A longitudinal test of the bi-directional relations between avoidance coping and PTSD severity during and after PTSD treatment

Digital transformation of mental health therapy by integrating digitalized cognitive behavioral therapy and eye movement desensitization and reprocessing

Digital therapy has gained popularity in the mental health field because of its convenience and accessibility. One major benefit of digital therapy is its ability to address therapist shortages. Posttraumatic stress disorder (PTSD) is a debilitating mental health condition that can develop after an individual experiences or witnesses a traumatic event. Digital therapy is an important resource for individuals with PTSD who may not have access to traditional in-person therapy. Cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) are two evidence-based psychotherapies that have shown efficacy in treating PTSD. This paper examines the mechanisms and clinical symptoms of PTSD as well as the principles and applications of CBT and EMDR. Additionally, the potential of digital therapy, including internet-based CBT, video conferencing-based therapy, and exposure therapy using augmented and virtual reality, is explored. This paper also discusses the engineering techniques employed in digital psychotherapy, such as emotion detection models and text analysis, for assessing patients' emotional states. Furthermore, it addresses the challenges faced in digital therapy, including regulatory issues, hardware limitations, privacy and security concerns, and effectiveness considerations. Overall, this paper provides a comprehensive overview of the current state of digital psychotherapy for PTSD treatment and highlights the opportunities and challenges in this rapidly evolving field.

Coping styles in refugees with PTSD: Results from a randomized trial comparing EMDR therapy and stabilization

BACKGROUND

While treatment of posttraumatic stress disorder (PTSD) in refugees is generally effective, many refugees remain symptomatic after treatment. Coping styles could be relevant to PTSD treatment response and as such may be a potential focus of PTSD treatment.

AIMS

The study aims to examine 1) if baseline coping styles are related to treatment response after EMDR therapy or stabilization, and 2) if coping styles change during these treatments.

METHOD

Seventy-two refugees with PTSD were randomly allocated to 12 hours of EMDR therapy or stabilization. A coping questionnaire (COPE-easy) and clinical interview for PTSD (CAPS-IV) were administered before and after treatment and at three-month follow-up. The association between baseline coping styles and PTSD symptom change was examined using regression analysis and a t-test. Changes in coping styles were analyzed using mixed design ANOVA.

RESULTS

No significant relations between baseline coping style levels and PTSD symptom changes were found. Additionally, coping style levels did not change significantly after either treatment.

CONCLUSION

Contrary to the hypothesis, we did not find any evidence that treatment was related to (changes in) coping style. Addressing pre-treatment coping styles among refugees receiving short-term therapy, may not be required for reducing PTSD. Changing coping styles may need a longer or different type of treatment.

Within-patient association between emotion regulation and outcome in prolonged exposure for posttraumatic stress disorder

OBJECTIVE

Difficulties with emotion regulation (ER) are a risk factor for the development and maintenance of posttraumatic stress disorder (PTSD). Less is known about temporal relations between ER and PTSD symptom change during treatment, including whether ER may represent a more potent change ingredient for some patients relative to others. This study examined the association between within-patient changes in ER and next-session PTSD symptom change and whether this association was more pronounced for patients with poorer baseline ER, more severe depression, or higher borderline personality disorder symptoms.

METHOD

Data derived from a randomized controlled trial (NCT01600456) in which 149 adults with PTSD received up to 10 sessions of prolonged exposure (PE) or PE + sertraline. Patients rated difficulties with ER and PTSD symptoms repeatedly during treatment. Moderators were assessed at baseline.

RESULTS

Cross-lagged, dynamic structural equation models revealed that ER improvements were associated with next-session reductions in PTSD (standardized effect = 0.13). PTSD symptom reduction was also associated with next-session ER improvement (standardized effect = 0.34). Moderator analyses revealed that the within-person ER-PTSD symptoms association was stronger for patients with higher baseline depression (standardized effect = 0.39).

CONCLUSIONS

Reductions in PTSD symptoms may facilitate ER improvements during PE and PE augmented with sertraline rather than improvements in ER producing changes in PTSD symptoms. For patients with higher severity co-occurring depression, ER may represent a more active change ingredient. PE therapists could therefore consider placing particular emphasis on improving ER capabilities when working with this subgroup of patients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Including Sexually and Gender Diverse Populations in 3,4-Methylenedioxymethamphetamine-Assisted Psychotherapy Trial Research

Sexually and gender diverse (SGD) populations experience an increased prevalence and severity of posttraumatic stress disorder (PTSD) compared with the general population. Minority stress theory contextualizes this increased disease burden by outlining how stigma and discrimination (e.g., homophobia and transphobia) contribute to worse mental health outcomes. The standard-of-care pharmacotherapy for PTSD is associated with significant treatment resistance. 3,4-Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy (MDMA-AP) has emerged as an investigational treatment for PTSD but has lacked consideration for SGD populations. This article explores next steps in clinical trial design and implementation for the study of MDMA-AP with SGD populations who have PTSD.

"I Felt Dirty in a Way a Shower Wouldn't Fix": A Qualitative Examination of Sexual Trauma-Related Mental Contamination

Trauma-related mental contamination (MC) is a distressing sense of dirtiness that arises absent a contaminant following a traumatic event. Existing work has linked MC to more severe posttraumatic stress disorder symptoms among individuals with sexual trauma histories and has begun to characterize some aspects of the experience of trauma-related MC. However, a more nuanced understanding of how individuals experience and respond to trauma-related MC is lacking. The present study explored lived experiences of trauma-related MC among a sample of 34 women with sexual trauma histories using semi-structured qualitative interviews. Women were asked about MC across several domains, including somatic locations where trauma-related MC is experienced; triggers for trauma-related MC; and engagement in MC-related coping strategies, including washing behaviors. Women reported experiencing trauma-related MC in various bodily locations (internal, external, and both). Both overtly trauma-related triggers (e.g., trauma-relevant people or words, sexual contact) and non-trauma-related triggers (e.g., sweating, being around other people) were mentioned. Women also reported experiencing a variety of emotions alongside trauma-related MC (e.g., disgust, shame, anger) and using a range of strategies to cope with trauma-related MC, including washing behaviors, distraction, and substance use. Findings suggest that triggers for and responses to trauma-related MC are heterogeneous. Future work should explore the role of context in individuals' experiences of and responses to trauma-related MC, as well as whether experiences of trauma-related MC may differ by gender or across settings. Increased understanding of trauma-related MC may inform efforts to more readily and effectively identify and target MC in clinical practice.

The prevalence of PTSD and coping strategies among Palestinian mental health professionals during political violence and wartime

Background

In times of war, mental health professionals are at an increased risk of developing psychological problems, including posttraumatic stress disorder (PTSD). The effects of conflicts or wars on mental health professionals in Palestine and their coping methods of dealing with these challenges remain unknown. This study aimed to assess the prevalence of PTSD symptoms and strategies for coping among mental health professionals in Palestine, in light of the ongoing Gaza war and political violence.

Methods

The study utilized a cross-sectional research design. Self-reported questionnaires, including the PCL-5 and Brief COPE scales, were used to gather data. The relationship between the research variables and PTSD symptoms was investigated using frequencies, percentages, bivariate analysis, Pearson correlation, and Pearson's chi-square test.

Results

A total of 514 participants were recruited, with an estimated prevalence of PTSD of 38.7%. Furthermore, the multivariate analysis revealed that having a prior history of trauma and feeling disabled or unable to deal with your patients during the current Gaza war and Israeli-Palestinian political violence increases the likelihood of developing PTSD symptoms. In addition, using venting, self-blame, and behavioral disengagement as coping strategies increases the likelihood of developing symptoms of PTSD. Moreover, using acceptance and substance use as coping strategies reduces the risk of developing PTSD symptoms.

Conclusion

The findings revealed a high prevalence of PTSD symptoms among mental health professionals during wartime and political violence. As a result, mental health professionals need immediate assistance in enhancing their mental wellbeing through supervision, psychotherapy, and comprehensive and continuous training.

