Posttraumatic appraisals in the development and persistence of posttraumatic stress symptoms

Adversity Interpreted: A Scoping Review of Adversity Appraisal Measurement

Although evidence suggests that individuals' appraisals (i.e., subjective interpretations) of adverse or traumatic life events may serve as a mechanism accounting for differences in adversity exposure and psychological adjustment, understanding this mechanism is contingent on our ability to reliably and consistently measure appraisals. However, measures have varied widely between studies, making conclusions about how best to measure appraisal a challenge for the field. To address this issue, the present study reviewed 88 articles from three research databases, assessing adults' appraisals of adversity. To be included in the scoping review, articles had to meet the following criteria: (1) published no earlier than 1999, (2) available in English, (3) published as a primary source manuscript, and (4) included a measure assessing for adults' (over the age of 18) subjective primary and/or secondary interpretations of adversity. Each article was thoroughly reviewed and coded based on the following information: study demographics, appraisal measurement tool(s), category of appraisal, appraisal dimensions (e.g., self-blame, impact, and threat), and the tool's reliability and validity. Further, information was coded according to the type of adversity appraised, the time in which the appraised event occurred, and which outcomes were assessed in relation to appraisal. Results highlight the importance of continued examination of adversity appraisals and reveal which appraisal tools, categories, and dimensions are most commonly assessed for. These results provide guidance to researchers in how to examine adversity appraisals and what gaps among the measurement of adversity appraisal which need to be addressed in the future research.

The longitudinal association between moral injury appraisals and psychological outcomes in refugees

BACKGROUND

Refugees report a diverse array of psychological responses following persecution and displacement. Little is known, however, regarding the mechanisms that underlie differential psychological reactions in refugees. This study investigated the longitudinal impact of negative moral appraisals about one's own actions [i.e. moral injury-self (MI-self) appraisals] and others' actions [i.e. moral injury-other (MI-others) appraisals] on a variety of psychological symptoms over a period of 6 months.

METHODS

Participants were 1085 Arabic, Farsi, Tamil, or English-speaking refugees who completed a survey at baseline and 6 months later either on-line or via pen-and-paper. The survey indexed demographic factors, exposure to potentially traumatic events (PTEs), exposure to ongoing stressors, MI-other appraisals, MI-self appraisals, re-experiencing and arousal symptoms, and feelings of sadness, anger and shame.

RESULTS

Findings indicated that, after controlling for demographics, PTE exposure and ongoing stressors, MI-other appraisals predicted increased re-experiencing and hyperarousal symptoms, and feelings of sadness and shame. MI-self appraisals predicted decreased feelings of shame, and decreased re-experiencing symptoms. In contrast, psychological symptoms at baseline did not as strongly influence MI appraisals 6 months later.

CONCLUSIONS

These findings highlight the important role that cognitive appraisals of adverse events play in the longitudinal course of psychological symptoms. These results thus have important implications for the development of tailored psychological interventions to alleviate the mental health burden held by refugees.

Child Posttraumatic Stress after Parental Cancer: Associations with Individual and Family Factors

Objective

This study aimed to examine the severity of posttraumatic stress disorder (PTSD) symptoms in children of parents with cancer and to identify individual and family factors associated with these symptoms.

Methods

The sample consisted of 175 children (52% girls, aged M = 11.98, SD = 3.20, range = 6–20 years) from 92 families, of which 90 parents with a current or past cancer diagnosis and 71 healthy co-parents also completed questionnaires. Children reported on PTSD symptoms, trauma-related cognitions, emotion regulation difficulties, general family functioning, and family communication. Both parents reported on their own PTSD symptoms. Associations were investigated using multilevel regression.

Results

Twenty-seven percentage of the children showed clinically relevant PTSD symptoms. Intraclass correlations indicated that children from the same family showed little overlap in these symptoms. Multilevel analyses showed that child trauma-related cognitions and emotion regulation difficulties were related to higher levels of PTSD symptoms at the individual level. General family functioning was only related to child PTSD symptoms at the family level. Child PTSD severity was unrelated to parental PTSD symptoms and family communication at the family level when taking into account the other factors.

Conclusions

The current study highlights the psychological impact of parental cancer on children. Individual factors contributed more strongly to child PTSD symptoms than family factors. Trauma-related cognitions and emotion regulation difficulties might be targeted through specific psychoeducation for children and parents, family-oriented support and interventions, and evidence-based treatments for child PTSD.

Mechanisms of Change in Trauma-Focused Treatment for PTSD: The Role of Rumination

OBJECTIVE

Cognitive behavioral therapy (CBT) has been well established in the treatment of posttraumatic stress disorder (PTSD). In recent years, researchers have begun to investigate its underlying mechanisms of change. Dysfunctional cognitive content, i.e. excessively negative appraisals of the trauma or its consequences, has been shown to predict changes in PTSD symptoms over the course of treatment. However, the role of change in cognitive processes, such as trauma-related rumination, needs to be addressed. The present study investigates whether changes in rumination intensity precede and predict changes in symptom severity. We also explored the extent to which symptom severity predicts rumination.

METHOD

As part of a naturalistic effectiveness study evaluating CBT for PTSD in routine clinical care, eighty-eight patients with PTSD completed weekly measures of rumination and symptom severity. Lagged associations between rumination and symptoms in the following week were examined using linear mixed models.

RESULTS

Over the course of therapy, both ruminative thinking and PTSD symptoms decreased. Rumination was a significant predictor of PTSD symptoms in the following week, although this effect was at least partly explained by the time factor (e.g., natural recovery or inseparable treatment effects). Symptom severity predicted ruminative thinking in the following week even with time as an additional predictor.

CONCLUSIONS

The present study provides preliminary evidence that rumination in PTSD is reduced by CBT for PTSD but does not give conclusive evidence that rumination is a mechanism of change in trauma-focused treatment for PTSD.

Type of Traumatic Events, Mental Health Problems, and Posttraumatic Cognitions Among Eastern Anatolian Women

Both severity and type of trauma play a role in mental health consequences. Interpersonal trauma, especially sexual abuse and intentional assaultive violence, form a risk for posttraumatic stress disorder (PTSD). However, few studies have factually compared the impact of trauma types on mental health. This study examined whether interpersonal violence (IPV), natural disasters and accidents (NDA), and life-threat and war (LTW) are differently associated with mental health problems among women. It further examined the mediating role of posttraumatic cognitions (PTCs) among the abovementioned three types of traumatic events and mental health problems. The participants were 1,569 Eastern Anatolian women (16-72 years of age). Traumatic events were assessed with the Life Events Checklist (LEC), mental health with the Diagnostic and statistical manual of mental disorders (5th ed.; DSM-5) diagnostic criteria for PTSD, psychiatric distress symptoms with the GHQ-28 (General Health Questionnaire) scales, and PTCs with the self-related and other-related scales of the Posttraumatic Cognitions Inventory (PTCI). As hypothesized, IPV was more significantly associated with PTSD, anxiety, and somatization symptoms than with NDA. The LTW was significantly associated with all symptoms. Both self-related and other-related PTCs partially mediated the association of both IPV and NDA with mental health problems. The findings are discussed from the perspectives of women and human rights, emphasizing also the importance of cognitive processing of traumatic experiences in enhancing good mental health.

