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Nguyen TNM, Disabato DJ, Gunstad J, Delahanty DL, George R, Muakkassa F, Mallat AF, Coifman KG. Can the positive buffer the negative? Testing the impact of protective childhood experiences on adjustment in adults following trauma exposure. ANXIETY, STRESS, AND COPING 2024; 37:60-76. [PMID: 37012026 PMCID: PMC10545812 DOI: 10.1080/10615806.2023.2193888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND It is unclear if protective childhood experiences (PCEs), like emotional support and economic stability, exert influence on adulthood adjustment. Prior research suggests PCEs can promote childhood resilience through increased social connection. In contrast, research has demonstrated potential life-long negative impacts of adverse childhood experiences (ACEs) on psychological health. This study examined the role of PCEs and ACEs in psychological symptoms following potentially traumatic events (PTE) in adults. METHODS Participants (N = 128) were adults admitted to two Level 1 Trauma Centers following violence, motor-vehicle crashes, or other accidents. Participants reported childhood experiences and completed assessments of depression, PTSD, and social support at one, four, and nine months post-PTE. RESULTS Structural Equation Modeling was used to simultaneously model PCEs and ACEs as predictors of psychological symptoms over time, with potential mediation through social support. PCEs overall did not directly affect psychological symptoms nor indirectly through social support. However, the emotional support component of PCEs had an indirect effect on psychological symptoms at baseline through social support. ACEs predicted greater psychological symptoms at baseline and over time. CONCLUSION PCEs consisting of childhood emotional support indirectly promote adjustment in adults after PTEs through initial social support, while ACEs exert direct effects on psychological symptoms.
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Affiliation(s)
- Tam N M Nguyen
- Departments of Psychological Science and Public Health, Kent State University, Kent, OH, USA
| | - David J Disabato
- Departments of Psychological Science and Public Health, Kent State University, Kent, OH, USA
| | - John Gunstad
- Departments of Psychological Science and Public Health, Kent State University, Kent, OH, USA
| | - Douglas L Delahanty
- Departments of Psychological Science and Public Health, Kent State University, Kent, OH, USA
| | - Richard George
- Department of Trauma, Summa Health Systems - Akron Campus, Akron, OH, USA
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
| | | | - Ali F Mallat
- Cleveland Clinic, Akron General Hospital, Akron, OH, USA
| | - Karin G Coifman
- Departments of Psychological Science and Public Health, Kent State University, Kent, OH, USA
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2
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Maciel MR, Calsavara VF, Zylberstajn C, Mello MF, Coimbra BM, Mello AF. Changes in attachment dimensions during the treatment of acute post-traumatic stress disorder in sexually assaulted Brazilian women. Front Psychol 2023; 14:1325622. [PMID: 38130963 PMCID: PMC10734689 DOI: 10.3389/fpsyg.2023.1325622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Attachment patterns are established during early childhood; however, extreme experiences throughout life may change this structure, either toward attachment security or insecurity. We analyzed changes in attachment dimensions in women with acute post-traumatic stress disorder (PTSD) following sexual assault, that were randomized to a 14-week treatment with either the medication sertraline or Interpersonal Psychotherapy. Methods Seventy-four adult women who presented significant reduction in PTSD symptoms across the trial responded to the Revised Adult Attachment Scale at baseline, on week 8 of treatment, and at the end of the trial, on week 14. We fitted a generalized linear model to explain the attachment anxiety and avoidance scores at baseline. A generalized linear mixed model investigated how attachment dimensions changed over time. Socioeconomic data, treatment type, history of childhood trauma, and PTSD severity over the 14-week period were the considered covariates. Results At baseline, attachment anxiety was associated with a history of early trauma. Attachment anxiety remained stable during the follow-up. Attachment avoidance, on the other hand, significantly increased from baseline to week 14. Higher avoidance was observed in patients with higher total PTSD scores and on the cluster of hyperarousal symptoms. Races other than White (black, mixed-race, or Asian) and younger age were associated with higher attachment avoidance. Discussion Contrary to our expectations, attachment avoidance increased during follow-up, indicating changes in the interpersonal realm beyond the symptoms of PTSD.
