared to the baseline class (class 3). Individuals who met the diagnostic criteria for PTSD were five times as likely to be members of class 1 and class 2 (OR = 5.09) compared to the baseline class. No significant associations were found between classes and gender.

CONCLUSION

The results underline the complexity of the interplay between multiple victimization experiences, traumatization, and suicide attempts.

PTSD and pain: exploring the impact of posttraumatic cognitions in veterans seeking treatment for PTSD

OBJECTIVE

Previous research has demonstrated a significant relationship between posttraumatic stress disorder (PTSD) and pain. While several models attempt to explain this relationship, significant questions remain regarding factors that may play a role in this interaction. The purpose of this study was to determine whether posttraumatic cognitions mediate the relationship between PTSD and pain.

DESIGN

The sample comprised 136 veterans who presented to the VA Ann Arbor Health Care System seeking evaluation and treatment in the PTSD clinic. Participants completed the Clinician-Administered PTSD Scale, the Posttraumatic Cognitions Inventory, and Brief Pain Inventory-Short Form, along with other assessments as part of their evaluation.

RESULTS

This study showed that the majority of patients (86.8%) reported some problems with pain. Further, the findings indicate that there is a significant relationship between PTSD severity and pain severity. Posttraumatic cognitions were not related to the level of pain experienced, but they were related to pain interference in this population.

CONCLUSIONS

In particular, negative cognitions regarding the self were associated with the level of pain-related interference, and partially mediated the relationship between PTSD and pain. The clinical implications of these findings are discussed.

Capturing intrusive re-experiencing in trauma survivors' daily lives using ecological momentary assessment

Intrusive memories are common following traumatic events and among the hallmark symptoms of posttraumatic stress disorder (PTSD). Most studies assess summarized accounts of intrusions retrospectively. We used an ecological momentary approach and index intrusive memories in trauma survivors with and without PTSD using electronic diaries. Forty-six trauma survivors completed daily diaries for 7 consecutive days recording a total of 294 intrusions. Participants with PTSD experienced only marginally more intrusions than those without PTSD, but experienced them with more "here and now quality," and responded with more fear, helplessness, anger, and shame than those without PTSD. Most frequent intrusion triggers were stimuli that were perceptually similar to stimuli from the trauma. Individuals with PTSD experienced diary-prompted voluntary trauma memories with the same sense of nowness and vividness as involuntary intrusive trauma memories. The findings contribute to a better understanding of everyday experiences of intrusive reexperiencing in trauma survivors with PTSD and offer clinical treatment implications.

A pilot prospective study of the relationship among cognitive factors, shame, and guilt proneness on posttraumatic stress disorder symptoms in female victims of sexual violence

This study prospectively examined the relationships among cognitive factors and severity of Posttraumatic stress disorder (PTSD) symptoms in female victims of sexual violence. Thirty-eight victims of sexual violence recruited from Center for Women Victims of Sexual and Domestic Violence at Ajou University Hospital. Cognitive factors and PTSD symptom were assessed within 4 months of sexual violence and 25 victims were followed-up 1 month after initial assessment. Repeated-measured ANOVA revealed that PTSD incidence and severity decreased over the month (F [1, 21]=6.61). Particularly, avoidant symptoms might decrease earlier than other PTSD symptoms (F [1, 21]=5.92). This study also showed the significant relationship between early negative trauma-related thoughts and subsequent PTSD severity. Shame and guilt proneness had significant cross-sectional correlations with PTSD severity, but did not show associations when depression severity is controlled. Our results suggest that avoidant symptoms might decrease earlier than other PTSD symptoms during the acute phase and that cognitive appraisals concerning the dangerousness of the world seem to play an important role in the maintenance of PTSD (r=0.499, P<0.05).

Effects of psychotherapy on trauma-related cognitions in posttraumatic stress disorder: a meta-analysis

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria for posttraumatic stress disorder (PTSD) incorporate trauma-related cognitions. This adaptation of the criteria has consequences for the treatment of PTSD. Until now, comprehensive information about the effect of psychotherapy on trauma-related cognitions has been lacking. Therefore, the goal of our meta-analysis was to determine which psychotherapy most effectively reduces trauma-related cognitions. Our literature search for randomized controlled trials resulted in 16 studies with data from 994 participants. We found significant effect sizes favoring trauma-focused cognitive-behavioral therapy as compared to nonactive or active nontrauma-focused control conditions of Hedges' g = 1.21, 95% CI [0.69, 1.72], p < .001 and g = 0.36, 95% CI [0.09, 0.63], p = .009, respectively. Treatment conditions with elements of cognitive restructuring and treatment conditions with elements of exposure, but no cognitive restructuring reduced trauma-related cognitions almost to the same degree. Treatments with cognitive restructuring had small advantages over treatments without cognitive restructuring. We concluded that trauma-focused cognitive-behavioral therapy effectively reduces trauma-related cognitions. Treatments comprising either combinations of cognitive restructuring and imaginal exposure and in vivo exposure, or imaginal exposure and in vivo exposure alone showed the largest effects.

Mindfulness-Based Stress Reduction for Posttraumatic Stress Symptoms

Mindfulness-based psychotherapies are associated with reductions in depression and anxiety. However, few studies address whether mindfulness-based approaches may benefit individuals with posttraumatic stress symptoms. The current pilot study explored whether group mindfulness-based stress reduction therapy reduced posttraumatic stress symptoms, depression, and negative trauma-related appraisals in 9 adult participants who reported trauma exposure and posttraumatic stress or depression. Participants completed 8 sessions of mindfulness-based stress reduction treatment, as well as pretreatment, midtreatment, and posttreatment assessments of psychological symptoms, acceptance of emotional experiences, and trauma appraisals. Posttraumatic stress symptoms, depression, and shame-based trauma appraisals were reduced over the 8-week period, whereas acceptance of emotional experiences increased. Participants’ self-reported amount of weekly mindfulness practice was related to increased acceptance of emotional experiences from pretreatment to posttreatment. Results support the utility of mindfulness-based therapies for posttraumatic stress symptoms and reinforce studies that highlight reducing shame and increasing acceptance as important elements of recovery from trauma.