Development and validation of the Trauma-Related Cognitions Scale

Cognitive theories suggest the manner in which individuals process trauma-related information influences posttraumatic sequelae. Interpretations about trauma can be maladaptive and lead to cognitive distortions implicated in the development of posttraumatic stress disorder (PTSD) through the processes of overaccommodation and assimilation. Alternatively, adaptive interpretations about trauma through the process of accommodation can lead to post-trauma resilience and recovery. The Trauma-Related Cognitions Scale (TRCS) provides a measure of beliefs associated with these cognitive processes. The TRCS was developed over the course of four phases. During Phase 1, 94 items derived from previously validated trauma cognition/beliefs measures were aggregated with 40 items developed by the authors. Phase 2 investigated the TRCS factor structure by fitting exploratory factor analysis (EFA) models to data from a non-clinical sample, resulting in a reduced 69-item TRCS representing four factors: the three theoretical cognitive processes of overaccommodation, assimilation, and accommodation, and an additional optimism factor. Phases 3 and 4 fit confirmatory factor analysis (CFA) models of the 69-item TRCS in a new non-clinical and a clinical sample, respectively, and further validation analyses were conducted. Initial evidence suggests the TRCS is a valid and reliable measure of trauma beliefs. Continued validation can determine its utility in both research and clinical contexts.

Cumulative Trauma and Adjustment in Women Exposed to a Campus Shooting: Examining the Role of Appraisals and Social Support

Experiencing repeated trauma can have increasingly detrimental effects on psychosocial functioning after subsequent stressors. These effects may be intensified for victims of interpersonal traumas given that these events are often associated with heightened risk for adverse outcomes. To better understand this relationship, the present study prospectively examined the effect of pre-shooting trauma exposure (i.e., interpersonal vs. non-interpersonal trauma) on psychological functioning (i.e., posttraumatic stress symptoms, depression) following a mass campus shooting. Based on previous research, it was expected that negative appraisals and social support would mediate this relationship. A sample of 515 college women reporting prior trauma exposure was assessed at four time points following the shooting (i.e., pre-shooting, 1-month, 6-months, and 12-months post-shooting). Bootstrap analyses with bias-corrected confidence intervals were conducted. Contrary to expectation, pre-shooting trauma exposure was unrelated to 12-month post-shooting outcomes and neither negative appraisals nor social support at 6-months post-shooting emerged as mediators. Interestingly, a history of non-interpersonal trauma was associated with greater post-shooting family and friend support than a history of interpersonal trauma. Ad hoc analyses showed that pre-shooting symptom severity and level of exposure to the shooting had indirect effects on post-shooting outcomes via post-shooting negative appraisals. These findings support that cumulative trauma, regardless of type, may not have an additive effect unless individuals develop clinically significant symptoms following previous trauma. Trauma severity also appears to play a meaningful role.

Trauma, posttraumatic stress disorder severity, and positive memories

Positive memories play an important role in the aetiology and maintenance of posttraumatic stress disorder (PTSD). However, most trauma research/clinical work has focused solely on the role of traumatic memories. Thus, we examined the relationship between count of retrieved positive memories and PTSD severity, factors associated with count of retrieved positive memories (i.e., rumination, negative/positive emotion dysregulation, fear of positive emotions), and the relationship between positive memory phenomenological domains and PTSD severity. The sample included 185 trauma-exposed participants recruited through Amazon's Mechanical Turk (Mage = 35.69 years; 63.80% female). Results of linear/hierarchical regressions showed that (1) PTSD severity did not predict count of (specific) positive memories; (2) greater positive emotion dysregulation predicted fewer retrieved positive memories controlling for PTSD severity; and (3) greater PTSD severity predicted more negative valence, less vividness, less coherence, less accessibility, less clear time perspective, fewer sensory details, and greater distancing ratings of the retrieved positive memory, controlling for sleep quantity/quality. Findings add to the literature by informing PTSD theoretical perspectives; enhancing an understanding of positive memories in PTSD/trauma treatments; and highlighting potential clinical targets (e.g., positive emotion regulation), when integrating a focus on positive memories into PTSD intervention.

Weekly Changes in Blame and PTSD Among Active-Duty Military Personnel Receiving Cognitive Processing Therapy

Both negative posttraumatic cognitions and posttraumatic stress disorder (PTSD) symptoms decrease over the course of cognitive-behavior therapy for PTSD; however, further research is needed to determine whether cognitive change precedes and predicts symptom change. The present study examined whether weekly changes in blame predicted subsequent changes in PTSD symptoms over the course of cognitive processing therapy (CPT). Participants consisted of 321 active duty U.S. Army soldiers with PTSD who received CPT in one of two clinical trials. Symptoms of PTSD and blame were assessed at baseline and weekly throughout treatment. Bivariate latent difference score modeling was used to examine temporal sequential dependencies between the constructs. Results indicated that changes in self-blame and PTSD symptoms were dynamically linked: When examining cross-construct predictors, changes in PTSD symptoms were predicted by prior changes in self-blame, but changes in self-blame were also predicted by both prior levels of and prior changes in PTSD. Changes in other-blame were predicted by prior levels of PTSD, but changes in other-blame did not predict changes in PTSD symptoms. Findings highlight the dynamic relationship between self-blame and PTSD symptoms during treatment in this active military sample.

A systematic review of the association between fault or blame-related attributions and procedures after transport injury and health and work-related outcomes

Attributions of fault are often associated with worse injury outcomes; however, the consistency and magnitude of these impacts is not known. This review examined the prognostic role of fault on health, mental health, pain and work outcomes after transport injury. A systematic search of five electronic databases (Medline, Embase, CINAHL, PsycINFO, Cochrane Library) yielded 16,324 records published between 2000 and January 2018. Eligibility criteria were: adult transport injury survivors; prospective design; multivariable analysis; fault-related factor analysed; pain, mental health, general health or work-related outcome. Citations (n = 10,558, excluding duplicates) and full text articles (n = 555) were screened manually (Reviewer 1), and using concurrent machine learning and text mining (Reviewer 2; using Abstrackr, WordStat and QDA miner). Data from 55 papers that met all inclusion criteria were extracted, papers were evaluated for risk of bias using the QUIPS tool, and overall level of evidence was assessed using the GRADE tool. There were six main fault-related factors classified as: fault or responsibility, fault-based compensation, lawyer involvement or litigation, blame or guilt, road user or position in vehicle, and impact direction. Overall there were inconsistent associations between fault and transport injury outcomes, and 60% of papers had high risk of bias. There was moderate evidence that fault-based compensation claims were associated with poorer health-related outcomes, and that lawyer involvement was associated with poorer work outcomes beyond 12 months post-injury. However, the evidence of negative associations between fault-based compensation claims and work-related outcomes was limited. Lawyer involvement and fault-based compensation claims were associated with adverse mental health outcomes six months post-injury, but not beyond 12 months. The most consistent associations between fault and negative outcomes were not for fault attributions, per se, but were related to fault-related procedures (e.g., lawyer engagement, fault-based compensation claims).

