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

Individual differences predict susceptibility to conditioned fear arising from psychosocial trauma

BACKGROUND

Classical Pavlovian fear conditioning has been widely used in preclinical studies to gain insights into anxiety-related disorders. In this study we examined whether pre-existing behavioral differences, and/or behavioral differences displayed during fear induction, predict the severity of the conditioned fear response that can develop after an episode of psychosocial conflict.

METHODS

Prior to conditioning, male rats (intruders) were behaviorally assessed using the novel environment exploration and defensive burying tests. These animals were subsequently placed in the territory of an older male (resident) that invariably attacked the intruder.

RESULTS

Upon return to this territory 24 h later, intruders moved less than controls and produced more distress vocalizations, indicating conditioned fear to context. Additionally, analyses revealed that both pre-existing behavioral differences, and the animal's response during social conflict, predicted the magnitude of the subsequent conditioned fear response. Specifically, animals that engaged in higher levels of novel environment exploration, that exhibited a greater number of defensive burying behaviors, and that demonstrated higher levels of fighting and guarding during social conflict, displayed less evidence of conditioned fear.

CONCLUSION

These findings show that the behavioral variability existent within a normal outbred population can predict the magnitude of the conditioned fear response.

Reduced autobiographical memory specificity predicts depression and posttraumatic stress disorder after recent trauma

In this prospective longitudinal study, the authors examined the relationship between reduced specificity in autobiographical memory retrieval and the development of depression, posttraumatic stress disorder (PTSD), and specific phobia after injury in an assault. Assault survivors (N = 203) completed the Autobiographical Memory Test (J. M. G. Williams & K. Broadbent, 1986) at 2 weeks after the trauma as well as structured clinical interviews at 2 weeks and 6 months. Participants with acute stress disorder or major depression at 2 weeks, but not those with phobia, retrieved fewer specific autobiographical memories than those without the respective disorder. Reduced memory specificity at 2 weeks also predicted subsequent PTSD and major depression at 6 months over and above what could be predicted from initial diagnoses and symptom severity. Moderator analyses showed that low memory specificity predicted later depression in participants with prior episodes of major depression but not in those without prior depression. Mediation analyses suggested that rumination partly mediated and perceived permanent change fully mediated the effects of low memory specificity on posttrauma psychopathology at follow-up.

Do cognitive models help in predicting the severity of posttraumatic stress disorder, phobia, and depression after motor vehicle accidents? A prospective longitudinal study

The study investigated the power of theoretically derived cognitive variables to predict posttraumatic stress disorder (PTSD), travel phobia, and depression following injury in a motor vehicle accident (MVA). MVA survivors (N = 147) were assessed at the emergency department on the day of their accident and 2 weeks, 1 month, 3 months, and 6 months later. Diagnoses were established with the Structured Clinical Interview for DSM-IV. Predictors included initial symptom severities; variables established as predictors of PTSD in E. J. Ozer, S. R. Best, T. L. Lipsey, and D. S. Weiss's (2003) meta-analysis; and variables derived from cognitive models of PTSD, phobia, and depression. Results of nonparametric multiple regression analyses showed that the cognitive variables predicted subsequent PTSD and depression severities over and above what could be predicted from initial symptom levels. They also showed greater predictive power than the established predictors, although the latter showed similar effect sizes as in the meta-analysis. In addition, the predictors derived from cognitive models of PTSD and depression were disorder-specific. The results support the role of cognitive factors in the maintenance of emotional disorders following trauma.

The influence of data-driven processing on perceptions of memory quality and intrusive symptoms in children following traumatic events

Ehlers and Clark [(2000). A cognitive model of post-traumatic stress disorder. Behaviour Research and Therapy, 38, 319-345] cognitive model of post-traumatic stress disorder (PTSD) has been relatively untested with children. Seventy-five children (7-16 years) were interviewed within 4 weeks of an injury that led to hospital treatment to examine whether peri-traumatic processing strategies (data-driven processing and fear) were associated with perceptions of memory quality and intrusive memories. Perceptions of memory quality mediated the relationship between data-driven processing and intrusive reactions but not avoidance, arousal or depressive reactions. Finally, the relationship between peri-event fear and intrusion reactions was mediated by perceptions of memory quality even after data-driven processing was controlled. The implications of these findings are discussed in the context of a cognitive developmental model of PTSD in children.

