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

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.

Cognitive therapy for post-traumatic stress disorder: development and evaluation

The paper describes the development of a cognitive therapy (CT) program for post-traumatic stress disorder (PTSD) that is based on a recent cognitive model (Behav. Res. Therapy 38 (2000) 319). In a consecutive case series, 20 PTSD patients treated with CT showed highly significant improvement in symptoms of PTSD, depression and anxiety. A subsequent randomized controlled trial compared CT (N = 14) and a 3-month waitlist condition (WL, N = 14). CT led to large reductions in PTSD symptoms, disability, depression and anxiety, whereas the waitlist group did not improve. In both studies, treatment gains were well maintained at 6-month follow-up. CT was highly acceptable, with an overall dropout rate of only 3%. The intent-to-treat effect sizes for the degree of change in PTSD symptoms from pre to post-treatment were 2.70-2.82 (self-report), and 2.07 (assessor-rated). The controlled effect sizes for CT versus WL post-treatment scores were 2.25 (self-report) and 2.18 (assessor-rated). As predicted by the cognitive model, good treatment outcome was related to greater changes in dysfunctional post-traumatic cognitions. Patient characteristics such as comorbidity, type of trauma, history of previous trauma, or time since the traumatic event did not predict treatment response, however, low educational attainment and low socioeconomic status were related to better outcome.

Cognitive Vulnerability to Emotional Disorders

A review of recent research on cognitive processing indicates that biases in attention, memory, and interpretation, as well as repetitive negative thoughts, are common across emotional disorders, although they vary in form according to type of disorder. Current cognitive models emphasize specific forms of biased processing, such as variations in the focus of attention or habitual interpretative styles that contribute to the risk of developing particular disorders. As well as predicting risk of emotional disorders, new studies have provided evidence of a causal relationship between processing bias and vulnerability. Beyond merely demonstrating the existence of biased processing, research is thus beginning to explore the cognitive causes of emotional vulnerability, and their modification.

The fallacy of ex-consequentia reasoning and the persistence of PTSD

Many individuals experience psychological distress after a potentially traumatic event, but only a minority develops chronic posttraumatic stress disorder (PTSD). According to the cognitive model of Ehlers and Clark (Behaviour Research and Therapy 38 (2000) 319), chronic PTSD results from distorted beliefs about the trauma or its sequelae. Given the availability of disconfirming information, why do such distorted beliefs persist? A recent promising line of research focuses on the "ex-consequentia" reasoning fallacy: "if I feel anxiety, there must be danger". Ex-consequentia reasoning may start a vicious circle in which subjective fear responses are used to erroneously validate thoughts of impending doom, which intensifies distress, etc. In other words, false alarms are not recognized and irrational beliefs are maintained. We previously found that other anxiety patients (Behaviour Research and Therapy 33 (1995) 917) and PTSD patients (Behaviour Research and Therapy 39 (2001) 1139) show ex-consequentia reasoning, that is, they appear to believe that anxiety symptoms imply the presence of danger. Interestingly, this was not restricted to situations relevant to the individual's anxiety disorder. Tentative data suggest that ex-consequentia reasoning is causally involved in the persistence of PTSD and anxiety disorders. These are presented and possible underlying mechanisms are discussed.

Hopelessness as a risk factor for post-traumatic stress disorder symptoms among interpersonal violence survivors

Post-traumatic stress disorder often co-occurs with depression, and they may share common risk factors. One possible common cognitive risk factor is hopelessness. Thus, we examined whether hopelessness was related to symptoms of post-traumatic stress disorder. Participants were 202 female survivors of interpersonal violence. Relationships between self-reported and interviewer-rated measures of hopelessness gathered at 2 weeks post-trauma and self-reported and interviewer-rated symptoms of post-traumatic stress disorder gathered at 2 weeks and 3 months post-trauma were examined. Hierarchical, simultaneous regression analyses that co-varied trauma type revealed that hopelessness was related to self-reported symptoms of post-traumatic stress disorder, both concurrently and prospectively. Follow-up analyses revealed that relationships between hopelessness and symptoms of post-traumatic stress disorder were due almost entirely to shared variance with depression. No relationships were found between hopelessness and interviewer-rated symptoms of post-traumatic stress disorder.

