Cognitive processing in post-trauma reactions: some preliminary findings

The Role of Anxiety and Depression in the Emotion Regulation Strategies of People Suffering from Post-Traumatic Stress Disorder

Researchers have explored the links between cognitive emotion regulation, impaired cognitive functioning, and anxiety-depression, including the link to anxiety and depression levels. However, very few studies have examined these dimensions in clinical populations with post-traumatic stress disorder (PTSD). A sample of 183 participants was divided into three groups: 59 trauma-exposed with PTSD, 61 trauma-exposed without PTSD, and 63 non-trauma-exposed non-PTSD (controls). All participants were assessed on the following dimensions: PTSD (PCL-5), cognitive emotion regulation (CERQ), anxiety and depression (HADS). Results indicate a specific profile of emotion regulation associated with PTSD. Compared to other groups, participants with PTSD showed more difficulty managing their emotions, with more rumination, self-blame, and catastrophizing. Moreover, these difficulties were also correlated with levels of anxiety and depression, that is, participants with PTSD who had higher anxiety and depression scores used more maladaptive strategies. The PTSD group used significantly more maladaptive cognitive emotion regulation strategies than the other groups, with distinct profiles related to anxiety and depressive symptomatology.

Quality of life trajectories after diagnosis of gynecologic cancer: a theoretically based approach

PURPOSE

The course of quality of life after diagnosis of gynecologic cancer is not well understood. We aimed to identify subgroups of gynecologic cancer patients with distinct trajectories of quality of life outcomes in the 18-month period after diagnosis. We also aimed to determine whether these subgroups could be distinguished by predictors derived from Social-Cognitive Processing Theory.

METHODS

Gynecologic cancer patients randomized to usual care as part of a psychological intervention trial (NCT01951807) reported on depressed mood, quality of life, and physical impairment soon after diagnosis and at five additional assessments ending 18 months after baseline. Clinical, demographic, and psychosocial predictors were assessed at baseline, and additional clinical factors were assessed between 6 and 18 months after baseline.

RESULTS

A two-group growth mixture model provided the best and most interpretable fit to the data for all three outcomes. One class revealed subclinical and improving scores for mood, quality of life, and physical function across 18 months. A second class represented approximately 12 % of patients with persisting depression, diminished quality of life, and greater physical disability. Membership of this high-risk subgroup was associated with holding back concerns, more intrusive thoughts, and use of pain medications at the baseline assessment (ps < .05).

CONCLUSIONS

Trajectories of quality of life outcomes were identified in the 18-month period after diagnosis of gynecologic cancer. Potentially modifiable psychosocial risk factors were identified that can have implications for preventing quality of life disruptions and treating impaired quality of life in future research.

Long-term consequences of minor head injury on family members

The emotional impact of a minor head injury on 25 relatives was investigated at interview six months after the event. Two and a half years later, eight of the relatives agreed to be reassessed. Psychological distress was identified at six months and appeared to persist for up to three years. This study was limited by the small number of participants, and further exploration with a larger sample is recommended.

Measuring workplace trauma response in Australian paramedics: an investigation into the psychometric properties of the Impact of Event Scale

Introduction

Investigation into the psychological effects of violence toward health care workers and its associated trauma is increasing. The Impact of Event Scale (IES) provides a measure of current, subjective, emotional distress symptomatic of a specific traumatic event. However, its validity among paramedics is largely unknown.

Problem

The purpose of this study was to investigate the psychometric properties and factor structure of the IES with a sample of Australian paramedics.

Methods

The study aimed to investigate the psychometric properties and factor structure of the 15-item IES with a sample of Australian paramedics using Exploratory Factor Analysis with model fit statistics as found in confirmatory analysis.

Results

Maximum Likelihood Factor Analysis with Varimax rotation supported the hypothesis that a two-factor solution would provide the best fit of the data. Procrustes rotation provided further support for this hypothesis indicating that the factors, labeled “Intrusion” and “Avoidance”, as well as the individual items of the 12-item final model, were a good fit to an ideal solution.