What predicts personal growth following a deployment? An examination of National Guard soldiers through the lens of posttraumatic growth

National Guard soldiers experience unique reintegration challenges. In addition to managing the consequences of combat-related trauma, they also navigate multiple transitions between military and civilian life. Despite these obstacles, many soldiers report positive outcomes and personal growth due to deployment, a phenomenon most commonly referred to in the literature as posttraumatic growth (PTG). The current study explored PTG in National Guard soldiers using a multidimensional longitudinal approach, with the goal of validating reports of PTG in soldiers. Data were collected from National Guard soldiers at pre-deployment, reintegration, one year post-deployment and two years post-deployment. Informed by PTG theory, three PTG constructs were measured (perceived ability to handle stress, social support seeking, and purpose in life) at each of the four time points, with increases in these constructs indicating growth. Potential predictors of growth in these PTG constructs were also explored. Results from a repeated measure latent profile analysis indicated that PTG did occur in certain soldiers, and that higher optimism and less severe PTSD symptoms predict this growth. These findings emphasize the importance of making efforts to facilitate PTG in soldiers.

Using experience sampling methodology (ESM) to improve our understanding of day-to-day intrusion frequency and related distress in survivors of trauma

BACKGROUND AND OBJECTIVES

Cognitive models of posttraumatic stress disorder (PTSD) suggest that appraisals of traumatic sequelae and subsequent distress drive the development and maintenance of PTSD. Posttraumatic research has relied heavily on macro-longitudinal designs, with weeks or months between assessments of trauma-related cognitions and symptoms. The present study uses experience sampling methodology (ESM) better understand the day-to-day experiences of trauma exposed individuals.

METHODS

One-hundred trauma exposed adults reported their posttraumatic symptoms, interpretations, and behaviours four times a day over a 10-day ESM period.

RESULTS

As anticipated, within-person fluctuations in negative appraisals of intrusions and maladaptive coping strategies (e.g., thought suppression) were significantly positively associated with intrusion frequency and related distress. In all cases, the associations for negative appraisals and maladaptive coping were stronger with intrusion related distress than intrusion frequency.

LIMITATIONS

The observed contemporaneous associations only demonstrate that variables reliably fluctuated together and cannot indicate causality.

CONCLUSIONS

The findings demonstrate that day-to-day fluctuations in trauma related perceptions and sequelae are significant and should be explored alongside broader individual differences to advance our understanding of the development, maintenance, and treatment of PTSD.

Alcohol-Related Problems As Moderators of PTSD Symptom Change During Use of a Web-Based Intervention for Hazardous Drinking and PTSD

OBJECTIVE

Alcohol-related problems (e.g., physical, interpersonal, intrapersonal, impulse control, social responsibility) can have an impact on posttraumatic stress disorder (PTSD) symptoms during treatment. Evidence-based online self-help tools exist to target alcohol use and related problems and co-occurring PTSD symptoms. It is unknown to what degree individuals with varying alcohol-related problems respond differently to web-based interventions for hazardous alcohol use and PTSD. The current study evaluated specific alcohol-related problems as potential moderators of PTSD symptom changes during the VetChange online intervention while controlling for average daily alcohol use, gender, race, and age.

METHOD

We conducted a secondary analysis of a randomized controlled trial that included 600 post-9/11 veterans (518 men and 82 women). Mixed-effects regression models of alcohol-related problems on PTSD severity scores over time were performed separately in an initial intervention group (IIG; n = 404) and a delayed intervention group (DIG; n = 196) that was used as a comparison condition.

RESULTS

Interpersonal problems emerged as a moderator of PTSD symptom changes in IIG such that veterans endorsing greater interpersonal problems demonstrated larger reductions in PTSD symptoms throughout VetChange. There were no significant moderation effects in DIG. Non-White veterans reported significantly higher PTSD symptoms during VetChange. Post hoc analyses indicated that veterans with higher interpersonal problems were more likely to engage in online intervention content focused on identifying high-risk drinking situations and coping with symptoms.

CONCLUSIONS

Findings imply that veterans reporting alcohol-related interpersonal problems may benefit the most from, and be more motivated to use, online interventions for hazardous alcohol use and PTSD symptoms.

Support-Seeking and Active Coping Mitigate the Association Between Posttrauma Symptom Severity and Attachment Insecurity in a Community Sample of Trauma Survivors

There is an established association between posttrauma symptom severity (PTSS) and attachment insecurity (anxiety and avoidance). However, few studies have examined this association among community samples of trauma-exposed individuals and identified factors that might moderate these associations. We sought to (a) replicate existing associations between PTSS and attachment insecurity in a community sample of trauma survivors and (b) determine the potential moderating role of support-seeking and coping behaviors. Our sample included 824 trauma-exposed individuals (MPCL-5 = 31.6, SD = 20.0; Mage = 37.4, SD = 13.2; 69.3% female; 79.1% White; 77.2% heterosexual). Participants completed an online survey via Amazon Mechanical Turk. Linear regression and moderation analyses tested the association between PTSS and attachment insecurity and whether support-seeking and coping behaviors moderated these associations. PTSS was positively associated with global attachment anxiety (β = .48, 95% confidence interval [.42, .54]) and global attachment avoidance (β = .06, [.15, .29]). The association between PTSS and attachment avoidance was weaker for people who reported greater instrumental and emotional support-seeking or greater active coping. This study provides evidence for the association between PTSS and attachment insecurity. Findings underscore the need to understand causal mechanisms underlying this association and critically evaluate how existing and future interventions can buffer attachment insecurity in trauma-exposed individuals.

Serially mediated effects of psychological inflexibility on quality of life of refugees in Uganda during coronavirus pandemic

The unexpected outbreak and rapid spread of COVID-19 necessitated radical and stringent control measures, consequently changing how people live globally. To vulnerable populations like refugees, who were already living a disrupted life, the outbreak of COVID-19 and accompanying control measures complicated their living conditions and drastically affected their mental health and, consequently, their quality of life. The current study aimed to test whether psychological inflexibility was a factor in lowering the quality of life of refugees in Uganda during the COVID-19 pandemic. The study further examines whether the effects of psychological inflexibility on quality of life were serially mediated by avoidance coping, perceived threat, adherence to COVID-19 control measures, and general mental health states. The study was conducted among refugees living in Kampala city suburbs and Bidibidi refugee settlement in Uganda. Data was collected using a survey questionnaire during the partial reopening of the economy in mid-2020, after the first lockdown. The analysis assesses a serial mediation model of the effects of psychological inflexibility on the quality of life of refugees through avoidance coping, perceived threat, adherence to COVID-19 control measures, and mental health using PROCESS Macro. The study involved 353 participants. Our analyses revealed that psychological inflexibility was negatively associated with the perceived threat, adherence, and quality of life. Psychological inflexibility was positively associated with avoidance coping and poor mental health. The data supported all hypothesized mediation paths. These findings support literature suggesting that psychological inflexibility is a maladaptive attribute that thwarts positive coping and behavior adjustment in times of crisis. Consequently, psychological inflexibility can worsen mental health problems and quality of life, especially in populations such as refugees in low-income countries who live in precarious conditions. Incorporating interventions that reduce psychological inflexibility in crisis management efforts can help refugees maintain good psychological functioning and quality of life.

Correlates of avoidance coping in trauma-exposed U.S. military veterans: Results from the National Health and Resilience in Veterans Study

Avoidant coping strategies, which involve cognitions and behaviors aimed to avoid dealing with stressful experiences, are associated with adverse long-term mental and physical health outcomes. In response to traumatic events, these strategies can be maladaptive as they may interfere with the adaptive integration of traumatic events into consolidated memories. Using data from a nationally representative sample of more than 3000 trauma-exposed U.S. military veterans (mean time since trauma 30.9 years, SD = 19.9), we employed a network analytic approach to examine pairwise associations between key sociodemographic, personality, and psychosocial risk factors in relation to the endorsement of avoidant coping strategies. Results revealed that negative affect symptoms of posttraumatic stress disorder (PTSD) and adverse childhood experiences were positively associated with engagement in avoidance coping, and that greater emotional stability and conscientiousness were negatively associated with this measure. Secondary network analysis of individual negative affect symptoms of PTSD suggested that blaming oneself and/or others for the traumatic event, emotional neglect, and sexual abuse were most strongly linked to avoidance coping. Collectively, these results suggest that strong feelings of blame related to trauma, emotional neglect, and sexual abuse are associated with greater likelihood of engaging in avoidance coping, while emotional stability and conscientiousness are associated with a lower likelihood of engaging in such strategies.