Esquemas desadaptativos e sua relação com o transtorno de estresse pós-traumático: uma revisão sistemática

Esquemas iniciais desadaptativos são elaborados ao longo da vida; embora duradouro e resistente à mudança, o esquema pode ser definido como uma rede de crenças estruturadas, inter-relacionadas, que norteiam o comportamento do indivíduo, podendo ser denominado de crença. Serve como modelo de processamento da informação para as vivências do indivíduo, fazendo da terapia um desafio. Este estudo visa investigar os principais esquemas/crenças disfuncionais e esquemas iniciais desadaptativos afetados no transtorno de estresse pós-traumático. Através de uma revisão sistemática em bases de dados eletrônicas entre os anos de 2000 e 2009, constatou-se uma associação entre o transtorno de estresse pós-traumático e esquemas/crenças disfuncionais; os esquemas mais afetados relacionam-se à visão de si, dos outros e do mundo. No que tange aos esquemas iniciais desadaptativos, os mais afetados são isolamento/alienação social e vergonha/defectividade. Esses resultados são clinicamente relevantes, pois é preciso considerar as distorções cognitivas subjacentes à sintomatologia pós-traumática.

Internet-based cognitive bias modification of interpretations in patients with anxiety disorders: a randomised controlled trial

BACKGROUND AND OBJECTIVES

Previous research suggests that negative interpretation biases stimulate anxiety. As patients with an anxiety disorder tend to interpret ambiguous information negatively, it was hypothesised that training more positive interpretations reduces negative interpretation biases and emotional problems.

METHODS

In a randomised, double-blind placebo-controlled trial, patients with different anxiety disorders were trained online over eight days to either generate positive interpretations of ambiguous social scenarios (n = 18) or to generate 50% positive and 50% negative interpretations in the placebo control condition (n = 18) (Study 1).

RESULTS

Positively trained patients made more positive interpretations and less negative ones than control patients. This training was followed by a decrease in anxiety, depression, and general psychological distress, but this effect was also observed in the control group. To get a better understanding of these unexpected results, we tested a 100% neutral placebo control group (Study 2, n = 19); now the scenarios described neutral, non-emotional situations and no valenced interpretations were generated. The results from this neutral group were comparable to the effects from the other control group.

LIMITATIONS

An advantage, but potentially also a disadvantage of the study is that CBM-I training was performed online with less control over the procedures and setting. In addition, the scenarios were not matched to the specific concerns of each patient and the training sessions were performed in close proximity to one another.

CONCLUSIONS

Compared to both control conditions, CBM-I had superior effects on interpretations, but not on emotions. The current findings showed the boundary conditions for CBM-I.

Mental defeat predicts distress and disability in Hong Kong Chinese with chronic pain

OBJECTIVES

The concept of mental defeat (MD) has been applied to describe the deeper impact of pain on the person's sense of self. It describes an intense psychological reaction to pain, whereby people feel that pain has taken away their autonomy and identity. Although MD has been found to characterize Western individuals who are most distressed and disabled by CP, it is debatable whether the concept can be generalized to the experience of CP patients in other cultures. The present study examined whether MD contributed to the prediction of distress and disability among Hong Kong (HK) Chinese reporting CP.

METHODS

Using questionnaires, the present study assessed MD, pain, distress, and disability in a sample of HK Chinese, comprising CP patients seeking specialist treatment and community volunteers with chronic or acute pain but not seeking specialist treatment.

RESULTS

MD was found to be elevated in CP patients seeking specialist treatment but not in nontreatment-seeking volunteers with pain of comparable duration and severity. Hierarchical regression indicated that MD was a significant predictor of functioning and distress, over and above the effects of pain severity and other potential demographic confounds.

DISCUSSION

These findings provide further evidence that MD is a factor that differentiates treatment-seeking from nontreatment-seeking individuals with CP. They also highlight the potential value of applying this psychological concept to the understanding and treatment of CP in HK Chinese.

An investigation of trauma-associated appraisals and posttraumatic stress disorder in British and Asian trauma survivors: the development of the Public and Communal Self Appraisals Measure (PCSAM)

Two studies examined the role of culture on cognitive appraisals of trauma and associated implications for posttraumatic psychological adjustment. Study 2 also investigated the reliability and validity of a new measure assessing public and communal aspects of trauma-associated appraisals (Public and Communal Self Appraisals Measure; PCSAM). Study 1′s non-clinical sample (N = 75) and Study 2′s sample of British and Asian trauma survivors with and without PTSD (N = 95) provided an everyday and trauma memory, completed an Appraisal Inventory, the Posttraumatic Cognitions Inventory and measures of PTSD. Study 2 participants also completed the PCSAM. Conjoined, there were cultural differences in appraisals of everyday and trauma experiences. Nonetheless, there appeared to be cultural similarities in the dysfunctional appraisals of those with PTSD. The PSCAM had good internal consistency, test-retest reliability, convergent validity, and discriminative validity. Findings are discussed in terms of combining cultural models of self with current PTSD models.

Posttraumatic Cognitions, Somatization, and PTSD severity among Asian American and White College Women with Sexual Trauma Histories

The need for trauma research with monoracial groups such as Asian Americans (AA) has recently been emphasized to better understand trauma experiences and inform interventions across populations. Given AA cultural contexts, posttraumatic cognitions and somatization may be key in understanding trauma experiences for this group. AA and White American (WA) trauma-exposed college women completed a survey on sexual trauma history, posttraumatic cognitions, somatic symptoms, and PTSD severity. For the overall sample, higher negative cognitions were associated with higher somatization. Asian race was associated with higher negative cognitions, which then predicted higher PTSD. Unexpectedly, WAs more strongly endorsed somatization than AAs. These findings indicate that posttraumatic cognitions may be helpful in understanding relationships between somatization and PTSD severity among those of Asian backgrounds and that the relationship between somatization and PTSD symptoms is culturally complex.

Paranoia and post-traumatic stress disorder in the months after a physical assault: a longitudinal study examining shared and differential predictors

BACKGROUND

Being physically assaulted is known to increase the risk of the occurrence of post-traumatic stress disorder (PTSD) symptoms but it may also skew judgements about the intentions of other people. The objectives of the study were to assess paranoia and PTSD after an assault and to test whether theory-derived cognitive factors predicted the persistence of these problems.

METHOD

At 4 weeks after hospital attendance due to an assault, 106 people were assessed on multiple symptom measures (including virtual reality) and cognitive factors from models of paranoia and PTSD. The symptom measures were repeated 3 and 6 months later.

RESULTS

Factor analysis indicated that paranoia and PTSD were distinct experiences, though positively correlated. At 4 weeks, 33% of participants met diagnostic criteria for PTSD, falling to 16% at follow-up. Of the group at the first assessment, 80% reported that since the assault they were excessively fearful of other people, which over time fell to 66%. Almost all the cognitive factors (including information-processing style during the trauma, mental defeat, qualities of unwanted memories, self-blame, negative thoughts about self, worry, safety behaviours, anomalous internal experiences and cognitive inflexibility) predicted later paranoia and PTSD, but there was little evidence of differential prediction.