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Affiliation(s)
- Mariana Rangel Maciel
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Cecilia Zylberstajn
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcelo Feijo Mello
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Bruno Messina Coimbra
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, Amsterdam, Netherlands
- Faculty of Social and Behavioural Sciences, Department of Methodology and Statistics, Utrecht University, Utrecht, Netherlands
| | - Andrea Feijo Mello
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Plouffe RA, Nazarov A, Forchuk CA, Gervasio J, Le T, Liu JJ, Nouri MS, Trahair C, Walker DL, Richardson JD. The roles of personality and resilience in associations between combat experiences and posttraumatic stress disorder among Canadian Armed Forces Veterans. PERSONALITY AND INDIVIDUAL DIFFERENCES 2023. [DOI: 10.1016/j.paid.2023.112141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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Ponder WN, Whitworth J, Ross K, Sherrill T. Attachment-Based Relationship Satisfaction in Deployed and Non-Deployed Military Veterans with Prevalent PTSD, Anxiety, and Depression. JOURNAL OF VETERANS STUDIES 2022. [DOI: 10.21061/jvs.v8i3.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Owens GP, Hamrick LA, Keller EM, Perkins M, Collins S, Thomas EA, Haag I, Swan S, Pickering N. Predictors of posttraumatic stress symptom severity and meaning made in treatment-seeking veterans. J Clin Psychol 2022; 78:2564-2578. [PMID: 35510293 DOI: 10.1002/jclp.23369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 03/17/2022] [Accepted: 04/15/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Combat-exposed veterans risk encountering events that disrupt beliefs. To facilitate reduced discrepancy between prior beliefs and current trauma appraisals, veterans may engage in a process of meaning-making. Meaning-making can lead to positive outcomes, such as integrating the traumatic event into one's life narrative or adapting global meaning (meaning made) or elicit distress. Given these potentially different outcomes, this study examined potential correlates of posttraumatic stress symptom (PTSS) severity and meaning made, including relationship attachment dimensions of anxiety and avoidance, and difficulties with emotion regulation, while controlling for combat exposure. METHOD Veterans receiving mental health services at a Veterans Affairs (VA) Medical Center and a VA community-based outpatient clinic (N = 130) completed measures through a paper-and-pencil survey. Almost all participants (92%) were male, with a mean age of 55.92 years. RESULTS In terms of meaning made, lower levels of attachment anxiety and emotional clarity (an aspect of emotion regulation) predicted higher meaning made. In terms of PTSS severity, higher attachment avoidance, attachment anxiety, and difficulties engaging in goal-directed behavior (an aspect of emotion regulation) significantly predicted higher PTSS severity. CONCLUSION Aspects of both attachment style and emotion regulation difficulties affect meaning made and PTSS severity. These constructs may be especially relevant for clinicians working with veterans to help PTSS and support meaning made postcombat.
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Affiliation(s)
- Gina P Owens
- Department of Psychology, University of Tennessee, Knoxville, Tennessee, USA
| | - Lauren A Hamrick
- Department of Psychology, University of Tennessee, Knoxville, Tennessee, USA
| | - Emily M Keller
- Department of Psychology, University of Tennessee, Knoxville, Tennessee, USA
| | - Marjorie Perkins
- Department of Psychology, University of Tennessee, Knoxville, Tennessee, USA
| | - Summer Collins
- Department of Psychology, University of Tennessee, Knoxville, Tennessee, USA
| | - Elizabeth A Thomas
- Department of Psychology, University of Tennessee, Knoxville, Tennessee, USA
| | - Ian Haag
- William C. Tallent VA Outpatient Clinic, Knoxville, Tennessee, USA
| | - Scott Swan
- William C. Tallent VA Outpatient Clinic, Knoxville, Tennessee, USA
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6
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Zhou X, Zhen R, Wu X. Insecure Attachment to Parents and PTSD among Adolescents: The Roles of Parent-Child Communication, Perceived Parental Depression, and Intrusive Rumination. Dev Psychopathol 2021; 33:1290-1299. [PMID: 32594930 DOI: 10.1017/s0954579420000498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Based on attachment theory and a social-cognitive model of posttraumatic stress disorder (PTSD), this study examined the roles of parent-child communication, perceived parental depression, and intrusive rumination in the association between insecure attachment to parents and PTSD among adolescents following the Jiuzhaigou earthquake. In this study, 620 adolescents were recruited to complete self-report questionnaires. The results showed that the direct association between anxious attachment and PTSD was significant, but that between avoidant attachment and PTSD was non-significant. In addition, both anxious and avoidant attachment had indirect associations with PTSD via the mediating effects of parent-child communication openness and problems, perceived parental depression, and intrusive rumination. However, the specific paths between anxious and avoidant attachment and PTSD were different. The findings indicated that insecure attachment among adolescents following the earthquake was predictive for their PTSD, and the mechanisms underlying the association between anxious attachment and PTSD and the association between avoidant attachment and PTSD were distinct. To alleviate PTSD, more attention should be paid to improving the quality of parent-child communication for adolescents with avoidant attachment to parents, and to reducing negative cognition in adolescents with anxious attachment.
