Coping Strategies as Moderators of the Association Between Combat Exposure and Posttraumatic Stress Disorder Symptoms

The present research examined selected coping strategies as moderators of the relationship between combat exposure and posttraumatic stress disorder (PTSD) symptoms among service members who were deployed to Iraq (N = 2,023) and Afghanistan (N = 1,023). A three‐factor model of coping was confirmed for both military operations: positive emotion‐focused, self‐blame, and prayer/spirituality. Positive emotion‐focused coping was inversely associated with PTSD symptoms (r = −.14) and buffered service members from the negative effects of combat exposure in both Iraq (r ² = .01) and Afghanistan (r ² = .02). Self‐blame coping was positively associated with PTSD symptoms in both samples (Iraq, r = .36; Afghanistan, r = .29) but only magnified the relationship between combat exposure and PTSD symptoms among service members in Iraq (r ² = .01) . These findings were replicated when controlling for unit cohesion and symptoms of depression. Prayer/spirituality coping was not significantly associated with PTSD symptoms, regardless of combat exposure. Discussion focuses on how specific positive emotion‐focused coping strategies may be helpful for military personnel in combat operations given the uncontrollable and chaotic nature of the environment. Implications include providing training for deploying personnel that covers the use of these positive emotion‐focused coping strategies and the potential problems with self‐blame. Such training may also be suitable for other high‐risk occupations in which employees face uncontrollable situations.     

Negative Cognitions Prior to Trauma Predict Acute Posttraumatic Stress Disorder Symptomatology

Based on emotional processing theory, preexisting negative cognitions may contribute to the development of posttraumatic stress disorder (PTSD) symptoms. The present study prospectively examined the association between preexisting PTSD‐related cognitions and subsequent acute PTSD symptoms, and the potential mediators of this association. We also compared the effect of preexisting depressive cognitions and preexisting PTSD‐related cognitions on PTSD symptoms. In the current study, 810 Taiwanese undergraduates completed a baseline survey (T1), of which 73.1% (n = 592) participated in a second survey two months later (T2). Of those who completed both surveys, 97 experienced a trauma at least one week before T2; this group comprised the final sample. Hierarchical regression showed that preexisting PTSD‐related cognitions (β = .38, p < .001, sr² = .117), but not preexisting depressive cognitions (β = .11, p = .315, sr² = .011), were a significant and substantial predictor of acute PTSD symptoms after we controlled for established pretrauma risk factors (i.e., gender, prior trauma, and prior psychological problems). Multiple mediation analysis revealed that negative appraisal of symptoms (a₁b₁ = 0.90, 95% CI [0.16, 2.18], P_M = .251) and trauma‐related rumination (a₃b₃ = 1.23, 95% CI [0.23, 2.86], P_M = .341), but not trauma memory disorganization (a₂b₂ = 0.65, 95% CI [?0.17, 1.92], P_M = .182), significantly mediated between preexisting PTSD‐related cognitions and acute PTSD symptoms. Our findings highlight the role of preexisting negative cognitions in acute PTSD symptomatology. The development of PTSD symptoms is likely determined by the interaction of risk factors before and after trauma.     

The Cycle of Violence: Associations Between Exposure to Violence,Trauma‐Related Symptoms and Aggression—Findings from Congolese Refugees in Uganda

War‐related trauma exposure has been linked to aggression and enhanced levels of community and family violence, suggesting a cycle of violence. Reactive aggression—an aggressive reaction to a perceived threat—has been associated with posttraumatic stress disorder (PTSD). In contrast, appetitive aggression—a hedonic, intrinsically motivated form of aggression—seems to be negatively related to PTSD in offender and military populations. This study examined the associations between exposure to violence, trauma‐related symptoms and aggression in a civilian population. In semistructured interviews, 290 Congolese refugees were questioned about trauma exposure, PTSD symptoms, and aggression. War‐related trauma exposure correlated positively with exposure to family and community violence in the past month (r = .31, p < .001), and appetitive (r = .18, p = .002) and reactive aggression (r = .29, p < .001). The relationship between war‐related trauma exposure and reactive aggressive behavior was mediated by PTSD symptoms and appetitive aggression. In a multiple sequential regression analysis, trauma exposure (β = .43, p < .001) and reactive aggression (β = .36, p < .001) were positively associated with PTSD symptoms, whereas appetitive aggression was negatively associated (β = ?.13, p = .007) with PTSD symptoms. Our findings were congruent with the cycle of violence hypothesis and indicate a differential relation between distinct subtypes of aggression and PTSD.     