Conclusion

The revision of the scale has improved its validity for use in the general population of paramedics, improving the potential for its use in trauma-related research.

Post-traumatic growth: finding positive meaning in cancer survivorship moderates the impact of intrusive thoughts on adjustment in younger adults

OBJECTIVE

We examined whether post-traumatic growth would moderate the impact of intrusive thoughts on a range of dimensions of well-being in a sample of younger adult survivors of various types of cancer.

METHODS

167 participants completed questionnaires regarding intrusive thoughts, post-traumatic growth, mental and physical health-related quality of life, positive and negative affect, life satisfaction, and spiritual well-being. Multiple regression analyses controlling for relevant background and cancer-related variables tested the interaction effects of post-traumatic growth and intrusive thoughts.

RESULTS

Intrusive thoughts were related to poorer adjustment on all indices except physical health-related quality of life. However, post-traumatic growth moderated the effects of intrusive thoughts on positive and negative affect, life satisfaction, and spiritual well-being in a protective fashion. That is, for those higher in post-traumatic growth, higher levels of intrusive thoughts were related to better adjustment.

CONCLUSIONS

The positive meaning that individuals assign to their cancer experience as reflected in their reports of post-traumatic growth appears to be important in determining the impact of intrusive thoughts on post-cancer adjustment.

Conflict in the Indian Kashmir Valley II: psychosocial impact

Background

India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in high levels of exposure to violence among the civilian population of Kashmir (India). A survey was done as part of routine programme evaluation to assess confrontation with violence and its consequences on mental health, health service usage, and socio-economic functioning.

Methods

We undertook a two-stage cluster household survey in two districts of Kashmir (India) using questionnaires adapted from other conflict areas. Analysis was stratified for gender.

Results

Over one-third of respondents (n = 510) were found to have symptoms of psychological distress (33.3%, CI: 28.3–38.4); women scoring significantly higher (OR 2.5; CI: 1.7–3.6). A third of respondents had contemplated suicide (33.3%, CI: 28.3–38.4). Feelings of insecurity were associated with higher levels of psychological distress for both genders (males: OR 2.4, CI: 1.3–4.4; females: OR 1.9, CI: 1.1–3.3). Among males, violation of modesty, (OR 3.3, CI: 1.6–6.8), forced displacement, (OR 3.5, CI: 1.7–7.1), and physical disability resulting from violence (OR 2.7, CI: 1.2–5.9) were associated with greater levels of psychological distress; for women, risk factors for psychological distress included dependency on others for daily living (OR 2.4, CI: 1.3–4.8), the witnessing of killing (OR 1.9, CI: 1.1–3.4), and torture (OR 2.1, CI: 1.2–3.7). Self-rated poor health (male: OR 4.4, CI: 2.4–8.1; female: OR 3.4, CI: 2.0–5.8) and being unable to work (male: OR 6.7, CI: 3.5–13.0; female: OR 2.6, CI: 1.5–4.4) were associated with mental distress.

Conclusion

The ongoing conflict exacts a huge toll on the communities' mental well-being. We found high levels of psychological distress that impacts on daily life and places a burden on the health system. Ongoing feelings of personal vulnerability (not feeling safe) was associated with high levels of psychological distress. Community mental health programmes should be considered as a way reduce the pressure on the health system and improve socio-economic functioning of those suffering from mental health problems.

Long-term trajectories of psychological adaptation among women diagnosed with gynecological cancers

OBJECTIVE

Women diagnosed with gynecological cancers may cope with a difficult treatment regimen that includes multiple abdominal surgeries and courses of chemotherapy and/or radiation. Little attention has been paid to identifying what factors place women at risk for long-term problems with psychological adaptation. The goal of the present study was to identify a set of demographic, medical, and predisposing factors as well as cognitive and social processing strategies that predict the trajectory of psychological distress and well-being among women diagnosed with gynecological cancer.

METHODS

One hundred thirteen women on active treatment for gynecological cancer completed measures at baseline, 3, 6, and 9 months afterward.