CONCLUSIONS

Paranoia after an assault may be common and distinguishable from PTSD but predicted by a strikingly similar range of factors.

Wounds that can't be seen: implicit trauma associations predict posttraumatic stress disorder symptoms

BACKGROUND AND OBJECTIVES

Prominent theories suggest that explicit and implicit cognitive biases are critical in the development and maintenance of posttraumatic stress disorder (PTSD). However, studies evaluating implicit PTSD-related cognitive biases are rare, and findings are mixed. We developed two adaptions of the Implicit Association Test (IAT), the "traumatized self" IAT (evaluations of the self as traumatized vs. healthy) and the "dangerous memory" IAT (evaluations of remembering as dangerous vs. safe), and investigated their psychometric properties and relations to PTSD symptoms and trauma exposure.

METHODS

Participants were visitors to the Project Implicit research website (Study 1: N = 347, Study 2: N = 501). They completed the IATs (Study 1: both IATs; Study 2: traumatized self IAT only), a trauma exposure measure, a PTSD symptom inventory, and explicit cognitive bias measures (Study 2 only).

RESULTS

Both IATs had good internal consistency, but only the traumatized self IAT was correlated with PSTD symptoms and identified participants meeting clinical cutoffs for PTSD symptoms. Study 2 focused on the traumatized self IAT and included explicit cognitive bias measures. The IAT correlated with PTSD symptoms and explicit cognitions, and predicted variance in PSTD symptoms above and beyond trauma exposure and explicit cognitions.

LIMITATIONS

Study designs were cross-sectional; samples were unselected; and PTSD symptoms were self-reported.

CONCLUSIONS

Despite these limitations, these studies provide preliminary validation of an implicit measure of PTSD-related cognitive bias - the traumatized self IAT - that is consistent with PTSD theories and may ultimately improve the identification and treatment of individuals with PTSD.

The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications

In the DSM-5, the diagnosis of posttraumatic stress disorder (PTSD) has undergone multiple, albeit minor, changes. These changes include shifting PTSD placement from within the anxiety disorders into a new category of traumatic and stressor-related disorders, alterations in the definition of a traumatic event, shifting of the symptom cluster structure from three to four clusters, the addition of new symptoms including persistent negative beliefs and expectations about oneself or the world, persistent distorted blame of self or others, persistent negative trauma-related emotions, and risky or reckless behaviors, and the addition of a dissociative specifier. The evidence or lack thereof behind each of these changes is briefly reviewed. These changes, although not likely to change overall prevalence, have the potential to increase the heterogeneity of individuals receiving a PTSD diagnosis both by altering what qualifies as a traumatic event and by adding symptoms commonly occurring in other disorders such as depression, borderline personality disorder, and dissociative disorders. Legal implications of these changes include continued confusion regarding what constitutes a traumatic stressor, difficulties with differential diagnosis, increased ease in malingering, and improper linking of symptoms to causes of behavior. These PTSD changes are discussed within the broader context of DSM reliability and validity concerns.

Cortisol at the emergency room rape visit as a predictor of PTSD and depression symptoms over time

BACKGROUND

Dysregulation of the hypothalamic-pituitary-adrenal axis, typically reflected by alterations in cortisol responsivity, has been associated with exposure to traumatic events and the development of stress-related disorders such as posttraumatic stress disorder (PTSD) and depression.

METHODS

Serum cortisol was measured at the time of a post sexual assault medical exam among a sample of 323 female victims of recent sexual assault. Analyses were conducted among 235 participants who provided data regarding history of previous assault as well as PTSD and depression symptoms during at least one of the three follow-ups.

RESULTS

Growth curve models suggested that prior history of assault and serum cortisol were positively associated with the intercept and negatively associated with the slope of PTSD and depression symptoms after controlling for covariates. Prior history of assault and serum cortisol also interacted to predict the intercept and slope of PTSD and depression symptoms such that women with a prior history of assault and lower ER cortisol had higher initial symptoms that decreased at a slower rate relative to women without a prior history and those with higher ER cortisol.

CONCLUSIONS

Prior history of assault was associated with diminished acute cortisol responsivity at the emergency room visit. Prior assault history and cortisol both independently and interactively predicted PTSD and depression symptoms at first follow-up and over the course a 6-month follow-up.

Finalizing PTSD in DSM-5: getting here from there and where to go next

The process that resulted in the diagnostic criteria for posttraumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association; ) was empirically based and rigorous. There was a high threshold for any changes in any DSM-IV diagnostic criterion. The process is described in this article. The rationale is presented that led to the creation of the new chapter, "Trauma- and Stressor-Related Disorders," within the DSM-5 metastructure. Specific issues discussed about the DSM-5 PTSD criteria themselves include a broad versus narrow PTSD construct, the decisions regarding Criterion A, the evidence supporting other PTSD symptom clusters and specifiers, the addition of the dissociative and preschool subtypes, research on the new criteria from both Internet surveys and the DSM-5 field trials, the addition of PTSD subtypes, the noninclusion of complex PTSD, and comparisons between DSM-5 versus the World Health Association's forthcoming International Classification of Diseases (ICD-11) criteria for PTSD. The PTSD construct continues to evolve. In DSM-5, it has moved beyond a narrow fear-based anxiety disorder to include dysphoric/anhedonic and externalizing PTSD phenotypes. The dissociative subtype may open the way to a fresh approach to complex PTSD. The preschool subtype incorporates important developmental factors affecting the expression of PTSD in young children. Finally, the very different approaches taken by DSM-5 and ICD-11 should have a profound effect on future research and practice.

Intrusion-based reasoning and depression: cross-sectional and prospective relationships

Intrusion-based reasoning refers to the tendency to form interpretations about oneself or a situation based on the occurrence of a negative intrusive autobiographical memory. Intrusion-based reasoning characterises post-traumatic stress disorder, but has not yet been investigated in depression. We report two studies that aimed to investigate this. In Study 1 both high (n = 42) and low (n = 28) dysphoric participants demonstrated intrusion-based reasoning. High-dysphoric individuals engaged in self-referent intrusion-based reasoning to a greater extent than did low-dysphoric participants. In Study 2 there were no significant differences in intrusion-based reasoning between currently depressed (n = 27) and non-depressed (n = 51) participants, and intrusion-based reasoning did not predict depressive symptoms at 6-month follow-up. Interestingly, previously (n = 26) but not currently (n = 27) depressed participants engaged in intrusion-based reasoning to a greater extent than never-depressed participants (n = 25), indicating the possibility that intrusion-based reasoning may serve as a "scar" from previous episodes. The implications of these findings are discussed.

