Patterns of recovery from trauma: the use of intraindividual analysis

PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies

OBJECTIVE

Sexual assault is associated with higher rates of posttraumatic stress disorder (PTSD) than other traumas, and the course of PTSD may differ by trauma type. However, the course of PTSD after sexual assault has not been summarized. The aim of this meta-analysis was to identify the prevalence and severity of PTSD and changes to the average rate of recovery in the 12 months following sexual assault.

METHOD

Authors searched four databases for prospective studies published before April 2020 and sought relevant unpublished data. Eligible studies assessed PTSD in at least 10 survivors of sexual assault in at least two time points, starting within 3 months postassault. Random effects linear-linear piecewise models were used to identify changes in average recovery rate and produce model-implied estimates of monthly point prevalence and mean symptom severity.

RESULTS

Meta-analysis of 22 unique samples (N = 2,106) indicated that 74.58% (95% confidence interval [CI]: [67.21, 81.29]) and 41.49% (95% CI: [32.36, 50.92]) of individuals met diagnostic criteria for PTSD at the first and 12th month following sexual assault, respectively. PTSD symptom severity was 47.94% (95% CI: [41.27, 54.61]) and 29.91% (95% CI: [23.10, 36.73]) of scales' maximum severity at the first and 12th month following sexual assault, respectively. Most symptom recovery occurred within the first 3 months following sexual assault, after which point the average rate of recovery slowed.

CONCLUSIONS

Findings indicate that PTSD is common and severe following sexual assault, and the first 3 months postassault may be a critical period for natural recovery.

Systematic Review: Effectiveness of psychosocial interventions on wellbeing outcomes for adolescent or adult victim/survivors of recent rape or sexual assault

Sexual assault and rape are common forms of sexual violence/abuse. The psychological/health consequences represent significant and ongoing harm. It seems imperative that victim/survivors receive evidence-based support within first response settings. To assess what psychosocial interventions work for victim/survivors of a recent sexual assault. Twenty-seven electronic databases were systematically searched. Narrative data synthesis was used to read across studies. Reporting format follows PRISMA checklist. Ten studies were identifed including range of interventions. The evidence is sparse and scientifically weak, common flaws are reviewed. There is some weak evidence for the impact of video and cognitive behavioural therapy (CBT) based interventions, especially trauma processing. There is a gap in the evidence base on psychosocial interventions for victim/survivors of sexual assault and higher quality research is required.

College Students' Perceptions of Barriers to Bystander Intervention

Sexual violence is a major problem on college campuses and is associated with a range of negative health consequences for victims. Teaching students to intervene as prosocial bystanders has become a common element of sexual assault prevention efforts; although these programs have demonstrated positive effects on participants' beliefs and knowledge, their impact on actual behavior is weaker. Understanding the factors that inhibit intervening in risky situations may enhance the effectiveness of bystander programs by identifying material that addresses these barriers. A sample of 281 first-year college students indicated whether they had encountered 10 situations that may present elevated risk of sexual or physical assault since arriving on campus, and if so, whether they had done something to intervene. If they had not intervened, they were asked to identify the barriers that had inhibited them. Participants also completed measures of two factors proposed to predict bystander behavior, self-efficacy and emotion regulation. A majority of participants intervened in most of the situations, but only 27% of participants intervened in every situation they encountered. Men and women differed in the barriers they identified most frequently across situations, with men endorsing Perceived Responsibility more often than women, and women reporting Skill Deficits more often than men. Neither men nor women perceived Audience Inhibition to be a significant barrier; it was salient in only one of the 10 situations. Students higher in global bystander self-efficacy were more likely to intervene and less likely to report barriers related to skill deficits and perceived responsibility. These results suggest that existing bystander intervention programs efforts can be improved by fostering a greater sense of collective responsibility in students and teaching specific intervention behaviors.

Traumas and Their Consequences According to Control-Mastery Theory

The aim of this article is to introduce the reader to how control-mastery theory (CMT; Gazzillo, 2016; Silberschatz, 2005; Weiss, 1993), an integrative relational cognitive-dynamic theory of mental functioning, psychopathology, and psychotherapeutic process, understands traumas, their consequences, and their mastery. In the first part of this article, we will present an overview of the debate about the definition of trauma within the different editions of the Diagnostic and Statistical Manual of Mental Disorders. Then, we will focus on the concept of complex traumas and on their consequences on mental health. Finally, we will discuss how CMT conceptualizes traumas and their pathological consequences. We will stress in particular how, according to CMT, in order for a painful experience to become a trauma, its victim has to come to believe that s/he caused it in the attempt to pursue a healthy and adaptive goal. In order to master traumas and disprove the pathogenic beliefs developed from them, people attempt to reexperience situations similar to the traumatic ones in safer conditions while giving them happier endings.