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Affiliation(s)
- Xiao Zhou
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, China
| | - Rui Zhen
- Institute of Psychological Science, Hangzhou Normal University, Hangzhou, China
| | - Xinchun Wu
- Faculty of Psychology, Beijing Normal University, Beijing, China
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7
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Overstreet C, DeViva JC, Amstadter A, McCarthy E, Southwick SM, Pietrzak RH. Resilience to traumatic stress in U.S. military veterans: Application of a novel classification approach in a nationally representative sample. J Psychiatr Res 2021; 140:301-307. [PMID: 34126424 DOI: 10.1016/j.jpsychires.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
Resilience has been of particular interest to researchers and clinicians focused on response to trauma. In the current study, we employed a novel, discrepancy-based psychiatric resilience (DBPR) analytic approach to operationalizing resilience and examined its relation to potentially protective psychosocial factors in a nationally representative sample of U.S. veterans (N = 2704). Cumulative lifetime trauma burden, severity of PTSD symptoms, and protective factors such as personality characteristics (e.g., conscientiousness), protective psychosocial characteristics (e.g., purpose in life), and social connectedness (e.g., secure attachment style) were assessed. PTSD Checklist (PCL) scores were regressed onto cumulative trauma burden for the entire sample and a predicted PCL score was generated for each veteran. Resilience was operationalized as a lower actual relative to predicted PCL score. Results of a relative importance analysis revealed that somatic symptoms (22.5% relative variance explained [RVE]), emotional stability (22.4% RVE), and a secure attachment style (14.1%) explained the majority of the variance in resilience scores. These results demonstrate the utility of a DBPR approach to operationalizing resilience in U.S. military veterans. They also identify potentially modifiable psychosocial factors that may be bolstered in prevention and treatment efforts designed to mitigate the negative effects of trauma and promote resilience in this population.
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Affiliation(s)
- Cassie Overstreet
- Department of Psychiatry, Yale University School of Medicine, 300 George St Ste 901, New Haven, CT, 06511, USA; National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
| | - Jason C DeViva
- Department of Psychiatry, Yale University School of Medicine, 300 George St Ste 901, New Haven, CT, 06511, USA; VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Ananda Amstadter
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, 800 E. Leigh Street, Biotech One, Richmond, VA, 23298, Richmond, VA, USA
| | - Elissa McCarthy
- National Center for PTSD, 215 North Main St. White River Junction, Vermont, 05009, USA
| | - Steven M Southwick
- Department of Psychiatry, Yale University School of Medicine, 300 George St Ste 901, New Haven, CT, 06511, USA; National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale University School of Medicine, 300 George St Ste 901, New Haven, CT, 06511, USA; National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
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Onu DU, Ugwu DI. Negative centralisation of HIV trauma influences health-related quality of life: Does posttraumatic growth buffer the link? INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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9
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Lim BH, Hodges MA, Lilly MM. The Differential Effects of Insecure Attachment on Post-Traumatic Stress: A Systematic Review of Extant Findings and Explanatory Mechanisms. TRAUMA, VIOLENCE & ABUSE 2020; 21:1044-1060. [PMID: 30599805 DOI: 10.1177/1524838018815136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
It is well-documented that insecure attachment poses substantial risks to post-trauma recovery. Although attachment anxiety reliably predicts and is associated with elevated post-traumatic stress symptoms (PTSS), the attachment avoidance-PTSS link has been far less consistent. This suggests both attenuating and enhancing connections between attachment difficulties and post-trauma outcomes. The goal of this study is 2-fold: (a) to review and summarize extant evidence concerning the relation between insecure attachment and PTSS and (b) to review mechanism(s) underlying attachment anxiety and attachment avoidance that may explain the development of PTSS. Following a systematic review of the empirical literature investigating attachment, trauma, and post-trauma reactions, a total of 138 studies were identified and summarized. The review further identifies explanatory mechanisms underlying the association between insecure attachment and PTSS, including stress appraisals, cognitive factors, self-esteem, emotion regulation strategies, social factors, and trauma-specific factors (i.e., type of trauma, extreme stress). Implications for practice, policy, and research are discussed.
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Affiliation(s)
- Ban Hong Lim
- University of California, Los Angeles, Los Angeles, CA, USA
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10
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Vulnerability Factors Associated with Lifetime Posttraumatic Stress Disorder among Veterans 40 Years after War. Healthcare (Basel) 2020; 8:healthcare8040359. [PMID: 32987683 PMCID: PMC7711782 DOI: 10.3390/healthcare8040359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/02/2022] Open
Abstract
Vulnerability factors for posttraumatic stress disorder (PTSD) development are still controversial. Our aim was to study the vulnerability factors for the development of war-related PTSD over a period of 40 years after exposure. A cross-sectional, observational study was carried out on 61 male traumatized war veterans, taking into consideration adverse childhood experiences (ACE), attachment orientations, number of non-war-related traumatic events, and war experiences. Lifetime PTSD was assessed by using the Clinician-Administered PTSD Scale. Insecure attachment styles were significantly associated with lifetime PTSD and even after adjustment for war exposure this was still significant. Non-war-related traumatic events were not associated with lifetime PTSD, whereas ACE were associated with lifetime PTSD. War-related experiences were also associated with lifetime PTSD, except for injury or disease. The results for our sample show that, 40 years after war, the intensity of war-related experiences and ACE were significantly and independently associated with the development of lifetime PTSD. Insecure attachment was significantly associated with lifetime PTSD, which, in turn, are both positively associated with war exposure. These findings may have implications for patient care, as they constitute a strong argument that attachment-focused therapies could well be necessary 40 years after trauma.