Post-traumatic stress disorder: the development of effective psychological treatments

Post-traumatic stress disorder (PTSD) has only relatively recently been introduced into the diagnostic classification of mental disorders. Building on advances in the treatment of other anxiety disorders, a range of effective psychological treatments for PTSD has been developed. The most effective of these treatments focus on the patient's memory for the traumatic event and its meaning. This paper briefly reviews the currently available evidence for these treatments. It then illustrates the process of developing effective psychological treatments by discussing how a combination of phenomenological, experimental and treatment development studies, and theoretical considerations was used to develop a trauma-focused cognitive-behavioral treatment, cognitive therapy (CT) for PTSD. This treatment program builds on Ehlers & Clark's (2000) model of PTSD, which specifies two core cognitive abnormalities in PTSD. First, people with chronic PTSD show idiosyncratic personal meanings (appraisals) of the trauma and/or its sequelae that lead to a sense of serious current threat. Second, the nature of the trauma memory explains the occurrence of re-experiencing symptoms. It is further proposed that the idiosyncratic appraisals motivate a series of dysfunctional behaviors (such as safety-seeking behaviors) and cognitive strategies (such as thought suppression and rumination) that are intended to reduce the sense of current threat, but maintain the problem by preventing change in the appraisals and trauma memory, and/or lead to increases in symptoms. CT addresses the cognitive abnormalities and maintaining behaviors in an individualized, but focused, way. Four randomized controlled trials and two dissemination studies showed that CT for PTSD is acceptable and effective.

Social bonds and posttraumatic stress disorder

Retrospective and prospective studies consistently show that individuals exposed to human-generated traumatic events carry a higher risk of developing Posttraumatic Stress Disorder (PTSD) than those exposed to other kinds of events. These studies also consistently identify perceptions of social support both before and after a traumatic event as an important factor in the determining vulnerability to the development of PTSD. We review the literature on interpersonal traumas, social support and risk for PTSD and integrate findings with recent advances in developmental psychopathology, attachment theory and social neuroscience. We propose and gather evidence for what we term the social ecology of PTSD, a conceptual framework for understanding how both PTSD risk and recovery are highly dependent on social phenomena. We explore clinical implications of this conceptual framework.

Rumination in posttraumatic stress disorder

Recent studies have shown that rumination is a powerful predictor of persistent posttraumatic stress disorder (PTSD). However, to date, the mechanisms by which rumination maintains PTSD symptoms are little understood. Two studies of assault survivors, a cross-sectional (N = 81) and a 6-month prospective longitudinal study (N = 73), examined several facets of ruminative thinking to establish which aspects of rumination provide the link to PTSD. The current investigation showed that rumination is not only used as a strategy to cope with intrusive memories but it also triggers such memories. Certain characteristics of rumination, such as compulsion to continue ruminating, occurrence of unproductive thoughts, and "why" and "what if" type questions, as well as negative emotions before and after rumination, were significantly associated with PTSD, concurrently and prospectively. These characteristics explained significantly more variance in PTSD severity than the mere presence of rumination, thereby indicating that not all ways of ruminative thinking are equally maladaptive.

Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan

The purpose of the present research was to identify rates of posttraumatic stress and depressive symptoms in soldiers returning from war. During reintegration training, U.S. Army soldiers, who recently returned from a 12-month deployment to either Iraq (Operation Iraqi Freedom, n = 2,275) or Afghanistan (Operation Enduring Freedom, n = 1,814), completed study materials. Surveys assessed self-reported levels of depression, posttraumatic stress, and life satisfaction. Results indicated that approximately 44% of soldiers who volunteered to participate self-reported clinically significant levels of depressive symptoms, posttraumatic stress symptoms, or both. Although assessing symptoms and not disorders, these results suggest a potentially high rate of mental health concerns in soldiers immediately after returning from a combat zone. Further research should examine the utility of broad scale interventions.

Trauma coping strategies and psychological distress: A meta-analysis

The identification of adaptive and maladaptive coping strategies following traumatic events has been the subject of much scientific inquiry. The current study sought through meta-analysis to evaluate the relationship between the use of approach and avoidance strategies (both problem-focused and emotion/cognitive focused) following trauma and psychological distress. Thirty-nine studies of coping following two types of traumatic events (interpersonal violence and severe injury) were retained in the meta-analysis. There was a consistent association between avoidance coping and distress, overall r = .37, but no association between approach coping and distress, overall r = -.03, but some important moderators existed. Implications of the results for future research regarding coping and trauma recovery are discussed.

Early predictors of chronic post-traumatic stress disorder in assault survivors

BACKGROUND

Some studies suggest that early psychological treatment is effective in preventing chronic post-traumatic stress disorder (PTSD), but it is as yet unclear how best to identify trauma survivors who need such intervention. This prospective longitudinal study investigated the prognostic validity of acute stress disorder (ASD), of variables derived from a meta-analysis of risk factors for PTSD, and of candidate cognitive and biological variables in predicting chronic PTSD following assault.

METHOD

Assault survivors who had been treated for their injuries at a metropolitan Accident and Emergency (A&E) Department were assessed with structured clinical interviews to establish diagnoses of ASD at 2 weeks (n=222) and PTSD at 6 months (n=205) after the assault. Candidate predictors were assessed at 2 weeks.

RESULTS

Most predictors significantly predicted PTSD status at follow-up. Multivariate logistic regressions showed that a set of four theory-derived cognitive variables predicted PTSD best (Nagelkerke R2=0.50), followed by the variables from the meta-analysis (Nagelkerke R2=0.37) and ASD (Nagelkerke R2=0.25). When all predictors were considered simultaneously, mental defeat, rumination and prior problems with anxiety or depression were chosen as the best combination of predictors (Nagelkerke R2=0.47).