Relation between PTSD symptom clusters and positive memory characteristics: A network perspective

Positive memory characteristics relate to posttraumatic stress disorder (PTSD) severity. We utilized a network approach to examine relations between PTSD clusters (intrusions, avoidance, negative alterations in cognitions and mood [NACM], alterations in arousal and reactivity [AAR]) and positive memory characteristics (count, accessibility, valence, vividness, coherence, time perspective, sensory details). We identified differential relations between PTSD clusters and positive memory characteristics, and central/bridging symptoms. Participants were an Amazon Mechanical Turk-recruited sample of 206 individuals (M_age = 35.36; 61.20% females). We estimated a regularized Gaussian Graphic Model comprising four nodes representing the PTSD clusters and six nodes representing positive memory characteristics. Regarding cross-community relations, AAR (highest node strength) was negatively associated with positive memory count, valence, coherence, and accessibility; avoidance was positively and negatively associated with positive memory vividness and count respectively. The NACM-AAR and intrusion-avoidance edges were significantly stronger than most edges. From the PTSD community, AAR and avoidance had the highest bridge strength and bridge expected influence respectively; from the positive memory community, coherence and vividness had the highest bridge strength and bridge expected influence respectively. Results indicate the potential pivotal role of AAR, avoidance, coherence, and vividness in the PTSD-positive memory relation, which renders them assessment/treatment targets pending further investigation.

Help in hand after traumatic events: a randomized controlled trial in health care professionals on the efficacy, usability, and user satisfaction of a self-help app to reduce trauma-related symptoms

Background: Despite the fact that many people are affected by trauma and suffer from posttraumatic stress symptoms (PTSS) there is a lack of easy-accessible interventions to self-manage these symptoms. Mobile apps may deliver low-intensity self-help to reduce trauma-related symptoms and empower individuals following trauma, such as high-risk professionals who are regularly exposed to potentially traumatic events. In this randomized controlled trial, we examined the efficacy, and evaluated the usability and user satisfaction of the app 'SUPPORT Coach' as a self-help tool to reduce trauma-related symptoms. Methods: Health care professionals (e.g. nurses, physicians, paramedics and ambulance drivers) completed an online screening on PTSS (T0). They were randomized when at least one PTSS was reported, either to the intervention (1 month unlimited access to SUPPORT Coach) or control condition (no access to SUPPORT Coach). Self-reported PTSS, negative trauma-related cognitions, psychological resilience, and social support were assessed online at baseline (T1), post-condition (T2), and 1 month follow-up (T3). Results: Of the 1175 participants screened, 287 (24.4%) indicated at least one posttraumatic stress symptom and were randomized. The majority of intervention condition participants (83%, n = 103) used SUPPORT Coach; they were slightly to moderately satisfied with the app. There was no significant group difference in change in PTSS and social support after one-month app usage. However, the intervention condition showed a greater decline in negative trauma-related cognitions at T2 and T3, and a larger increase in psychological resilience at T3 than the control condition. Conclusions: SUPPORT Coach without guidance could potentially provide easy-accessible self-help to diminish negative trauma-related cognitions, and strengthen resilience in coping with adversities. However, since the attrition rate was substantially higher in the intervention than in control condition, our findings should be interpreted with caution and warrant replication.

Relation of positive memory recall count and accessibility with post-trauma mental health

Positive memory encoding and retrieval deficits have an empirical relation with several post-trauma outcomes. Drawing from the Contractor et al. model, we examined relations between positive memory characteristics and post-trauma mental health indicators. A trauma-exposed community sample of 203 participants (Mage = 35.40 years; 61.10% female) was recruited via Amazon's Mechanical Turk. Participants completed measures of posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5), depression (Patient Health Questionnaire-9), posttraumatic cognitions (Posttraumatic Cognitions Inventory), affect (Positive and Negative Affect Schedule), count/number of recalled specific positive memories (Autobiographical Memory Test) and accessibility of a specific positive memory (i.e., subjective ease of recalling details of a memory; Memory Experiences Questionnaire-Short Form). Linear regression results indicated that PTSD intrusion severity, PTSD negative alterations in cognitions and mood (NACM) severity, PTSD alterations in arousal and reactivity (AAR) severity, self-blame, and positive affect significantly and negatively predicted the count of specific positive memories. Further, PTSD NACM severity, PTSD AAR severity, negative cognitions about the self, and negative affect significantly and negatively predicted accessibility of a specific positive memory. Thus, count/accessibility of specific positive memories was associated with several post-trauma mental health indicators; this highlights the relevance and potential impact of integrating positive memories into trauma treatment.

Event Centrality: Factor Structure and Links to Posttraumatic Stress Disorder Symptom Clusters

Event centrality is defined as the extent to which traumatic events are perceived to be integral to one's life. However, there are discrepancies regarding the factor structure of event centrality, as the factor structure may differ depending on the nature of the trauma. Event centrality has predicted posttraumatic stress disorder (PTSD); yet, few studies have taken into account other key cognitive predictors of PTSD, such as posttraumatic cognitions. The PTSD symptom clusters also remain largely unexamined, despite potential specificity in their ties to event centrality. The aims of the current study were to: (a) examine the factor structure of event centrality and whether the structure differs following interpersonal versus noninterpersonal trauma; (b) investigate whether event centrality predicts PTSD symptom clusters beyond posttraumatic cognitions; and (c) determine if the associations between event centrality, posttraumatic cognitions, and PTSD are equivalent between trauma types. The study aims were examined utilizing 263 college students (M_age = 24.54, SD = 6.29; 79.8% female; 58% White). Event centrality was best represented by one factor, which was consistent between groups. Structural equation models indicated that event centrality and posttraumatic cognitions regarding the self predicted each of the PTSD symptom clusters across groups, βs = .27-.58. However, event centrality was more strongly related to avoidance symptoms among individuals who experienced a noninterpersonal trauma. For both the interpersonal and noninterpersonal groups, event centrality had equivalent ties to each cluster. Even after accounting for negative trauma-related beliefs, event centrality appears to be relevant in understanding posttrauma functioning.