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11
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Sciarrino NA, Moschetto JM, Choquette EM, Davis BC, Bannister JA. Understanding the impact of attachment insecurity on PTSD symptoms among male Veterans and military personnel. MILITARY PSYCHOLOGY 2020; 32:379-389. [PMID: 38536335 PMCID: PMC10013455 DOI: 10.1080/08995605.2020.1774322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/22/2020] [Indexed: 10/23/2022]
Abstract
Attachment insecurity (i.e., attachment anxiety and attachment avoidance) has been found to contribute to PTSD symptom severity in Veterans. However, little is known of the unique contribution of attachment insecurity on individual PTSD symptom clusters. In a community sample of 106 combat-deployed Veterans, active duty service members, and reservists, this study examined: (1) the relationships between childhood family experience, combat experience, attachment insecurity, and PTSD symptom clusters, and (2) the influence of attachment insecurity on PTSD symptom clusters. Results revealed significant correlations between attachment anxiety and all PTSD symptom clusters (rs = .22 -.43) and attachment avoidance and PTSD symptom clusters, except the avoidance cluster (rs = .21 -.36). Four multiple regression analyses were employed to address the second study aim. Childhood family experiences predicted negative alterations in cognitions and mood (β = -.30) and alterations in arousal and reactivity (β = -.20). Further, combat experience significantly predicted each symptom cluster of PTSD (βs = .03 -.44). In the second step, attachment anxiety and attachment avoidance were added to each model. Attachment anxiety and attachment avoidance predicted negative alterations in cognitions and mood (βs = .22 and .35) and alterations in arousal and reactivity (βs = .27 and .17). Inconsistent with previous research, attachment insecurity did not predict symptoms of avoidance. These results highlight the impact of attachment among a diverse sample of trauma exposed individuals and may provide insights for clinical implications and therapeutic approaches when working with Veterans and military personnel high in attachment insecurity.
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Affiliation(s)
- Nicole A. Sciarrino
- James A. Haley Veterans’ Hospital, Tampa, Florida
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | | | | | - Brittany C. Davis
- James A. Haley Veterans’ Hospital, Tampa, Florida
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, Florida
| | - Jenny A. Bannister
- James A. Haley Veterans’ Hospital, Tampa, Florida
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, Florida
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12
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Heenan A, Greenman PS, Tassé V, Zachariades F, Tulloch H. Traumatic Stress, Attachment Style, and Health Outcomes in Cardiac Rehabilitation Patients. Front Psychol 2020; 11:75. [PMID: 32047467 PMCID: PMC6997333 DOI: 10.3389/fpsyg.2020.00075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/10/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Research on psychosocial risk factors in cardiovascular disease (CVD) has identified traumatic stress and attachment style as independent risk factors for the development of CVD and poor prognosis for those with established CVD. Exploring the interrelationships between these variables will inform psychosocial risk factor modeling and potential avenues for intervention. Therefore, the hypothesis that attachment style is related to health outcomes among CR patients and that traumatic stress mediates this relationship was tested. METHODS Patients in a cardiac rehabilitation program (n = 201) completed validated self-report measures of traumatic stress and attachment style at baseline (program intake). Health outcomes were assessed at baseline and 3 months, including anxiety, depression, quality of life, fasting blood glucose, glycated hemoglobin (HbA1c), and cholesterol (HDL ratio). Multivariate structural equation modeling was used to fit the data. RESULTS Of the 201 participants, 42 (21%) had trauma scores indicating the probable presence of posttraumatic stress disorder. Via greater levels of traumatic stress, greater attachment anxiety at baseline was indirectly related to greater anxiety, depression, fasting blood glucose, and HbA1c, and poorer physical and mental quality of life. There were no significant indirect effects on HDL ratios. CONCLUSION Greater attachment anxiety predicted greater traumatic stress; this, in turn, predicted poorer health outcomes. Screening and treatment for these constructs in CVD patients is warranted.