Cerebral cortical thinning in brain regions involved in emotional regulation relates to persistent symptoms in subjects with posttraumatic stress disorder

A considerable proportion of individuals exposed to trauma experience chronic and persistent posttraumatic stress disorder (PTSD). However, the specific brain and clinical features that render trauma-exposed individuals more susceptible to enduring symptoms remain elusive. This study investigated 112 trauma-exposed participants who had been diagnosed with PTSD and 112 demographically-matched healthy controls. Trauma-exposed participants were classified into those with current PTSD (persistent PTSD, n = 78) and those without (remitted PTSD, n = 34). Cortical thickness analysis was performed to discern group-specific brain structural characteristics. Coping strategies and resilience levels, assessed as clinical attributes, were compared across the groups. The persistent PTSD group displayed cortical thinning in the superior frontal cortex (SFC), insula, superior temporal cortex, dorsolateral prefrontal cortex, superior parietal cortex, and precuneus, relative to the remitted PTSD and control groups. Cortical thinning in the SFC was associated with increased utilization of maladaptive coping strategies, while diminished thickness in the insula correlated with lower resilience levels among trauma-exposed individuals. These findings imply that cortical thinning in brain regions related to coping strategy and resilience plays a vital role in the persistence of PTSD symptoms.

Associations of psychological inflexibility with posttraumatic stress disorder and adherence to COVID-19 control measures among refugees in Uganda: The moderating role of coping strategies

Refugees are vulnerable to developing mental health problems. The unprecedented appearance and rapid spread of COVID-19 exacerbated this vulnerability, especially in low-income countries where refugees survive on humanitarian aid and live in congested settlements. These appalling living conditions are a stressor, making adherence to COVID-19 control measures impractical and an additional psychological strain for refugees. The present study examined how psychological inflexibility is associated with adherence to COVID-19 control measures. A sample of 352 refugees from Kampala City and Bidibidi settlements were recruited. Refugees with high levels of psychological inflexibility reported higher PTSD symptom severity and low adherence to COVID-19 control measures. Moreover, PTSD severity mediated the association between psychological inflexibility and adherence, while avoidance coping moderated both direct and indirect effects. Interventions for reducing psychological inflexibility and avoidance coping may be essential in boosting adherence to measures relevant to the current and future status of the pandemic, along with other crises that refugees face.

Psychological Capital and Quality of life of Refugees in Uganda During COVID-19 Pandemic: A Serial Mediation Model

Background: The COVID-19 pandemic has in the past two years caused and continues to cause enormous effects on lifestyle, mental health, and quality of life. With no known treatment and vaccination, behavioral control measures became central in controlling the pandemic. However, the intensity of the pandemic and the stringent control measures were immensely stressful. The control measures became an added psychological burden to people living in precarious situations such as refugees in low-income countries. Purpose: Given the benefits of psychological capital, the present study aimed at investigating the role of psychological capital in enhancing the quality of life among refugees in Uganda during the COVID-19 pandemic. It was hypothesized that the effects of psychological capital on quality of life are serially mediated through coping strategies, adherence to COVID-19 control measures, and mental health. Methods: Data was collected using a self-administered questionnaire in July and August 2020 after the first lockdown. Participants were 353 South Sudanese and Somali refugees living in Kampala city suburbs and Bidibidi refugee settlement. Findings: Psychological capital was positively associated with approach coping, mental health, and quality of life. However, psychological capital was negatively associated with adherence to COVID-19 control measures. Significant indirect effects of psychological capital on quality of life through approach coping, mental health, and adherence were found. However, serial mediation effects were only substantial via approach coping and mental health. Conclusion: Psychological capital is an important resource in coping with the challenges posed by COVID-19 and maintaining a good level of psychological functioning and quality of life. Preserving and boosting psychological capital is essential in responding to COVID-19 and other related disasters and crises, which are common in vulnerable populations such as refugee communities in low-income countries.

Symptoms of major depressive disorder and post-traumatic stress disorder in veterans with mild traumatic brain injury: A network analysis

Mild Traumatic Brain Injury (mTBI, or concussion) is a debilitating condition that often leads to persistent cognitive and mental health problems post-injury. Post-traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) are two most commonly occurring mental health problems following mTBI and are suggested to be strong contributors to the persistent post-concussion symptoms. Thus, it is important to understand the symptomatology of PTSD and MDD post-mTBI, to better inform targets for behavioral health interventions. Therefore, the current study examined the symptom structure of post-mTBI co-morbid PTSD and MDD through network approaches; we compared the network structure of participants with a positive mTBI screen (N = 753) to the network structure of participants with a negative mTBI screen (N = 2044); lastly, we examined a network of PTSD and MDD symptoms with clinical covariates in a positive mTBI sample. We found that feeling distant/cutoff (P10) and difficulty concentrating (P15) were the most central symptoms in the positive mTBI network and sleep problems were the most prominent bridge nodes across the disorders. No significant difference between the positive and negative mTBI network were found through network comparison tests. Moreover, anxiety and insomnia were strongly associated with sleep symptoms and irritability symptoms, and emotional support and resilience were potential buffers against most of the PTSD and MDD symptoms. The results of this study might be particularly useful for identifying targets (i.e., feeling distant, concentration and sleep problems) for screening, monitoring and treatment after concussion to better inform post-mTBI mental health care and to improve treatment outcomes.

Posttraumatic stress disorder and coping strategies in the postpartum period: A symptomics approach

Posttraumatic stress disorder (PTSD) has been increasingly recognized as a potential mental health concern for new mothers. Elevated PTSD symptoms have been associated with maladaptive coping strategies in the postpartum period, a time when women face many challenges, demands, and stressors. However, PTSD symptoms manifest in heterogeneous ways, and focusing only on total symptom scores may obscure more nuanced associations with particular coping styles. In a large, ethnically diverse sample of postpartum women from across the United States (N = 1,315), first we examined associations between total PTSD symptom severity with three distinct coping styles: active-emotional, avoidant-emotional, and problem-focused. In models adjusting for race and educational attainment, total PTSD symptom severity was significantly positively associated with tendencies to use active- and avoidant-emotional, but not problem-focused, coping. We then adopted a novel "symptomics" approach, employing relative importance analyses to examine associations between individual PTSD symptoms with the coping styles. These analyses identified PTSD symptoms that were most strongly associated with each coping style. Notably, whereas several symptoms explained variance in avoidant-emotional coping, only a few symptoms contributed most to active-emotional and problem-focused coping. Moreover, non-specific symptoms of PTSD that are shared with other psychopathology (e.g., difficulty concentrating, loss of interest) explained significant proportions of variance across all coping styles. Collectively, results suggest that a symptomics approach may provide more nuanced insight into how PTSD symptoms are linked to various coping styles in postpartum women, which can help inform potential screening and intervention targets for at-risk women during this period.

Longitudinal relationships among posttraumatic stress disorder symptom clusters in response to positive memory processing

BACKGROUND AND OBJECTIVES

Avoidance, inherent to posttraumatic stress disorder (PTSD) symptomatology, is theoretically and empirically linked to the maintenance of PTSD symptom severity. While research indicates traumatized individuals avoid positive and trauma memories, several PTSD treatments focus exclusively on traumatic memories. We examined the mediating role of PTSD's avoidance in the relationship between processing positive memories and PTSD cluster severity (intrusion, mood/cognitions, arousal).

METHODS

Sixty-five trauma-exposed college students (M_age = 22.52; 86.10% female) were randomly assigned to 3 conditions: narrating/processing, writing/processing, or control (same task across baseline [T0] and follow-up [T1]).

RESULTS

Half-longitudinal mediation models indicated participation in the narrating vs. writing and control conditions predicted decreases in T1 intrusion severity via reduction in T1 avoidance severity. Similarly, participation in the narrating vs. writing and control conditions predicted decreases in T1 mood/cognitions' severity via reduction in T1 avoidance severity. Participation in the narrating vs. writing condition predicted decreases in T1 arousal severity via reduction in T1 avoidance severity.

LIMITATIONS

Data was obtained from an analogue small-size sample of university students. In addition, sessions were only 6-8 days apart, with the processing component of each session lasting ∼30 min.

CONCLUSIONS

Processing positive memories may relate to lower PTSD severity via a reduction in PTSD's avoidance, paralleling effects of processing trauma memories. Our findings support future investigations of the mechanisms underlying impacts of positive memory processing in the context of PTSD treatments.