Social defeat and PTSD symptoms following trauma

OBJECTIVES

Research indicates that constructs relevant to social rank predict a diagnosis of post-traumatic stress disorder (PTSD), including mental defeat, alienation, and shame. However, no studies have yet explored a social rank view explicitly.

DESIGN

This was a community-based study carried out online. Analyses were both cross-sectional and longitudinal over 6 months.

METHODS

Participants were recruited online for a cross-sectional study (Study 1, n = 194) and a 6-month longitudinal study (Study 2, n = 81). Measures included self-report measures of PTSD symptoms (the Post-Traumatic Diagnostic Scale) and social rank (including measures of unfavourable social comparison, social defeat, and internal/external entrapment).

RESULTS

Cross-sectional analysis showed that social defeat, but not other aspects of social rank, was independently predictive of a diagnosis of PTSD. Longitudinal analysis showed that greater social defeat at baseline predicted less improvement in PTSD symptoms, whereas greater reduction in social defeat over the 6-month follow-up predicted greater improvement in PTSD symptoms.

CONCLUSIONS

In addition to the implications for understanding the role of social (rather than individual mental) defeat in the aetiology of PTSD, interventions could usefully incorporate methods that either increase social status or else minimize the impact of low status (e.g., through the use of compassion-focused approaches).

Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder

OBJECTIVE

There is a growing body of evidence for the effectiveness of trauma-focused cognitive behavior therapy (TF-CBT) for posttraumatic stress disorder (PTSD), but few studies to date have investigated the mechanisms by which TF-CBT leads to therapeutic change. Models of PTSD suggest that a core treatment mechanism is the change in dysfunctional appraisals of the trauma and its aftermath. If this is the case, then changes in appraisals should predict a change in symptoms. The present study investigated whether cognitive change precedes symptom change in Cognitive Therapy for PTSD, a version of TF-CBT.

METHOD

The study analyzed weekly cognitive and symptom measures from 268 PTSD patients who received a course of Cognitive Therapy for PTSD, using bivariate latent growth modeling.

RESULTS

Results showed that (a) dysfunctional trauma-related appraisals and PTSD symptoms both decreased significantly over the course of treatment, (b) changes in appraisals and symptoms were correlated, and (c) weekly change in appraisals significantly predicted subsequent reduction in symptom scores (both corrected for the general decrease over the course of therapy). Changes in PTSD symptom severity did not predict subsequent changes in appraisals.

CONCLUSIONS

The study provided preliminary evidence for the temporal precedence of a reduction in negative trauma-related appraisals in symptom reduction during trauma-focused CBT for PTSD. This supports the role of change in appraisals as an active therapeutic mechanism.

Predicting Chronic Posttraumatic Stress Disorder in Bereaved Relatives

The objectives of the present study were to examine the prevalence of posttraumatic stress disorder (PTSD) and to identify predicative risk factors for PTSD in bereaved people after a terminal illness. Fifty-four persons (mean age 60 years) participated in the study. Demographic, peritraumatic, and psychosocial factors were assessed in order to identify variables that affected PTSD severity. Six months after the loss, 21.6 % of the subjects had PTSD, an 8.6 % decrease from PTSD measured one month after the loss. Intake of medicine after the loss, place of death, not having a close intimate, negative affectivity, and the A2 criterion predicted 65 % of PTSD severity. A considerable number of the bereaved were still at great risk for developing PTSD six months after loss.

Current status on behavioral and biological markers of PTSD: a search for clarity in a conflicting literature

Extensive research has identified stereotypic behavioral and biological abnormalities in post-traumatic stress disorder (PTSD), such as heightened autonomic activity, an exaggerated startle response, reduced basal cortisol levels and cognitive impairments. We have reviewed primary research in this area, noting that factors involved in the susceptibility and expression of PTSD symptoms are more complex and heterogeneous than is commonly stated, with extensive findings which are inconsistent with the stereotypic behavioral and biological profile of the PTSD patient. A thorough assessment of the literature indicates that interactions among myriad susceptibility factors, including social support, early life stress, sex, age, peri- and post-traumatic dissociation, cognitive appraisal of trauma, neuroendocrine abnormalities and gene polymorphisms, in conjunction with the inconsistent expression of the disorder across studies, confounds attempts to characterize PTSD as a monolithic disorder. Overall, our assessment of the literature addresses the great challenge in developing a behavioral and biomarker-based diagnosis of PTSD.

The prevalence of full and partial posttraumatic stress disorder among people with severe mental illness in Israel

Research has shown higher rates of trauma exposure and posttraumatic stress disorder (PTSD) among persons with severe mental illness (SMI). The aim of this study was to assess the prevalence of traumatic events and full and partial PTSD among people with SMI and their associations with trauma-related cognitions and depressive symptoms. A total of 122 persons with SMI were assessed for trauma exposure and PTSD. A subsample of 40 participants, 20 with PTSD and 20 without PTSD, were randomly selected, and their posttraumatic cognitions and depressive symptoms were assessed. The prevalence of traumatic events was 90%, and 19% met full diagnostic criteria for PTSD, and 20% had partial PTSD. The people with PTSD had more depressive symptoms and negative cognitions. PTSD in SMI is highly prevalent and underdiagnosed.

Differential roles of thought suppression and dispositional mindfulness in posttraumatic stress symptoms and craving

Exposure to traumatic events often results in severe distress which may elicit self-medication behaviors. Yet, some individuals exposed to trauma do not develop post-traumatic stress symptoms and comorbid addictive impulses. In the wake of traumatic events, psychological processes like thought suppression and mindfulness may modulate post-traumatic stress and craving for substances. We examined the differential roles of mindfulness and suppression in comorbid post-traumatic stress and craving among a sample of 125 persons with extensive trauma histories and psychiatric symptoms in residential treatment for substance dependence. Results indicated that thought suppression, rather than extent of trauma history, significantly predicted post-traumatic stress symptom severity while dispositional mindfulness significantly predicted both post-traumatic stress symptoms and craving. In multiple regression models, mindfulness and thought suppression combined explained nearly half of the variance in post-traumatic stress symptoms and one-quarter of the variance in substance craving. Moreover, multivariate path analysis indicated that prior traumatic experience was associated with greater thought suppression, which in turn was correlated with increased post-traumatic stress symptoms and drug craving, whereas dispositional mindfulness was associated with decreased suppression, post-traumatic stress, and craving. The maladaptive strategy of thought suppression appears to be linked with adverse psychological consequences of traumatic life events. In contrast, dispositional mindfulness appears to be a protective factor that buffers individuals from experiencing more severe post-traumatic stress symptoms and craving.