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Affiliation(s)
- Adam Heenan
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Paul S. Greenman
- Département de Psychoéducation et de Psychologie, Universite du Québec en Outaouais, Gatineau, QC, Canada
- Institut du Savoir Montfort, Ottawa, ON, Canada
| | - Vanessa Tassé
- Département de Psychoéducation et de Psychologie, Universite du Québec en Outaouais, Gatineau, QC, Canada
| | | | - Heather Tulloch
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Psychology, University of Ottawa, Ottawa, ON, Canada
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13
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Partner attachment and the development of traumatic and anxious-depressive symptoms among university students. SEXOLOGIES 2020. [DOI: 10.1016/j.sexol.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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14
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Exploring the relations of psychopathic and narcissistic personality traits to military experiences in National Guard personnel. PERSONALITY AND INDIVIDUAL DIFFERENCES 2020. [DOI: 10.1016/j.paid.2019.109554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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15
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Machado J, Bruno J, Rotonda C, Siles J, Steinmetz T, Zambelli C, Vismara L, Tarquinio C. Attachement au partenaire et développement de symptômes traumatiques et anxieux-dépressifs chez les étudiants. SEXOLOGIES 2020. [DOI: 10.1016/j.sexol.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Lindert J, Lee LO, Weisskopf MG, McKee M, Sehner S, Spiro A. Threats to Belonging-Stressful Life Events and Mental Health Symptoms in Aging Men-A Longitudinal Cohort Study. Front Psychiatry 2020; 11:575979. [PMID: 33424657 PMCID: PMC7793980 DOI: 10.3389/fpsyt.2020.575979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/30/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: Stressful life events, especially relationship events, are frequent in adult life. We investigated the impact of a variety of stressful life events on symptoms of depression, anxiety, and hostility. Methods: We analyzed data from a large prospective cohort study of men (n = 1,437) in the Boston area (assessed in 1985, 1988, and 1991). Main outcomes were measures of depression, anxiety and hostility symptoms. We used the Elders Life Stress Inventory (ELSI) to measure stressful life events in the past 12 months and examine their association with symptoms of depression, anxiety and hostility. First, we analyzed the association of stressful life events with symptom changes; second, we categorized stressful life events into finance/work, health, relationships, loss, living situations events; and third, we estimated the specific association between relationship events and depression, anxiety and hostility symptoms using multilevel models. Results: The most frequent stressful life events were health, relationship, and financial events. Depression, anxiety, and hostility symptoms were relatively stable among men who did not experience these life events. However, those who reported life events in the past 12 months had a greater increase in symptoms of depression (+0.05; 95% CI: 0.01 to 0.10) and of hostility (+0.05; 95% CI: 0.01 to 0.09) than those who did not. Additionally, we found a significant decrease in hostility (-0.05; 95% CI: -0.08 to -0.01) in those experiencing no life events. Conclusion: Relationship events were more important than any other type of events, and were significantly associated with increased depression and hostility in aging men. Although the effects were small, the results point to a need to understand better the impact of relationships on psychopathology in the aging population.
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Affiliation(s)
- Jutta Lindert
- Department of Health and Social Work, University of Applied Sciences Emden, Emden, Germany.,Women's Research Center, Brandeis University, Waltham, MA, United States
| | - Lewina O Lee
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.,National Center for Posttraumatic Stress Disorder, Veterans Affairs Boston Healthcare System, Boston, MA, United States
| | - Marc G Weisskopf
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - Martin McKee
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Susanne Sehner
- Institute for Medical Biometry and Epidemiology, Institute for Epidemiology and Statistics, University of Hamburg, Hamburg, Germany
| | - Avron Spiro
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.,National Center for Posttraumatic Stress Disorder, Veterans Affairs Boston Healthcare System, Boston, MA, United States.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
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Lamkin J, Hundt N, Ahearn EP, Stanley M, Smith TL. Patterns of Treatment Disengagement and Personality Traits Associated With Posttraumatic Stress Disorder in Recent-Era U.S. Veterans Receiving Cognitive Processing Therapy. J Trauma Stress 2019; 32:625-632. [PMID: 31356704 DOI: 10.1002/jts.22428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/14/2019] [Accepted: 02/20/2019] [Indexed: 11/12/2022]
Abstract
Low treatment engagement is a barrier to implementation of empirically supported treatments for posttraumatic stress disorder (PTSD) among veterans. Understanding personality traits that predict dropout may help focus attempts to improve engagement. The current study included 90 veterans who served in recent conflicts in Iraq and/or Afghanistan and participated in a trial of cognitive processing therapy for PTSD. Goals were to characterize (a) personality correlates of PTSD, (b) patterns of engagement (i.e., attendance and homework completion), and (c) personality correlates of reduced engagement. Higher levels of PTSD symptoms were associated with a range of characteristics, including affective lability, r = .44 p < .001; anxiety, r = .38, p < .001; identity problems, r = .57, p < .001; intimacy problems, r = .34, p = .001; low affiliation, r = .33, p = .002; oppositionality, r = .36, p = .001; restricted expression, r = .35, p = .001; and suspiciousness, r = .50, p < .001. Notably, veterans with worse PTSD symptoms endorsed more cognitive dysregulation, r = .40, p < .001; and less insecure attachment, r = .14, p = .190, than expected. Only 52.2% of veterans completed the 12-session course of treatment and 31.0% of participants completed fewer than six sessions. Personality traits did not predict attendance or homework completion. Disengagement continues to be a significant issue in trauma-focused treatment for veterans with PTSD. Understanding veteran-level factors, such as personality traits, may be useful considerations for future research seeking to understand and improve engagement.