A Qualitative Study of Self and Caregiver Perspectives on How Autistic Individuals Cope With Trauma

Background

Coping can moderate the relationship between trauma exposure and trauma symptoms. There are many conceptualisations of coping in the general population, but limited research has considered how autistic individuals cope, despite their above-average rates of traumatic exposure.

Objectives

To describe the range of coping strategies autistic individuals use following traumatic events.

Methods

Fourteen autistic adults and 15 caregivers of autistic individuals, recruited via stratified purposive sampling, completed semi-structured interviews. Participants were asked to describe how they/their child attempted to cope with events they perceived as traumatic. Using an existing theoretical framework and reflexive thematic analysis, coping strategies were identified, described, and organized into themes.

Results

Coping strategies used by autistic individuals could be organized into 3 main themes: (1) Engaging with Trauma, (2) Disengaging from Trauma, and (3) Self-Regulatory Coping. After the three main themes were developed, a fourth integrative theme, Diagnostic Overshadowing, was created to capture participants' reports of the overlap or confusion between coping and autism-related behaviors.

Conclusions

Autistic individuals use many strategies to cope with trauma, many of which are traditionally recognized as coping, but some of which may be less easily recognized given their overlap with autism-related behaviors. Findings highlight considerations for conceptualizing coping in autism, including factors influencing how individuals cope with trauma, and how aspects of autism may shape or overlap with coping behavior. Research building on these findings may inform a more nuanced understanding of how autistic people respond to adversity, and how to support coping strategies that promote recovery from trauma.

A predictive coding account of value-based learning in PTSD: Implications for precision treatments

While there are a number of recommended first-line interventions for posttraumatic stress disorder (PTSD), treatment efficacy has been less than ideal. Generally, PTSD treatment models explain symptom manifestation via associative learning, treating the individual as a passive organism - acted upon - rather than self as agent. At their core, predictive coding (PC) models introduce the fundamental role of self-conceptualisation and hierarchical processing of one's sensory context in safety learning. This theoretical article outlines how predictive coding models of emotion offer a parsimonious framework to explain PTSD treatment response within a value-based decision-making framework. Our model integrates the predictive coding elements of the perceived: self, world and self-in the world and how they impact upon one or more discrete stages of value-based decision-making: (1) mental representation; (2) emotional valuation; (3) action selection and (4) outcome valuation. We discuss treatment and research implications stemming from our hypotheses.

PTSD Symptoms and Coping with COVID-19 Pandemic among Treatment-Seeking Veterans: Prospective Cohort Study

Background: The aim of this study was to examine post-traumatic stress disorder (PTSD) symptom levels and coping strategies during the COVID-19 pandemic among treatment-seeking veterans with pre-existing PTSD. Method: A cohort of 176 male treatment-seeking veterans with pre-existing PTSD during the first COVID-19 pandemic lockdown (T1) and 132 participants from the same cohort one year after the onset of the pandemic (T2) participated in a longitudinal study. All participants responded to a COVID-19-related questionnaire and the following measures: the Life Events Checklist for DSM-5 (LEC-5), PTSD Checklist for DSM-5 (PCL-5) and the Brief COPE. Results: The intensity of overall PTSD symptoms, avoidance symptoms and negative alterations in cognitions and mood was lower at T2. PTSD symptoms were not significantly correlated with SARS-CoV-2 potentially traumatic events (PTE) at T2. Veterans scored higher on emotion-focused and problem-focused coping than on dysfunctional coping. Conclusions: Veterans with pre-existing PTSD who were receiving long-term treatment coped with COVID-19 stressors without the effects of retraumatization and a consequent worsening of PTSD symptoms.

Something Distressing This Way Comes: The Effects of Trigger Warnings on Avoidance Behaviors in an Analogue Trauma Task

Avoidance is one of the purported benefits and harms of trigger warnings-alerts that upcoming content may contain traumatic themes. Yet, previous research has focused primarily on emotional responses. Here, we used a trauma analogue design to assess people's avoidance behavior in response to stimuli directly related to an analogue trauma event. University undergraduates (n = 199) watched a traumatic film and then viewed film image stills preceded by either a trigger warning or a neutral task instruction. Participants had the option to "cover" and avoid each image. Apart from a minor increase in avoidance when a warning appeared in the first few trials, we found that participants did not overall avoid negative stimuli prefaced with a trigger warning any more than stimuli without a warning. In fact, participants were reluctant overall to avoid distressing images; only 12.56% (n = 25) of participants used the option to cover such images when given the opportunity to do so. Furthermore, we did not find any indication that trigger warning messages help people to pause and emotionally prepare themselves to view negative content. Our results contribute to the growing body of literature demonstrating that warnings seem trivially effective in achieving their purported goals.

Uses of Energy Psychology Following Catastrophic Events

Energy psychology, as most widely practiced, integrates the manual stimulation of acupuncture points with imaginal exposure, cognitive restructuring, and other evidence-based psychotherapeutic procedures. Efficacy for energy psychology protocols has been established in more than 120 clinical trials, with meta-analyses showing strong effect sizes for PTSD, anxiety, and depression. The approach has been applied in the wake of natural and human-made disasters in more than 30 countries. Four tiers of energy psychology interventions following the establishment of safety, trust, and rapport are described, including (1) immediate relief/stabilization, (2) reducing limbic arousal to trauma-based triggers, (3) overcoming complex psychological difficulties, and (4) promoting optimal functioning. The first tier is most pertinent in psychological first aid immediately following a disaster, with the subsequent tiers progressively being introduced over time with complex stress reactions and chronic disorders. Advantages of adding the stimulation of acupuncture points to a conventional exposure approach are identified, and challenges around cultural sensitivities and unintended effects are discussed. After establishing a framework for introducing energy psychology in disaster relief efforts, reports from a sampling of settings are presented, based on interviews with this paper's author. These include accounts of relief work with survivors of mass shootings, genocide, ethnic warfare, earthquakes, hurricanes, tornadoes, floods, wildfires, and the COVID-19 pandemic. Hundreds of other reports from the field show a pattern of strong outcomes following the use of energy psychology in the days or weeks after a disaster and in the subsequent treatment of trauma-based psychological problems. Many of these accounts corroborate one another in terms of rapid relief and long-term benefits. Finally, examples of more efficient delivery methods utilizing large groups, lay counselors, digital technology, and cultivating community resilience are presented.

Effect of patient characteristics on posttraumatic stress disorder treatment retention among veterans: A systematic review

To identify baseline patient characteristics (i.e., demographic and psychological factors, military background) associated with better posttraumatic stress disorder (PTSD) treatment retention among veterans, we conducted a systematic review. After an electronic database search for studies of PTSD treatment in veterans, two reviewers independently screened the literature for eligibility, abstracted study-level information, and assessed risk of bias. As most studies used multivariate models to assess multiple potential predictors of retention simultaneously, the results were described narratively. The GRADE approach, adapted for prognostic literature, was used to assess the overall quality of evidence (QoE). In total, 19 studies reported in 25 publications met the inclusion criteria (n = 6 good quality, n = 9 fair quality, n = 4 poor quality). Definitions of treatment completion and dropout varied, and some studies lumped different therapy approaches together. Older age and higher treatment expectations were associated with better retention (moderate QoE). In 5 of 6 studies, baseline PTSD severity was not associated with retention, and the remaining study reported an association between better retention and more severe PTSD symptoms; the presence of more co-occurring psychiatric disorders was associated with better retention (moderate QoE). QoE was low or insufficient to support conclusions for any other characteristics due to inconsistent results, imprecision, potential publication bias, possible study population overlap, study limitations, or lack of studies. More research is needed regarding the associations between modifiable factors (e.g., motivation, barriers, expectations) and retention, and consistent definitions of treatment completion and minimally adequate treatment should be adopted throughout the field.