The Role of Rumination and Negative Affect in Meaning Making Following Stressful Experiences in a Japanese Sample

Stressful experiences can lead to meaning making that is seen as central in adjustment. Although rumination and negative affect are important factors of meaning making, little is known about the mechanisms involved. This study aimed to examine the meaning making process, focusing on the role of intrusive and deliberate rumination and negative affect. The principal hypotheses were as follows: negative affect is positively related to threat evaluation and intrusive rumination, while regret and guilt are positively related to deliberate rumination; intrusive rumination is negatively related to finding meaning, whereas deliberate rumination is positively related to finding meaning. A total of 383 undergraduate students were asked to remember their most stressful life event and complete a questionnaire containing the Event Related Rumination Inventory and items about negative affect, threat evaluation, and finding meaning about the stressful life event. For 342 of the final sample, structural equation modeling based on the study hypotheses showed that both deliberate and intrusive rumination immediately after the event were positively associated with finding meaning. Intrusive rumination at present, however, was negatively related to finding meaning. This study also revealed the effects of negative affect: helplessness, sadness, and fear induced intrusive rumination; moreover, regret was positively associated with deliberate rumination.

The relationship between moral injury appraisals, trauma exposure, and mental health in refugees

BACKGROUND

Refugees are often exposed to multiple traumatic experiences, leading to elevated rates of psychological disorders. There is emerging evidence that appraisals of traumatic events as violating deeply held moral beliefs and frameworks (i.e., moral injury) impact negatively on refugee mental health. Despite this, no research has systematically investigated moral injury appraisals in refugees.

METHOD

Participants were 222 refugees from diverse backgrounds who had recently resettled in Australia. They completed measures of mental health in Arabic, Farsi, Tamil, or English through an online survey. This study first investigated the factor structure of the Moral Injury Appraisals Scale (MIAS), and then examined the relationship between the moral injury factors and key predictor (age, gender, trauma exposure) and outcome (Posttraumatic stress disorder [PTSD] symptom clusters, anger, and depression) variables.

RESULTS

Confirmatory factor analyses of the MIAS supported a two-factor model, comprising a Moral Injury-Other (MI-Other) factor (i.e., interpreting the violation as being enacted by others) and a Moral Injury-Self (MI-Self) factor (i.e., interpreting the violation as being enacted by oneself). Structural equation modeling analyses indicated that both factors were predicted by higher trauma exposure, and both predicted more severe anger and depression. Notably, while MI-Other was associated with more severe PTSD, MI-Self was associated with lower levels of intrusions.

CONCLUSION

These results suggest that there may be subtypes of moral injury appraisals that are associated with different mental health outcomes. These findings have potential implications for designing treatments that address the psychological impact of the refugee experience.

Driving cognitions, rumination, and posttraumatic stress disorder in road traffic accidents survivors

This study evaluated the relationships between driving cognitions (i.e., panic-related cognitions, accident-related cognitions, and social-related cognitions), rumination, and posttraumatic stress disorder (PTSD) symptoms in a sample of road traffic accidents (RTAs) survivors. We also investigated the indirect effect of driving cognitions on PTSD symptoms through rumination. The sample included 633 drivers (62% were men; Mage = 36.09; standard deviation [SD] = 11.42 years). The participants completed scales measuring driving cognitions, rumination, and PTSD symptoms, as well as providing their demographic information. The results showed that all three types of driving cognitions assessed in the present study and rumination were significantly positively associated with PTSD symptoms. Furthermore, rumination mediated the relation between social-related cognitions and PTSD symptoms. The implications for PTSD treatment and future research are discussed.

What Acute Stress Protocols Can Tell Us About PTSD and Stress-Related Neuropsychiatric Disorders

Posttraumatic stress disorder (PTSD), the fifth most prevalent mental disorder in the United States, is a chronic, debilitating mental illness with as yet limited options for treatment. Hallmark symptoms of PTSD include intrusive memory of trauma, avoidance of reminders of the event, hyperarousal and hypervigilance, emotional numbing, and anhedonia. PTSD is often triggered by exposure to a single traumatic experience, such as a traffic accident, a natural catastrophe, or an episode of violence. This suggests that stressful events have a primary role in the pathogenesis of the disorder, although genetic background and previous life events are likely involved. However, pathophysiology of this mental disorder, as for major depression and anxiety disorders, is still poorly understood. In particular, it is unknown how can a single traumatic, stressful event induce a disease that can last for years or decades. A major shift in the conceptual framework investigating neuropsychiatric disorders has occurred in recent years, from a monoamine-oriented hypothesis (which dominated pharmacological research for over half a century) to a neuroplasticity hypothesis, which posits that structural and functional changes in brain circuitry (largely in the glutamate system) mediate psychopathology and also therapeutic action. Rodent stress models are very useful to understand pathophysiology of PTSD. Recent studies with acute or subacute stress models have shown that exposure to short-time stressors (from several minutes to a few hours) can induce not only rapid, but also sustained changes in synaptic function (glutamate release, synaptic transmission/plasticity), neuroarchitecture (dendritic morphology, synaptic spines), and behavior (cognitive functions). Some of these changes, e.g., stress-induced increased glutamate release and dendrite retraction, are likely connected and occur more rapidly than previously thought. We propose here to use a modified version of a simple and validated protocol of footshock stress to explore different trajectories in the individual response to acute stress. This new conceptual framework may enable us to identify determinants of resilient versus vulnerable response as well as new targets for treatment, in particular for rapid-acting antidepressants. It will be interesting to investigate the putative prophylactic action of ketamine toward the maladaptive effects of acute stress in this new protocol.

A Longitudinal Investigation of Moral Injury Appraisals Amongst Treatment-Seeking Refugees

There is currently an unprecedented number of forcibly displaced people worldwide. Understanding psychological mechanisms that contribute to the mental health of refugees and asylum-seekers is important for informing the development of effective interventions for these populations. Moral injury appraisals represent an important potential cognitive mechanism that may contribute to psychological symptoms following exposure to persecution, war, and displacement. In the current study, we investigated the longitudinal association between moral injury appraisals related to one's own perceived transgressions (moral injury-self), others' perceived transgressions (moral injury-other), and PTSD and depression symptoms. Participants in this study were 134 refugees receiving treatment at two outpatient clinics in Switzerland who completed survey measures investigating these concepts. Of these, 71 were followed up 2 to 4 years later. Path analyses revealed that greater depression symptoms were associated with subsequent increases in moral injury-self appraisals (β = 0.25, SE = 0.08, 95% CI [0.11, 0.43], p = 0.002). In contrast, greater moral injury-self appraisals were associated with subsequent decreases in PTSD symptoms (β = -0.23, SE = 0.11, 95% CI = [-0.44, -0.31], p = 0.035). Findings suggest that different types of moral injury appraisals may be associated with differential psychological outcomes. These results have important potential implications for policy and treatment of refugees and asylum-seekers, highlighting the importance of targeting cognitive factors in the maintenance and treatment of psychological distress, and considering the post-migration context when working with refugees.