Psychological intimate partner violence: the major predictor of posttraumatic stress disorder in abused women

Intimate partner violence (IPV) significantly impacts women mental and physical wellbeing and therefore represents a worldwide public health problem. A clear association between IPV and increased risk to develop posttraumatic stress disorder (PTSD) has been documented. However, few studies examined how different features of IPV (physical, psychological, sexual) interact with other traumatic stress experiences (physical, psychological and sexual childhood abuse and adulthood victimization by other/s than the partner) in determining PTSD. Women abused by the partner (n=75) were compared with non-abused control women (n=52). Information about sociodemographic profile and relevant personal characteristics was obtained through structured interviews. A comprehensive questionnaire was designed for a face-to-face interview in order to obtain detailed information about duration and frequency of the different types of violent acts above mentioned. The incidence and severity of symptoms of current PTSD were assessed with Echeburua's Severity of Symptom Scale of Posttraumatic Stress Disorder, a structured interview based on DSM-IV criteria. Women suffering from IPV had a significantly higher rate of PTSD symptomatology as compared to control women, whereas childhood abuse variables did not explain PTSD score variance. In addition, the severity of IPV was significantly and positively correlated with the intensity of PTSD symptoms. Women involved in an abusive relationship were more frequently exposed to other experiences of adulthood victimization, suggesting that their higher PTSD vulnerability could be a result of cumulative traumatic experiences. A relevant result of the correlation analysis was the strong, positive association between PTSD and each different type of IPV. In particular, the psychological component of intimate partner violence was the strongest predictor of posttraumatic stress disorder. This study underlines the importance of separating the effects of the different types of intimate partner abuse when taking into account its effects on women mental health.

Change in Cognitive Mediators of Rape's Impact on Psychosocial Health Across 2 Years of Recovery

A previously published cross-sectional model of cognitive mediation of rape's impact on health (M. P. Koss, A. J. Figueredo, & R. J. Prince, 2002) was replicated longitudinally. Rape survivors (n = 59) were assessed 4 times at 3-24 months postrape. Growth curve analysis demonstrated significant change in all mediators and outcomes. Previously reported effects of Characterological Self-Blame, Behavioral Self- Blame, and Maladaptive Beliefs on Psychosocial Distress were partially cross-validated in intercept and slope data. The results suggest that Characterological Self-Blame sets the initial level of Psychosocial Distress and that reduction in Behavioral Self-Blame drives recovery. These effects on distress were wholly mediated through self-blame's association with alterations in beliefs about self and others.

Developing new treatments: on the interplay between theories, experimental science and clinical innovation

It is often argued that behaviour therapy and cognitive-behaviour therapy have a sound theoretical and experimental basis. In the early days of behaviour therapy, the learning theory accounts that were the basis of treatment made clear suggestions about the procedures that were likely to be effective in treatment. In contrast, more recent cognitive-behavioural models tend to specify targets for therapy, but not the procedures that might be optimal for changing the targets. As a consequence, a considerable amount of work has to be done in order to create an effective cognitive-behavioural treatment from a promising cognitive-behavioural model. The process by which cognitive-behavioural treatments are developed is rarely discussed in the literature. For this reason, the way in which one group has used a mixture of phenomenological, experimental and treatment development studies to create effective cognitive therapy programmes for anxiety disorders is described.

PTSD and world assumptions following myocardial infarction: a longitudinal study

The study aims to examine the association between exposure to trauma, posttraumatic stress disorder (PTSD), and world assumptions. The study included 3 groups of subjects: PTSD myocardial infarction (MI) patients, non-PTSD MI patients, and matched controls. World assumptions were examined twice: within a week of the patient's MI (Time 1) and 7 months later (Time 2). The findings indicate that world assumptions are not related to exposure to trauma but are associated with PTSD.

Cognitive approaches to posttraumatic stress disorder: the evolution of multirepresentational theorizing

The evolution of multirepresentational cognitive theorizing in psychopathology is illustrated by detailed discussion and analysis of a number of prototypical models of posttraumatic stress disorder (PTSD). Network and schema theories, which focus on a single, explicit aspect/format of mental representation, are compared with theories that focus on 2 or more explicit representational elements. The author argues that the latter theories provide a more complete account of PTSD data, though are not without their problems. Specifically, it is proposed that at least 3 separate representational elements-associative networks, verbal/propositional representations, and schemas-are required to generate a comprehensive cognitive theory of PTSD. The argument that the development of multirepresentational cognitive theory in PTSD is a paradigm case for the development of similar theories in other forms of psychopathology is elaborated, and a brief agenda is proposed promoting 2 levels of theorizing-deep, formal theory alongside more localized, applied theory.

Risk factors for the development versus maintenance of posttraumatic stress disorder

This study examined risk factors for posttraumatic stress disorder (PTSD) in Vietnam veterans: 68 women and 414 men of whom 88 were White, 63 Black, 80 Hispanic, 90 Native Hawaiian, and 93 Japanese American. Continuation ratio logistic regression was used to compare the predictive power of risk factors for the development versus maintenance of full or partial PTSD. The development of PTSD was related to premilitary, military, and postmilitary factors. The maintenance of PTSD was related primarily to military and postmilitary factors. Multivariate analyses identified different models for development and maintenance. We conclude that development of PTSD is related to factors that occur before, during, and after a traumatic event, whereas failure to recover is related primarily to factors that occur during and after the event.