RESULTS

Women with poorer physician-rated performance status and self-reported functional impairment, women who were Caucasian, women who have received previous psychological treatments, women who were less expressive of positive emotions, women who had unsupportive friends and family, and women who were less able to find something positive in the cancer experience reported poorer adaptation.

CONCLUSIONS

This study identified a set of risk factors for poor long-term psychological adaptation among women diagnosed with gynecological cancers. Healthcare professionals working with these women can use these risk factors to screen for patients who may require additional psychological services.

Optimism and life events as predictors of fear appraisals in mothers of children undergoing hematopoietic stem cell transplantation

Although mothers' fear appraisals about their child's future health and well-being affect their own psychological adjustment to their child's hematopoietic stem cell transplantation (HSCT), little is known about antecedents of maternal fear appraisals. This longitudinal study investigated several potential antecedents of these fear appraisals: maternal optimism, recent negative life events, lifetime history of traumatic events, and medical characteristics of the child's disease and HSCT course. One hundred-forty mothers were interviewed during their child's hospitalization for HSCT and at 3-and 6-months post-HSCT. Structural equation modeling was used to test a model of hypothesized relations. Consistent with predictions, lower optimism and a greater number of negative life events were independently associated with greater maternal fear appraisals. Contrary to expectations, lifetime history of trauma was not associated with maternal fear appraisals. Mothers' fear appraisals during their child's hospitalization were, in turn, associated with their fear appraisals up to 6 months later. These data identify a subset of mothers who may be particularly in need of an intervention to increase optimistic coping strategies, improve coping with negative life events, and reduce fear appraisals to improve their adjustment following their child's HSCT.

Couple-focused group intervention for women with early stage breast cancer

This study examined the efficacy of a couple-focused group intervention on psychological adaptation of women with early stage breast cancer and evaluated whether perceived partner unsupportive behavior or patient functional impairment moderated intervention effects. Two hundred thirty-eight women were randomly assigned to receive either 6 sessions of a couple-focused group intervention or usual care. Intent-to-treat growth curve analyses indicated that participants assigned to the couples' group reported lower depressive symptoms. Women rating their partners as more unsupportive benefited more from the intervention than did women with less unsupportive partners, and women with more physical impairment benefited more from the intervention group than did women with less impairment. Subgroup analyses comparing women attending the couple-focused group intervention with women not attending groups and with usual care participants indicated that women attending sessions reported significantly less distress than did women receiving usual care and women who dropped out of the intervention.

Perceived social support and secondary traumatic stress symptoms in emergency responders

This study investigated prevalence rates of secondary traumatic stress symptoms in Israeli Police forensic technicians, and the relationship between these symptoms and perceived social support as well as perceived severity of prior trauma (combat, work, personal). Ninety technicians from the Israeli Police Forensic Investigation Unit participated in the study. Intrusion and avoidance measured within the medium range of severity, whereas distress symptoms were below clinical threshold. Intrusion was significantly related to avoidance, distress, and the perceived severity of prior personal and work-related exposure. No significant relationship was found between perceived social support and secondary traumatic stress symptoms. The data suggest that this cohort utilized avoidance effectively as a defense against intrusion.

Children exposed to warfare: a longitudinal study

Following the 1991 Gulf War a group of 94 children in Iraq were interviewed at 6 months, 1 year, and 2 years after the war. The group was exposed to the bombing of a shelter where more than 750 were killed. Selected items from different inventories, including the Impact of Event Scale (IES) assessed children's reactions. Results reveal that children continue to experience sadness and remain afraid of losing their family. Although there was no significant decline in intrusive and avoidance reactions as measured by the IES from 6 months to 1 year following the war, reactions were reduced 2 years after the war. However, the scores were still high, indicating that symptoms persist, with somewhat diminished intensity over time.