CONCLUSION

Questionnaires measuring mental defeat, rumination and pre-trauma psychological problems may help to identify assault survivors at risk of chronic PTSD.

Vulnerability associations and symptoms of post-traumatic stress disorder in soldiers deployed to Iraq

The purpose of this prospective study was to examine whether explicit and implicit vulnerability associations before and after trauma exposure predict the onset and persistence of post-traumatic stress disorder (PTSD) symptoms. The implicit association test (IAT) was modified to assess associations of self with vulnerability related cues. Dutch soldiers completed the IAT 6 weeks before being deployed to Iraq, and again 5 months upon return home. They also rated an explicit vulnerability scale. PTSD symptoms were assessed 5 and 15 months after deployment with a clinical interview and questionnaire. The results showed that (1) the pre-deployment vulnerability measures did not predict PTSD symptoms at 5 months, (2) both explicit and implicit post-deployment vulnerability measures explained unique variance in concurrent PTSD symptoms, over and above pre-existing neuroticism, and (3) only the explicit post-deployment vulnerability measure predicted unique variance in later PTSD symptoms (at 15 months), after controlling for earlier symptoms. This was no longer the case after controlling for neuroticism. The results suggest that strong implicit associations between the self and vulnerability are a consequence rather than a cause of PTSD symptoms.

Posttraumatic stress disorder: etiology, epidemiology, and treatment outcome

Posttraumatic stress disorder (PTSD) results from exposure to a traumatic event that poses actual or threatened death or injury and produces intense fear, helplessness, or horror. U.S. population surveys reveal lifetime PTSD prevalence rates of 7% to 8%. Potential reasons for varying prevalence rates across gender, cultures, and samples exposed to different traumas are discussed. Drawing upon a conditioning model of PTSD, we review risk factors for PTSD, including pre-existing individual-based factors, features of the traumatic event, and posttrauma social support. Characteristics of the trauma, particularly peritraumatic response and related cognitions, and posttrauma social support appear to confer the greatest risk for PTSD. Further work is needed to disentangle the interrelationships among these factors and elucidate the underlying mechanisms. Based upon existing treatment outcome studies, we recommend use of exposure therapies and anxiety management training as first-line treatment for PTSD. Among psychopharmacological treatments, selective serotonin reuptake inhibitors evidence the strongest treatment effects, yet these effects are modest compared with psychological treatments.

The Driving Cognitions Questionnaire: development and preliminary psychometric properties

Recent research has suggested that fear of driving is common in the general population. People may have various concerns when driving, and instruments for the assessment of these concerns are lacking. The present paper describes the development and preliminary evaluation of the Driving Cognitions Questionnaire (DCQ). The DCQ is a 20-item scale that measures three areas of driving-related concerns--panic-related, accident-related, and social concerns. In three separate samples from different countries (n=69, 100, and 78), the scale showed good internal consistency and substantial correlations with measures of the severity of driving fear. It discriminated well between people with and without driving phobia. It also showed convergent validity with other measures. The questionnaire shows promise for use in research and clinical practice.

Predictors of psychological distress and positive resources among Palestinian adolescents: trauma, child, and mothering characteristics

OBJECTIVE

The aim was to examine how traumatic and stressful events, responses to violence, child characteristics, and mothering quality, as measured in middle childhood predict psychological distress and positive resources in adolescence.

METHOD

The participants were 65 Palestinian adolescents (17+/-.85 years; 52% girls), who had been studied during the First Intifada (T1), during the Palestinian Authority rule (T2) and before the Second Al Aqsa Intifada (T3) in Gaza. Psychological distress was indicated by PTSD, and depressive symptoms and positive resources by resilient attitudes and satisfaction with quality of life, all measured at T3. The predictors that were measured at T1 were exposure to military violence, active coping with violence and children's intelligence, cognitive capacity, and neuroticism. Mothering quality and stressful life-events were measured at T2, the former reported by both the mother and the child, and the latter by the mother.

RESULTS

Adolescents' PTSD symptoms were most likely if they had been exposed to high levels of traumatic and stressful experiences and had poor cognitive capacity and high neuroticism in middle childhood. Only high levels of childhood military violence and stressful life-events predicted high depressive symptoms and low satisfaction with quality of life in adolescence.

CONCLUSIONS

Military violence in childhood forms risks for both increased psychological distress and decreased positive resources. However, child characteristics such as cognitive capacity and personality are important determinants of psychological vulnerability in military trauma.

Mental defeat in chronic pain: initial exploration of the concept

OBJECTIVES

"Mental defeat" has been found to be an important psychologic reaction to painful trauma. Chronic pain patients also report mental defeat in relation to their experience of pain episodes. A measure of mental defeat was devised and evaluated in terms of (1) psychometric properties and (2) specificity of scores in relation to disabling chronic pain.