Emotional avoidance and social support interact to predict depression symptom severity one year after traumatic exposure

Individuals exposed to a traumatic event commonly develop symptoms of depression, a psychiatric disorder associated with a number of negative clinical and public health consequences. Both intrapersonal and interpersonal risk factors have been associated with heightened risk for depression following traumatic event exposure; however, less is known about how these risk factors may interact to predict trauma-exposed individuals' risk of subsequently developing depression symptoms. This study examined the interactive influence of emotional avoidance (an intrapersonal risk factor) and perceived social support (an interpersonal risk factor) on the development of depression symptoms over a one-year period among N = 46 individuals recruited shortly after visiting a hospital emergency department for treatment following exposure to a traumatic event. Results revealed a significant main effect of emotional avoidance on 12-month depression symptoms. The main effect was qualified by an emotional avoidance by perceived social support interaction: the relation of emotional avoidance to 12-month depression symptoms was positive and significant only for individuals with low levels of perceived social support. Results highlight the need to consider both intrapersonal and interpersonal risk factors, as well as their interaction, when predicting which individuals may be most at risk to develop depression following traumatic event exposure.

Sexual assault victimization and psychopathology: A review and meta-analysis

Sexual assault (SA) is a common and deleterious form of trauma. Over 40years of research on its impact has suggested that SA has particularly severe effects on a variety of forms of psychopathology, and has highlighted unique aspects of SA as a form of trauma that contribute to these outcomes. The goal of this meta-analytic review was to synthesize the empirical literature from 1970 to 2014 (reflecting 497 effect sizes) to understand the degree to which (a) SA confers general risk for psychological dysfunction rather than specific risk for posttraumatic stress, and (b) differences in studies and samples account for variation in observed effects. Results indicate that people who have been sexually assaulted report significantly worse psychopathology than unassaulted comparisons (average Hedges' g=0.61). SA was associated with increased risk for all forms of psychopathology assessed, and relatively stronger associations were observed for posttraumatic stress and suicidality. Effects endured across differences in sample demographics. The use of broader SA operationalizations (e.g., including incapacitated, coerced, or nonpenetrative SA) was not associated with differences in effects, although including attempted SA in operationalizations resulted in lower effects. Larger effects were observed in samples with more assaults involving stranger perpetrators, weapons, or physical injury. In the context of the broader literature, our findings provide evidence that experiencing SA is major risk factor for multiple forms of psychological dysfunction across populations and assault types.

Building emotional resilience over 14 sessions of emotion focused therapy: Micro-longitudinal analyses of productive emotional patterns

OBJECTIVE

Pascual-Leone and Greenberg's sequential model of emotional processing has been used to explore process in over 24 studies. This line of research shows emotional processing in good psychotherapy often follows a sequential order, supporting a saw-toothed pattern of change within individual sessions (progressing "2-steps-forward, 1-step-back"). However, one cannot assume that local in-session patterns are scalable across an entire course of therapy. Thus, the primary objective of this exploratory study was to consider how the sequential patterns identified by Pascual-Leone, may apply across entire courses of treatment.

METHOD

Intensive emotion coding in two separate single-case designs were submitted for quantitative analyses of longitudinal patterns. Comprehensive coding in these cases involved recording observations for every emotional event in an entire course of treatment (using the Classification of Affective-Meaning States), which were then treated as a 9-point ordinal scale.

RESULTS

Applying multilevel modeling to each of the two cases showed significant patterns of change over a large number of sessions, and those patterns were either nested at the within-session level or observed at the broader session-by-session level of change.

DISCUSSION

Examining successful treatment cases showed several theoretically coherent kinds of temporal patterns, although not always in the same case. Clinical or methodological significance of this article: This is the first paper to demonstrate systematic temporal patterns of emotion over the course of an entire treatment. (1) The study offers a proof of concept that longitudinal patterns in the micro-processes of emotion can be objectively derived and quantified. (2) It also shows that patterns in emotion may be identified on the within-session level, as well as the session-by-session level of analysis. (3) Finally, observed processes over time support the ordered pattern of emotional states hypothesized in Pascual-Leone and Greenberg's (2007) model of emotional processing.