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Affiliation(s)
- Joanna Lamkin
- Veterans Affairs (VA), Health Services Research and Development Service, Houston Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Natalie Hundt
- Veterans Affairs (VA), Health Services Research and Development Service, Houston Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Eileen P Ahearn
- Department of Psychiatry, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA.,William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Melinda Stanley
- Veterans Affairs (VA), Health Services Research and Development Service, Houston Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Tracey L Smith
- Veterans Affairs (VA), Health Services Research and Development Service, Houston Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
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18
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Chung MC, Freh FM. The trajectory of bombing-related posttraumatic stress disorder among Iraqi civilians: Shattered world assumptions and altered self-capacities as mediators; attachment and crisis support as moderators. Psychiatry Res 2019; 273:1-8. [PMID: 30634110 DOI: 10.1016/j.psychres.2019.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 01/01/2019] [Accepted: 01/01/2019] [Indexed: 11/27/2022]
Abstract
This study examined the impact of bombing on posttraumatic stress disorder (PTSD) and psychiatric co-morbidity over time, whether this relationship was mediated by shattered world assumptions and altered self-capacities, and whether the mediational effects were moderated by attachment style and crisis support among Iraqi civilians. One hundred and fifty-nine Iraqi civilians completed questionnaires measuring the aforementioned psychological constructs. Bombing exposure was associated with PTSD and psychiatric co-morbidity over time; 87% and 77% met the criteria for PTSD at baseline and five months respectively. Shattered world assumptions and altered self-capacities mediated the impact of bombing exposure on PTSD and psychiatric co-morbidity over time. The mediational effect for shattered world assumptions was not moderated by attachment style and crisis support. However, the mediational effect for altered self-capacities was moderated by fearful attachment and a medium level of crisis support. To conclude, following bombing, Iraqi civilians' assumptions about the world and others can change. These changes can have long term effects on psychological distress but are not influenced by childhood attachment experiences or the amount of crisis support received. Bombing can also change civilians' perceptions of internal capacities like emotional regulation, particularly those with fearful attachment who rely on crisis support to some extent.
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Affiliation(s)
- Man Cheung Chung
- Department of Educational Psychology, Ho Tim Building, Faculty of Education, the Chinese University of Hong Kong, Shatin, NT, Hong Kong.
| | - Fuaad Mohammed Freh
- University of Anbar, College of Education for Humanities, Department of Psychology, Iraq
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19
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Bannister JA, Lopez FG, Menefee DS, Norton PJ, Wanner J. Military and Premilitary Trauma, Attachment Orientations, and Posttraumatic Stress Disorder Severity Among Male and Female Veterans. J Trauma Stress 2018; 31:558-567. [PMID: 30091801 DOI: 10.1002/jts.22309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/14/2018] [Accepted: 04/23/2018] [Indexed: 11/08/2022]
Abstract
Samples in prior studies examining attachment theory in the military have been predominantly composed of male combat veterans. Given the rates of sexual trauma among female veterans and differences in the association between attachment and posttraumatic stress disorder (PTSD) severity for sexual trauma survivors, it was necessary to consider the attachment characteristics of veterans within a mixed-sex sample. Participants were a mixed-sex veteran sample seeking inpatient trauma-related treatment (N = 469). Using independent samples t tests, we examined sex differences in attachment. Consistent with our hypothesis, women reported a higher level of attachment anxiety than did men, t(351) = -2.12, p = .034. Women also reported a higher level of attachment avoidance, t(351) = -2.44, p = .015. Using hierarchical regression, we examined the contribution of attachment anxiety and avoidance to PTSD severity, partialing out variance accounted for by demographic variables and traumatic experiences. Consistent with our hypotheses, attachment avoidance predicted PTSD severity on the Clinician-Administered PTSD Scale for DSM-IV (CAPS), β = .20, p < .001, and the PTSD Checklist-Civilian Version (PCL-C), β = .18, p < .001. Attachment anxiety did not predict CAPS severity but did predict PCL-C severity, β = .11, p = .020. These results suggest the association between attachment avoidance and PTSD is not exclusive to combat trauma and may apply more generally to the larger veteran population. Higher levels of attachment anxiety and avoidance among female veterans potentially implicate the presence of greater attachment fearfulness among this particular subpopulation of veterans.