Posttraumatic Stress Disorder Following Stillbirth: Trauma Characteristics, Locus of Control, Posttraumatic Cognitions

This study examined the incidence of PTSD and psychiatric co-morbidity among women who experienced stillbirth and investigated the relationship between locus of control, trauma characteristics of stillbirth, posttraumatic cognitions, PTSD and co-morbid psychiatric symptoms following stillbirth. Fifty women recorded information on stillbirth experiences, and completed the Posttraumatic Stress Diagnostic Scale, General Health Questionnaire-28, Edinburgh Post-natal Depression Scale, Rotter's Locus of Control Scale and the Posttraumatic Cognitions Inventory. 60, 28 and 12 % met the diagnostic criteria for probable full-PTSD, partial and no-PTSD respectively. Sixty-two percent and 54 % scored at or above the cutoff of the General Health Questionnaire-28 and postnatal depression respectively. Women who experienced stillbirth reported significantly more psychiatric co-morbid and post-natal depressive symptoms than the comparison group. Both groups were similar in locus of control. Women who experienced stillbirth reported negative cognitions about the self the most. After adjusting for postnatal depression, trauma characteristics were significantly correlated with Posttraumatic cognitions which, in turn, were significantly correlated with PTSD and psychiatric co-morbidity. Locus of control was not significantly correlated with psychological outcomes. Mediational analyses showed that negative cognitions about self mediated the relationship between trauma characteristics and psychiatric co-morbidity only. Women reported a high incidence of probable PTSD and co-morbid psychiatric symptoms following stillbirth. Stillbirth trauma characteristics influenced how they negatively perceived themselves. This then specifically influenced general psychological problems rather than PTSD symptoms.

Development and preliminary performance of a risk factor screen to predict posttraumatic psychological disorder after trauma exposure

OBJECTIVE

We examined data from a prospective study of risk factors that increase vulnerability or resilience, exacerbate distress, or foster recovery to determine whether risk factors accurately predict which individuals will later have high posttraumatic (PT) symptom levels and whether brief measures of risk factors also accurately predict later symptom elevations.

METHOD

Using data from 129 adults exposed to traumatic injury of self or a loved one, we conducted receiver operating characteristic (ROC) analyses of 14 risk factors assessed by full-length measures, determined optimal cutoff scores, and calculated predictive performance for the nine that were most predictive. For five risk factors, we identified sets of items that accounted for 90% of variance in total scores and calculated predictive performance for sets of brief risk measures.

RESULTS

A set of nine risk factors assessed by full measures identified 89% of those who later had elevated PT symptoms (sensitivity) and 78% of those who did not (specificity). A set of four brief risk factor measures assessed soon after injury identified 86% of those who later had elevated PT symptoms and 72% of those who did not.

CONCLUSIONS

Use of sets of brief risk factor measures shows promise of accurate prediction of PT psychological disorder and probable PTSD or depression. Replication of predictive accuracy is needed in a new and larger sample.

Cognitive restructuring and imagery modification for posttraumatic stress disorder (CRIM-PTSD): A pilot study

BACKGROUND AND OBJECTIVES

Cognitive restructuring and imagery modification for PTSD (CRIM-PTSD) is a new short intervention. It consists of the cognitive restructuring of core trauma-related dysfunctional beliefs about the self and the use of imagery to encourage more functional beliefs. A randomized controlled trial showed that CRIM was effective for reducing posttraumatic stress disorder (PTSD) in survivors of childhood sexual abuse (CSA) when it focused on the feeling of being contaminated. For this study, CRIM was adapted to treat PTSD symptoms more generally and after various types of trauma by addressing the patients' negative self-concept.

METHODS

Ten patients with PTSD received two assessment sessions, two treatment sessions, and a booster session. The Clinician-Administered PTSD Scale (CAPS) was administered prior to and four weeks after treatment. Self-ratings, e.g., the Posttraumatic Diagnostic Scale (PDS) and the Posttraumatic Cognitions Inventory (PTCI), were administered at baseline, immediately posttreatment, and four weeks after treatment.

RESULTS

The participants showed significant improvements in both clinician-rated (d = 2.55; p < 0.01) and self-reported PTSD symptoms (d = 1.47; p < 0.01). One month after treatment, 9 patients no longer fully met the diagnostic criteria for PTSD.

LIMITATIONS

The results are limited by the small sample size and the lack of a control group.

CONCLUSIONS

This pilot study suggests that addressing the negative self-concept of PTSD patients using a combination of cognitive techniques and imagery modification can effectively reduce PTSD symptoms. Further research is needed to assess the treatment's effects and stability in a randomized controlled trial.

Temporal Sequencing of Change in Posttraumatic Cognitions and PTSD Symptom Reduction During Prolonged Exposure Therapy

Prolonged exposure (PE) effectively reduces negative cognitions about self, world, and self-blame associated with posttraumatic stress disorder (PTSD), with changes in posttraumatic cognitions being associated with reductions in PTSD symptoms (Foa & Rauch, 2004). Further, recent research has demonstrated that cognitive change is a likely mechanism for PTSD symptom reduction in PE (Zalta et al., 2014). The present study examines temporal sequencing of change in three domains of posttraumatic cognitions (i.e., negative cognitions about the self, negative cognitions about the world, and self-blame) and PTSD symptoms during the course of PE. Adult outpatients meeting diagnostic criteria for PTSD were recruited at 4 sites. Participants (N=46) received 8 sessions of PE over 4 to 6weeks. PTSD symptoms and posttraumatic cognitions were assessed at pretreatment and Sessions 2, 4, 6, and 8. PTSD symptom severity and negative cognitions about the self and the world each decreased significantly from pre- to posttreatment, while self-blame cognitions were unchanged. Examination of temporal sequencing of changes during the course of PE via time-lagged mixed effects regression modeling revealed that preceding levels of negative cognitions about the world drove successive severity levels of PTSD symptoms, whereas preceding PTSD symptom severity did not drive subsequent negative cognitions about the world. Reductions in negative cognitions about the self led to subsequent improvement in PTSD. Improvement in PTSD symptoms in prior sessions was related to later reduction in negative cognitions about the self, though the impact of negative cognitions in influencing subsequent symptom change demonstrated a stronger effect. Results support that reductions in negative cognitions about the self and world are mechanisms of change in PE, which may have valuable implications for maximizing treatment effectiveness.