METHODS

A total of 304 participants completed the Pain Self Perception Scale, a questionnaire designed to measure mental defeat as a reaction to pain. Participants also completed the Short-Form McGill Pain Questionnaire and Hospital Anxiety and Depression Scale. Chronic pain patients from a tertiary hospital clinic (n=94) were compared with patients experiencing acute pain (n=38), pain-free controls (n=79), community volunteers suffering from chronic pain (n=32) or acute pain (n=30), and patients diagnosed with anxiety disorders (n=31). Test-retest reliability was assessed in subsamples of chronic pain patients and community volunteers.

RESULTS

The mental defeat measure was both internally consistent and reliable. Chronic pain patients showed elevated levels of mental defeat relative to all other groups, including people with chronic pain of the same intensity of pain who were not seeking treatment. Pain-specific mental defeat may be linked to disability and the seeking of specialist treatment.

CONCLUSIONS

Research on mental defeat may allow the development of new treatment strategies for chronic pain syndromes and a better understanding of the link between chronic pain, depression, and posttraumatic stress disorder.

Does dissociation further our understanding of PTSD?

Peritraumatic dissociation, and other dissociative reactions, refer to alterations in awareness in the context of a traumatic experience. This review provides an overview of the current conceptualization of dissociation, critiques methodological approaches to studying dissociation, and reviews the evidence for the purported relationship between dissociative reactions and posttraumatic stress disorder. The evidence challenges the notion that a linear relationship exists between dissociation and psychiatric morbidity. Future research should abandon the global construct of dissociation, and study the specific responses that involve altered awareness under experimental conditions.

Emotional numbing weakens abused inner-city women's resiliency resources

Conservation of resources theory (S. E. Hobfoll, 1988, 1999) hypothesizes that loss of resiliency resources can contribute to abused women's posttraumatic stress disorder (PTSD) symptoms, which, in turn, contribute to a further loss of resources, which can make abused women even more vulnerable to future stressors. This study investigates the impact of PTSD symptoms on abused women's future loss of resources-resources that women both value and need to aid their ongoing adjustment. Posttraumatic stress disorder symptoms contributed to future resource loss in abused women, even when controlling for the effects of prior resource loss and depression. Emotional numbing symptoms of PTSD accounted most for women's resource loss. Findings highlight the importance of research and intervention that more directly examines the link between emotions and resource loss.

Posttraumatic appraisals in the development and persistence of posttraumatic stress symptoms

Cognitive models of posttraumatic stress disorder (PTSD) posit that appraisal plays an important role in the development and persistence of PTSD. This study examined posttraumatic appraisals and their relationship to the development and course of PTSD symptoms. Two hundred fifty-three injury survivors were assessed for PTSD symptoms and posttraumatic cognitions across a 12-month period. A path analytic modeling approach showed that posttraumatic appraisals were important direct and indirect predictors of later PTSD severity. The findings suggest that appraisals made in the aftermath of trauma have a significant influence on subsequent psychological adjustment.

Intrusive memories and ruminations related to violent crime among young offenders: phenomenological characteristics

Very little is known about the nature of perpetrator's memories of violent crime. The authors conducted semistructured interviews with a representative sample of 105 young offenders convicted of serious violence, assessing intrusive memories, ruminations, and symptoms of posttraumatic stress disorder related to their violent crime. Forty-eight (46%) participants described significant intrusive memories of the assault, and 38 (36%) reported ruminations related to the assault. Ethnic origin and historical variables explained 19% of the variance of posttraumatic stress disorder symptom severity; intrusion and rumination characteristics added an additional 48% explained variance. The intrusive memories tended to concern the moment when the event turned for the worse for the perpetrator. The findings have implications for risk assessment and therapeutic interventions for violent offenders.

Enduring consequences of terrorism: 7-month follow-up survey of reactions to the bombings in London on 7 July 2005

BACKGROUND

Terrorist attacks can have psychological effects on the general public.

AIMS

To assess the medium-term effects of the July 2005 London bombings on the general population in London and to identify risk factors for persistent effects.

METHOD

We telephoned 1010 Londoners 11-13 days after the bombings to assess stress levels, perceived threat and travel intentions. Seven months later, 574 respondents were contacted again and asked similar questions, and questions concerning altered perceptions of self and the world.

RESULTS

;Substantial stress' (11%), perceived threat to self (43%) and reductions in travel because of the bombings (19%) persisted at a reduced level; other perceived threats remained unchanged. A more negative world view was common. Other than degree of exposure to the bombings, there were no consistent predictors of which people with short-term reactions would develop persistent reactions.

CONCLUSIONS

A longer-term impact of terrorism on the perceptions and behaviour of Londoners was documented.

A mediational model of trait negative affectivity, dispositional thought suppression, and intrusive thoughts following laboratory stressors

Two studies examined the relationships among trait negative affectivity, dispositional thought suppression, and intrusions in non-clinical samples. In Study 1 (N=87), participants were presented with a series of emotionally evocative images and intrusions were examined 48 h after presentation via self-report. In Study 2 (N=118), intrusions were examined using a behavioral Key-press and self-report at two time points (5 and 20 min) following exposure to a series of emotionally evocative images. In each study, participants were assessed for trait negative affectivity and the tendency to engage in thought suppression in response to unpleasant cognitions. Results from both studies support a model in which chronic thought suppression fully mediates the relationship between negative affectivity and the frequency of intrusions.