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Affiliation(s)
- Jenny A Bannister
- Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, Texas.,Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, Texas
| | - Frederick G Lopez
- Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, Texas
| | - Deleene S Menefee
- Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, Texas.,The Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | - Peter J Norton
- School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Jill Wanner
- Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, Texas.,The Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
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20
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Broadbridge CL. Is the centralization of potentially traumatic events always negative? An expansion of the Centrality of Events Scale. APPLIED COGNITIVE PSYCHOLOGY 2018. [DOI: 10.1002/acp.3403] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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21
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Preliminary evidence for the use and efficacy of mobile health applications in managing posttraumatic stress disorder symptoms. Health Syst (Basingstoke) 2017. [DOI: 10.1057/hs.2016.2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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22
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Owens GP. Predictors of Posttraumatic Growth and Posttraumatic Stress Symptom Severity in Undergraduates Reporting Potentially Traumatic Events. J Clin Psychol 2016; 72:1064-76. [DOI: 10.1002/jclp.22309] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 02/03/2016] [Accepted: 02/27/2016] [Indexed: 11/10/2022]
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23
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Shura RD, Rutherford BJ, Fugett A, Lindberg MA. An Exploratory Study of Attachments and Posttraumatic Stress in Combat Veterans. CURRENT PSYCHOLOGY 2015. [DOI: 10.1007/s12144-015-9390-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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24
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Woodhouse S, Ayers S, Field AP. The relationship between adult attachment style and post-traumatic stress symptoms: A meta-analysis. J Anxiety Disord 2015; 35:103-17. [PMID: 26409250 DOI: 10.1016/j.janxdis.2015.07.002] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 07/14/2015] [Accepted: 07/15/2015] [Indexed: 10/23/2022]
Abstract
There is increasing evidence that adult attachment plays a role in the development and perseverance of symptoms of posttraumatic stress disorder (PTSD). This meta-analysis aims to synthesise this evidence and investigate the relationship between adult attachment styles and PTSD symptoms. A random-effects model was used to analyse 46 studies (N=9268) across a wide range of traumas. Results revealed a medium association between secure attachment and lower PTSD symptoms (ρˆ=-.27), and a medium association, in the opposite direction, between insecure attachment and higher PTSD symptoms (ρˆ=.26). Attachment categories comprised of high levels of anxiety most strongly related to PTSD symptoms, with fearful attachment displaying the largest association (ρˆ=.44). Dismissing attachment was not significantly associated with PTSD symptoms. The relationship between insecure attachment and PTSD was moderated by type of PTSD measure (interview or questionnaire) and specific attachment category (e.g. secure, fearful). Results have theoretical and clinical significance.
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Affiliation(s)
| | - Susan Ayers
- School of Health Sciences, City University London, United Kingdom.
| | - Andy P Field
- School of Psychology, University of Sussex, United Kingdom
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25
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Abstract
The present study examined correlates of work volition—the perceived capacity to make occupational choices despite constraints—with a diverse sample of 213 U.S. veterans. Veterans with higher levels of formal education, higher yearly incomes, were married, and were employed, endorsed greater work volition. Those who experienced lower posttraumatic stress disorder (PTSD) symptoms, endorsed lower levels of neuroticism, higher levels of conscientiousness, and higher levels of internal locus of control, also demonstrated greater levels of work volition. A structural model was run where PTSD symptoms, neuroticism, and conscientiousness were hypothesized to predict work volition via locus of control and compared with an alternative model. After identifying a best fitting model, bootstrapping analyses demonstrated that locus of control fully mediated the relations between PTSD symptoms, neuroticism, and conscientiousness to work volition. Specifically, the key reason PTSD symptoms, neuroticism, and conscientiousness were related to work volition was their effect on general locus of control. Practical implications are discussed.
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26
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Bosmans MWG, van der Velden PG. Longitudinal interplay between posttraumatic stress symptoms and coping self-efficacy: A four-wave prospective study. Soc Sci Med 2015; 134:23-9. [PMID: 25875423 DOI: 10.1016/j.socscimed.2015.04.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Trauma-related coping self-efficacy (CSE), the perceived capability to manage one's personal functioning and the myriad environmental demands of the aftermath of potentially traumatic events (PTE), has been shown to affect psychological outcomes after these events. Aim of the present four-wave study was to examine the cross-lagged relationships between CSE and posttraumatic stress disorder (PTSD) symptoms following PTEs in order to examine direction of influence. Levels of CSE and PTSD symptoms were measured with 4-month intervals. In addition, prospectively assessed personality traits and general self-efficacy perceptions as well as peritraumatic distress were entered in the analyses. The study sample consists of adult respondents of a representative internet panel who experienced PTE in the six months before T1, and did not experience any new PTE or life event between T1 and T3 (N = 400). Respondents were administered the coping self-efficacy scale (CSE-7), impact of event scale (IES) and arousal items of IES-R at each wave (T1 through T3), as well as questions on peritraumatic stress and prospectively measured personality traits (T0). Results of structural equation modeling showed that the effect of CSE on subsequent PTSD symptom levels was dominant. CSE significantly predicted subsequent symptoms, over and above earlier symptom levels, with higher CSE associated with lower PTSD. Symptoms in turn, did not predict subsequent levels of CSE. Higher peritraumatic distress was associated with both higher initial PTSD symptoms and lower initial CSE levels. Higher levels of the personality traits of emotional stability and agreeableness were associated with higher initial CSE levels. This supports a model in which CSE perceptions play an important role in recovery from trauma.