Neuroticism and self-criticism associated with posttraumatic stress disorder in a nationally representative sample

Broad and specific psychological traits may uniquely differentiate trauma victims with PTSD from trauma victims without PTSD, but there is a need for representative, population-based research. We investigated elevated neuroticism and self-criticism in association with the presence versus absence of PTSD in a nationally representative sample of adults who experienced a traumatic stressor. Respondents were from the National Comorbidity Survey Part II (N=5877) (). Individuals who experienced one or more traumatic events were selected (N=3238). In separate regression analyses, elevated levels of neuroticism and self-criticism were each significantly associated with PTSD among men and women who had experienced one or more traumatic events. After controlling for types of traumas experienced and other previously identified factors (Bromet, Sonnega, & Kessler, 1998. American Journal of Epidemiology, 147, 353-361), neuroticism remained significantly associated with PTSD in women and both neuroticism and self-criticism remained significant in men. Evidence from this nationally representative sample of adults who experienced traumatic events suggests that self-criticism and especially the broad personality domain of neuroticism may represent robust psychological dimensions associated with the presence of PTSD.

The role of cognitive variables in psychological functioning after the death of a first degree relative

The present study sought to explore the relationship between negative cognitions and emotional problems after bereavement, with a group of 329 adults who had suffered the loss of a first degree relative. The following cognitions were assessed: global negative beliefs, cognitions about self-blame, negative cognitions about other people's responses after the loss, and negative cognitions about one's own grief reactions. Results showed that each of these cognitive variables was significantly related to the severity of symptoms of traumatic grief, depression and anxiety, even when background and loss-related variables that were initially found to influence symptom severity, were statistically controlled. When the shared variance between the cognitive variables was controlled, it was found that global negative beliefs about life, the world, and the future, and threatening interpretations of grief reactions each explained a unique proportion of variance in traumatic grief symptom severity. Global negative beliefs about life, the self and the future, and threatening interpretations of grief explained most variance in depression, while negative beliefs about the self and threatening interpretations of grief explained most variance in anxiety. Overall, the findings are in support of cognitive theories of grief, and suggest that effective treatment of problematic grief will need to address negative cognitions.

Gender, social support, and PTSD in victims of violent crime

Gender differences in social support levels and benefits were investigated in 118 male and 39 female victims of violent crime assessed for PTSD symptomatology 1 and 6 months postcrime. Within 1 month postcrime both genders reported similar levels of positive support and support satisfaction, but women reported significantly more negative responses from family and friends. Women also reported an excess of PTSD symptoms that was similar at 1 and 6 months postcrime, and negative responses mediated the relationship between gender and later symptoms. Overall negative response and support satisfaction, but not positive support, were significantly associated with PTSD symptoms. However, the effects of support satisfaction and negative response on 6-month symptoms were significantly greater for women than men. The findings are consistent with previous studies of predominantly female assault victims concerning the stronger impact of negative over positive support, and might help explain women's higher PTSD risk in civilian samples.

Posttraumatic stress disorder following assault: the role of cognitive processing, trauma memory, and appraisals

Two studies of assault victims examined the roles of (a) disorganized trauma memories in the development of posttraumatic stress disorder (PTSD), (b) peritraumatic cognitive processing in the development of problematic memories and PTSD, and (c) ongoing dissociation and negative appraisals of memories in maintaining symptomatology. In the cross-sectional study (n = 81), comparisons of current, past, and no-PTSD groups suggested that peritraumatic cognitive processing is related to the development of disorganized memories and PTSD. Ongoing dissociation and negative appraisals served to maintain PTSD symptoms. The prospective study (n = 73) replicated these findings longitudinally. Cognitive and memory assessments completed within 12-weeks postassault predicted 6-month symptoms. Assault severity measures explained 22% of symptom variance; measures of cognitive processing, memory disorganization, and appraisals increased prediction accuracy to 71%.

Psychological theories of posttraumatic stress disorder

We summarize recent research on the psychological processes implicated in posttraumatic stress disorder (PTSD) as an aid to evaluating theoretical models of the disorder. After describing a number of early approaches, including social-cognitive, conditioning, information-processing, and anxious apprehension models of PTSD, the article provides a comparative analysis and evaluation of three recent theories: Foa and Rothbaum's [Foa, E. B. & Rothbaum, B. O. (1998). Treating the trauma of rape: cognitive behavioral therapy for PTSD. New York: Guilford Press] emotional processing theory; Brewin, Dalgleish, and Joseph's [Psychological Review 103 (1996) 670] dual representation theory; Ehlers and Clark's [Behaviour Research and Therapy 38 (2000) 319] cognitive theory. We review empirical evidence relevant to each model and identify promising areas for further research.