Contributions of risk and protective factors to prediction of psychological symptoms after traumatic experiences

OBJECTIVE

Traumatic experiences cause considerable suffering and place a burden on society due to lost productivity, increases in suicidality, violence, criminal behavior, and psychological disorder. The impact of traumatic experiences is complicated because many factors affect individuals' responses. By employing several methodological improvements, we sought to identify risk factors that would account for a greater proportion of variance in later disorder than prior studies.

METHOD

In a sample of 129 traumatically injured hospital patients and family members of injured patients, we studied pre-trauma, time of trauma, and post-trauma psychosocial risk and protective factors hypothesized to influence responses to traumatic experiences and posttraumatic (PT) symptoms (including symptoms of PTSD, depression, negative thinking, and dissociation) two months after trauma.

RESULTS

The risk factors were all significantly correlated with later PT symptoms, with post-trauma life stress, post-trauma social support, and acute stress symptoms showing the strongest relationships. A hierarchical regression, in which the risk factors were entered in 6 steps based on their occurrence in time, showed the risks accounted for 72% of the variance in later symptoms. Most of the variance in PT symptoms was shared among many risk factors, and pre-trauma and post-trauma risk factors accounted for the most variance.

CONCLUSIONS

Collectively, the risk factors accounted for more variance in later PT symptoms than in previous studies. These risk factors may identify individuals at risk for PT psychological disorders and targets for treatment.

Posttraumatic Stress Disorder, Hostile Cognitions and Aggression in Iraq/Afghanistan Era Veterans

OBJECTIVE

Most veterans with posttraumatic stress disorder (PTSD) are not violent, yet research has demonstrated that there is a substantial minority who are at increased risk. This study tested hypotheses regarding hyperarousal symptoms and hostile cognitions (i.e., "hostility") as potential mechanisms of the association between PTSD and physical aggression in a longitudinal sample of Iraq/Afghanistan era veterans.

METHOD

The sample included U.S. veterans between the ages of 18 and 70 who served in the military after September 11, 2001. At baseline, 301 veterans were evaluated for PTSD and completed self-report measures of hostility. At six-month follow-up 275 veterans and their family members or friends reported on the veterans' physical aggression over the preceding interval. Regression models were used to evaluate relationships among PTSD status, hyperarousal cluster symptoms, and hostility at baseline, and physical aggression at six months. Bootstrapping was used to test for the mediation of baseline PTSD and six-month aggression by hostility.

RESULTS

PTSD significantly predicted physical aggression over six months, but hyperarousal cluster symptoms did not account for unique variance among the three clusters in the longitudinal model. Hostility partially mediated the association of PTSD at baseline and physical aggression at six months.

CONCLUSIONS

Hostility may be a mechanism of the association of PTSD and physical aggression in veterans, suggesting the potential utility of targeting hostile cognitions in therapy for anger and aggression in veterans with PTSD.

Rape survivors' trauma-related beliefs before and after Cognitive processing therapy: associations with PTSD and depression symptoms

This study examined whether cognitive distortions (i.e., assimilated and overaccommodated thoughts) and realistic (i.e., accommodated) thoughts assessed from impact statements written 5-10 years after completing cognitive processing therapy (CPT) accurately predicted posttreatment maintenance or decline in treatment gains during the same period. The sample included 50 women diagnosed with posttraumatic stress disorder (PTSD) secondary to rape who participated in a randomized clinical trial of CPT for PTSD. Cognitions were assessed via coding and analyses of participants' written impact statements at three time points: beginning of treatment, end of treatment, and at 5-10 years follow-up. Primary mental health outcomes were symptoms of PTSD (Clinician-Administered PTSD Scale) and depression (Beck Depression Inventory). Changes in trauma-related beliefs between the end of treatment and long-term follow-up were associated with concomitant changes in PTSD and depression symptoms (effect sizes ranging from r = .35-.54). Declines in accommodated thinking and increases in overaccommodated thinking were associated with elevations in symptomatology. Improvement in accommodated thinking and declines in overaccommodated thinking were associated with lower PTSD and depression symptoms during this same time period. Findings provided support for the role of changes in accommodated and overaccommodated thinking being associated with level of PTSD and depression many years after participating in CPT.

Accounting for sex differences in PTSD: A multi-variable mediation model

BACKGROUND

Approximately twice as many females as males are diagnosed with posttraumatic stress disorder (PTSD). However, little is known about why females report more PTSD symptoms than males. Prior studies have generally focused on few potential mediators at a time and have often used methods that were not ideally suited to test for mediation effects. Prior research has identified a number of individual risk factors that may contribute to sex differences in PTSD severity, although these cannot fully account for the increased symptom levels in females when examined individually.

OBJECTIVE

The present study is the first to systematically test the hypothesis that a combination of pre-, peri-, and posttraumatic risk factors more prevalent in females can account for sex differences in PTSD severity.

METHOD

The study was a quasi-prospective questionnaire survey assessing PTSD and related variables in 73.3% of all Danish bank employees exposed to bank robbery during the period from April 2010 to April 2011. Participants filled out questionnaires 1 week (T1, N=450) and 6 months after the robbery (T2, N=368; 61.1% females). Mediation was examined using an analysis designed specifically to test a multiple mediator model.

RESULTS

Females reported more PTSD symptoms than males and higher levels of neuroticism, depression, physical anxiety sensitivity, peritraumatic fear, horror, and helplessness (the A2 criterion), tonic immobility, panic, dissociation, negative posttraumatic cognitions about self and the world, and feeling let down. These variables were included in the model as potential mediators. The combination of risk factors significantly mediated the association between sex and PTSD severity, accounting for 83% of the association.

CONCLUSION

The findings suggest that females report more PTSD symptoms because they experience higher levels of associated risk factors. The results are relevant to other trauma populations and to other trauma-related psychiatric disorders more prevalent in females, such as depression and anxiety.

An Integrated Model of Posttraumatic Stress and Growth

A number of recent models have examined cognitive predictors of posttraumatic stress and posttraumatic growth (S. Barton, A. Boals, & L. Knowles, 2013; J. Groleau, L. Calhoun, A. Cann, & G. Tedeschi, 2013; K. N. Triplett, R. G. Tedeschi, A. Cann, L. G. Calhoun, & C. L. Reeve, 2012). The current study examined an integrated model of predictors of distress and perceived growth in 194 college undergraduates. Domains covered included the roles of core belief challenge, event centrality, posttrauma cognitions, and event-related rumination. Negative cognitions about the self and the centrality of the event directly predicted both growth and distress, although intrusive rumination predicted only posttraumatic stress disorder symptoms, and deliberate rumination predicted only posttraumatic growth. Future research should continue to examine the shared and unique predictors of postevent growth and distress.