A Mixed-Methods and Prospective Approach to Understanding Coping Behaviors, Depression, Hopelessness, and Acute Stress in a U.S. Convenience Sample During the COVID-19 Pandemic

The COVID-19 pandemic has led to increases in U.S. residents' stressors while limiting many of the resources previously available to cope with stress. Coping behaviors may contribute to the prevention or proliferation of psychological distress during and after the pandemic. Understanding these coping behaviors and associated psychological outcomes can help health educators develop programs that encourage effective coping and promote mental health. This study used a sequential mixed-methods approach informed by Roth and Cohen's conceptualization of coping to understand the use of approach coping behaviors- which are active and directed toward the perceived threat-and avoidance coping behaviors-which include activity directed away from perceived threat during the COVID-19 pandemic. U.S. residents (N = 2,987) were surveyed online in April 2020 and again in September 2021. Open-ended responses at baseline were thematically analyzed to illustrate coping behaviors in participants' own words. At baseline, more than half (56%) of the sample met criteria for probable depression, 51% for acute stress symptoms, and 42% for moderate to severe hopelessness. At follow-up, 45% meet criteria for probable depression and 23% for acute stress. However, the proportion of the sample who reported moderate to severe hopelessness increased to 48%. We used mixed-effects general linear models to examine changes over time and found that increases in approach coping behaviors were associated with decreases in depressive symptoms and hopelessness; increases in avoidance coping were associated with higher levels of depressive symptoms and higher levels of hopelessness. Increases in both types of coping were associated with increases in acute stress symptoms related to COVID-19. Although there was some attenuation in distress in our sample between April 2020 and September 2021, our findings suggest a need for interventions that encourage the use of approach coping behaviors and that both increase access to and decrease stigma for mental health support.

Examining the associations between PTSD symptoms and aspects of emotion dysregulation through network analysis

Despite the clearly established link between posttraumatic stress disorder (PTSD) and emotion dysregulation, little is known about how individual symptoms of PTSD and aspects of emotion dysregulation interrelate. The network approach to mental health disorders provides a novel framework for conceptualizing the association between PTSD and emotion dysregulation as a system of interacting nodes. In this study, we estimated the structural relations among PTSD symptoms and aspects of emotion dysregulation within a large sample of women who participated in a multi-site study of sexual revictimization (N = 463). We estimated expected influence to reveal differential associations among PTSD symptoms and aspects of emotion dysregulation. Further, we estimated bridge expected influence to identify influential nodes connecting PTSD symptoms and aspects of emotion dysregulation. Results highlighted the key role of concentration difficulties in expected influence and bridge expected influence. Findings highlight several PTSD symptoms and aspects of emotion dysregulation that may be targets for future intervention.

Changes in Trauma-Related Cognitions and Emotions After Eliciting Moral Elevation: Examining the Effects of Viewing Others' Virtuous Behavior on Veterans with PTSD

Moral elevation is described as feeling inspired after witnessing someone perform a virtuous act. Past work suggests the features of moral elevation may be contrary to PTSD, yet few studies have directly tested its impact on relevant symptoms. This experimental study assessed changes in trauma-related cognitions and emotions from after a trauma reminder task to after an elevation induction exercise. We hypothesized that higher elevation after the induction exercise would be associated with greater reductions in cognitions and emotions. Veterans with probable PTSD (N = 38) completed measures of trauma-related cognitions and emotions, once after a written trauma narrative exercise (T1) and again after watching two videos designed to elicit elevation (T2). Veterans also completed measures of state elevation after each video. Results suggest veterans experienced small, significant decreases in self-blame (d = 0.36) and negative beliefs about others (d = 0.46), and medium, significant decreases in guilt (d = 0.68), shame (d = 0.60), and negative beliefs about self (d = 0.69) between T1 and T2. As hypothesized, higher elevation was associated with significantly greater reductions in multiple outcomes above and beyond the effects of general positive affect. Specifically, there were medium effects for changes in shame (β = -0.42, SE = 0.17, p = .019, Δf ² = 0.25), negative view of others (β = -0.34, SE = 0.16, p = .044, Δf ² = 0.20), and a large effect for changes in negative view of self (β = -0.31, SE = 0.13, p = .019, Δf ² = 0.54). These findings suggest elevation may be well-suited to target trauma-related symptoms and future research should further examine its clinical utility.

Psychometric Properties of the Korean version of the Emotion Regulation Questionnaire (K-ERQ) in a Clinical Sample

OBJECTIVE

The Emotion Regulation Questionnaire (ERQ) is one of the widely used instruments to assess emotion regulation skills in many countries, including Korea. However, its psychometric properties have not been validated within this population. Also, the ERQ has increasingly been used in studies with psychiatric patients despite a general lack of validation in clinical settings. Therefore, the present study aimed to investigate the psychometric properties of the Korean version of the ERQ (K-ERQ) using a clinical sample in Korea.

METHODS

One hundred and ninety-three psychiatric patients completed a packet of self-report measures, including K-ERQ, K-BDI-II, K-ASI-3, PCL-5-K, AUDIT-K. Confirmatory factor analysis (CFA) was administered to investigate the factor structure of the K-ERQ, and internal reliability and validity were examined.

RESULTS

Results of the CFA supported the two-factor structure, but only after the removal of one item. The K-ERQ showed good internal consistency reliability, and its concurrent validity was also confirmed. Cognitive reappraisal was negatively correlated with depression and alcohol use disorder-related symptoms, and expressive suppression was positively correlated with depression, anxiety sensitivity, posttraumatic stress disorder (PTSD)-related symptoms and alcohol use disorder-related symptoms. Significant group differences were found in the use of emotion regulation strategies; patients with PTSD reported the higher level of cognitive reappraisal than patients with depressive disorders, bipolar disorders, and attention-deficit hyperactivity disorder.

CONCLUSION

The 9-itemed K-ERQ is a reliable and valid tool to assess the emotion regulation strategies in a Korean clinical sample. Our study also adds preliminary evidence on the usefulness of the ERQ in clinical settings.

Mindful nonreactivity moderates the relationship between posttraumatic stress disorder and depression

PTSD and depression represent major individual and societal burdens. Depression is commonly comorbid with PTSD among veterans, although buffers of this relationship are unclear. We evaluated whether facets of mindfulness moderated the relationship between PTSD and depression in veterans with PTSD (N = 70). Three facets - nonjudging, acting with awareness, and nonreactivity - were assessed as moderators. Results indicated nonreactivity significantly attenuated the relationship between PTSD and depression (p=.013), such that veterans with high nonreactivity (+1 SD) showed a nonsignificant relationship between PTSD and depression, whereas veterans with average (Mean; p<.001) and low (-1 SD; p<.001) nonreactivity exhibited a significant relationship.

Avoidance behaviour generalizes to eye processing in posttraumatic stress disorder

BACKGROUND

Avoidance describes any action designed to prevent an uncomfortable situation or emotion from occurring. Although it is a common reaction to trauma, avoidance becomes problematic when it is the primary coping strategy, and plays a major role in the development and maintenance of posttraumatic stress disorder (PTSD). Avoidance in PTSD may generalize to non-harmful environmental cues that are perceived to be unsafe.

OBJECTIVE

We tested whether avoidance extends to social cues (i.e. emotional gazes) that are unrelated to trauma.

METHOD

A total of 159 participants (103 who had been exposed to the 2015 Paris terrorist attacks and 56 who had not) performed a gaze-cueing task featuring sad, happy and neutral faces. Attention to the eye area was recorded using an eyetracker. Of the exposed participants, 52 had been diagnosed with PTSD (PTSD+) and 51 had not developed PTSD (PTSD-). As a result of the preprocessing stages, 52 PTSD+ (29 women), 50 PTSD- (20 women) and 53 nonexposed (31 women) participants were included in the final analyses.

RESULTS

PTSD+ participants looked at sad eyes for significantly less time than PTSD- and nonexposed individuals. This effect was negatively correlated with the intensity of avoidance symptoms. No difference was found for neutral and happy faces.

CONCLUSIONS

These findings suggest that maladaptive avoidance in PTSD extends to social processing, in terms of eye contact and others' emotions that are unrelated to trauma. New therapeutic directions could include targeting sociocognitive deficits. Our findings open up new and indirect avenues for overcoming maladaptive avoidance behaviours by remediating eye processing.Trial registration: ClinicalTrials.gov identifier: NCT02810197.

HIGHLIGHTS

Avoidance is a key symptom of posttraumatic stress disorder (PTSD).Avoidance is often viewed as limited to reminders linked to the trauma.Results show that attention to the eyes of sad faces is also affected by PTSD. This effect is correlated with avoidance symptoms in PTSD.