Self‐Compassion as a Prospective Predictor of PTSD Symptom Severity Among Trauma‐Exposed U.S. Iraq and Afghanistan War Veterans

U.S. combat veterans of the Iraq and Afghanistan wars have elevated rates of posttraumatic stress disorder (PTSD) compared to the general population. Self‐compassion, characterized by self‐kindness, a sense of common humanity when faced with suffering, and mindful awareness of suffering, is a potentially modifiable factor implicated in the development and maintenance of PTSD. We examined the concurrent and prospective relationship between self‐compassion and PTSD symptom severity after accounting for level of combat exposure and baseline PTSD severity in 115 Iraq and Afghanistan war veterans exposed to 1 or more traumatic events during deployment. PTSD symptoms were assessed using the Clinician Administered PTSD Scale for DSM‐IV (CAPS‐IV) at baseline and 12 months (n =101). Self‐compassion and combat exposure were assessed at baseline via self‐report. Self‐compassion was associated with baseline PTSD symptoms after accounting for combat exposure (β = ?.59; p < .001; ΔR² = .34; f² = .67; large effect) and predicted 12‐month PTSD symptom severity after accounting for combat exposure and baseline PTSD severity (β = ?.24; p = .008; ΔR² = .03; f² = .08; small effect). Findings suggest that interventions that increase self‐compassion may be beneficial for treating chronic PTSD symptoms among some Iraq and Afghanistan war veterans.     

Protective Factors,Coping Appraisals,and Social Barriers Predict Mental Health Following Community Violence: A Prospective Test of Social Cognitive Theory

This study tested social cognitive theory of posttraumatic adaptation in the context of mass violence, hypothesizing that pre‐event protective factors (general self‐efficacy and perceived social support) would reduce posttraumatic stress symptoms (PTSS) and depression severity through boosting post‐event coping self‐efficacy appraisals (mediator). We qualified hypotheses by predicting that post‐event social support barriers would disrupt (moderate) the health‐promoting indirect effects of pre‐event protective factors. With a prospective longitudinal sample, we employed path models with bootstrapping resampling to test hypotheses. Participants included 70 university students (71.4% female; 40.0% White; 34.3% Asian; 14.3% Hispanic) enrolled during a mass violence event who completed surveys one year pre‐event and 5–6 months post‐event. Results revealed significant large effects in predicting coping self‐efficacy (mastery model, R ²= .34; enabling model, R ²= .36), PTSS (mastery model, R ²= .35; enabling model, R ²= .41), and depression severity (mastery model, R ²= .43; enabling model, R ²= .46). Overall findings supported study hypotheses, showing that at low levels of post‐event social support barriers, pre‐event protective factors reduced distress severity through boosting coping self‐efficacy. However, as post‐event social support barriers increased, the indirect, distress‐reducing effects of pre‐event protective factors were reduced to nonsignificance. Study implications focus on preventative and responsive intervention.     

Equine‐Assisted Therapy for Anxiety and Posttraumatic Stress Symptoms

We tested the efficacy of the Equine Partnering Naturally^© approach to equine‐assisted therapy for treating anxiety and posttraumatic stress disorder (PTSD) symptoms. Participants were 16 volunteers who had experienced a Criterion A traumatic event, such as a rape or serious accident, and had current PTSD symptoms above 31 on the PTSD Checklist (PCL‐S; Weathers, Litz, Herman, Huska, & Keane, 1993). Participants engaged in tasks with horses for 6 weekly 2‐hour sessions. Immediately following the final session, participants reported significantly reduced posttraumatic stress symptoms, d = 1.21, less severe emotional responses to trauma, d = 0.60, less generalized anxiety, d = 1.01, and fewer symptoms of depression, d = 0.54. As well, participants significantly increased mindfulness strategies, d = 1.28, and decreased alcohol use, d = 0.58. There was no significant effect of the treatment on physical health, proactive coping, self‐efficacy, social support, or life satisfaction. Thus, we found evidence that the Equine Partnering Naturally^© approach to equine‐assisted therapy may be an effective treatment for anxiety and posttraumatic stress symptoms. Future research should include larger groups, random assignment, and longer term follow‐up.     