Is there a common pathway to developing ASD and PTSD symptoms?

Numerous studies have identified risk factors for acute and long-term posttraumatic stress symptoms following traumatic exposure. However, little is known about whether there are common pathways to the development of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). Research suggests that a common path to ASD and PTSD may lie in peritraumatic responses and cognitions. The results of structural equation modeling in a national sample of Danish bank robbery victims (N=450) show that peritraumatic panic, anxiety sensitivity, and negative cognitions about self were significant common risk factors for both ASD severity and PTSD severity when controlled for the effect of the other risk factors. The strongest common risk factor was negative cognitions about self. Future research should focus on replicating these results as they point to possible areas of preventive and treatment actions against the development of traumatic stress symptoms.

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.

Thinking about trauma: the unique contributions of event centrality and posttraumatic cognitions in predicting PTSD and posttraumatic growth

Researchers have been investigating possible pathways to negative (posttraumatic stress disorder [PTSD]) and positive (posttraumatic growth [PTG]) reactions to trauma in recent decades. Two cognitive constructs, event centrality and posttraumatic cognitions, have been implicated to uniquely predict PTSD symptoms in an undergraduate sample. The current pair of studies attempted to (a) replicate this finding in an undergraduate sample, (b) replicate this finding in a treatment-seeking sample, and (c) explore whether these 2 cognitive constructs uniquely predict PTG. The first study consisted of 500 undergraduate students, whereas the second study consisted of 53 treatment-seeking clients. Results indicated both posttraumatic cognitions and event centrality uniquely predicted PTSD in the undergraduate (R(2) = .46) and treatment-seeking samples (R(2) = .46). These 2 cognitive constructs also predicted PTG in the undergraduate sample (R(2) = .37), but only posttraumatic cognitions predicted PTG in the treatment-seeking sample (R(2) = .17). The relationships between PTG varied, depending on whether PTG for high or low event-centrality events were assessed. The original model was supported within both populations for PTSD symptoms, and its extension to PTG was supported within the treatment-seeking sample. These results underscore cognitive and narrative factors in the progression of trauma.

The role of attribution of trauma responsibility in posttraumatic stress disorder following motor vehicle accidents

BACKGROUND

Motor vehicle accidents (MVAs) are highly prevalent and associated with adverse psychological outcomes.

METHODS

The present study used data from the National Comorbidity Survey-Replication (NCS-R) to examine the association between injury, role in an MVA (driver/nondriver), attributions of responsibility for the accident, and posttraumatic stress disorder (PTSD), amongst 165 MVA survivors.

RESULTS

Findings indicated that drivers with external attributions of the MVA (i.e. who considered others to be at fault for the MVA) were significantly more likely to have a diagnosis of PTSD than drivers with internal attributions (i.e. considering themselves to be at fault) and nondrivers with external attributions of the accident. Further, serious injury sustained in the accident was related to greater likelihood of developing PTSD.

CONCLUSIONS

External attributions for the MVA among drivers, as well as serious injury during the accident, were related to higher rates of PTSD. The present findings have implications for models that highlight the importance of posttraumatic cognitions in contributing to mental health following a traumatic event.

Posttraumatic stress disorder in children and adolescents: neuroendocrine perspectives

Posttraumatic stress disorder (PTSD) is a syndrome of distress that develops after exposure to traumatic life experiences. Dysregulation of both the hypothalamic-pituitary-adrenal (HPA) axis and the locus caeruleus/norepinephrine-sympathetic nervous system (LC/NE-SNS) is associated with the pathophysiology of the disorder. Studies have demonstrated a neuroendocrine profile unique to adults with PTSD, with centrally elevated corticotropin-releasing hormone (CRH), low cortisol in the periphery, and elevated catecholamines. Traumatic stress experiences in early life are strong predisposing factors for later PTSD development. In addition, early life stress programs the developing brain to overreact to future stressors. In children and adolescents involved in motor vehicle accidents, we found that high evening salivary cortisol and morning serum interleukin 6 concentrations were predictive of PTSD development 6 months later. We demonstrated a progressive divergence of the HPA and LC/NE-SNS axes of the stress system, which may be part of the pathophysiologic mechanism responsible for PTSD maintenance. An initial elevation of cortisol in the aftermath of the trauma, followed by a gradual normalization and finally low cortisol secretion, together with a gradual elevation of catecholamines over time, may represent the natural history of neuroendocrine changes in pediatric PTSD. Thus, the low cortisol concentrations found in adults with PTSD may reflect prior trauma and might represent a biologic vulnerability factor for later PTSD development.

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.

Negative expectancies in posttraumatic stress disorder: neurophysiological (N400) and behavioral evidence

BACKGROUND

Posttraumatic stress disorder (PTSD) is a disorder that theoretically and clinically is thought to be associated with persistent and exaggerated negative expectancies. This study used the N400 event-related potential (ERP) to investigate expectancies for threatening endings to ambiguous sentence stems. The N400 ERP is thought to reflect the amount of effort required to integrate a stimulus into a given context. In sentence reading tasks, the N400 is reliably larger when a word is unexpected.

METHOD

In this study, fifty-seven trauma survivors of various types (22 with PTSD and 35 without) read ambiguous sentence stems on a computer screen. These sentence stems were completed with either an expected ("The unfortunate man lost his…wallet"), unexpected ("The unfortunate man lost his…artist"), or threatening word endings ("The unfortunate man lost his…leg").

RESULTS

Participants with PTSD, as compared to those without, showed significantly smaller N400s to threatening sentence endings suggesting enhanced expectancies for threat. Behavioral responses supported this conclusion.

CONCLUSIONS

These findings are consistent with the clinical presentation of hypervigilance and proposed revisions to the DSM-V that emphasize persistent and exaggerated negative expectations about one's self, others, or the world. Relative to earlier behavioral studies, this work further suggests that this expectancy bias occurs automatically and at the early stages of information processing. The discussion focuses on the potential impact of a negative expectancy bias in PTSD and the value of the ambiguous sentence paradigm for studying PTSD as well as other disorders.

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.

Categorical and dimensional study of the predictive factors of the development of a psychotrauma in victims of car accidents

OBJECTIVE

This study aimed to evaluate the predictive factors of the emergence of complete PTSD and subsyndromal PTSD (defined as individuals exposed to a traumatic event with at least one psychopathological impact, such as hyperarousal, avoidance or persistent re-experiencing) following a motor vehicle accident (MVA).

METHODS

We recruited 155 adult MVA patients, physically injured and admitted to trauma service, over two years. In the week following the accident, patients were asked to complete questionnaires assessing their social situation (sex, age, marital and employment status, prior MVA or trauma), comorbidity (MINI), distress (PDI) and dissociation (PDEQ) experienced during and immediately after the trauma. An evaluation using the CAPS was conducted six months after the trauma to assess a possible PTSD.