The effect of trauma on the severity of obsessive-compulsive spectrum symptoms: A meta-analysis

It is important to consider trauma-related sequelae in the etiology and maintenance of psychopathology, namely understudied disorders such as those belonging to the Obsessive-Compulsive Spectrum (OCS). This meta-analysis examined the association between past trauma exposure and current severity of OCS disorder symptoms. A systematic literature search was conducted with 24 (N=4557) articles meeting inclusion criteria. A significant overall effect size was obtained (r=0.20), indicating that exposure to past trauma is associated with a higher severity of OCS symptoms, with a stronger association for females (β=0.01, p<.001) but not varying as a function of relationship status. Four types of interpersonal trauma (violence, emotional abuse, sexual abuse, and neglect) were associated with OCS symptom severity (r=0.19 -0.24) and past trauma was significantly associated with more severe compulsions (r=0.17), but not obsessions. Results suggest an important link between multiple types of past trauma exposure and OCS symptoms.

General and Culturally Specific Factors Influencing Black and White Rape Survivors' Self-Esteem

Grounded in a culturally inclusive ecological model of sexual assault recovery framework, the influence of personal (e.g., prior victimization), rape context (e.g., degree of injury during last assault), and postrape response factors (e.g., general and cultural attributions, rape related coping) on self-esteem of Black and White college women, who were survivors of attempted and completed rape, were examined. As predicted, Black and White women identified similar general variables (e.g., general attributions) as important in the recovery process. Black women, however, identified a cultural factor (i.e., cultural attributions) as more important in influencing their reactions to the last rape compared to their White counterparts. Using path analysis, findings from this cross-sectional study indicated that severity of the last assault and prior victimization were related to lower self-esteem indirectly through avoidance coping strategies, and victim blame attributions for the latter. Results also suggested that the link between cultural attributions and self-esteem was explained through victim blame attributions, primarily for Black participants. The model accounted for 26% of variance in self-esteem.

Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future

Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.

Acceptance and Commitment Therapy in the Treatment of Posttraumatic Stress Disorder

The current article describes the application of a behavioral psychotherapy, acceptance and commitment therapy (ACT), to the treatment of post-traumatic stress disorder (PTSD). It is argued that PTSD can be conceptualized as a disorder that is developed and maintained in traumatized individuals as a result of excessive, ineffective attempts to control unwanted thoughts, feelings, and memories, especially those related to the traumatic event(s). As ACT is a therapeutic method designed specifically to reduce experiential avoidance, it may be a treatment that is particularly suited for individuals with PTSD. The application of ACT to PTSD is described, and a case example is used to demonstrate how this therapy can be successfully used with individuals presenting for life problems related to a traumatic event.

Changes in Autonomic Nervous System Activity are Associated with Changes in Sexual Function in Women with a History of Childhood Sexual Abuse

INTRODUCTION

Women with histories of childhood sexual abuse (CSA) have higher rates of sexual difficulties, as well as high sympathetic nervous system response to sexual stimuli.

AIM

The study aims to examine whether treatment-related changes in autonomic balance, as indexed by heart rate variability (HRV), were associated with changes in sexual arousal and orgasm function.

METHODS

In study 1, we measured HRV while writing a sexual essay in 42 healthy, sexually functional women without any history of sexual trauma. These data, along with demographics, were used to develop HRV norms equations. In study 2, 136 women with a history of CSA were randomized to one of three active expressive writing treatments that focused on their trauma, sexuality, or daily life (control condition). We recorded HRV while writing a sexual essay at pretreatment, posttreatment, and 2-week, and 1- and 6-month follow-ups; we also calculated the expected HRV for each participant based on the norms equations from study 1.

MAIN OUTCOME MEASURES

The main outcome measures used were HRV, Female Sexual Function Index, Sexual Satisfaction Scale--Women.

RESULTS

The difference between expected and observed HRV decreased over time, indicating that, posttreatment, CSA survivors displayed HRV closer to the expected HRV of a demographics-matched woman with no history of sexual trauma. Also, over time, participants whose HRV became less dysregulated showed the biggest gains in sexual arousal and orgasm function. These effects were consistent across condition.

CONCLUSIONS

Treatments that reduce autonomic imbalance may improve sexual well-being among CSA populations.

Interpreting Progress Feedback to Guide Clinical Decision-Making in Children's Mental Health Services

Measurement feedback systems (MFSs) can help improve clinical outcomes by enhancing clinical decision-making. Unfortunately, limited information exists to guide the use and interpretation of data from MFSs. This study examined the amount of data that would provide a reasonable and reliable prediction of a client's rate of symptomatology in order to help inform clinical decision-making processes. Results showed that use of more data predicted greater levels of accuracy. However, there were diminishing returns on the ability for additional data to improve predictive accuracy. Findings inform efforts to develop guidelines on the interpretation of data from MFSs.

Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: New insights from brain science

Since Freud, clinicians have understood that disturbing memories contribute to psychopathology and that new emotional experiences contribute to therapeutic change. Yet, controversy remains about what is truly essential to bring about psychotherapeutic change. Mounting evidence from empirical studies suggests that emotional arousal is a key ingredient in therapeutic change in many modalities. In addition, memory seems to play an important role but there is a lack of consensus on the role of understanding what happened in the past in bringing about therapeutic change. The core idea of this paper is that therapeutic change in a variety of modalities, including behavioral therapy, cognitive-behavioral therapy, emotion-focused therapy, and psychodynamic psychotherapy, results from the updating of prior emotional memories through a process of reconsolidation that incorporates new emotional experiences. We present an integrated memory model with three interactive components - autobiographical (event) memories, semantic structures, and emotional responses - supported by emerging evidence from cognitive neuroscience on implicit and explicit emotion, implicit and explicit memory, emotion-memory interactions, memory reconsolidation, and the relationship between autobiographical and semantic memory. We propose that the essential ingredients of therapeutic change include: (1) reactivating old memories; (2) engaging in new emotional experiences that are incorporated into these reactivated memories via the process of reconsolidation; and (3) reinforcing the integrated memory structure by practicing a new way of behaving and experiencing the world in a variety of contexts. The implications of this new, neurobiologically grounded synthesis for research, clinical practice, and teaching are discussed.

Substantial symptom changes in naturalistic recovery from aversive events

OBJECTIVE

Researchers have recommended examining trajectories of recovery from aversive events, including sudden gains and spikes. We examined rates, attributions for, and outcomes associated with substantial symptom improvements and brief exacerbations after aversive events.

METHOD

Sixty-three women completed questionnaire measures of mood, depression, and posttraumatic stress disorder symptoms. They used a Life History Calendar (LHC) to draw the trajectory of symptom levels from the event to the present, and were interviewed regarding the course of their symptoms. Based on the LHC and interview, we coded whether each participant experienced substantial improvements and/or brief exacerbations and reasons for them.

RESULTS

Participants frequently experienced substantial improvements and brief exacerbations, most of which they attributed to external events. Substantial improvements-but not substantial brief exacerbations-were associated with significantly lower symptom levels.

CONCLUSION

Substantial improvements are similar to sudden gains in therapy samples. Substantial improvements in avoidance and mood have positive, bidirectional effects on each other.

Trajectories of PTSD symptoms following sexual assault: is resilience the modal outcome?

Theoretical frameworks positing qualitatively distinct trajectories of posttrauma outcome have received initial empirical support, but have not been investigated in cases of severe interpersonal trauma. To address this limitation, we conducted latent class growth analysis with longitudinal data collected from 119 female sexual assault survivors at 1-, 2-, 3-, and 4-months postassault. Participants' mean age was 33 years; 63% were White. We hypothesized that given the severity of exposure associated with sexual assault, resilience would not be the modal course of adaptation. Four distinct PTSD growth trajectories, representing unique latent classes of participants, best fit the data: a high chronic trajectory, a moderate chronic trajectory, a moderate recovery trajectory, and a marked recovery trajectory. Contrary to previous studies and recent theoretical models, resilience and resistance trajectories were not observed, as high levels of distress were evident in nearly all participants at 1-month postassault. These results suggest that theoretical models of posttrauma response positing resilience as the modal outcome may not generalize to cases of sexual assault.

Specificity of fear and disgust experienced during traumatic interpersonal victimization in predicting posttraumatic stress and contamination-based obsessive-compulsive symptoms

Emerging evidence has documented comorbidity between posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) among individuals with a history of traumatic events. There is growing recognition of the importance of disgust in each of these conditions independently. No study, however, has examined the potential role of disgust in these conditions following traumatic event exposure. The current study examined the unique role of peritraumatic fear, self-focused disgust, and other-focused disgust in predicting posttraumatic stress symptoms and contamination-based OC symptoms among 49 adult women (M(age)=28.37, SD=13.86) with a history of traumatic interpersonal victimization. Results demonstrated that intensity of peritraumatic self-focused disgust was significantly related to contamination-based OC symptoms while peritraumatic fear and other-focused disgust were related to posttraumatic stress symptoms. These results highlight the need for future research aimed at elucidating the nature of the association between disgust experienced during traumatic events and subsequent psychopathology.