The Role of Social Support in Exposure Therapy for Operation Iraqi Freedom/Operation Enduring Freedom Veterans: A Preliminary Investigation

The lack of social support has consistently been identified as a relevant factor in the development, maintenance, and treatment of posttraumatic stress disorder (PTSD). Prospective studies with combat veterans have supported the erosion model of social support in the development of PTSD. This model posits that increased PTSD symptoms lead to diminished social support over time. Additional epidemiological work that has investigated mental health and functional impairment in recently returning Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans has suggested that interpersonal problems coincide with the onset of PTSD. Despite research that suggests OIF/OEF veterans experience high rates of PTSD and associated interpersonal problems, no studies have examined social support in relation to treatment response in this group. The current study examined the role of four theorized functional aspects of social support- emotional/informational support, positive social interactions, affectionate support, and tangible support- on pretreatment PTSD symptom severity and treatment response in a sample of OIF/OEF veterans receiving exposure-based psychotherapy. Findings showed that positive social interactions were negatively correlated with pretreatment symptom severity, and emotional/informational support was positively related to increased treatment response. Together, these findings suggest that specific types of social support may have an important influence on the course of exposure treatment.

PTSD and re-offending risk: the mediating role of worry and a negative perception of other people's support

BACKGROUND

Studies of posttraumatic stress disorder (PTSD) are mainly focused on victims of trauma. Very few studies explored the links between PTSD symptoms and re-offending risk in perpetrators of violence.

OBJECTIVE

The aim of the study was to assess the effect of PTSD symptoms on re-offending risk in prisoner populations with a focus on indirect effects of worry and a negative perception of other people's support on the relationship between PTSD and re-offending risk.

METHODS

75 prisoners (25 females, mean age: 44.36 years; 50 males, mean age: 34.7 years) were assessed for exposure to child abuse and neglect, PTSD symptoms, worry, a negative perception of other people's support and re-offending risk. Mediation analyses tested the indirect effects of worry and a negative perception of other people's support on the relationship between PTSD and re-offending risk.

RESULTS

72% participants presented PTSD symptoms and 30.7% were at risk of re-offending. Mediation analyses supported the hypothesis of a mediation pathway from PTSD to worry and a negative perception of other people's support to an increased risk of re-offending.

CONCLUSIONS

The results indicate that prisoners report high rates of PTSD symptoms; furthermore, they highlight an important relationship between PTSD and re-offending risk. Findings suggest that future research should test further the indirect effects of negative cognitive and emotional states on the relationship of PTSD and re-offending risk and explore more in depth the role of PTSD to assess and treat prisoners.

The relationship of PTSD to negative cognitions: a 17-year longitudinal study

With the growing interest in the role of cognitions in PTSD, this prospective study examined the course and bi-directional relationship between post-trauma cognitions and symptoms of PTSD. A sample of Israeli combat veterans, including former prisoners of war, was assessed in 1991, and later followed up in 2003 and 2008. PTSD symptoms were measured at three time points. Cognitions concerning the self and the world were measured twice. Applying autoregressive cross-lagged (ARCL) modeling strategy, initial PTSD symptoms predicted subsequent negative cognitions but not vice versa. In addition, repeated measures design revealed that individuals with chronic PTSD symptoms had relatively negative cognitions that further amplified with time. More specifically, increasingly negative cognitions were documented among ex-prisoners of war. The main findings suggest that negative cognitions are fueled by PTSD and that in chronic PTSD there is an amplification of pathogenic outcomes over time. Discussion of the findings is in the context of current cognitive models of PTSD.

Risk factors for posttraumatic stress disorder in female help-seeking victims of sexual assault

Posttraumatic stress disorder (PTSD) is common in the aftermath of rape and other sexual assault, but the risk factors leading to PTSD following rape have been shown to differ from those related to PTSD following nonsexual assault. This prospective study examined risk factors for PTSD severity in 148 female help-seeking victims of sexual assault. Approximately 70% of the victims experienced significant levels of traumatization, with 45% reporting symptoms consistent with a probable PTSD diagnosis. Regression analyses showed that relationship with the assailant, number of assailants, the nature of the assault, perceived positive social support, support satisfaction, feeling let down by others, and prior exposure to sexual trauma did not significantly predict PTSD severity at the final level of analysis. In accordance with suggestions by Dancu, Riggs, Hearst-Ikeda, and Shoyer (1996), it is suggested that this is partly caused by a very high degree of traumatization in the sample. Instead, previous nonsexual traumatic experiences and negative affectivity accounted for 30% of the variance in PTSD severity. Although more research is needed on risk factors of assault-related PTSD, these findings suggest that although sexual assault is associated with a high degree of PTSD severity, prior nonsexual victimization and high levels of negative affectivity appear to further increase the vulnerability toward developing symptoms of assault-related PTSD.

Reducing unwanted trauma memories by imaginal exposure or autobiographical memory elaboration: an analogue study of memory processes

Unwanted memories of traumatic events are a core symptom of post-traumatic stress disorder. A range of interventions including imaginal exposure and elaboration of the trauma memory in its autobiographical context are effective in reducing such unwanted memories. This study explored whether priming for stimuli that occur in the context of trauma and evaluative conditioning may play a role in the therapeutic effects of these procedures. Healthy volunteers (N = 122) watched analogue traumatic and neutral picture stories. They were then randomly allocated to 20 min of either imaginal exposure, autobiographical memory elaboration, or a control condition designed to prevent further processing of the picture stories. A blurred picture identification task showed that neutral objects that preceded traumatic pictures in the stories were subsequently more readily identified than those that had preceded neutral stories, indicating enhanced priming. There was also an evaluative conditioning effect in that participants disliked neutral objects that had preceded traumatic pictures more. Autobiographical memory elaboration reduced the enhanced priming effect. Both interventions reduced the evaluative conditioning effect. Imaginal exposure and autobiographical memory elaboration both reduced the frequency of subsequent unwanted memories of the picture stories.