Hypnotizability and trauma symptoms after burn injury

This study investigated the association of trauma symptoms and hypnotizability in 43 hospitalized survivors of burn injury. Three to 17 days after the injury, participants rated the frequency of intrusive and avoidance symptoms and were interviewed with the posttraumatic stress disorder module of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-III-R. The Hypnotic Induction Profile was also administered at the postburn, hospital stage of recovery. Results indicated that when participants were divided into low, mid-range, and high hypnotizability categories, high hypnotizability was associated with more intrusive, avoidance, and arousal symptoms. Although causal relations cannot be assessed in this cross-sectional study, these results suggest that, as compared to the low and mid-range categories, high hypnotizables may experience a greater frequency of trauma symptoms after burn injury.

Intrusion, avoidance, and psychological distress among individuals with cancer

OBJECTIVE

The goal of the study was to examine the utility of Creamer's cognitive processing theory of trauma in a sample of individuals undergoing treatment for cancer. This theory proposes that avoidance is a maladaptive strategy of dealing with intrusive thoughts about a traumatic experience and suggests that avoidance mediates the relation between intrusive thoughts and later psychological distress. The role of disease-related factors, specifically changes in physical impairment and disease stage, was also examined.

METHODS

Patients (N = 189) undergoing treatment for cancer completed questionnaires at three time points, spaced 3 months apart. Intrusive thoughts, functional impairment, and psychological distress were assessed at Time 1, avoidance and functional impairment at Time 2, and psychological distress was assessed again at Time 3. The fit of the model was tested separately for patients with early-stage (stages 1 and 2) and late-stage (stages 3 and 4) disease.

RESULTS

The mediational role for avoidance was supported among patients with advanced stages of cancer but not for patients with early-stage disease. Results were inconsistent with predictions about the role of physical impairment. Among individuals with late-stage cancer, changes in functional impairment were not predictive of greater avoidance, and impairment had a significant but weak effect on the change in distress. Among patients with early-stage cancer, a deterioration in physical impairment was associated with increases in avoidance, and deterioration in physical impairment increased distress.

CONCLUSIONS

The results of this study were partially consistent with Creamer's cognitive processing theory. A moderating effect was found for disease stage on associations between intrusions, avoidance, physical impairment, and distress.

"It was never that bad": biased recall of grief and long-term adjustment to the death of a spouse

At 6 months following the death of their spouse, 37 participants reported their grief-related symptoms and thoughts, and then, approximately 4.5 years later, they attempted to recall how they felt at the time of the 6-month report. Although participants were far less distressed at recall than initially, they recalled their 6-month grief rather accurately. Participants did however overestimate prior grief-related intrusive ideation. Participant's current level of grief predicted what they recalled slightly better than the actual initial grief. Conversely, what they recalled predicted current levels of grief across various measures. Participants whose grief diminished relatively little over time tended to overestimate prior grief more. The retrospective reappraisal that one's past grief was not severe may indicate effective coping.

Clinical treatment of posttraumatic stress disorder: conceptual challenges raised by recent research

OBJECTIVE

This paper highlights some of the recent findings in the field of posttraumatic stress disorder (PTSD) and examines their impact on conceptions of trauma-focused clinical treatment.

METHOD

A series of research findings in the area of epidemiology, phenomenology, neurobiology and treatment are summarised.

RESULTS

The findings from these studies present critical challenges for clinicians who wish to treat trauma survivors using specialised trauma treatments. The major challenge is one of avoiding a simplistic view of PTSD as a singular response to trauma, as this perception may result in an underestimation of the complexity and disabling quality of the disorder, and lead to the formulation of treatment plans that are simplistic or incomplete.

CONCLUSIONS

A more precise characterisation of the nature and range of the stress responses of trauma victims will significantly improve treatments of trauma survivors.