Overgeneral memory and suppression of trauma memories in post-traumatic stress disorder

The study investigated the relationship between the suppression of trauma memories and overgeneral memory in 42 assault survivors with and without PTSD. Overgeneral memory (OGM) was assessed with a standard autobiographical memory test (AMT). Participants completed two further AMTs under the instructions to either suppress or not suppress assault memories, in counterbalanced order. Participants with PTSD retrieved fewer and more general memories when following the suppression instruction than participants without PTSD, but not under the control instruction. OGM correlated with PTSD symptom severity, and measures of cognitive avoidance. The results are discussed with reference to current theories of overgeneral memory and its possible relationship with PTSD.

Intrusive images in PTSD and in traumatised and non-traumatised depressed patients: a cross-sectional clinical study

Although intrusive images are a hallmark of post-traumatic stress disorder (PTSD) and also occur in depression, little is known about the differences and similarities of such images in these conditions. Our study focuses on the qualities and triggers of intrusive images and responses to them in three groups--patients with PTSD, and depressed patients with and without trauma (n=65)-to highlight the diagnostic specificity of intrusive images for PTSD and depression. We distinguished intrusive images from verbal intrusive cognitions such as rumination and intrusive (brief) lexical thoughts. Consistent with the literature, the intrusive images of PTSD patients had a more "here-and-now quality" and were perceived more visually compared to those of both depressed groups. The groups showed a good deal of similarity concerning other image qualities. Most importantly, the intrusive images in PTSD and depressed patients with and without trauma were perceived as similarly distressing. Rumination and intrusive (brief) lexical thoughts were two of the five most named triggers of intrusive images. Limitations, such as the lack of a control group, and the clinical implications of these results are discussed, demonstrating the need to help non-PTSD patients with and without trauma to deal with intrusive images.

Intrusive memories in perpetrators of violent crime: emotions and cognitions

The authors investigated factors that may determine whether perpetrators of violent crime develop intrusive memories of their offense. Of 105 young offenders who were convicted of killing or seriously harming others, 46% reported distressing intrusive memories, and 6% had posttraumatic stress disorder. Intrusions were associated with lower antisocial beliefs before the assault, greater helplessness, fear, dissociation, data-driven processing and lack of self-referent processing during the assault, more disorganized assault narratives, and greater negative view of the self, negative interpretations of intrusive memories, perceived permanent change, and self-blame. In a logistic regression analysis, the cognitive and emotional variables explained substantial variance over and above demographic factors. The results suggest that cognitive factors that predict reexperiencing symptoms in victims of crime generalize to perpetrators.

Posttraumatic stress disorder symptoms in trauma-exposed college students: the role of trauma-related cognitions, gender, and negative affect

Considerable evidence indicates a prominent role for trauma-related cognitions in the development and maintenance of posttraumatic stress disorder (PTSD) symptoms. The present study utilized regression analysis to examine the unique relationships between various trauma-related cognitions and PTSD symptoms after controlling for gender and measures of general affective distress in a large sample of trauma-exposed college students. In terms of trauma-related cognitions, only negative cognitions about the self were related to PTSD symptom severity. Gender and anxiety symptoms were also related to PTSD symptom severity. Theoretical implications of the results are discussed.

Counterfactual thinking and posttraumatic stress reactions

Preoccupation with alternative outcomes (counterfactual thinking) is a central component of the ruminations of trauma victims. The questions investigated were whether such thinking should be distinguished from general rumination and whether elements of counterfactual thinking might relate to the process of adjustment. A sample of assault victims was interviewed. They completed a battery of self-report scales and thought-listing procedures. Frequency of counterfactual thinking was closely associated with continuing levels of posttraumatic distress. However, high availability of counterfactuals (as indexed by verbal fluency) was related to potentially adaptive outcomes, such as the generation of behavioral plans. In addition, as expected, levels of different aspects of counterfactual thinking were moderated by metacognitive control strategies as a function of time since the trauma.

IQ and posttraumatic stress symptoms in children exposed to interpersonal violence

BACKGROUND

The literature is mixed as to the relationship between intelligence quotient (IQ) and Posttraumatic Stress Disorder (PTSD) symptomatology in adult populations. Even less is known about the relationship in children who have been traumatized.

METHODS

Fifty-nine children and adolescents (mean age = 10.6) with a history of interpersonal violence were evaluated with respect to PTSD symptomatology, number of traumas, and estimated Verbal, Performance and Full scale IQ scores. PTSD symptomatology included symptom levels for cluster B (re-experiencing), cluster C (avoidance and numbing), and cluster D (Hypervigilance) and criterion F, functional impairment.

RESULTS

Results indicated that Full scale and Verbal IQ were significantly associated with the number of traumas, re-experiencing symptoms, and impairment. Performance IQ was only associated with impairment. Regression analyses suggested that together PTSD symptomatology predicted Full scale and Verbal IQ but nor Performance IQ and impairment was the single best predictor of IQ generally.