A consideration of select pre-trauma factors as key vulnerabilities in PTSD

Posttraumatic stress disorder (PTSD) is a pathological response to a traumatic event. A number of risk and vulnerability factors predicting PTSD development have been identified in the literature. Many of these variables are specific factors occurring during and after exposure to a traumatic event or are not measured prospectively to assess temporal sequence. Recent research, however, has begun to focus on pre-trauma individual differences that could contribute to risk for developing PTSD. The present review proposes that a number of biological and cognitive vulnerability factors place individuals at risk for PTSD development prior to the actual experience of trauma. Accordingly, this review provides a summary of evidence for a select number of these factors as pre-trauma vulnerabilities to PTSD. Included is a discussion of biological factors, including molecular genetic studies of systems regulating serotonin, catecholamines, and glucocorticoids as well as aspects of the neuroendocrine system. Specific cognitive factors are also considered, including intelligence, neuropsychological functioning and cognitive biases such as negative attributional style and appraisals. For each factor, the present review summarizes evidence to date regarding PTSD vulnerability and highlights directions for future research in this area.

Cognitive and non-cognitive factors associated with posttraumatic stress symptoms in mothers of children with type 1 diabetes

BACKGROUND

The experience of having a child diagnosed with type 1 diabetes mellitus (T1DM) can negatively impact on the mother's well-being and trigger posttraumatic stress symptoms. To date, only one study has examined the role of non-cognitive factors in predicting the occurrence of PTSD in parents of children diagnosed with diabetes. However, in the broader PTSD literature is has been shown that both non-cognitive variables and cognitive variables predict PTSD in traumatized populations.

AIMS

The current study aimed to investigate the relationship of both non-cognitive (trauma severity, psychiatric history and social support) and cognitive variables (negative cognitive appraisals and dysfunctional cognitive appraisals) with PTSD in mothers of children recently diagnosed with diabetes.

METHOD

A single group survey design and self-report questionnaires were used to investigate the relationship between both non-cognitive (trauma severity, psychiatric history and history of trauma, and social support) and cognitive factors (negative cognitive appraisals and dysfunctional strategies) and PTSD symptoms in mothers of children who had been diagnosed with type 1 diabetes in the last 5 years.

RESULTS

All cognitive variables were positively associated with PTSD symptoms. In contrast, of the non-cognitive variables, only social support was significantly (negatively) associated with PTSD symptoms. Moreover, regression analysis found that cognitive variables explained variance in PTSD symptoms over and above that contributed by the non-cognitive variables.

CONCLUSIONS

This supports the cognitive model of PTSD. The implications of the study with regards to early detection of and therapies for PTSD in this population are discussed.

Investigating Cognitive Pathways to Psychopathology: Predicting Depression and Posttraumatic Stress Disorder From Early Responses After Assault

Depression and posttraumatic stress disorder (PTSD) are common after trauma, but it remains unclear what factors determine which disorder a trauma survivor will develop. A prospective longitudinal study of 222 assault survivors assessed candidate predictors derived from cognitive models of depression and PTSD at 2 weeks posttrauma (N = 222), and depression and PTSD symptom severities (N = 183, 82%) and diagnoses at 6 months (N = 205, 92%). Structural equation modeling showed that the depression and PTSD models predicted both depression and PTSD symptom severity, but that the disorder-specific models predicted the respective outcome best (43% for depression, 59% for PTSD symptom severity). Maintaining cognitive variables (hopelessness and self-devaluative thoughts in depression; cognitive responses to intrusive memories and persistent dissociation in PTSD) showed the clearest specific relationships with outcome. Model-derived variables predicted depression and PTSD diagnoses at 6 months over and above what could be predicted from initial diagnoses. Results support the role of cognitive factors in the development of depression and PTSD after trauma, and provide preliminary evidence for some specificity in maintaining cognitive mechanisms.

The contribution of threat probability estimates to reexperiencing symptoms: a prospective analog study

BACKGROUND AND OBJECTIVES

Individuals with posttraumatic stress disorder (PTSD) are hypothesized to have a "sense of current threat." Perceived threat from the environment (i.e., external threat), can lead to overestimating the probability of the traumatic event reoccurring (Ehlers & Clark, 2000). However, it is unclear if external threat judgments are a pre-existing vulnerability for PTSD or a consequence of trauma exposure. We used trauma analog methodology to prospectively measure probability estimates of a traumatic event, and investigate how these estimates were related to cognitive processes implicated in PTSD development.

METHODS

151 participants estimated the probability of being in car-accident related situations, watched a movie of a car accident victim, and then completed a measure of data-driven processing during the movie. One week later, participants re-estimated the probabilities, and completed measures of reexperiencing symptoms and symptom appraisals/reactions.

RESULTS

Path analysis revealed that higher pre-existing probability estimates predicted greater data-driven processing which was associated with negative appraisals and responses to intrusions. Furthermore, lower pre-existing probability estimates and negative responses to intrusions were both associated with a greater change in probability estimates. Reexperiencing symptoms were predicted by negative responses to intrusions and, to a lesser degree, by greater changes in probability estimates.

LIMITATIONS

The undergraduate student sample may not be representative of the general public. The reexperiencing symptoms are less severe than what would be found in a trauma sample.

CONCLUSIONS

Threat estimates present both a vulnerability and a consequence of exposure to a distressing event. Furthermore, changes in these estimates are associated with cognitive processes implicated in PTSD.

Hopelessness, defeat, and entrapment in posttraumatic stress disorder: their association with suicidal behavior and severity of depression

Research has shown an increased frequency of suicidal behaviors in those with PTSD, but few studies have investigated the factors that underlie the emergence of suicidal behavior in PTSD. Two theories of suicide, the Cry of Pain and the Schematic Appraisal Model of Suicide, propose that feelings of hopelessness, defeat, and entrapment are core components of suicidality. This study aimed to examine the association between suicidal behavior and hopelessness, defeat, and entrapment in trauma victims with and without a PTSD diagnosis. The results demonstrated that hopelessness, defeat, and entrapment were significantly positively associated with suicidal behavior in those with PTSD. Hopelessness and defeat were also significantly positively associated with suicidal behavior in trauma victims without PTSD. In those with PTSD, the relationship between suicidal behavior and hopelessness and entrapment remained significant after controlling for comorbid depression. The findings provide support for the contemporary theories of suicidality and have important clinical implications.

Daily stressors in patients with acute whiplash associated disorders

PURPOSE

Stressors in acute whiplash associated disorders (WAD), as reported on a daily basis, have hitherto been neglected in research. The primary aim of this study was to describe the most stressful daily situation or event reported by individuals with acute WAD within a month of a whiplash trauma. Another aim was to describe the meaning and significance of these daily stressors, i.e. primary appraisal.

METHOD

A descriptive design with a content analysis approach was used. 260 WAD-daily coping assessments (WAD-DCA) generated during 1 week by 51 participants with acute WAD were included in the study. Stressors were analysed using qualitative content analysis.

