Screening for trauma histories,posttraumatic stress disorder (PTSD), and subthreshold PTSD in psychiatric outpatients

The ability of the Structured Clinical Interview for DSM-IV (SCID) posttraumatic stress disorder (PTSD) module's screening question to identify individuals with PTSD or subthreshold PTSD was examined. First, the screen's sensitivity for detecting a trauma history was determined. Second, the incremental validity of a more thorough trauma assessment was examined by determining how many individuals responded negatively to the screen but then were diagnosed with PTSD or subthreshold PTSD. Last, the optimal SCID termination point for assessing subthreshold PTSD was determined. Using a trauma list increased the number of participants reporting a trauma; however, the SCID screen captured almost all individuals who had PTSD or subthreshold PTSD. When one screens for subthreshold PTSD, the SCID can be terminated on failure to meet Criterion B.     

Emotional working memory capacity in posttraumatic stress disorder (PTSD)

Participants with a lifetime history of posttraumatic stress disorder (PTSD) and trauma-exposed controls with no PTSD history completed an emotional working memory capacity (eWMC) task. The task required them to remember lists of neutral words over short intervals while simultaneously processing sentences describing dysfunctional trauma-related thoughts (relative to neutral control sentences). The task was designed to operationalise an everyday cognitive challenge for those with mental health problems such as PTSD; namely, the ability to carry out simple, routine tasks with emotionally benign material, while at the same time tackling emotional laden intrusive thoughts and feelings. eWMC performance, indexed as the ability to remember the word lists in the context of trauma sentences, relative to neutral sentences, was poorer overall in the PTSD group compared with controls, suggestive of a particular difficulty employing working memory in emotion-related contexts in those with a history of PTSD. The possible implications for developing affective working memory training as an adjunctive treatment for PTSD are explored.     

A double‐edged sword: Event centrality,PTSD and posttraumatic growth

Previous research has demonstrated negative mental health consequences (including PTSD symptoms) of construing a potentially traumatic event as central to one's identity. In the current paper, we replicated an association between event centrality and PTSD symptoms. We also found event centrality similarly predicts posttraumatic growth (PTG) even after controlling for PTSD symptoms, depression, DSM‐IV A1 and A2 status of the event, coping styles and cognitive processing of the event. Because predictive relationships between event centrality and PTSD symptoms, as well as event centrality and PTG were positive, construing an event as central to one's identity can indeed become a double‐edged sword, allowing for both debilitation and growth. Copyright © 2010 John Wiley & Sons, Ltd.     

A memory-based model of posttraumatic stress disorder: evaluating basic assumptions underlying the PTSD diagnosis

In the mnemonic model of posttraumatic stress disorder (PTSD), the current memory of a negative event, not the event itself, determines symptoms. The model is an alternative to the current event-based etiology of PTSD represented in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The model accounts for important and reliable findings that are often inconsistent with the current diagnostic view and that have been neglected by theoretical accounts of the disorder, including the following observations. The diagnosis needs objective information about the trauma and peritraumatic emotions but uses retrospective memory reports that can have substantial biases. Negative events and emotions that do not satisfy the current diagnostic criteria for a trauma can be followed by symptoms that would otherwise qualify for PTSD. Predisposing factors that affect the current memory have large effects on symptoms. The inability-to-recall-an-important-aspect-of-the-trauma symptom does not correlate with other symptoms. Loss or enhancement of the trauma memory affects PTSD symptoms in predictable ways. Special mechanisms that apply only to traumatic memories are not needed, increasing parsimony and the knowledge that can be applied to understanding PTSD.     

Stability of emotions for traumatic memories in acute and chronic PTSD

While memory for central factual information regarding an emotional event is considered to be relatively accurate, memory for emotions seem to be quite inaccurate (Christianson & Safer, 1995). We extended this line of research to examine memory for the emotional intensity surrounding a traumatic event (e.g., memory for the fear and horror of the event). We conducted a series of two studies. In Study 1, we examined memory for the emotional intensity of the traumatic event in recent sexual or non-sexual assault victims with acute PTSD at 2 and 12 weeks following the assault. In Study 2, we compared memory for emotional intensity in sexual and non-sexual assault victims with either acute or chronic PTSD at initial assessment and 12 weeks later. For both studies, participants were asked to recall general emotional intensity, fear intensity, and dissociative intensity of the traumatic event. Results suggested that memory for the fear of the traumatic event did not fluctuate over time. However, memory for the general emotional and dissociative intensity did fluctuate over time, decreasing for individuals with acute PTSD and increasing for individuals with chronic PTSD.     