The mediating role of trauma-related symptoms in the relationship between sexual victimization and physical health symptomatology in undergraduate women

Previous research suggests that posttraumatic stress symptomatology is a partial mediator of the relationship between sexual assault history in adolescence/adulthood and physical health symptomatology (e.g., Eadie, Runtz, & Spencer-Rodgers, 2008). The current study assessed a broader, more inclusive potential mediator, trauma-related symptoms in the relationship between sexual victimization history (including both childhood and adolescent/adulthood sexual victimizations) and physical health symptomatology in a college sample. Participants were 970 young women (M = 18.69, SD = 1.01), who identified mostly as Caucasian (86.7%), from 2 universities who completed a survey packet. Path analysis results provide evidence for trauma-related symptoms as a mediator in the relationship between adolescent/adulthood sexual assault and physical health symptomatology, χ(2) (1, N = 970) = 1.55, p = .21; comparative fit index = 1.00; Tucker-Lewis index = 0.99; root mean square error of approximation = .02, 90% confidence interval [.00, .09], Bollen-Stine bootstrap statistic, p = .29. Childhood sexual abuse was not related to physical health symptomatology, but did predict trauma-related symptoms. Implications of these findings suggest that college health services would benefit from targeted integration of psychiatric and medical services for sexual assault survivors given the overlap of psychological and physical symptoms.

Conceptualizing mindfulness and acceptance as components of psychological resilience to trauma

Mindfulness- and acceptance-based conceptualizations of PTSD implicate experiential avoidance and non-mindful behavior in the etiology and maintenance of the disorder. If experiential avoidance is associated with vulnerability to PTSD, then a mindful and accepting orientation toward experience may confer psychological resilience following exposure to trauma. This article examines how mindfulness- and acceptance-based theories of psychopathology relate to risk of and resilience to PTSD. Research is reviewed dealing with the impact of experiential avoidance, avoidant coping, dissociation, acceptance, and mindfulness on PTSD symptom severity and posttraumatic functioning. This review suggests that trait mindfulness and acceptance are associated with greater psychological adjustment following exposure to trauma, while experiential avoidance, persistent dissociation, and coping strategies involving emotional disengagement are associated with greater PTSD symptom severity and related psychopathology. Methodological challenges are explored and suggestions for future research and PTSD prevention programs are discussed.

The Relationships Between Perceived Levels of Control, Psychological Distress, and Legal System Variables in a Sample of Sexual Assault Survivors

Information regarding psychological distress, perceived levels of temporal control, and legal system success and satisfaction ratings were collected from 41 survivors of sexual assault. Results suggest that self-blame and offender blame may differentially impact posttraumatic stress disorder (PTSD) and depressive symptom severity. In addition, participants who perceived a greater risk of future assault reported higher levels of depressive and PTSD symptoms. Furthermore, perceptions of present control over the recovery process were related to lower levels of psychological distress. For those who reported the assault to police, lower levels of legal system success and satisfaction were linked to higher levels of perceived control over present recovery.

Longitudinal research with sexual assault survivors: a methodological review

Longitudinal research designs are relatively rare in the academic literature on rape and sexual assault despite their tremendous methodological rigor and scientific utility. In the interest of promoting wider use of such methods, we conducted a methodological review of projects that have used prospective longitudinal designs to study the occurrence of sexual victimization throughout the lifespan and/or the process of change during rape recovery (N = 32 projects). Five questions were examined: (a) What were the substantive foci of these longitudinal studies? (b) How were survivors recruited? (c) What participation rates were typical? (d) How long were participants followed over time and with what success rates? and (e) What incentives were used to increase participation? Most studies focused on postassault sequelae and recruited survivors from hospital emergency departments and other first-response help-seeking sites with highly variable participation rates. Retention rates were comparable across studies (approximately 70%).

Israeli civilians under heavy bombardment: prediction of the severity of post-traumatic symptoms

CONTEXT

The military conflict that occurred between Lebanon and Israel in July and August of 2006 was characterized by the heavy bombardment of specific geographic regions in Israel, resulting in considerable civilian casualties and property damage.

OBJECTIVE

Israeli civilians directly and indirectly exposed to bombardment were compared on exposure to the recent bombardment, trauma history, perceived life threat and peri-traumatic dissociation during the recent bombardment, and current post-traumatic stress disorder (PTSD) symptom severity.

DESIGN, SETTING, AND PARTICIPANTS

Following the conflict, data were collected by telephone from 317 Israeli residents randomly selected from two towns that were subject to differing levels of exposure to the bombardment.

INTERVENTION(S)

None

MAIN OUTCOME MEASURE(S)

Exposure to trauma during the Second Lebanon War, prior trauma exposure, PTSD symptom severity, perceived life threat, and peri-traumatic dissociation.