Psychological impact of diagnosis and risk reduction among cancer survivors

Life-threatening health events prompt psychological distress that may motivate individuals to reduce health risks. If so, interventions timed to take advantage of these 'teachable moments' could be particularly effective. To explore this association, early stage prostate and breast cancer patients were identified from a hospital-based tumor registry within 6 years of diagnosis. These patients (n=920) completed a mailed survey assessing the Horowitz impact of events scale, risk behaviors and readiness to change the behaviors. Breast cancer patients, younger patients and those reporting poor health status reported the greatest impact of the cancer diagnosis. Impact was inversely associated with time from diagnosis for prostate, but not breast cancer patients. Prostate patients who reported exercising regularly had lower impact scores than those who were not exercising (medians: 0.13 vs 0.56, respectively; p=0.02). Breast patients who were eating five or more fruits and vegetables reported lower impact scores than those who were not eating the recommended servings (0.75 vs 1.06, respectively; p=0.03). Breast patients who were non-smokers reported lower impact scores than smokers (0.88 vs 1.31, respectively; p=0. 02). Prospective studies are needed to understand the psychological impact of cancer diagnosis and how it might facilitate or impede the adoption of health promoting behaviors.

Anger in former East German political prisoners: relationship to posttraumatic stress reactions and social support

Anger is a salient symptom of traumatized victims and a major sign for posttraumatic stress disorder (PTSD). However, the causes for the increased level of anger remain almost unknown. The present study investigates the interrelationship of anger, posttraumatic stress reactions, and social support in a group of former East German political prisoners (N = 91). Assessments included the German version of the Anxiety Disorders Schedule (DIPS) as well as measures of anger (STAXI), posttraumatic stress reactions (IES-R), and social support (SSQ). As expected, participants reported a high level of anger. Most measures of anger, posttraumatic stress reactions, and social support were significantly correlated. Within structural equation modeling, trait-anger was shown to be directly activated by the experience of chronic posttraumatic intrusions. Social support appeared to lessen the level of anger. The results confirm findings from studies on other traumatic events and provide additional information on the relationship between posttraumatic anger and social support. The findings indicate that treatments for PTSD might be effectively supplemented by addressing anger and social support.

Intrusive thoughts and psychological distress among breast cancer survivors: global meaning as a possible protective factor

Previous research has consistently demonstrated a positive association between intrusive thoughts about stressful experiences and psychological distress. The strength of this relation, however, has varied considerably across studies. To examine the possibility that an individual's sense of global meaning (i.e., the existential belief that one's life has purpose and order) may moderate the relation between intrusive thoughts and psychological distress, the authors conducted telephone assessments of 61 women who had survived breast cancer. Results confirmed that the frequency of intrusive thoughts was positively related to psychological distress. Global meaning, moreover, moderated the relation between intrusive thoughts and psychological distress consistent with the authors' hypotheses. Among women with lower global meaning, more frequent intrusive thoughts were associated with higher psychological distress. No association was found between intrusive thoughts and psychological distress among those participants with higher global meaning.

When the earth stops shaking: earthquake sequelae among children diagnosed for pre-earthquake psychopathology

OBJECTIVE

To examine risk and protective processes for posttraumatic stress reactions and negative sequelae following the Northridge earthquake (EQ) among youths diagnosed for pre-EQ psychopathology.

METHOD

Symptoms of posttraumatic stress disorder (PTSD), depression, general anxiety, and social impairment were evaluated using telephone interviews among 66 children participating in a family-genetic study of childhood-onset depression at the time of the EQ.

RESULTS

Significant predictors of PTSD symptoms 1 year after the EQ included perceived stress and resource loss associated with the EQ, a pre-EQ anxiety disorder, and more frequent use of cognitive and avoidance coping strategies. PTSD symptoms were associated with high rates of concurrent general anxiety symptoms, depressive symptoms, and social adjustment problems with friends. The only significant correlation between sibling scores was on measures of sibling reports of objective exposure.

CONCLUSIONS

Preexisting anxiety disorders represent a risk factor for postdisaster PTSD reactions. Postdisaster services need to attend to the needs of these youths as well as those of youths experiencing high levels of subjective stress, resource loss, and/or high exposure. That children within families show significant variation in postdisaster reactions underscores the need for attention to individual child characteristics and unshared environmental attributes.