Neurobiological Alterations in Females With PTSD: A Systematic Review

Most females experience at least one traumatic event in their lives, but not all develop PTSD. Despite considerable research, our understanding of the key factors that constitute risk for PTSD among females is limited. Previous research has largely focused on sex differences, neglecting within group comparisons, thereby obviating differences between females who do and do not develop PTSD following exposure to trauma. In this systematic review, we conducted a search for the extent of existing research utilizing magnetic resonance imaging (MRI) to examine neurobiological differences among females of all ages, with and without PTSD. Only studies of females who met full diagnostic criteria for PTSD were included. Fifty-six studies were selected and reviewed. We synthesized here findings from structural MRI (sMRI), functional MRI (fMRI), diffusion tensor imaging (DTI), and resting state functional connectivity (rs-FC MRI) studies, comparing females with and without PTSD. A range of biopsychosocial constructs that may leave females vulnerable to PTSD were discussed. First, the ways timing and type of exposure to trauma may impact PTSD risk were discussed. Second, the key role that cognitive and behavioral mechanisms may play in PTSD was described, including rumination, and deficient fear extinction. Third, the role of specific symptom patterns and common comorbidities in female-specific PTSD was described, as well as sex-specific implications on treatment and parenting outcomes. We concluded by identifying areas for future research, to address the need to better understand developmental aspects of brain alterations, the differential impact of trauma types and timing, the putative role of neuroendocrine system in neurobiology of PTSD among females, and the impact of social and cultural factors on neurobiology in females with PTSD.

Meat in a Seat: A Grounded Theory Study Exploring Moral Injury in Canadian Public Safety Communicators, Firefighters, and Paramedics

The work of public safety personnel (PSP) is inherently moral; however, the ability of PSP to do what is good and right can be impeded and frustrated, leading to moral suffering. Left unresolved, moral suffering may develop into moral injury (MI) and potential psychological harm. The current study was designed to examine if MI is relevant to frontline public safety communicators, firefighters, and paramedics. Semi-structured interviews (n = 3) and focus groups (n = 3) were conducted with 19 participants (public safety communicators (n = 2); paramedics (n = 7); and firefighters (n = 10)). Interviews and focus groups were audio-recorded, transcribed, coded, and constantly compared in accordance with the grounded theory method. A conceptual theory of "frustrating moral expectations" emerged, with participants identifying three interrelated properties as being potentially morally injurious: chronic societal problems, impaired systems, and organizational quagmires. Participants navigated their moral frustrations through both integrative and disintegrative pathways, resulting in either needing to escape their moral suffering or transforming ontologically. The current study results support MI as a relevant concept for frontline PSP. Given the seriousness of PSP leaving their profession or committing suicide to escape moral suffering, the importance of the impact of MI on PSP and public safety organizations cannot be ignored or underestimated. Understanding the similarities and differences of morally injurious exposures of frontline PSP may be critical for determining mental health and resilience strategies that effectively protect PSP.

Efficacy of immersive PTSD treatments: A systematic review of virtual and augmented reality exposure therapy and a meta-analysis of virtual reality exposure therapy

BACKGROUND

Virtual reality exposure therapy (VRET) and augmented reality exposure therapy (ARET) are digitally assisted psychotherapies that potentially enhance posttraumatic stress disorder (PTSD) treatment by increasing a patient's sense of presence during exposure therapy. This study aimed to systematically review current evidence regarding the efficacy of VRET and ARET as PTSD treatment.

METHODS

A systematic electronic database search, a systematic quality assessment and two meta-analyses were conducted in accordance with PRISMA guidelines.

RESULTS

Eleven studies on the efficacy of VRET for PTSD (n = 438) were found, but no studies on the efficacy of ARET. The majority of VRET studies were of a low quality and had heterogeneous results. Meta-analyses showed VRET outperformed waitlist control (standardized mean difference -0.64 (95% CI -1.05 to -0.22)) while no significant difference was found between VRET and active treatment conditions (standardized mean difference -0.25 (95% CI -0.77 to 0.27)).

CONCLUSION

VRET was superior to waitlist control groups and as effective as other psychotherapies. However, the results showed considerable heterogeneity due to the low number of studies and variety of VRET methods. VRET may be an effective alternative to current treatments and shows promise for the treatment of PTSD patients that have not responded to previous treatment. Future research should focus on high quality RCTs, including information on side effects and adverse events, with sufficient numbers of participants. This study recognizes a research gap regarding the efficacy of ARET, while it may have potential for PTSD treatment.

Perceived organizational support and PTSD symptoms of frontline healthcare workers in the outbreak of COVID-19 in Wuhan: The mediating effects of self-efficacy and coping strategies

The present study aimed to examine the effect of perceived organizational support on the PTSD symptoms of frontline healthcare workers, and to examine the mediating effects of coping self-efficacy and coping strategies in this relationship. A short-term longitudinal study design was used to conduct two waves of online surveys in March and April 2020. Participants comprised 107 medical staff in both waves of investigation. Self-efficacy, coping strategies, and perceived organizational support were reported at Wave 1, and PTSD symptoms were reported at Wave 2. Results indicated that (1) The prevalence of probable PTSD was 9.3% and 4.7% on the Chinese version of the Impact of Events Scale-Revised of 33 and 35, respectively. Local healthcare workers had greater risks of PTSD than the members of medical rescue teams. Doctors reported higher PTSD symptoms than nurses. (2) Perceived organizational support had a significant indirect effect on PTSD symptoms through the mediation of problem-focused coping strategies and the sequential mediating effect of coping self-efficacy and problem-focused coping strategies. The findings highlight the importance of providing adequate organizational support to reduce PTSD symptoms in frontline medical staff during the COVID-19 pandemic.

Course and Predictors of Posttraumatic Stress Disorder in the Canadian Armed Forces: A Nationally Representative, 16-Year Follow-up Study: Cours et prédicteurs du trouble de stress post-traumatique dans les Forces armées canadiennes: une étude de suivi de 16 ans nationalement représentative

OBJECTIVE

This study examined baseline risk and protective predictors and interim correlates of the persistence/recurrence, remission, and onset of posttraumatic stress disorder (PTSD) in a 16-year prospective, nationally representative sample of Canadian Forces members and veterans.

METHODS

The 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey is a prospective study of 2,941 regular force service members and veterans who participated in the 2002 Canadian Community Health Survey on Mental Health and Wellbeing: Canadian Forces Supplement (n = 5,155; ages 15 to 64 years; response rate 68%). PTSD diagnoses in 2002 and 2018 were used to create 4 groups: (1) no lifetime, (2) remitted, (3) new onset, and (4) persistent/recurrent PTSD. Multinomial regressions were conducted to identify predictors of PTSD courses.

RESULTS

Female sex, being a junior noncommissioned member (vs. officer), and land (vs. air) operations in 2002 were associated with all PTSD courses relative to no lifetime PTSD (relative risk ratio [RRR] range: 1.28 to 3.65). After adjusting for sociodemographic variables, baseline predictors of all PTSD courses included lifetime mental disorder, history of mental health care utilization, all trauma type categories (deployment-associated, sexual, "other"), and the number of lifetime traumatic events (RRR range: 1.14 to 8.95). New ("since 2002") traumas, transitioning to veteran status, and alcohol dependence were mostly associated with the new onset and persistent/recurrent PTSD courses (RRR range: 1.79 to 4.31), while mental health care utilization and greater avoidance coping were associated with all PTSD courses (RRR range: 1.10 to 17.87). Protective factors for several PTSD courses at one or both time points included social support, social network size, and problem-focused coping (RRR range: 0.71 to 0.98).

CONCLUSIONS

This is the first population-based survey to examine the longitudinal course of PTSD in Canadian Forces members. Prevention and intervention programs focused on bolstering social support and active coping strategies as possible protective factors/correlates may help mitigate the development and persistence of PTSD.

Predictors of Psychological Distress and Resilience in the Post-COVID-19 Era

Background

The COVID-19 global pandemic has had profound effects on mental health and wellbeing. The present study examined trends in distress and recovery in the aftermath of COVID-19 in China. Predictors that might increase risks or provide protections again distress were explored.

Method

Participants were recruited using social media during the COVID-19 pandemic to complete a baseline and 6-week follow-up survey (N = 241). The change patterns of PTSD symptoms from baseline to follow-up were characterized using latent class growth analysis (LCGA). A repeated-measures ANOVA was conducted to explore the differences in the depressive symptoms across trajectory groups. Multinominal logistic regression was performed to investigate potential predictors of the outcome trajectories.