RESULTS

The residents directly affected by the bombardment (Kiryat Shmona; KS) endorsed more trauma exposure, (p <0.01); more prior trauma, (p <0.01); more life threat, (p <0.01); and greater PTSD symptomatology (12 % of KY participants and 38% of KS participants had probable PTSD), compared to residents in the comparison town (Kfar Yona; KY). Both groups reported a similar degree of peri-event dissociation (KS: M = 7.2 +/-3.7; KY: M = 7.3 +/-3.0). Perceived life threat mediated the relationship between exposure to bombardment and PTSD symptomatology. Time spent in bomb shelters was not associated with PTSD symptom severity. Prior shelling-related trauma negatively predicted PTSD.

CONCLUSIONS

The terror of bombardment is a risk factor for PTSD among civilians. Although there is considerable resilience in chronically threatened communities, it is prudent to develop and implement public health approaches to prevent those most distressed during and after attacks from developing PTSD. Because, to a small degree, prior trauma exposure buffers the response to bombardment, interventions should consider leveraging citizens' past successful coping.

Longitudinal associations between post-traumatic distress and depressive symptoms following a traumatic event: a test of three models

BACKGROUND

Symptoms of post-traumatic stress disorder (PTSD) and depression are highly co-morbid following a traumatic event. Nevertheless, decisive evidence regarding the direction of the relationship between these clinical entities is missing.

METHOD

The aim of the present study was to examine the nature of this relationship by comparing a synchronous change model (PTSD and depression are time synchronous, possibly stemming from a third common factor) with a demoralization model (i.e. PTSD symptoms causing depression) and a depressogenic model (i.e. depressive symptoms causing PTSD symptoms). Israeli adult victims of single-event traumas (n=156) were assessed on measures of PTSD and depression at 2, 4 and 12 weeks post-event.

RESULTS

A cross-lagged structural equation modeling (SEM) analysis provided results consistent with the synchronous change model and the depressogenic model.

CONCLUSIONS

Depressive symptoms may play an important role in the development of post-traumatic symptoms.

Struggling to survive: sexual assault, poverty, and mental health outcomes of African American women

A substantial body of research documents the mental health consequences of sexual assault including, but not limited to, depression, posttraumatic stress disorder, substance use, and suicidality. Far less attention has been given to the mental health effects of sexual assault for ethnic minority women or women living in poverty. Given African American women's increased risk for sexual assault and increased risk for persistent poverty, the current study explores the relationship between income and mental health effects within a sample of 413 African American sexual assault survivors. Hierarchical regression analyses revealed that after controlling for childhood sexual abuse there were positive relationships between poverty and mental health outcomes of depression, posttraumatic stress disorder, and illicit drug use. There was no significant relationship between poverty and suicidal ideation. Counseling and research implications are discussed.

Temporal relations between sleep problems and both traumatic event exposure and PTSD: a critical review of the empirical literature

There has been growing interest in the interrelations among traumatic event exposure, posttraumatic stress disorder (PTSD), and sleep problems. A wealth of research has examined the associations among these factors and there is an emerging literature focused on how sleep problems relate to both traumatic event exposure and PTSD across time. The current review provides a detailed analysis of studies pertaining to the temporal patterning of sleep problems and traumatic event-related factors (e.g., traumatic event exposure, PTSD) and draws conclusions regarding the current state of this literature. Research coalesces to suggest (1) exposure to a traumatic event can interfere with sleep, (2) PTSD is related to the development of self-reported sleep problems, but evidence is less clear regarding objective indices of sleep, and (3) limited evidence suggests sleep problems may interfere with recovery from elevated posttraumatic stress levels. Future research now needs to focus on understanding mechanisms involved in these patterns to inform the prevention and treatment of comorbid sleep problems and PTSD.

Sexual Assault and Current Mental Health: The Role of Help-Seeking and Police Response

We examine the extent to which seeking help from social service agencies, family and friends, reporting to the police, or responses by the police might buffer or exacerbate the impact of sexual assault on mental health outcomes among sexual assault victims.The trend in many cases was for help-seeking and police response to exacerbate the impact of sexual assault victimization. With respect to depression, we found that the association of rape penetration was greater among those seeking help from social services and those reporting their victimization to the police. Although arresting the offender appears to be associated with higher levels of depression, it actually results in a lower probability of heavy episodic drinking.

The impact of sudden gains in cognitive behavioral therapy for posttraumatic stress disorder

This study investigated sudden gains, i.e., rapid and stable improvements, in posttraumatic stress disorder (PTSD) symptoms that may occur in cognitive-behavioral therapy. Twenty-nine of 72 participants (39.2%) experienced a sudden gain during treatment. Mixed model ANOVAs analyzed sudden gains impact on clinician-rated PTSD symptom severity, patient-rated PTSD symptom severity, and patient-rated depressive symptom severity. Sudden gains in PTSD symptomology were associated with greater reductions in PTSD symptom severity for the avoidance/numbing and hyperarousal symptom clusters at posttreatment. By 6-month follow-up, the sudden gains group had maintained those reductions in symptoms, but the nonsudden gains group had achieved equal reductions in symptom severity. Participants experiencing sudden gains on PTSD measures had lower depression severity at posttreatment and follow-up.