Maintenance of intrusive memories in posttraumatic stress disorder: a cognitive approach

Intrusive recollections are very common immediately after traumatic events and are considered necessary aspects of emotional processing. However, if these intrusive recollections persist over a long time, they are linked to long-term psychiatric disorder, especially Posttraumatic Stress Disorder (PTSD). This paper discusses the need to investigate factors involved in the maintenance of intrusive traumatic recollections. It is suggested that the idiosyncratic meaning of the intrusive recollections predicts the distress caused by them, and the degree to which the individual engages in strategies to control the intrusions. These control strategies maintain the intrusive recollections by preventing a change in the meaning of the trauma and of the traumatic memories. It is further suggested that what is needed is a comprehensive assessment of the processes that prevent change in meaning, going beyond the assessment of avoidance. In particular, safety behaviours, dissociation and numbing, suppression of memories and thoughts about trauma, rumination, activation of other emotions such as anger and guilt and corresponding cognitions, and selective information processing (attentional and memory biases) may be involved in the maintenance of intrusive recollections. Preliminary data supporting these suggestions from studies of individuals involved in road traffic accidents and survivors of child sexual abuse are described.

Emotional processing in survivors of the Jupiter cruise ship disaster

Twenty-three survivors of the Jupiter cruise ship disaster completed the Impact of Events Scale, a measure of intrusion and avoidance, as well as measures of arousal and affect at two points in time: between 3 and 7 months (Time 1) and between 12 and 14 months (Time 2) following the event. The aim of the present study was to explore the relationship between intrusion and avoidance and symptoms of depression and anxiety. The results suggest that although higher scores on intrusion and avoidance are strongly associated with poorer psychological outcome at each point in time, it is only intrusion which may be predictive of later symptoms. Avoidance would seem to be a response to early distress. These data are discussed with reference to a cognitive--emotional processing model of post-traumatic stress disorder.

Expressive and defensive behavior during discourse on unresolved topics: a single case study of pathological grief

Both psychodynamic and social-cognitive theoretical domains have control process models of behavior but with different ideas about the purpose and loci of control. This study examines expressive and defensive behaviors associated with different topics of discourse in the time-limited psychotherapy of a woman treated for pathological grief. Conceptually the study is based on a model of defensive control processes that integrates states of mind and person schemas. Theoretically derived measures of discourse topics, verbal and nonverbal defensive behaviors, emotional disclosure, and states of mind were applied to transcripts and videotapes of the entire therapy. Evidence from combined cluster and factor analyses supported the existence of recurring emotionally significant states. Two of these are particularly interesting from a clinical perspective: One, a "shimmering" state of intense emotional expression with concurrent signs of avoidance, was associated with topics identified clinically as stressful, unresolved, and conflictual. The other, a state of more uniformly stifled emotionality, was characteristic of discourse thought of clinically as resistance.

The Herald of Free Enterprise disaster: the relationship of intrusion and avoidance to subsequent depression and anxiety

Twenty-five survivors completed the Impact of Events Scale, a measure of intrusive reexperiencing and avoidant behaviour, approx. 7 months following the Herald of Free Enterprise disaster. The aim of the present study was to examine the relationship of scores on these scales to scores on the Beck Depression Inventory and the Spielberger State Anxiety Inventory at approx. 19 months subsequent to the event. Greater intrusive reexperiencing was found to be associated with greater depression and anxiety over and above the intensity of exposure and the fact of bereavement. These data are discussed with reference to a cognitive processing model of post-traumatic stress.

Psychiatric morbidity in bus crews following violent assault: a follow-up study

In a prospective study 22 bus crews who were victims of physical assault were assessed using standardized psychiatric instruments, followed up for 18 months and compared to a non-assaulted control group drawn from the same bus garage. At initial assessment the assaulted group, compared to the controls showed a significant increase in psychiatric impairment and distress (as measured by the GHQ-30 and IES respectively), with 23% of assault victims developing post-traumatic stress disorder as defined by DSM-III-R. At follow-up, while high levels of both psychiatric impairment and distress persisted there was evidence that they may be separate phenomena.