CONCLUSIONS

Findings provide support for an association between PTSD symptoms and IQ, particularly verbal IQ. Two possible reasons for this relationship are that higher levels of Verbal IQ may serve as a premorbid protective factor against the development of re-experiencing symptoms, or performance on post-trauma Verbal IQ measures may be negatively impacted by expression of PTSD symptoms. Longitudinal studies are needed to clarify which of these two possibilities explains the association.

Longitudinal studies of PTSD: overview of findings and methods

Posttraumatic stress disorder (PTSD) has a discernible starting point and typical course, hence the particular appropriateness of longitudinal research in this disorder. This review outlines the salient findings of longitudinal studies published between 1988 and 2004. Studies have evaluated risk factors and risk indicators of PTSD, the disorder's trajectory, comorbid disorders and the predictive role of acute stress disorder. More recent studies used advanced data analytic methods to explore the sequence of causation that leads to chronic PTSD. Advantages and limitations of longitudinal methods are discussed.

An analogue study of intrusions

According to cognitive theorists, intrusive trauma memories have their origin in how information during the event is processed. Two studies investigated functional cognitive strategies during medical crises that might protect against intrusions. In Study 1, interviews with health-care professionals were used to identify cognitive strategies judged to be effective in controlling emotions and dealing with medical crises. Study 2 systematically manipulated the use of those strategies in a trauma analogue film paradigm. Experimental participants reported fewer intrusions, and less fear and avoidance of film-related stimuli during the subsequent week than controls. The manipulation did not affect anxiety during the film or memory disorganization. Implications for cognitive theories of intrusion development are discussed.

The role of negative interpretations of intrusive memories in depression

BACKGROUND

Recent investigations have shown that intrusive memories of negative past events, the hallmark symptom of posttraumatic stress disorder (PTSD), are also commonly experienced in depression. This study explored whether Ehlers and Steil's [Ehlers, A., Steil, R., 1995. Maintenance of intrusive memories in posttraumatic stress disorder: a cognitive approach. Behavioural and Cognitive Psychotherapy, 23, 217-249] model of PTSD maintenance, which focuses on the role played by negative interpretations of intrusive symptoms in the persistence of PTSD, also describes processes that operate in depression.

METHODS

Eighty-four undergraduate students were interviewed to identify the presence of intrusive memories in the previous week. Participants who reported an intrusive memory were administered self-report questionnaires that indexed cognitive and affective responses to the memory.

RESULTS

Negative interpretations of intrusive memories were significantly correlated with cognitive avoidance (particularly rumination) and depression severity, after controlling for intrusion frequency and severity of memory content. Negative meaning was the strongest predictor of depression, explaining variance over and above intrusion frequency. Ruminative responses to intrusions were highly correlated with depression.

LIMITATIONS

The use of an unselected student sample.

CONCLUSIONS

The demonstrated utility of Ehlers and Steil's [Ehlers, A., Steil, R., 1995. Maintenance of intrusive memories in posttraumatic stress disorder: A cognitive approach. Behavioural and Cognitive Psychotherapy, 23, 217-249] model of PTSD to account for one aspect of depression maintenance supports recent commentaries [Harvey, A.G., Watkins, E., Mansell, W., Shafran, R., 2004. Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. New York: Oxford University Press] that call for a transdiagnostic approach to understanding the cognitive and behavioural processes that underpin psychological disorders.

PTSD in victims of sexual assault: test of a major component of the Ehlers-Clark theory

We investigated a major component of the Ehlers-Clark theory of post-traumatic stress disorder (PTSD) in a sample of 50 female victims of sexual assault. In particular, we tested the hypothesis that the victims' appraisals of the trauma and its consequences contribute significantly to the persistence of PTSD symptoms. The results indicated that the victims' appraisals of the sexual assault and its sequelae are strongly and positively related to PTSD symptoms. This finding remained significant after statistically controlling for the perceived severity of the assault. Most of the results are consistent with the Ehlers-Clark theory.

A contemporary learning theory perspective on the etiology of anxiety disorders: it's not what you thought it was

The authors describe how contemporary learning theory and research provide the basis for perspectives on the etiology and maintenance of anxiety disorders that capture the complexity associated with individual differences in the development and course of these disorders. These insights from modern research on learning overcome the shortcomings of earlier overly simplistic behavioral approaches, which sometimes have been justifiably criticized. The authors show how considerations of early learning histories and temperamental vulnerabilities affect the short- and long-term outcomes of experiences with stressful events. They also demonstrate how contextual variables during and following stressful learning events affect the course of anxiety disorder symptoms once they develop. This range of variables can lead to a rich and nuanced understanding of the etiology and course of anxiety disorders.