Sexual Violence Therapy Group in a Women's Correctional Facility: A Preliminary Evaluation

This pilot study was an evaluation of an 8‐week exposure‐based therapy group targeting sexual trauma in incarcerated women, an underserved population with high rates of trauma exposure. Preliminary findings from 14 female prisoners showed significant decreases in depressive and anxiety symptoms from pre‐ to posttreatment. Of the women who were above the screening cutoff for possible posttraumatic stress disorder (PTSD; n = 13), depression (n = 12), and generalized anxiety disorder (GAD; n = 12) at pretreatment, approximately 60% had recovered, meaning they had symptom reductions that placed them below the cutoff at posttreatment (n = 8 for PTSD; n = 8 for depression, and n = 9 for GAD). In addition, 85% of participants reported a clinically significant reduction in depressive symptoms and 50% in GAD symptoms. The findings show promise for successful group treatment of sexual violence sequelae in incarcerated women.     

The Bidirectional Dyadic Association Between Tendency to Forgive,Self‐Esteem,Social Support,and PTSD Symptoms Among Terror‐Attack Survivors and Their Spouses

This study examined the dyadic association of terror attack survivors’ and spouses’ internal resources, tendency to forgive (self, others, and situational forgiveness), self‐esteem, and the external resource of social support, as associated with victims’ and spouses’ posttraumatic stress disorder (PTSD) symptoms, using the actor–partner interdependence model. Based on lists by the One Family organization in Israel, 108 couples participated in the study. The study results demonstrate that in the dyad relationship, survivors’ tendency to forgive others and social support relate both to survivors’ decreased levels of PTSD symptom severity (β = ?.20, p = .021; β = ?.55 p < .001) and spouses’ decreased levels of PTSD symptom severity (β = ?.21, p = .015; β = ?.27, p = . 004), whereas spouses’ self‐esteem relates to both spouses’ and survivors’ decreased levels of PTSD symptom severity (β = ?.57, p < .001; β = ?.14, p = .041). The findings underscore the role of the survivor–spouse unit by highlighting the dyad relationship of internal and external resources as associated with both survivors’ and spouses’ PTSD symptoms. Theoretical and clinical implications of the findings are discussed.     

Associations Between Trauma‐Related Rumination and Symptoms of Posttraumatic Stress and Depression in Treatment‐Seeking Female Veterans

Trauma‐related rumination is a cognitive style characterized by repetitive negative thinking about the causes, consequences, and implications of a traumatic experience. Frequent trauma‐related rumination has been linked to posttraumatic stress disorder (PTSD) and depression in civilian samples but has yet to be examined among military veterans. This study extended previous research by examining trauma‐related rumination in female veterans who presented to a Veterans Affairs women's trauma recovery clinic (N = 91). The study had two main aims: (a) to examine associations between trauma‐related rumination and specific PTSD symptoms, adjusting for the overlap between trauma‐related rumination and other relevant cognitive factors, such as intrusive trauma memories and self‐blame cognitions; and (b) to assess associations between trauma‐related rumination, PTSD, and depression, adjusting for symptom comorbidity. At intake, patients completed a semistructured interview and self‐report questionnaires. Primary diagnoses were confirmed via medical record review. Trauma‐related rumination was common, with more than 80% of patients reporting at least sometimes engaging in this cognitive style in the past week. After adjusting for other relevant cognitive factors, trauma‐related rumination was significantly associated with several specific PTSD symptoms, r_ps = .33–.48. Additionally, the severity of trauma‐related rumination was associated with overall PTSD symptom severity, even after adjusting for comorbid depression symptoms, r_p² = .35. In contrast, the association between trauma‐related rumination and depressive symptom severity was not significant after adjusting for comorbid PTSD symptoms, r_p² = .008. These results highlight trauma‐related rumination as a unique contributing factor to the complex clinical presentation for a subset of trauma‐exposed veterans.     