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27
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Franz CE, Lyons MJ, Spoon KM, Hauger RL, Jacobson KC, Lohr JB, McKenzie R, Panizzon MS, Thompson WK, Tsuang MT, Vasilopoulos T, Vuoksimaa E, Xian H, Kremen WS. Post-traumatic stress symptoms and adult attachment: a 24-year longitudinal study. Am J Geriatr Psychiatry 2014; 22:1603-12. [PMID: 24636844 PMCID: PMC4138283 DOI: 10.1016/j.jagp.2014.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 02/14/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Attachment theory has become a key framework for understanding responses to and consequences of trauma across the life course. We predicted that more severe post-traumatic stress (PTS) symptoms at age 37 years would be associated with insecure attachment at age 55 and with worse PTS symptoms 24 years later at age 61, and that age 55 attachment would mediate the influence of earlier PTS symptoms on later symptoms. DESIGN Data on PTS self-reported symptoms were available for 975 community-dwelling participants from the longitudinal Vietnam Era Twin Study of Aging at ages 37 and 61 years. At age 55, participants completed the Experiences in Close Relationships Inventory, a measure of adult attachment. RESULTS PTS symptoms at ages 37 and 61 correlated (r = 0.43; p <0.0001). Multiple mediation models found significant direct effects of age 37 PTS symptoms on age 61 PTS symptoms (β = 0.26; 95% confidence interval: 0.19-0.33). Anxious and avoidant attachment at age 55 predicted PTS symptoms at age 61 (r = 0.34 and 0.25; ps <0.0001, respectively) and also significantly mediated PTS symptoms over time, showing that insecure attachment increased PTS severity. Participants with higher age 37 PTS symptoms were more likely to have a history of divorce; marital status did not mediate PTS. CONCLUSIONS Analyses demonstrate the persistence of PTS symptoms from early midlife into early old age. Mediation analyses revealed that one path through which PTS symptoms persisted was indirect: through their influence on attachment insecurity. This study provides insight into ongoing interconnections between psychological and interpersonal responses to stress.
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Affiliation(s)
- Carol E. Franz
- Department of Psychiatry, University of California San Diego
| | | | - Kelly M. Spoon
- Department of Psychiatry, University of California San Diego
| | - Richard L. Hauger
- Department of Psychiatry, University of California San Diego,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
| | | | - James B. Lohr
- Department of Psychiatry, University of California San Diego,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
| | | | | | | | - Ming T. Tsuang
- Department of Psychiatry, University of California San Diego,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
| | | | - Eero Vuoksimaa
- Department of Psychiatry, University of California San Diego,Department of Public Health, University of Helsinki
| | - Hong Xian
- Department of Statistics, St. Louis University,Research Service, VA St. Louis Healthcare System
| | - William S. Kremen
- Department of Psychiatry, University of California San Diego,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
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28
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Owens GP, Held P, Blackburn L, Auerbach JS, Clark AA, Herrera CJ, Cook J, Stuart GL. Differences in relationship conflict, attachment, and depression in treatment-seeking veterans with hazardous substance use, PTSD, or PTSD and hazardous substance use. JOURNAL OF INTERPERSONAL VIOLENCE 2014; 29:1318-1337. [PMID: 24255069 DOI: 10.1177/0886260513506274] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Veterans (N = 133) who were seeking treatment in either the Posttraumatic Stress Program or Substance Use Disorders Program at a Veterans Affairs Medical Center (VAMC) and, based on self-report of symptoms, met clinical norms for posttraumatic stress disorder (PTSD) or hazardous substance use (HSU) completed a survey related to relationship conflict behaviors, attachment styles, and depression severity. Participants were grouped into one of three categories on the basis of clinical norm criteria: PTSD only, HSU only, and PTSD + HSU. Participants completed the PTSD Checklist-Military, Experiences in Close Relationships Scale-Short Form, Center for Epidemiologic Studies-Depression scale, Alcohol Use Disorders Identification Test, Drug Use Disorders Identification Test, and Psychological Aggression and Physical Violence subscales of the Conflict Tactics Scale. Most participants were male and Caucasian. Significant differences were found between groups on depression, avoidant attachment, psychological aggression perpetration and victimization, and physical violence perpetration and victimization. Post hoc analyses revealed that the PTSD + HSU group had significantly higher levels of depression, avoidant attachment, and psychological aggression than the HSU only group. The PTSD + HSU group had significantly higher levels of physical violence than did the PTSD only group, but both groups had similar mean scores on all other variables. Potential treatment implications are discussed.
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