Sequential Temporal Dependencies in Associations Between Symptoms of Depression and Posttraumatic Stress Disorder: An Application of Bivariate Latent Difference Score Structural Equation Modeling

Depression and posttraumatic stress disorder (PTSD) are highly comorbid conditions that may arise following exposure to psychological trauma. This study examined their temporal sequencing and mutual influence using bivariate latent difference score structural equation modeling. Longitudinal data from 182 emergency room patients revealed level of depression symptom severity to be positively associated with changes in PTSD intrusion, avoidance, and hyperarousal over 3 time intervals, beginning shortly after the traumatic event. Higher scores on depression anticipated increases (or worsening) in PTSD symptom severity. The pattern of influence from PTSD symptom severity to change in depression symptom severity simply followed the general trend toward health and well-being. Results are discussed in terms of the dynamic interplay and associated mechanisms of posttrauma depression and PTSD symptom severity.

Rape treatment outcome research: empirical findings and state of the literature

This article reviews empirical support for treatments targeting women sexually assaulted during adolescence or adulthood. Thirty-two articles were located using data from 20 separate samples. Of the 20 samples, 12 targeted victims with chronic symptoms, three focused on the acute period post-assault, two included women with chronic and acute symptoms, and three were secondary prevention programs. The majority of studies focus on posttraumatic stress disorder (PTSD), depression, and/or anxiety as treatment targets. Cognitive Processing Therapy and Prolonged Exposure have garnered the most support with this population. Stress Inoculation Training and Eye Movement Desensitization and Reprocessing also show some efficacy. Of the four studies that compared active treatments, few differences were found. Overall, cognitive behavioral interventions lead to better PTSD outcomes than supportive counseling does. However, even in the strongest treatments more than one-third of women retain a PTSD diagnosis at post-treatment or drop out of treatment. Discussion highlights the paucity of research in this area, methodological limitations of examined studies, generalizability of findings, and important directions for future research at various stages of trauma recovery.

PTSD Symptoms and Self-Rated Recovery Among Adult Sexual Assault Survivors: The Effects of Traumatic Life Events and Psychosocial Variables

Prior research has demonstrated that self-blame is predictive of more posttraumatic stress disorder (PTSD) symptoms and poorer recovery ( Frazier, 2003 ; Koss, Figueredo, & Prince, 2002 ), and perceived control over recovery is associated with less distress ( Frazier, 2003 ) in adult sexual assault (ASA) survivors. A structural equation model was tested to examine the role of traumatic events, self-blame, perceived control over recovery, and coping strategies on PTSD symptoms and self-rated recovery in women ASA survivors. Adaptive coping partially mediated the effects of other traumas, self-blame, and perceived control over recovery on PTSD symptoms and showed a small positive association with increased PTSD symptoms. As hypothesized, maladaptive coping partially mediated the effects of other traumas, self-blame, and perceived control over recovery on both PTSD symptoms and self-rated recovery; greater maladaptive coping was associated with increased PTSD symptoms and lower self-rated recovery. Implications and directions for future research are discussed.

Male-on-Male Rape of an Adult Man: A Case Review and Implications for Interventions

Male-on-male rape is a critical and timely topic for mental health nurses as they continue to improve their value to society. Only recently have scholars begun to address adult male sexual assault and rape survivorship. A reality for some of the men mental health nurses encounter in practice, male sexual assault and rape causes despair and suffering for which mental health nurses can help facilitate health and healing. As illustrated in a case review of male-on-male rape and selected literature, quality humanistic interpersonal relationships are deemed important for the survivor's health. J Am Psychiatr Nurses Assoc, 2009; 14(6), 454-461.

[Psychotherapy for traumatized children and adolescents--cognitive-behavioral treatments]

According to cognitive-behavioral models, both the avoidance of trauma-associated cues, as well as cognitive distortions of the trauma and the initial symptoms thereof lead to and subsequently maintain traumatic disorders. Trauma-focused cognitive behavioral therapy often starts with stabilizing interventions such as relaxation training. The main intervention consists of exposure to external trauma-associated cues (exposure in vivo) and to mental trauma reminders (exposure in sensu). Cognitive interventions aim to modify feelings of exaggerated guilt and shame. Of the different cognitive-behavioral programmes validated, trauma-focused cognitive-behavioral therapy yields the best evidence, particularly in the treatment of sexually abused children and adolescents.