A Test of Adolescent Internalizing and Externalizing Symptoms as Prospective Predictors of Type of Trauma Exposure and Posttraumatic Stress Disorder

The present study utilized longitudinal data from a high‐risk community sample (N = 377; 166 trauma‐exposed; 202 males; 175 females; 73% non‐Hispanic Caucasian) to test pretrauma measures of adolescent internalizing and externalizing symptoms as unique prospective predictors of type of trauma exposure and PTSD over and above the influence of correlated family adversity (a composite of family conflict, stress, and parental psychopathology). Data were analyzed with logistic and multinomial logistic regressions. Results indicated that females, but not males, with higher levels of internalizing (OR = 2.91) and externalizing (OR = 2.37) symptoms during adolescence were significantly more likely to be exposed to assaultive violence (over and above family adversity). In fact, males with higher levels of internalizing symptoms were significantly less likely to be exposed to assaultive violence (OR = 0.54). Neither internalizing nor externalizing symptoms uniquely predicted exposure to traumatic events that did not involve assaultive violence. Among trauma‐exposed participants, the unique association between internalizing symptoms and later PTSD yielded an odds ratio of 1.79 (p = .07) over and above the influences of family adversity, type of trauma exposure, and gender. Assaultive violence exposure fully mediated the association between females’ externalizing symptoms and future PTSD. Findings may help inform the prevention of both assaultive violence exposure and PTSD.     

Changes in Coping and Negative Cognitions as Mechanisms of Change in Online Treatment for Rape‐Related Posttraumatic Stress Disorder

Cognitive behavioral therapy (CBT)–based interventions, including those administered via telepsychology, represent efficacious posttraumatic stress disorder (PTSD) treatments. Despite demonstrated efficacy, limited research has examined mechanisms of change for CBT. We examined trauma‐related cognitions and coping as treatment mechanisms among 46 women who completed a randomized clinical trial of a CBT‐based, telepsychology‐delivered interactive program for rape survivors. The results indicated that both the interactive program, d = 1.5, and the active control condition, a psychoeducational website, d = 1.4, resulted in large reductions in posttest PTSD symptoms. Analysis of residual gain scores showed that reductions in the three types of assessed trauma‐related cognitions were strongly related to reductions in PTSD symptoms among women assigned to the interactive program, rs = .60–.79, but only weakly related to symptom reduction among those assigned to active control, rs = .06–.31. The results also suggest that increases in trauma‐related approach coping were weakly related to reductions in PTSD symptoms among participants in the interactive program, rs = ?.16 and ?.17, but, conversely, decreases in trauma‐related approach coping were weakly related to reductions in PTSD symptoms among those in the active control group, rs = .07 and .28. Reductions in avoidance coping were modestly related to reductions in PTSD symptoms among women in the interactive program, rs = .38 and .38, but unrelated to changes in PTSD symptoms among those assigned to the active control, rs = .03 and .05. Implications for future work examining mechanisms of change for PTSD treatments are discussed.     

Traumatic Event Exposure,Posttraumatic Stress Disorder,and Sleep Disturbances in a National Sample of U.S. Adults

Posttraumatic stress disorder (PTSD) is a highly prevalent, debilitating disorder found to develop after exposure to a potentially traumatic event (PTE). Individuals with PTSD often report sleep disturbances, specifically nightmares and insomnia, which are listed within the criteria for PTSD. This research examined prevalence of insomnia and nightmares within a national sample of 2,647 adults (data weighted by age and sex to correct for differences in sample distribution) who had been exposed to one or more PTEs. Prevalence of self‐reported sleep disturbance, sleep disturbances by PTE type, and gender differences were examined. All participants completed a self‐administered, structured online interview that assessed exposure to stressful events and PTSD symptoms. Among individuals who met DSM‐5 criteria for PTSD, a large majority (more than 92%) reported at least one sleep disturbance. Insomnia was relatively more prevalent than PTE‐related nightmares among individuals with PTSD and among all PTE‐exposed individuals. A higher number of PTEs experienced significantly increased the likelihood of both trauma‐related nightmares and insomnia, McFadden's pseudo R² = .07, p < .001. Women exposed to PTEs were more likely to endorse experience of insomnia, χ²(1, N = 2,647) = 99.13, p < .001, φ = .194, and nightmares compared to men, χ²(1, N = 2,648) = 82.98, p < .001, φ = .177, but this gender difference was not significant among individuals with PTSD, ps = .130 and .050, respectively. Differences in sleep disturbance prevalence by PTE type were also examined. Implications for treatment and intervention and future directions are discussed.     