RESULTS

The reported stressors generated 13 categories covering a wide range of stressful situations in daily life related to (i) work, (ii) physical symptoms, (iii) feelings and cognitions, (iv) family and home responsibilities and (v) recreation. The majority of the stressors were appraised as "expected" as well as "disabling". Most threatening stressors were related to work, driving and feelings/cognitions.

CONCLUSIONS

The wide variety of stressors indicates that it is not only pain itself that influences daily life in acute WAD. Early identification of individual and situation-specific stressors gives new data regarding what bothers individuals suffering from WAD after a collision and may be helpful in understanding the coping process in relation to specific stressors and stressor appraisals.

Peritraumatic distress and the course of posttraumatic stress disorder symptoms: a meta-analysis

OBJECTIVE

To examine how peritraumatic distress modulates the severity of posttraumatic stress disorder (PTSD) according to the timing of the PTSD symptom assessments.

METHOD

A systematic literature review of English- and French-language studies having administered the Peritraumatic Distress Inventory (PDI) was conducted. Meta-analyses were performed on correlations relating PDI and PTSD symptom scores obtained from the sampled studies. The meta-analyses, which included calculations of regression slopes, took into consideration the time at which PTSD symptoms were assessed following the traumatic event and the timing of the PDI assessment.

RESULTS

The literature review yielded a total of 22 studies. The meta-analysis performed over all studies resulted in a pooled correlation coefficient of 0.55 between the PDI and PTSD symptom scores. Meta-regression analyses conducted over all data revealed no apparent decrease in the correlations according to the timing of the PTSD symptom assessments. However, there were numerical or statistically significant declines in regression slopes when the meta-regressions were separately conducted on studies having administered the PDI either within, or following, a 1-month period after a traumatic event.

CONCLUSIONS

While PDI or PTSD symptom score correlations remain generally significant, they tend to decline as time elapses between the traumatic event and the PTSD assessment. This suggests there may be factors other than peritraumatic distress that increasingly account for the long-term trajectory PTSD symptoms.

PTSD as Meaning Violation: Testing a Cognitive Worldview Perspective

The cognitive perspective on post-traumatic stress disorder (PTSD) has been successful in explaining many PTSD-related phenomena and in developing effective treatments, yet some of its basic assumptions remain surprisingly under-examined. The present study tested two of these assumptions: (1) situational appraisals of the event as violating global meaning (i.e., beliefs and goals) is related to PTSD symptomatology, and (2) the effect of situational appraisals of violation on PTSD symptomatology is mediated by global meaning (i.e., views of self and world). We tested these assumptions in a cross-sectional study of 130 college students who had experienced a DSM-IV level trauma. Structural equation modeling showed that appraisals of the extent to which the trauma violated one's beliefs and goals related fairly strongly to PTSD. In addition, the effects of appraisals of belief and goal violations on PTSD symptoms were fully mediated through negative global beliefs about both the self and the world. These findings support the cognitive worldview perspective, highlighting the importance of the meaning individuals assign to traumatic events, particularly the role of meaning violation.

Understanding the relationship of perceived social support to post-trauma cognitions and posttraumatic stress disorder

Poor social support in the aftermath of a traumatic event is a well-established risk factor for posttraumatic stress disorder (PTSD) among adult trauma survivors. Yet, a great deal about the relationship between social support and PTSD remains poorly understood. In this study, we analyzed data from 102 survivors of a serious motor vehicle accident (MVA) at 4 weeks (Time 1) and 16 weeks (Time 2) post-MVA. We assessed the role of perceived dyadic social support, positive dyadic interaction, and negative dyadic interaction in the development and maintenance of PTSD. In addition, we examined how these social support constructs work together with negative post-trauma cognitions to affect the maintenance of PTSD. Neither perceived social support nor the quality of social interaction (i.e., positive or negative) was associated with PTSD symptom severity at Time 1. However, among those with elevated PTSD symptom severity at Time 1, greater social support and positive social interaction and lower negative social interaction were each associated with reductions in PTSD symptom severity from Time 1 to Time 2. For social support and negative social interaction, this association ceased to be significant when jointly assessed with negative post-trauma cognitions, suggesting that perceived social support and negative dyadic interaction were associated with maintenance of PTSD symptom severity because of their association with negative post-trauma cognitions. These results provide support to models and treatments of PTSD that emphasize the role of negative post-trauma cognitions in maintenance of PTSD.

Posttraumatic stress disorder symptoms, intimate partner violence perpetration, and the mediating role of shame processing bias

Posttraumatic stress disorder (PTSD) may produce internal "threats to the self," which generate shame. Shame is theoretically and empirically linked to intimate partner violence (IPV) perpetration. We examined relations among PTSD, cognitive processing of shame-relevant information, and IPV perpetration. Forty-seven community participants completed an emotional Stroop task with shame-relevant and neutral words. Stimuli were presented supraliminally (i.e., until vocal response) and subliminally (i.e., below an individualized threshold of conscious awareness). Facilitated color-naming of shame-relevant words (thought to reflect congruence between shame and self-schemas) mediated the relation between PTSD severity and IPV perpetration frequency. Mediation results for subliminal stimuli suggest that biased processing of shame cues may occur preconsciously and potentially catalyze processes (i.e., expectations of rejection in ambiguous situations with one's partner; avoidance that minimizes discomfort and protects self-image) that lead to IPV perpetration. Psychotherapeutic approaches to PTSD and IPV should consider the role of facilitated processing of shame cues.

Trauma-related dreams of Australian veterans with PTSD: content, affect and phenomenology

OBJECTIVE

Consensus on the parameters of trauma-related dreams required to meet criteria for post-traumatic stress disorder (PTSD) is critical when: (i) the diagnosis requires a single re-experiencing symptom; and (ii) trauma dreams are prevalent in survivors without PTSD.

METHOD

This study investigated the phenomenology of PTSD dreams in 40 veterans, using structured interview and self-report measures.

RESULTS

Dream content varied between replay, non-replay, and mixed, but affect was largely the same as that experienced at the time of trauma across all dream types. ANOVA indicated no difference between dream types on PTSD severity or nightmare distress.

CONCLUSIONS

The findings provide preliminary support for non-replay dreams to satisfy the DSM B2 diagnostic criterion when the affect associated with those dreams is the same as that experienced at the time of the traumatic event.

Cognitive distortions in an acutely traumatized sample: an investigation of predictive power and neural correlates

BACKGROUND

Current theories of post-traumatic stress disorder (PTSD) place considerable emphasis on the role cognitive distortions such as self-blame, hopelessness or preoccupation with danger play in the etiology and maintenance of the disorder. Previous studies have shown that cognitive distortions in the early aftermath of traumatic events can predict future PTSD severity but, to date, no studies have investigated the neural correlates of this association.