PTSD symptom trajectories: from early to chronic response

This study aimed to identify posttraumatic stress disorder (PTSD) symptom trajectories across the first 12 months following traumatic injury. Three hundred and seven consecutively admitted injury survivors were assessed for severity of PTSD symptoms just prior to discharge, and at 3 and 12 months postinjury. Growth modeling was used to determine the curve that best fit the trajectory for each symptom cluster over the 12-month period. Individuals with 12-month PTSD showed significantly higher re-experiencing, arousal, and avoidance symptoms at eight days posttrauma relative to those without, and these symptoms escalated over time. Those without PTSD maintained their relatively low symptom levels. These findings highlight that individuals who will go onto develop PTSD have a distinctly different symptom course than those who recover.     

An experimental analysis of chronic posttraumatic stress among adolescents

The Fear Survey Schedule (FSS), State Trait Anxiety Inventory (STAI), and the Lebanese Fear Inventory (FLI, an endemic index of war fears) were administered to a sample of Lebanese junior high school students 27 days before the Israeli invasion of 1982. Six months after the disengagement of forces, the investigator located 16 subjects who had been in West Beirut throughout the siege and 46 subjects who had evacuated to safer environs. The inventories were readministered to the subjects according to a counterbalanced regimen and no significant differences were noted between the preinvasion scores of the evacuees and nonevacuees or between the postinvasion scores of the evacuees and nonevacuees. No significant differences were observed when the aggregate FSS and STAI estimates that were recorded before and after the invasion were compared. On the other hand, the aggregate LFI scores were significantly lower after the invasion. The results are discussed from within the social learning framework of fear acquisition.     

Specificity of episodic and semantic aspects of autobiographical memory in relation to symptoms of posttraumatic stress disorder (PTSD)

Two studies examined the relationship between the ability to access specific autobiographical material in memory and presence/symptoms of posttraumatic stress. In Study 1, a sample of refugees with a diagnosis of posttraumatic stress disorder (PTSD) completed the Autobiographical Memory Test (AMT) in which they had to generate specific episodic autobiographical memories in response to emotion-related cue words. Results showed that reduced specificity of memories on the AMT was associated with an increased frequency of trauma-related flashbacks but with reduced use of effortful avoidance to deal with trauma-related intrusions in the day-to-day. Study 2 examined retrieval of semantic autobiographical information from previous lifetime periods in groups of cancer survivors with posttraumatic stress and healthy controls. The cancer survivors were able to generate fewer specific semantic details about the personal past compared to the controls. The more symptomatic survivors showed the greatest memory impairment. The data from both studies are discussed in terms of compromised access to specific autobiographical material in distressed trauma survivors reflecting a process of affect regulation.     

Posttraumatic distress and the presence of posttraumatic growth and meaning in life: Experiential avoidance as a moderator

Existing models of trauma suggest that for recovery to occur, trauma related cues and emotions require awareness and openness while survivors continue committing action toward valued life aims (other than regulating emotions). Based on this theoretical framework, an unwillingness to be in contact with distressing thoughts and feelings (experiential avoidance) might operate together with posttraumatic distress to predict when people find benefits and meaning in the aftermath of trauma. We hypothesized that people reporting posttraumatic distress and less reliance on experiential avoidance would report greater posttraumatic growth and meaning in life compared with other trauma survivors. We administered questionnaires to 176 college students reporting at least one traumatic event. Results supported these moderation models. This is the fourth study (with different samples, measures, and methodologies) to provide evidence that a combination of excessive anxiety and a heavy reliance on experiential avoidance leads to attenuated well-being. We discuss the implications for understanding heterogeneous trauma reactions.     