Rumination Moderates the Associations Between PTSD and Depressive Symptoms and Risky Behaviors in U. S. Veterans

Risky behaviors, including unsafe sex, aggression, rule breaking, self‐injury, and dangerous substance use have become a growing issue for U.S. veterans returning from combat deployments. Evidence in nonveteran samples suggests that risky behaviors reflect efforts to cope with and alleviate depressive and/or anxious symptoms, particularly for individuals with poor emotion‐regulation skills. These associations have not been studied in veterans. Rumination, or repeated thoughts about negative feelings and past events, is a coping strategy that is associated with several psychopathologies common in veterans. In this cross‐sectional study, 91 recently returned veterans completed measures of trait rumination, self‐reported risky behaviors, and symptoms of posttraumatic stress disorder (PTSD) and depression. Analyses revealed that veterans with more depressive and PTSD symptoms reported more risky behaviors. Moreover, rumination significantly interacted with PTSD symptoms and depressive symptoms (both β = .21, p < .05), such that psychiatric symptoms were associated with risky behaviors only for veterans with moderate to high levels of rumination. Although cross‐sectional, these findings support theory that individuals with poor coping skills may be particularly likely to respond to negative mood states by engaging in risky behaviors. Implications include using rumination‐focused interventions with veterans in order to prevent engagement in risky behaviors.     

Mindfulness,Self‐Compassion,Posttraumatic Stress Disorder Symptoms,and Functional Disability in U.S. Iraq and Afghanistan War Veterans

Mindfulness and self‐compassion are overlapping, but distinct constructs that characterize how people relate to emotional distress. Both are associated with posttraumatic stress disorder (PTSD) and may be related to functional disability. Although self‐compassion includes mindful awareness of emotional distress, it is a broader construct that also includes being kind and supportive to oneself and viewing suffering as part of the shared human experience—a potentially powerful way of dealing with distressing situations. We examined the association of mindfulness and self‐compassion with PTSD symptom severity and functional disability in 115 trauma‐exposed U.S. Iraq/Afghanistan war veterans. Mindfulness and self‐compassion were each uniquely, negatively associated with PTSD symptom severity. After accounting for mindfulness, self‐compassion accounted for unique variance in PTSD symptom severity (f² = .25; medium ES). After accounting for PTSD symptom severity, mindfulness and self‐compassion were each uniquely negatively associated with functional disability. The combined association of mindfulness and self‐compassion with disability over and above PTSD was large (f² = .41). After accounting for mindfulness, self‐compassion accounted for unique variance in disability (f² = .13; small ES). These findings suggest that interventions aimed at increasing mindfulness and self‐compassion could potentially decrease functional disability in returning veterans with PTSD symptoms.     

The Strongest Correlates of PTSD for Firefighters: Number,Recency, Frequency,or Perceived Threat of Traumatic Events?

Firefighters experience a wide range of traumatic events while on duty and are at risk to develop psychopathology and posttraumatic stress disorder (PTSD). According to cognitive models, the person's interpretation of the traumatic event is responsible for the development of PTSD rather than the traumatic event itself. This cross‐sectional study aimed to explore the contribution of perceived threat to explain PTSD symptoms in Portuguese firefighters, after adjusting for potential confounding factors. A sample of 397 firefighters completed self‐report measures of exposure to traumatic events, psychopathology, and PTSD. Perceived threat explained unique variance in PTSD symptoms, R² = .40, ΔR² = .02, F(10, 367) = 24.55, p < .001, Cohen's f² =.03, after adjusting for psychopathology, number, recency, and frequency of the events, and other potential confounding variables. The association between psychopathology and PTSD was also moderated by perceived threat, R² = .43, ΔR² = .03, F(11, 366) = 25.33, p < .001, Cohen's f² =.05. Firefighters may benefit from interventions that focus on perceived threat to prevent PTSD symptoms.     