A prospective test of anxiety sensitivity as a moderator of the relation between gender and posttraumatic symptom maintenance among high anxiety sensitive young adults

The primary aim of this study was to evaluate the individual and combined influence of anxiety sensitivity (AS) and gender on the longitudinal prediction of posttraumatic symptoms. A large nonclinical sample of young adults (n=404) was prospectively followed over approximately 18 months. The primary findings indicated that gender and AS were uniquely associated with posttraumatic symptom levels during the follow-up period. Moreover, AS appeared more strongly (positively) related to posttraumatic stress symptoms during the follow-up period among females than males. These data provide novel prospective evidence regarding the interplay of relatively well-established risk factors implicated in the maintenance of posttraumatic stress symptoms.

Discontinuities and cognitive changes in an exposure-based cognitive therapy for depression

Significant shifts or discontinuities in symptom course can mark points of transition and reveal important change processes. The authors investigated 2 patterns of change in depression-the rapid early response and a transient period of apparent worsening that the authors call a depression spike. Participants were 29 patients diagnosed with major depressive disorder who enrolled in an open trial of an exposure-based cognitive therapy. Hierarchical linear modeling revealed an overall cubic shape of symptom change and that both the rapid response and spike patterns predicted lower posttreatment depression. Patients wrote weekly narratives about their depression. Early narratives of rapid responders were coded as having more hope than those of nonrapid responders. The narratives of patients with a depression spike had more cognitive-emotional processing during this period of arousal than those without a spike. Findings are discussed in the context of cognitive-emotional processing theories in depression and anxiety disorders.

Change is not always linear: the study of nonlinear and discontinuous patterns of change in psychotherapy

The study of discontinuities and nonlinear change has been a fruitful endeavor across the sciences, as these shifts can provide a window into the organization of complex systems and the processes that are associated with transition. A common assumption in psychotherapy research has been that change is gradual and linear. The research designs and statistics used to study change often reflect this assumption, but some recent research reveals other patterns of change. We briefly review relevant literature on dynamical systems theory and on life transition and post-traumatic growth to highlight the significance of nonlinear and discontinuous change across areas of psychology. We describe recent applications of these ideas and methods to the study of change in psychotherapy and encourage their use to complement more traditional clinical trial designs.

Smoking, traumatic event exposure, and post-traumatic stress: a critical review of the empirical literature

The current review critically examines the extant empirical literature focused on the associations among cigarette smoking, trauma, and post-traumatic stress. Inspection of the extant literature suggests that smoking rates are significantly higher among persons exposed to a traumatic event relative to those without such exposure. Moreover, smoking rates appear particularly high among persons with post-traumatic stress disorder (PTSD). In terms of the direction of this relation, evidence most clearly suggests that post-traumatic stress is involved in the development of smoking. Significantly less is known about the role of trauma and PTSD in terms of cessation outcome. Limitations of extant work, clinical implications, and key directions for future study are delineated.

Latent difference score approach to longitudinal trauma research

In this article, the authors introduce a latent difference score (LDS) approach to analyzing longitudinal data in trauma research. The LDS approach accounts for internal sources of change in an outcome variable, including the influence of prior status on subsequent levels of that variable and the tendency for individuals to experience natural change (e.g., a natural decrease in posttraumatic stress disorder [PTSD] symptoms over time). Under traditional model assumptions, the LDSs are maximally reliable and therefore less likely to introduce biases into model testing. The authors illustrate the method using a sample of children who experienced significant burns or other injuries to examine potential influences (i.e., age of child-adolescent at time of trauma and ongoing family strains) on PTSD symptom severity over time.

Posttraumatic stress after a motor vehicle accident: a six-month follow-up study utilizing latent growth modeling

Features of posttraumatic stress disorder (PTSD) for 596 survivors of motor vehicle accidents were examined by self-report measures at 1 week, 1 month, 3 months, and 6 months after the motor vehicle accident (MVA). Latent growth modeling was utilized to study the trend and predictors of the level of distress. Results indicated that 5-20% of the participants reported to have a significant level of posttraumatic stress in one, two, or three of the PTSD symptom clusters within the period studied. Survivors with significant acute stress 1 week after the MVA had a higher risk for developing chronic posttraumatic stress. Although the severity of intrusive and hyperarousal symptoms decreased over time, the severity of avoidance symptoms remained unchanged. Factors predicting the course of PTSD after an MVA are identified.

Characterizing time in longitudinal trauma research

Despite the proliferation of longitudinal trauma research, careful attention to timing of assessments is often lacking. Patterns in timing of assessments, alternative time structures, and the treatment of time as an outcome are discussed and illustrated using trauma data.