Results

Four longitudinal outcome trajectories were identified: chronic (PTSD symptoms remained high; 14.9%), resilient (symptoms remained low; 43.2%), recovered (symptoms decreased from symptomatic levels to asymptomatic; 19.5%), and delayed (symptoms increased from asymptomatic levels to symptomatic; 22.4%). Hopelessness and maladaptive coping strategies were unique predictors of distress and resilience as well as longer-term trajectories.

Conclusion

Individuals evidenced four outcome trajectories of distress in the aftermath of COVID-19 in China. Despite the uncertainty and high levels of stress related to the pandemic, the majority of the sample demonstrated resilience and recovery. It is essential to identify individuals at risk for chronic and delayed distress in order to build resilience.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12529-021-10036-8.

Children's Coping and Perceptions of Coping Efficacy After Sexual Abuse: Links to Trauma Symptoms

Despite an emphasis on coping following childhood sexual abuse (CSA) to reduce trauma-related symptoms, very few studies have researched the associations between sexually abused children's coping and trauma-related difficulties, and perceived coping efficacy has been largely overlooked. The current study investigated whether children's use and perceived efficacy of avoidant, internalized, angry, and active/social coping strategies were associated with caregiver- and child-reported posttraumatic stress symptoms (PTSS), and caregiver-reported internalizing and externalizing symptoms among 202 sexually abused children (8-12 years; M = 10.47 years, SD = 1.70 years). Children reported using approximately eight types of coping strategies (M = 8.29, SD =2.50). Regression models indicated that internalized and angry coping were associated with child-reported PTSS. In contrast to expectations, none of the types of coping strategies were linked with caregiver's reports of PTSS or internalizing and externalizing symptoms. Interestingly, perceived efficacy of coping was largely unrelated to symptoms, with only perceived efficacy of avoidant coping inversely related to child-reported PTSS. Perceived efficacy was not tied to caregiver's reports of children's symptoms. Coping strategies may be associated with children's, but not caregiver's, reports of children's trauma-related difficulties. Furthermore, perceived efficacy of coping strategies may also be largely unrelated to children's symptoms, or children may have limited insight regarding the efficacy of their coping strategies. To further inform trauma-focused interventions that support effective long-term coping, future research should investigate which coping strategies children perceive to be efficacious, as well as potential reasons why.

Dynamics of risk: Recent changes in psychological inflexibility precede subsequent changes in returning US veterans' posttraumatic stress

OBJECTIVES

As a malleable risk-factor, psychological inflexibility is implicated in the development and maintenance of posttraumatic stress symptoms (PTS). Unfortunately, limited research has addressed whether changes in psychological inflexibility are antecedent to changes in PTS severity over time, or whether such changes are mutually dependent.

METHODS

Utilizing bivariate latent difference score modeling, this longitudinal study sequenced intraindividual changes in psychological inflexibility and PTS severity within a sample of 305 returning US veterans. Veterans' self-reported psychological inflexibility and PTS severity were assessed quarterly over 1 year.

RESULTS

Results indicated that early reductions in psychological inflexibility potentiated later declines in veterans' PTS severity, accounting for veterans' prior levels of psychological inflexibility and PTS severity.

CONCLUSIONS

These findings underscore the unique role of changes in psychological inflexibility as an important mechanism of change in PTS severity and provide empirical support for an antecedent model of the role of psychological inflexibility in PTS recovery.

Factors influencing utilization and perception of health care: a qualitative study among traumatized Yazidi refugees in Germany

BACKGROUND

Ensuring adequate utilization of healthcare services for displaced populations is critical, yet there are well-documented treatment gaps. Yazidi women captured by the Islamic State (IS) were subjected to extreme trauma and violence. This study aims to understand perceptions of healthcare providers and utilization of these services among women who experienced extreme trauma.

METHODS

This is a qualitative study with voluntary participation offered to approximately 400 women resettled through the Special Quota Program. An empirical approach was used to collect data and a grounded theory approach was used for content analysis. Participants ranked their interactions with providers on a Likert scale. Posttraumatic stress disorder (PTSD) symptoms were assessed using the impact of event scale-revised questionnaire.

RESULTS

A total of 116 Yazidi women participated in this study. The women experienced an average of 6.8 months of captivity by IS and 93% met criteria for probable PTSD. Eighty-three percent of the women interacted with a physician; 80% found this interaction helpful. Sixty-nine percent interacted with psychologists; 61% found this interaction helpful. Six themes emerged: "reminders of trauma" and "hopelessness" in relation to the traumatic experience; "immediate relief" and "healing through pharmaceutical treatment" in relation to provider interventions, and "support" and "cultural differences" in relation to interactions with providers.

CONCLUSIONS

There exist major barriers to care for Yazidi women who experienced extreme trauma, particularly in regards to psychiatric care. Perceptions of healthcare providers and perceived effectiveness of therapy are critical factors that must be taken into consideration to improve healthcare utilization and outcomes.

Posttraumatic stress disorder symptoms and coping with the lockdown among help-seeking veterans before and during the COVID-19 pandemic

AIM

To compare the severity of posttraumatic stress disorder (PTSD) symptoms and of particular PTSD clusters among help-seeking veterans before and during the COVID-19 lockdown. The second aim was to identify the main coping strategies used.

METHODS

Male war veterans (N=176) receiving outpatient treatment at the Referral Center for PTSD were assessed at baseline (12-18 months before the pandemic declaration in March 2020) and during the COVID-19 pandemic lockdown (March-June 2020). The Life Events Checklist for DSM-5, PTSD Checklist for DSM-5, and The Brief COPE were used.

RESULTS

Direct exposure to the virus in our sample was low, and the majority of participants followed the preventive measures. The severity of the overall PTSD symptoms and of clusters of symptoms significantly decreased compared with the first assessment. At the second assessment, all participants still fulfilled the PTSD diagnosis criteria. During the lockdown, the participants used emotion-focused and problem-focused coping rather than dysfunctional coping.

CONCLUSION

The severity of PTSD symptoms decreased during the lockdown. Further research is needed to study the trajectories of long-term psychopathology.

Validation and Construct Validity of the Posttraumatic Avoidance Behaviour Questionnaire in a Sample of Trauma-Exposed Black Women

Engaging in posttraumatic avoidance behaviors after a traumatic incident is associated with posttraumatic stress disorder (PTSD) outcomes. Given the inherent limitations in the scope of the two-item assessment of posttraumatic avoidance used in commonly administered measures of PTSD symptoms, the 25-item Posttraumatic Avoidance Behaviour Questionnaire (PABQ) was developed to assess a range of avoidance behaviors, including avoidance of visual and sensory reminders, trauma-related thoughts, and agoraphobia, as well as avoidance related to the home, sleep, and social interaction. However, the PABQ's utility is limited by its lack of (a) construct validity and (b) validation in diverse samples. To address these limitations, we examined the psychometric properties of PABQ scores in a sample of trauma-exposed Black women (N = 601, M age = 41 years). Confirmatory factor analyses indicated that the original seven-factor model fit the data well when Item 8 was excluded, χ² (231, N = 602) = 497.86, RMSEA = .04, 90% CI [.04, .05], CFI = .99, TLI = .989, WRMR = .939, but reliability estimates were variable (i.e., Cronbach's αs = .70-.91). In addition, we found support for convergent validity, clinical validity, and incremental validity. These results provide evidence for the psychometric strengths of the PABQ in minority samples and suggest that it is a valid assessment of posttraumatic avoidance in Black women.

Gender as a moderator of the association of military sexual trauma and posttraumatic stress symptoms

OBJECTIVE

The current study examined the moderating role of gender on the association of military sexual trauma (MST) type (harassment-only vs. assault) and posttraumatic stress symptoms (PTSS) using the 6-factor Anhedonia Model.

METHODS

Participants were 1321 service members/veterans. Two-part hurdle models assessed the moderating role of gender on the association of MST type with the presence (at least "moderate" symptoms endorsed within each cluster) or severity of PTSS and symptom clusters.

RESULTS

Among those who experienced assault MST, women were at higher risk for the presence of intrusive, avoidance, negative affect, and anhedonia symptoms, and higher risk for more severe negative affect symptoms. Among those who experienced harassment-only MST, men were at higher risk of more severe PTSS symptoms overall and in the intrusive and dysphoric arousal symptom clusters. No other significant differences were observed.

CONCLUSIONS

Gathering information on MST type may be helpful in treatment planning.