Conceptual and perceptual priming and dissociation in chronic posttraumatic stress disorder

Cognitive models of posttraumatic stress disorder (PTSD) assert that memory processes play a significant role in PTSD (see e.g., Ehlers & Clark, 2000). Intrusive reexperiencing in PTSD has been linked to perceptual processing of trauma-related material with a corresponding hypothesized lack of conceptual processing. In an experimental study that included clinical participants with and without PTSD (N = 50), perceptual priming and conceptual priming for trauma-related, general threat, and neutral words were investigated in a population with chronic trauma-induced complaints as a result of the Troubles in Northern Ireland. The study used a new version of the word-stem completion task (Michael, Ehlers, & Halligan, 2005) and a word-cue association task. It also assessed the role of dissociation in threat processing. Further evidence of enhanced perceptual priming in PTSD for trauma stimuli was found, along with evidence of lack of conceptual priming for such stimuli. Furthermore, this pattern of priming for trauma-related words was associated with PTSD severity, and state dissociation and PTSD group made significant contributions to predicting perceptual priming for trauma words. The findings shed light on the importance of state dissociation in trauma-related information processing and posttraumatic symptoms.     

Directed forgetting following mood induction in chronic posttraumatic stress disorder patients

Current research of posttrauma sequelae suggests that intrusive rather than avoidant-dissociative models more accurately represent the encoding processes of trauma cues. However, posttraumatic stress disorder (PTSD) is often conceptualized as a phasic phenomenon, altering between arousal and avoidance states. The failure to support a relationship between avoidant encoding style and PTSD may reflect this alteration. To explore this hypothesis, participants with PTSD and controls (no PTSD) completed an item-cued directed-forgetting task, following either a dissociative or a serenity (control) mood induction. Results suggested that, following the serenity induction, a standard directed-forgetting effect was observed. However, following the dissociation induction, this effect was not observed. The role of dissociation in impairing encoding via lack of selective rehearsal or source discrimination is discussed.     

Emotion-specific and emotion-non-specific components of posttraumatic stress disorder (PTSD): implications for a taxonomy of related psychopathology

Many cognitive theories of posttraumatic stress disorder (PTSD), including our own SPAARS model, propose that one basis of the disorder is the cognitive system's persistent failure to resolve discrepancies between trauma-related information and the content of pre-existing mental representations, such as schemas. This leads to the characteristic PTSD symptom pattern of re-experiencing and avoidance of trauma-related material. Furthermore, the nature of this unresolved discrepancy revolves around appraisals of threat and the corresponding emotion profile in PTSD is therefore predominantly intense fear and anxiety. This paper argues that this general framework can be extended to discrepancies around other appraisal dimensions such as loss, and consequently to other emotions such as sadness. A localized taxonomy is therefore proposed comprising emotional disorders that resemble PTSD in their basic patterns of re-experiencing and avoidance symptoms--what we call their 'emotion-non-specific component'--but that differ from PTSD in terms of the core emotions involved--what we call their 'emotion-specific component'. The clinical and nosological implications of this argument are discussed.     

Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.     

Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault.

Cognitive factors hypothesised to influence the development and maintenance of PTSD were investigated. 92 assault victims completed questionnaires assessing a range of cognitive variables. Factors relating to onset of PTSD were investigated by comparing victims who did and who did not suffer PTSD. Factors relating to maintenance of PTSD were investigated by comparing victims who had recovered from PTSD with victims who had persistent PTSD. Cognitive factors associated with both onset and maintenance of PTSD were: appraisal of aspects of the assault itself (mental defeat, mental confusion, appraisal of emotions); appraisal of the sequelae of the assault (appraisal of symptoms, perceived negative responses of others, permanent change); dysfunctional strategies (avoidance/safety seeking) and global beliefs impacted by assault. Cognitive factors that were associated only with the onset of PTSD were: detachment during assault; failure to perceive positive responses from others and mental undoing. Relationships between the cognitive variables and PTSD remained significant when variations in perceived and objective assault severity were statistically controlled. The cognitive factors identified in the study may contribute to PTSD directly, by generating a sense of ongoing threat, or indirectly, by motivating cognitive and behavioural strategies that prevent recovery, or by affecting the nature of the traumatic memory.     