Early psychological interventions for adult survivors of trauma: a review

Psychological interventions after traumatic events have only recently been evaluated in randomized, controlled trials. Recent systematic reviews concluded that single sessions of individual psychological debriefing are not effective in reducing distress or subsequent posttraumatic stress disorder (PTSD) symptoms. The present article reviews trials of early cognitive behavior therapy (CBT) after trauma. Cognitive behavioral therapy was more effective than supportive counseling in preventing chronicity of PTSD symptoms; however, in most available studies it remained unclear whether supportive counseling facilitated or retarded recovery, compared with no intervention. A brief CBT program given in the first month of trauma was not superior to repeated assessment; however, a course of CBT of up to 16 sessions given at 1-4 months after trauma was superior to self-help, repeated assessment, and no intervention. Possible reasons for the difference in efficacy between CBT and debriefing or self-help are discussed. These include the way of working through traumatic memories and the impact of the interventions on patients' interpretations of their PTSD symptoms. Possible ways of identifying people who are in need of specialist psychological intervention after trauma and who are unlikely to recover on their own are discussed. Some ideas for alternative ways of offering help to trauma survivors are presented, and methodologic suggestions for future research are given.

Maltreatment and trauma: tracking the connections in adolescence

Posttraumatic stress disorder is one of the most common and often prolonged consequences of childhood maltreatment. In this article the authors consider theories of trauma continuity, with emphasis on a relational path to maladjustment that links childhood maltreatment to elevated trauma symptomatology and intimate victimization in adolescent dating relationships.

Cognitive predictors of posttraumatic stress disorder in children: results of a prospective longitudinal study

The present study explored whether cognitive factors specified in the Ehlers and Clark model (Behav. Res. Ther. 38 (2000) 319) of posttraumatic stress disorder (PTSD) predict chronic PTSD in children who had experienced a road traffic accident. Children were assessed at 2 weeks, 3 months, and 6 months after the accident. Data-driven processing during the accident, negative interpretation of intrusive memories, alienation from other people, anger, rumination, thought suppression and persistent dissociation at initial assessment predicted PTSD symptom severity at 3 and 6 months. On the basis of sex and stressor severity variables, 14% of the variance of PTSD symptoms at 6 months could be explained. The accuracy of the prediction increased to 49% or 53% when the cognitive variables measured at initial assessment or 3 months, respectively, were taken into account.

Towards a cognitive-behavioral model of PTSD in children and adolescents

Posttraumatic stress disorder in children and adolescents has been studied only for the past 15-20 years and is the subject of a burgeoning corpus of research. Much research has focused on examining whether children and adolescents have the same responses to trauma as those experienced by adults. Many of the research tools used to investigate children's responses are taken from measures designed for use with adults, and these measures have proven to be useful. However, it has not been established that children's responses to traumatic events are related to the same underlying processes as are adults' responses. The possible application of 2 recent cognitive models of PTSD in adults to understanding PTSD in children and adolescents is discussed in this paper, within the context of what is already known about children's reaction to trauma and existing theoretical accounts of childhood PTSD. Particular attention is paid toward the nature of children's memories of traumatic events and how these memories relate to the reexperiencing symptoms of PTSD, and cognitive processes that may play a role in the maintenance of PTSD. It is proposed that the adoption of a more specific cognitive-behavioral framework in the study of this disorder may be beneficial and lead to better treatment outcomes.

A longitudinal study of "intrusion-based reasoning" and posttraumatic stress disorder after exposure to a train disaster

Previously, we found that chronic PTSD relates to "intrusion-based reasoning" (IR), i.e. the tendency to interpret distressing intrusions themselves as evidence that danger is impending, regardless of objective danger information (Engelhard et al., Behav. Res. Ther. 39 (2001) 1139). This study was intended to elucidate the causal status of this relation. Twenty-nine residents of a Belgian town witnessed a train crash and were assessed for IR and PTSD symptoms within 1 month and were re-assessed for PTSD at 3.5 months. Fourteen control residents did not witness the crash and were also tested for IR. The IR paradigm involved rating the danger of brief scenarios in which objective danger and presence of intrusions about the crash were systematically varied. The directly exposed residents showed greater danger ratings to scenarios in which intrusions were included than did the controls. IR was strongly related to both acute and chronic PTSD symptoms. It did not significantly predict chronic PTSD symptoms after controlling for acute symptoms, although the partial correlation (r=0.26, p=0.09) was in the expected direction. The data suggest that IR is involved in the onset and maintenance of PTSD symptoms, but more clarity about causality awaits future larger and experimental studies.