Self-efficacy and coping style in Iraq and Afghanistan-era veterans with and without mild traumatic brain injury and posttraumatic stress disorder

OBJECTIVE

To examine self-efficacy and coping style in combat-exposed Veterans with and without mild traumatic brain injury (mTBI) history and posttraumatic stress disorder (PTSD).

METHODS

Veterans (N = 81) were categorized into four groups: comorbid mTBI and PTSD (n = 23), PTSD-only (n = 16), mTBI-only (n = 25), and combat-exposed controls (n = 17). Outcomes included the Self-Efficacy for Symptom Management Scale and the Brief Coping Orientation to Problems Experienced.

RESULTS

Significant group effects were found on self-efficacy and coping style, even when adjusting for total mTBIs and psychiatric comorbidities. Post-hoc analyses revealed that the comorbid and PTSD-only groups generally had lower self-efficacy than the mTBI-only and control groups and that the PTSD-only group used less action-focused coping than the mTBI-only and control groups.

CONCLUSION

Our results suggest that self-efficacy and coping style vary as a function of mTBI history and PTSD status and that it may be important to integrate these malleable factors into interventions for this population.

Latent cause inference during extinction learning in trauma-exposed individuals with and without PTSD

BACKGROUND

Problems in learning that sights, sounds, or situations that were once associated with danger have become safe (extinction learning) may explain why some individuals suffer prolonged psychological distress following traumatic experiences. Although simple learning models have been unable to provide a convincing account of why this learning fails, it has recently been proposed that this may be explained by individual differences in beliefs about the causal structure of the environment.

METHODS

Here, we tested two competing hypotheses as to how differences in causal inference might be related to trauma-related psychopathology, using extinction learning data collected from clinically well-characterised individuals with varying degrees of post-traumatic stress (N = 56). Model parameters describing individual differences in causal inference were related to multiple post-traumatic stress disorder (PTSD) and depression symptom dimensions via network analysis.

RESULTS

Individuals with more severe PTSD were more likely to assign observations from conditioning and extinction stages to a single underlying cause. Specifically, greater re-experiencing symptom severity was associated with a lower likelihood of inferring that multiple causes were active in the environment.

CONCLUSIONS

We interpret these results as providing evidence of a primary deficit in discriminative learning in participants with more severe PTSD. Specifically, a tendency to attribute a greater diversity of stimulus configurations to the same underlying cause resulted in greater uncertainty about stimulus-outcome associations, impeding learning both that certain stimuli were safe, and that certain stimuli were no longer dangerous. In the future, better understanding of the role of causal inference in trauma-related psychopathology may help refine cognitive therapies for these disorders.

Family and occupational functioning following military trauma exposure and moral injury

INTRODUCTION

Evidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual's occupational and familial functioning remains poorly understood.

METHOD

Thirty male veterans who reported exposure to either traumatic or morally injurious events and 15 clinicians were recruited for semi-structured qualitative interviews.

RESULTS

While many veterans experienced psychological distress postevent, those who experienced PMIEs especially reported social withdrawal and engagement in aggressive, risk-taking behaviours. This was highly distressing for family members and created a tense, volatile home and workplace environment that was difficult for others to navigate. Following PMIEs, employment could be used as a cognitive avoidance strategy or as a means to atone for transgressive acts. In cases of moral injury, clinicians considered that targeted support for spouses and accessible guidance to help children to better understand how their military parent may be feeling would be beneficial.

CONCLUSIONS

This study provides some of the first evidence of the pervasive negative impact of PMIEs on veterans' familial and occupational functioning. These findings highlight the need to comprehensively screen for the impact of moral injury on daily functioning in future studies that goes beyond just an assessment of psychological symptoms.

Peritraumatic reactions during the COVID-19 pandemic - The contribution of posttraumatic growth attributed to prior trauma

Trauma survivors who suffer from posttraumatic stress disorder (PTSD) symptoms may be particularly vulnerable when facing the COVID-19 pandemic. Yet trauma exposure may also lead to salutogenic outcomes, known as posttraumatic growth (PTG). Nevertheless, the implications of PTG attributed to prior trauma, for trauma survivors' adjustment when facing additional stressors, are unclear. Addressing this gap, 528 Israeli trauma survivors were assessed for PTG and PTSD symptoms attributed to prior trauma, as well as peritraumatic stress symptoms related to the pandemic, as part of an online survey. Analyses revealed that being younger, female, quarantined, negatively self-rating one's health status, and suffering from PTSD symptoms were associated with elevated peritraumatic stress symptoms. Furthermore, PTG attributed to prior trauma made a significant contribution in explaining elevated intrusion, avoidance, and hyperarousal symptoms. The present results point to the need for clinicians to take into account reports of PTG attributed to prior trauma when treating trauma survivors during the current pandemic.

The relationship between meaning in life and post-traumatic stress symptoms in US military personnel: A meta-analysis

BACKGROUND

Subjective meaning in life has been theorized to play a critical role in the adjustment to traumatic events. However, its association with post-traumatic stress symptoms has not been quantitatively reviewed.

METHODS

Informed by Park's integrated meaning-making model and evidenced-based psychological treatments for post-traumatic stress disorder, the goals of this meta-analysis were to: (1) to determine the direction and magnitude of the association between meaning in life and post-traumatic stress symptoms; and (2) to examine potential moderators of this association (i.e., age, sex, race, marital status, type of trauma, and meaning in life conceptualization). CINAHL, Embase, PILOT, PsycINFO, PubMed, and Web of Science core collection databases were searched.

RESULTS

A random-effects meta-analysis was conducted on 26 associations (N = 9,751). A significant, moderate, negative relationship was found between meaning in life and post-traumatic stress symptoms (r = -0.41; 95% CI: -0.47 to -0.35, k = 25). No significant moderators were detected.

CONCLUSIONS

Findings suggest that meaning in life plays a crucial role in adjustment to traumatic events. Development and testing of randomized controlled trials to determine whether increases in meaning in life result in reductions of post-traumatic stress in US military personnel may facilitate ongoing efforts aimed at recovery from trauma.

Process-based functional analysis can help behavioral science step up to novel challenges: COVID - 19 as an example

Historically speaking, the behavioral tradition advanced functional analysis as a method of applying existing principles to novel situations. In the more than half a century since that idea was advanced, functional analysis has either fallen into disuse, as in most of applied psychology, or has been used but modified to a point that is virtually inapplicable elsewhere, as in applied behavior analysis work with severe developmental disabilities. In this paper we argue that the current challenges with COVID-19 present an ideal time to reinvigorate functional analysis by combining it with the growing body of evidence on processes of change, organized under an extended evolutionary meta-model. This new form of process-based functional analysis takes advantage of the strengths of contextual behavioral science, while opening avenues of fruitful interaction with other wings of intervention and evolutionary science more generally. Using the psychological flexibility model as an example, we show how this approach solves the key problems of classical functional analysis and helps professionals deal with novel challenges such as those posed by COVID-19. Humanity is now facing an extraordinary and unexpected situation. Behavioral science needs to rise to that challenge in a way that provides both immediate practical value and greater assurance of long-term benefits for our understanding of human complexity more generally. Process-based functional analysis can be a vehicle to do just that.

Risk and Protective Factors for PTSD in Caregivers of Adult Patients with Severe Medical Illnesses: A Systematic Review

Caregivers of severely ill individuals often struggle to adjust to new responsibilities and roles while experiencing negative psychological outcomes that include depression, anxiety and Post-Traumatic Stress Disorder (PTSD). This systematic review aims to outline potential risk and protective factors for the development of PTSD in caregivers of adult subjects affected by severe somatic, potentially life-threatening illnesses. Twenty-nine studies on caregivers of adult patients affected by severe, acute, or chronic somatic diseases have been included. Eligibility criteria included: full-text publications reporting primary, empirical data; PTSD in caregivers of adult subjects affected by severe physical illnesses; risk and/or protective factors related to PTSD; and English language. Specific sociodemographic and socioeconomic characteristics, besides the illness-related distress, familiar relationships, exposure characteristics, coping style, and support, were identified as relevant risk/protective factors for PTSD. The review limitations are the small number of studies; studies on different types of diseases; studies with same samples. It is crucial to consider factors affecting caregivers of severely ill adult patients in order to plan effective intervention strategies aimed at reducing the risk of an adverse mental health outcome and at enhancing the psychological endurance of this population.