Long-term improvement in coping skills following multimodal treatment in war veterans with chronic PTSD

Due to the long-lasting and resistant symptoms characteristic of chronic combat posttraumatic stress disorder (PTSD), its treatment is complex and often requires a tailored therapeutic approach incorporating both psychotherapy and pharmacotherapy. A multimodal approach of psychoeducative, sociotherapeutic, and dynamically oriented trauma-focused groups is described. We assessed the short- and long-term effectiveness of this therapeutic program by monitoring its impact on PTSD symptoms, depression, neurotic symptoms, coping skills, and quality of life for three years. The findings revealed short-term reduction in the symptoms of PTSD and depression, while the long-term results were manifested as the increased use of all coping mechanisms and a greater level of obsession.     

A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault

The effectiveness of psychological treatments for PTSD is likely to be enhanced by improved understanding of the factors involved in maintaining the disorder. Ehlers and Clark [A cognitive model of persistent posttraumatic stem disorder Behav. Res. Ther. 38 (2000) 319-345] recently proposed a cognitive model of maintenance. The current study aimed to investigate several cognitive factors highlighted in Ehlers and Clark's model using a prospective design. Fifty-seven victims of physical or sexual assault participated in the study. Cognitive factors were assessed within 4 months of assault and victims were followed-up 6 and 9 months after the assault. Cognitive variables which significantly predicted PTSD severity at both follow-ups were: cognitive processing style during assault (mental defeat, mental confusion, detachment); appraisal of assault sequelae (appraisal of symptoms, perceived negative responses of others, permanent change); negative beliefs about self and world; and maladaptive control strategies (avoidance/safety seeking). Relationships between early appraisals, control strategies, and processing styles and subsequent PTSD severity remained significant after statistically controlling for gender and perceived assault severity. These findings support the cognitive model of PTSD proposed by Ehlers and Clark and suggest that effective treatment will need to address these cognitive factors.     

The impact of posttraumatic growth,transformational leadership,and self-efficacy on PTSD and depression symptom severity among combat Veterans

Previous research has established self-efficacy as essential to postdeployment adjustment among Veterans, and perceived transformational leadership is well known for its positive effects on follower outcomes across contexts. However, little is known regarding how transformational leadership may relate to posttraumatic growth and self-efficacy in fostering psychological wellbeing among combat Veterans. The purpose of this study was to examine the role of transformational leadership in predicting posttraumatic stress disorder (PTSD) and depression symptoms among combat Veterans, as well as how posttraumatic growth and postdeployment coping self-efficacy may influence these relations. The study sample consisted of 130 combat Veterans recruited from a university, Veterans Affairs medical center, and the greater community. Path analysis based on bootstrapped resampling revealed postdeployment coping self-efficacy and perceived transformational leadership as predictors of lower PTSD and depression symptom severity. In addition, mediation modeling revealed that postdeployment coping self-efficacy mediated the relation between transformational leadership and both PTSD and depression, while posttraumatic growth did not predict PTSD symptoms. These findings may aid in the prediction of PTSD and depression symptoms among Veterans, which may then influence pre-deployment leadership training among military personnel as well as clinical treatment protocols for Veterans.     

Responsivity to stress in chronic posttraumatic stress disorder due to childhood sexual abuse

The purpose of this study was to investigate psychological, cardiovascular, and neuroendocrine reactivity to standardized stress tests (orthostatic challenge, Stroop Color Word Test) in drug-free adult women with chronic PTSD due to repetitive childhood sexual abuse. At baseline, the 11 patients showed significantly higher mean scores on the Symptom Check List-90 and the Profile of Mood States than 13 healthy female controls, whereas baseline cardiovascular or hormonal parameters showed no differences between the groups. Also, no significant differences were found between the two groups in cardiovascular and hormonal responsivity to the stress tests. Thus, in the presence of robust psychological differences, the patients with chronic PTSD due to childhood sexual abuse did not show alterations in baseline values of neurobiological parameters, nor did they react differently to a physical and mental stress test when compared to healthy controls.