Contribution of cognitive factors to the prediction of post-traumatic stress disorder, phobia and depression after motor vehicle accidents

Past research into the psychological consequences of traumatic events has largely focused on post-traumatic stress disorder (PTSD), although other anxiety disorders and depression are also common in the aftermath of trauma. Little is known about differential predictors of these conditions. The present study investigated the extent to which theoretically derived cognitive variables predict PTSD, phobias and depression after motor vehicle accidents. The cognitive predictors were compared to a set of established, mainly non-cognitive predictors. In addition, we tested how disorder-specific the cognitive predictors are. Participants (n=101) were interviewed within a year after having been injured in a motor vehicle accident. Diagnoses of PTSD, travel phobias and depression, symptom severities and predictor variables were assessed with self-report questionnaires and structured interviews. In multiple regression analyses, the sets of cognitive variables derived from disorder-specific models explained significantly greater proportions of the variance of the symptom severities than the established predictors (PTSD 76% vs. 45%, depression 72% vs. 46% and phobia 66% vs. 40%), and than cognitive variables derived from the models of the other disorders. In addition, the majority of individual cognitive variables showed the expected pattern of differences between diagnostic groups. The results support the hypothesis that disorder-specific sets of cognitive factors contribute to the development and maintenance of PTSD, phobias and depression following traumatic events.

Disclosure und wahrgenommene gesellschaftliche Wertschätzung als Opfer als Prädiktoren von PTB bei Kriminalitätsopfern

Zusammenfassung. Theoretischer Hintergrund: Traumatisierte fühlen sich oft ungenügend unterstützt und wertgeschätzt und ziehen sich von zwischenmenschlichen Kontakten zurück. Es wird angenommen, dass dies die Traumaverarbeitung und Genesung von der Posttraumatischen Belastungsstörung (PTB) verhindern kann. Fragestellungen: Lässt sich PTB-Symptomatik durch interpersonelle Variablen vorhersagen? Besitzen diese Variablen zusätzlichen Erklärungswert zu schon bekannten PTB-Prädiktoren? Methode: Mittels Fragebogenstudie wurden zwei interpersonelle Konzepte “Gesellschaftliche Wertschätzung als Opfer/Überlebender“ und “Offenlegen traumatischer Erfahrungen (Disclosure)“ zusammen mit posttraumatischen kognitiven Veränderungen (PTCI - Foa, Ehlers, Clark, Tolin & Orsillo, 1999 ) bei 151 Kriminalitätsopfern untersucht. Daneben wurden Traumacharakteristika, PTB-Symptomatik (IES-R), allgemeine Psychopathologie (BSI), Gesundheitsstatus (SF-36), und soziale Unterstützung (F-SozU) erhoben. Ergebnisse: Disclosure und gesellschaftliche Wertschätzung klärten zusätzlich zu den bekannten Variablen bis zu 11% der Störungsvarianz auf. Schlussfolgerung: Die Ergebnisse demonstrieren den klinisch vermuteten Einfluss interpersoneller Faktoren auf die PTB-Symptomatik. Die Studie zeigt Möglichkeiten und Grenzen der Erfassung dieser Variablen im Self-report auf.

Trauma narratives and emotional processing

The present study examined the relations between indicators of emotional processing (e.g. trauma narratives), posttraumatic stress symptoms, and psychological distress in two military samples (N = 120) exposed to significant training accidents. Trauma narratives were collected at 2-3 weeks, while outcome measures (e.g. IES-15, PTSS-10, and GHQ-30) were collected at 2-3 weeks, and 4 months after the accidents. Emotional processing was indexed by the content of positive and negative emotional expressions in the trauma narratives. The results showed that positive emotional expressions were associated with lower levels of psychological distress, whereas negative emotional expressions were linked to trauma specific symptoms and psychological distress at 2-3 weeks. Negative emotional expressions explained between 6-8% of the variance in trauma specific symptoms at 2-3 weeks, and 11% of the variance in psychological distress symptoms at 4 months after the traumatic event.

Unwanted memories of assault: what intrusion characteristics are associated with PTSD?

Intrusive memories are common in the immediate aftermath of traumatic events, but neither their presence or frequency are good predictors of the persistence of posttraumatic stress disorder (PTSD). Two studies of assault survivors, a cross-sectional study (N=81) and a 6-month prospective longitudinal study (N=73), explored whether characteristics of the intrusive memories improve the prediction. Intrusion characteristics were assessed with an Intrusion Interview and an Intrusion Provocation Task. The distress caused by the intrusions, their "here and now" quality, and their lack of a context predicted PTSD severity. The presence of intrusive memories only explained 9% of the variance of PTSD severity at 6 months after assault. Among survivors with intrusions, intrusion frequency only explained 8% of the variance of PTSD symptom severity at 6 months. Nowness, distress and lack of context explained an additional 43% of the variance. These intrusion characteristics also predicted PTSD severity at 6 months over and above what could be predicted from PTSD diagnostic status at initial assessment. Further predictors of PTSD severity were rumination about the intrusive memories, and the ease and persistence with which intrusive memories could be triggered by photographs depicting assaults. The results have implications for the early identification of trauma survivors at risk of chronic PTSD.