Does Perpetrating Violence Damage Mental Health? Differences Between Forcibly Recruited and Voluntary Combatants in DR Congo

As a consequence of the ongoing conflict in the Democratic Republic of the Congo (DRC), combatants are constantly involved in various forms of violence. Findings concerning the impact of perpetrating violence on mental health are contradictory, ranging from increasing to buffering the risk for mental ill health. The present study investigated the impact of perpetrating violence on mental health. In total, 204 forcibly recruited and voluntary male combatants (mean age = 24.61 years) from different armed groups in the eastern DRC took part in the study. In a semistructured interview, respondents were questioned about appetitive aggression and posttraumatic stress disorder (PTSD) as well as self‐experienced violence and self‐perpetrated violent offending. A multivariate analysis of variance (η² = .23) revealed that voluntary combatants perpetrated more violent acts (η² = .06) and showed higher appetitive aggression η² = .03). A moderated multiple regression analysis (R² = .20) showed that perpetrating violence was positively related to PTSD in forcibly recruited combatants, but not in voluntary combatants. Thus, perpetrating violence may not necessarily qualify as a traumatic stressor. Further studies might consider assessing the combatant's perception of committing violent acts.     

The Ending Self‐Stigma for Posttraumatic Stress Disorder (ESS‐P) Program: Results of a Pilot Randomized Trial

Experiences of and concerns about encountering stigma are common among veterans with posttraumatic stress disorder (PTSD). One common and serious consequence is self‐stigma, which is when an individual comes to believe that common negative stereotypes and assumptions about PTSD are true of oneself. The current study was a pilot randomized trial that evaluated the feasibility, acceptability, and preliminary outcomes of the Ending Self‐Stigma for PTSD (ESS‐P) program, a nine‐session group intervention that aims to assist veterans with PTSD learn tools and strategies to address stigma and self‐stigma. Veterans (N = 57) with a diagnosis of PTSD who were receiving treatment in U.S. Veterans Health Administration outpatient mental health programs were recruited. Participants were randomized to either ESS‐P or minimally enhanced treatment as usual and assessed at baseline and after treatment on clinical symptoms, self‐stigma, self‐efficacy, recovery, and sense of belonging. Information on mental health treatment utilization for the 3 months before and after group treatment was also collected. Compared to controls, there was a significant decrease in self‐stigma, d = ?0.77, and symptoms of depression, d = ?0.76, along with significant increases in general and social self‐efficacy, ds = 0.73 and 0.60, respectively, and psychological experience of belonging, d = 0.46, among ESS‐P participants. There were no differences regarding recovery status or changes in treatment utilization. The results of the pilot study suggest that participation in ESS‐P may help reduce self‐stigma and improve self‐efficacy and a sense of belonging in veterans with PTSD.     

Exposure to Violence During Ferguson Protests: Mental Health Effects for Law Enforcement and Community Members

There is little information available on the mental health effects of exposure to shared community violence such as the August 2014 violence that occurred in Ferguson, Missouri. This study sought to examine the relationship between proximity to community violence and mental health in both community members and police officers. We recruited 565 adults (community, n = 304, and police, n = 261) exposed to the violence in Ferguson to complete measures of proximity to violence, posttraumatic stress, depression, and anger. Using structural equation modeling, we assessed aspects of proximity to violence—connectedness, direct exposure, fear from exposure, media exposure, reactions to media, and life interruption—as correlates of posttraumatic stress disorder (PTSD) symptoms, depression, and anger. The final model yielded (n = 432), χ²(d = 12) = 7.4, p = .830; comparative fit index = 1.0, root mean square error of approximation = 0 [0, .04]. All aspects of proximity except direct exposure were associated with mental health outcomes. There was no moderation as a function of community versus police. Race moderated the relationship between life interruptions and negative outcomes; interruption was related to distress for White, but not Black community members. Based on group comparisons, community members reported more symptoms of PTSD and depression than law enforcement (η_p² = .06 and .02, respectively). Black community members reported more PTSD and depression than White community members (η_p² = .05 and .02, respectively). Overall, distress was high, and mental health interventions are likely indicated for some individuals exposed to the Ferguson events.