METHOD

We conducted a prospective study with 106 acutely traumatized subjects, assessing symptom severity at three time points within the first 3 months post-trauma. A subsample of 20 subjects additionally underwent a functional 4-T magnetic resonance imaging (MRI) scan at 2 to 4 months post-trauma.

RESULTS

Cognitive distortions proved to be a significant predictor of concurrent symptom severity in addition to diagnostic status, but did not predict future symptom severity or diagnostic status over and above the initial symptom severity. Cognitive distortions were correlated with blood oxygen level-dependent (BOLD) signal strength in brain regions previously implicated in visual processing, imagery and autobiographic memory recall. Intrusion characteristics accounted for most of these correlations.

CONCLUSIONS

This investigation revealed significant predictive value of cognitive distortions concerning concurrent PTSD severity and also established a significant relationship between cognitive distortions and neural activations during trauma recall in an acutely traumatized sample. These data indicate a direct link between the extent of cognitive distortions and the intrusive nature of trauma memories.

The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5

BACKGROUND

There is considerable debate about the cross-cultural applicability of the posttraumatic stress disorder (PTSD) category as currently specified. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds. This review examines various types of cross-cultural validity of the PTSD criteria as defined in DSM-IV-TR, and presents options and preliminary recommendations to be considered for DSM-5.

METHODS

Searches were conducted of the mental health literature, particularly since 1994, regarding cultural-, race-, or ethnicity-related factors that might limit the universal applicability of the diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria for DSM-5.

RESULTS

Substantial evidence of the cross-cultural validity of PTSD was found. However, evidence of cross-cultural variability in certain areas suggests the need for further research: the relative salience of avoidance/numbing symptoms, the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms. This review also indicates the need to modify certain criteria, such as the items on distressing dreams and on foreshortened future, to increase their cross-cultural applicability. Text additions are suggested to increase the applicability of the manual across cultural contexts: specifying that cultural syndromes-such as those indicated in the DSM-IV-TR Glossary-may be a prominent part of the trauma response in certain cultures, and that those syndromes may influence PTSD symptom salience and comorbidity.

CONCLUSIONS

The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

Longitudinal evaluation of the relationship between maladaptive trauma coping and distress: examination following the mass shooting at Virginia Tech

Growing evidence supports that the coping strategies that individuals utilize are a key predictor of distress following trauma. However, there is limited longitudinal research examining the relationship between psychological distress and coping over time, and even less research examining the possibility of reciprocal relationships between distress and coping, despite the fact that prior theoretical work posits such a relationship. The current study modeled the relationship between distress (PTSD and general distress) and maladaptive coping over time in a sample of 368 college women exposed to the mass shooting at Virginia Tech (VT). Participants completed web surveys regarding their distress, shooting-related coping, and shooting-related PTSD 2 months, 6 months, and 1 year following the shooting. They also completed measures of their psychological distress prior to the shooting as part of an unrelated study. A structural cross-lagged model with latent variables supported a reciprocal relationship between maladaptive coping and general psychological distress over time. In contrast, the cross-lagged model evaluating the relationship between PTSD and maladaptive coping supported that PTSD symptoms predicted coping over time, but there was no reciprocal relationship between coping and PTSD. Implications of the findings for future work examining adjustment following traumatic events are discussed.

Trauma, identity and mental health in UK military veterans

BACKGROUND

Military service can lead to profound changes in identity, both in servicemen's perception of themselves and in their relationship to the world, but the significance of these changes for psychopathology is unclear. We investigated whether the extent and valence of identity change was related to the degree of military trauma exposure or to post-traumatic stress disorder (PTSD) and suicide attempts. We further sought to describe the nature of such changes using qualitative analysis.

METHOD

A total of 153 veterans in receipt of a war pension for PTSD or physical disability were identified. Interviews established retrospectively DSM-IV diagnoses of PTSD and reports of suicidal ideation or behaviour since enlistment were examined.

RESULTS

Trauma exposure alone was unrelated to any measure of identity change. By contrast, PTSD was associated with a relationship to the world that had changed in a negative direction. It was also associated with a changed perception of self, which could be either positive or negative. After controlling for trauma exposure and PTSD, suicidal behaviours were associated with more negative perceptions of the world. These perceptions of the world included disillusionment about human nature and a more specific rejection of civilian life.

CONCLUSIONS

PTSD and suicidal behaviours in veterans seem not to be associated with significantly more negative views of the self but rather with more alienation from civilian life. This has serious consequences for engaging veterans in National Health Service (NHS) mental health services and for the provision of effective treatment.

Changes in negative beliefs following three brief programs for facilitating recovery after assault

BACKGROUND

This study examines whether changes in negative beliefs about oneself, others, and the world occur as a result of early intervention aimed at preventing the development of chronic PTSD and further explores whether changes in negative beliefs during early intervention mediate long-term changes in psychopathology and functioning.

METHODS

Ninety recent female assault survivors were randomized to 4-week early intervention programs: brief cognitive behavioral intervention, weekly assessment, or supportive counseling (SC). Changes in negative beliefs were examined from preintervention to postintervention.

RESULTS

Negative beliefs improved across interventions, with somewhat less benefit reported by participants receiving SC. As expected, before intervention more severe negative beliefs were associated with higher initial trauma reactions and these negative beliefs generally improved from preintervention to postintervention. Moreover, for the brief cognitive-behavioral intervention, changes in perceptions of self and one's safety mediated longer-term changes in trauma-related symptoms.

CONCLUSIONS

The present results highlight the potential importance of changes in negative beliefs in long-term adjustment of recent assault survivors.

The role of cognitive appraisal in adaptation to traumatic stress in adults with serious mental illness: a critical review

A compelling body of literature suggests that negative appraisal may be associated with adverse reactions to traumatic stress. However, very few studies have examined how appraisal influences posttraumatic adaptation in people with serious mental illness (SMI) despite evidence of disproportionately high prevalence rates of trauma exposure and Posttraumatic Stress Disorder (PTSD) in this population. The purpose of this article is to provide a critical analysis of the theoretical and empirical literature on cognitive appraisal and psychological adaptation to traumatic stress with a specific focus on individuals diagnosed with SMI. It will be argued that appraisal is a key correlate that may partially account for higher rates of PTSD in people diagnosed with major mood and schizophrenia-spectrum disorders, meriting special consideration for future research.