Das Gletscherbahnunglück von Kaprun in Österreich im Jahr 2000

Zusammenfassung. Es werden die Zusammenhänge zwischen Posttraumatischen Belastungsstörungen, Copingstrategien sowie intrusiven Erinnerungen bei Kriminalbeamten nach dem Gletscherbahnunglück von Kaprun, Österreich (2000) untersucht. In einer prospektiven Längsschnittuntersuchung wurden über zwei Zeitpunkte hinweg, sechs Wochen (t1) und sechs Monate (t2), 74 Kriminalbeamte mit Hilfe der “Posttraumatic Stress Diagnostic Scale“ (PDS), dem “Coping Strategies Questionnaire“ sowie dem “Response to Intrusion Questionnaire“ (RIQ, Clohessy & Ehlers, 1999 ) untersucht. Sechs Wochen bzw. sechs Monate nach dem Ereignis war bei sechs Kriminalbeamten (9.4%) eine Posttraumatische Belastungsstörung feststellbar. Wunschdenken, Vermeidung, emotionale Katharsis und Positive Re-Interpretation korrelierten mit Symptomen der Posttraumatischen Belastungsstörung zum Messzeitpunkt t2. Negative Einschätzungen intrusiver Erinnerungen und Dissoziation erklärten 35% (t1) bzw. 22% (t2) der Varianz Posttraumatischer Belastungsstörungen. Psychologische Faktoren wie Negative Interpretationen intrusiver Erinnerungen und Dissoziation tragen wesentlich zur Entwicklung und Aufrechterhaltung posttraumatischer Belastungssymptome bei.

Pathological responses to terrorism

Many important gains have been made in understanding PTSD and other responses to trauma as a result of neuroscience-based observations. Yet there are many gaps in our knowledge that currently impede our ability to predict those who will develop pathologic responses. Such knowledge is essential for developing appropriate strategies for mounting a mental health response in the aftermath of terrorism and for facilitating the recovery of individuals and society. This paper reviews clinical and biological studies that have led to an identification of pathologic responses following psychological trauma, including terrorism, and highlights areas of future-research. It is important to not only determine risk factors for the development of short- and long-term mental health responses to terrorism, but also apply these risk factors to the prediction of such responses on an individual level. It is also critical to consider the full spectrum of responses to terrorism, as well as the interplay between biological and psychological variables that contribute to these responses. Finally, it is essential to remove the barriers to collecting data in the aftermath of trauma by creating a culture of education in which the academic community can communicate to the public what is and is not known so that survivors of trauma and terrorism will understand the value of their participation in research to the generation of useful knowledge, and by maintaining the acquisition of knowledge as a priority for the government and those involved in the immediate delivery of services in the aftermath of large-scale disaster or trauma.

PTSD and Treatment Adherence: the role of health beliefs

Health beliefs have been shown to influence a myriad of medical treatment decisions. More recently, the impact of health beliefs on treatment decisions for mental illness has become a focus of study. This study examines the health beliefs and treatment behavior of veterans with posttraumatic stress disorder (PTSD). Using standard survey methodology, we assessed beliefs about the cause of PTSD, expected duration and controllability of symptoms, and life consequences of having PTSD. Treatment participation and medication compliance were assessed, as were common treatment correlates, such as patient-provider relationships, dosing frequency, side effect severity, number of prescribed medications, and use of drugs or alcohol to control PTSD symptoms. Explanatory models of PTSD, perceived controllability, and use of benzodiazepines were found to predict psychiatric medication use. Negative life consequences of PTSD were associated with participation in psychotherapy. Assessment of health beliefs may help providers to understand their patients' treatment behavior and to facilitate treatment engagement.

Preventing Post-traumatic Stress Disorder After Mass Exposure to Violence

Bioterrorism preparedness plans must take into account the psychosocial consequences of exposure to mass violence. If possible, post-traumatic stress disorder (PTSD), which is associated with significant morbidity and cost, should be prevented. There are, however, no effective interventions that have been scaled up to prevent PTSD following mass exposure to violence. In fact, randomized controlled trials of the most commonly used preventive intervention, psychological debriefing, suggest no efficacy, or even potential harm. Fortunately, randomized controlled trials of cognitive behavioral therapy--that is, targeting individuals who are symptomatic in the weeks after trauma--reveal significant efficacy. Given the potential for repeated mass violence exposure, public health professionals need to refine methods for screening and tracking large numbers of casualties. At the same time, the use of telephone and internet-based cognitive behavioral therapy protocols should be further tested as strategies for bringing the only effective early intervention for PTSD to scale. Research on preventive pharmacotherapy for PTSD and on the effects of media exposure on PTSD severity is also a priority.

Enhanced priming for trauma-related material in posttraumatic stress disorder

Intrusive reexperiencing in posttraumatic stress disorder (PTSD) has been linked to perceptual priming for trauma-related material. A prospective longitudinal study (N = 69) investigated perceptual priming for trauma-related, general threat, and neutral words in assault survivors with and without PTSD, using a new version of the word-stem completion task. Survivors with PTSD showed enhanced priming for trauma-related words. Furthermore, priming for trauma-related words measured soon after the trauma was associated with subsequent PTSD severity at 3, 6, and 9 months. The enhanced priming effect was specific to trauma-related words. Enhanced perceptual priming for traumatic material appears to be one of the cognitive processes operating in PTSD.