RESULTS

At six months, 25.8% of the participants developed subsyndromal symptoms and 7.74% developed complete PTSD. The three symptoms that best discriminated the groups were dysphoric emotion, perceived life threat and dissociation. Logistic regression results showed that the strongest predictor of PTSD was the perceived life threat. In addition, a dimensional approach to the results revealed significant correlations between (1) peritraumatic distress and persistent re-experiencing or hyperarousal and (2) dissociation score and avoidance strategy. The presence of a prior traumatic event reinforces avoidance strategies.

CONCLUSIONS

Our results stress that peritraumatic factors (especially the perception of a life threat) are good predictors of PTSD development. A dimensional perspective allows better identification of psychological complications following an MVA.

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 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.

Self-worth mediates the effects of violent loss on PTSD symptoms

Although research has confirmed that violent losses can exacerbate grief reactions, few investigations have explored underlying mechanisms. In this study, the authors used a dataset on bereaved spouses and bereaved parents at 4- and 18-months postloss to examine the mediating effects of self-worth and worldviews (benevolence and meaningfulness beliefs). Persons bereaved by violent causes had significantly more posttraumatic stress disorder (PTSD), grief, and depression symptoms at 4- and 18-months postloss than persons bereaved by natural causes. Moreover, self-worth but not worldviews mediated the effects of violent loss on PTSD and depression symptoms cross sectionally and PTSD symptoms longitudinally. Findings underscore that self-views are a critical component of problematic reactions to violent loss, but fail to support the role of "shattered" worldviews.

Predicting posttraumatic stress disorder symptoms and pain intensity following severe injury: the role of catastrophizing

BACKGROUND

A number of theories have proposed possible mechanisms that may explain the high rates of comorbidity between posttraumatic stress disorder (PTSD) and persistent pain; however, there has been limited research investigating these factors.

OBJECTIVE

The present study sought to prospectively examine whether catastrophizing predicted the development of PTSD symptoms and persistent pain following physical injury.

DESIGN

Participants (N=208) completed measures of PTSD symptomatology, pain intensity and catastrophizing during hospitalization following severe injury, and 3 and 12 months postinjury. Cross-lagged path analysis explored the longitudinal relationship between these variables.

RESULTS

Acute catastrophizing significantly predicted PTSD symptoms but not pain intensity 3 months postinjury. In turn, 3-month catastrophizing predicted pain intensity, but not PTSD symptoms 12 months postinjury. Indirect relations were also found between acute catastrophizing and 12-month PTSD symptoms and pain intensity. Relations were mediated via 3-month PTSD symptoms and 3-month catastrophizing, respectively. Acute symptoms did not predict 3-month catastrophizing and catastrophizing did not fully account for the relationship between PTSD symptoms and pain intensity.

CONCLUSIONS

Findings partially support theories that propose a role for catastrophizing processes in understanding vulnerability to pain and posttrauma symptomatology and, thus, a possible mechanism for comorbidity between these conditions.

ASD and PTSD in rape victims

In recent years, a number of studies have investigated the prediction of posttraumatic stress disorder (PTSD) through the presence of acute stress disorder (ASD). The predictive power of ASD on PTSD was examined in a population of 148 female rape victims who visited a center for rape victims shortly after the rape or attempted rape. The PTSD diagnosis based solely on the three core symptom clusters was best identified by a subclinical ASD diagnosis based on all ASD criteria except dissociation. However, a full PTSD diagnosis including the A( 2) and F criteria was best identified by classifying victims according to a full ASD diagnosis. Regardless of whether cases were classified according to full PTSD status or according to meeting the criteria for the three PTSD core symptom clusters, the classification was correct only in approximately two thirds of the cases. A regression analysis based on ASD severity and sexual problems following the rape accounted for only 28% of the PTSD severity variance. In conclusion, the ASD diagnosis is not an optimal method for identifying those most at risk for PTSD. It remains to be seen whether a better way can be found.

Trauma-related appraisals and coping styles of injured adults with and without symptoms of PTSD and their relationship to work potential

PURPOSE

This study aimed to document the self-reported trauma-related appraisals and coping strategies of injured workers with and without symptoms of posttraumatic stress disorder (PTSD) and to explore relationships between these cognitive variables and work potential.

METHOD

Sixty-nine (55% males) respondents previously admitted to a teaching hospital following accidental injury completed a self-report survey which included measures for PTSD, trauma-related appraisals, coping strategies and work potential approximately 8 months post-accident.

RESULTS

Nineteen percent of the sample reported symptoms consistent with a PTSD diagnosis, and these participants reported more negative appraisals about the self and the world, greater use of avoidant coping and poorer work outcomes than those without clinically significant PTSD symptoms. After partialing out the influence of PTSD symptom severity, active cognitive coping was associated with increased work potential and negative appraisals of the world was associated with reduced work potential.

CONCLUSIONS

Trauma-related appraisals and coping strategies are associated with work potential following accidental injury. Although the role of negative appraisals in the maintenance of PTSD is well documented, this study identified negative appraisals of the world as being associated with work potential after controlling for PTSD symptoms. Reducing negative appraisals of the world and increasing active coping may influence work potential, however, longitudinal studies that substantiate the direction of the associations are required.

Intrusive cognitions and their appraisal in anxious cancer patients

OBJECTIVE

Previous research found that anxious cancer patients experience uncontrollable negative intrusive cognitions that have an impact on coping and are associated with significant psychological distress. This is the first study to examine the appraisal of intrusive cognitions in an anxious group of cancer patients.

METHODS

A sample of 139 anxious cancer patients was assessed for evidence of intrusive phenomena, including memories, images and thoughts. Patients completed the Response to Intrusions Questionnaire and the Impact of Event Scale in relation to intrusive cognitions.

RESULTS

Forty-eight percent (67/139) reported frequent, uncontrollable intrusive cognitions. Intrusive thoughts and images were equally as common and images were associated with increased distress and uncontrollability. A significant positive linear relationship was found between the number of intrusions and anxiety severity (P<0.05). Negative appraisal of intrusive cognitions was associated with anxiety (P<0.01) and depression severity (P<0.01), intrusion-specific distress (P<0.01), rumination (P<0.01) and cognitive avoidance (P<0.01), after controlling for intrusion frequency.

CONCLUSION

Negative appraisal of intrusive cognitions plays a significant role in psychological distress and intrusion-specific distress in anxious cancer patients. Finding similarities in the types of intrusive cognitions reported by cancer patients and other anxious populations highlights the potential applicability of psychological therapies developed to reduce the frequency and impact of intrusive cognitions.