Cognitive-behavioral coping strategies associated with combat-related PTSD in treatment-seeking OEF–OIF Veterans

Psychiatry Research 189 (2011) 251–258

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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Cognitive-behavioral coping strategies associated with combat-related PTSD in treatment-seeking OEF–OIF Veterans Robert H. Pietrzak ⁎, Ilan Harpaz-Rotem, Steven M. Southwick National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA

a r t i c l e

i n f o

Article history: Received 1 February 2011 Received in revised form 17 June 2011 Accepted 7 July 2011 Keywords: Veterans Combat Posttraumatic stress disorder Thought control Coping Avoidance

a b s t r a c t Posttraumatic stress disorder (PTSD) is associated with intrusive trauma-related thoughts and avoidance behaviors that contribute to its severity and chronicity. This study examined thought control and avoidance coping strategies associated with both a probable diagnosis and symptom severity of combat-related PTSD in a sample of 167 treatment-seeking Operations Enduring Freedom and Iraqi Freedom (OEF–OIF) Veterans. Within one year of returning from deployment, Veterans completed a survey containing measures of combat exposure, coping strategies, psychopathology, and postdeployment social support. Veterans with a positive screen for PTSD scored higher than Veterans without a positive screen for PTSD on measures of worry, selfpunishment, social control, behavioral distraction, and avoidance coping strategies. Worry and social avoidance coping were positively related to PTSD symptoms, and greater perceptions of understanding from others were negatively related to these symptoms. A structural equation model revealed that scores on a measure of postdeployment social support were negatively associated with scores on measures of maladaptive cognitive coping (i.e., worry, self-punishment) and avoidance coping (social and non-social avoidance coping) strategies, which were positively associated with combat-related PTSD symptoms. These results suggest that maladaptive thought control and avoidance coping may partially mediate the relation between postdeployment social support and combat-related PTSD symptoms in treatment-seeking OEF–OIF Veterans. Consistent with cognitive therapy models, these findings suggest that interventions that target maladaptive coping strategies such as worry, self-punishment, and social avoidance, and that bolster social support, most notably understanding from others, may help reduce combat-related PTSD symptoms in this population. Published by Elsevier Ireland Ltd.

1. Introduction Posttraumatic stress disorder (PTSD) is one of the most prevalent psychiatric disorders in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF–OIF), with approximately 1 in 6 Veterans meeting screening criteria for this condition (Tanielian and Jaycox, 2008; Thomas et al., 2010). PTSD is associated with intrusive, trauma-related thoughts (Litz and Keane, 1989; Resick and Schnicke, 1992) and avoidance behaviors (Marx and Sloan, 2005; Morina, 2007; Solomon and Mikulincer, 2007), which contribute to the severity and chronicity of this disorder. Cognitive theories of posttraumatic stress disorder (PTSD) have highlighted the importance of identifying dysfunctional cognitions

⁎ Corresponding author at: National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue/151E, West Haven, CT 06516, USA. Tel.: + 1 860 638 7467; fax: + 1 203 937 3481. E-mail address: [email protected] (R.H. Pietrzak). 0165-1781/$ – see front matter. Published by Elsevier Ireland Ltd. doi:10.1016/j.psychres.2011.07.019

that contribute to the persistence of this disorder (Litz and Keane, 1989; Resick and Schnicke, 1992). Repeated avoidance of intrusive thoughts and feelings may prevent habituation to and extinction of fear-related stimuli, and impede modification of threat-based beliefs (Litz and Keane, 1989). Adjustment to trauma is challenging, as thoughts, physiological arousal mechanisms, and attentional processes are oriented to planning for future threats (Wells, 2000). Accordingly, cognitive coping processes are often characterized by excessive worry and self-punishment (Warda and Bryant, 1998; Reynolds and Wells, 1999; Koss et al., 2002). For example, the belief that worrying about a threat will enhance one's ability to avoid harm may cause hypersensitivity to potential threats, which is associated with increased severity of PTSD symptoms (Litz and Keane, 1989; Resick and Schnicke, 1992), and may contribute to the maintenance of this disorder (Schell et al., 2004; Marshall et al., 2006; Solomon et al., 2009). Management of these thoughts requires flexibility in cognitive coping strategies (e.g., reappraisal, solicitation of social resources), which is a major focus of cognitive-behavioral interventions for PTSD (Monson et al., 2006; Rizvi et al., 2009; Sobel et al., 2009; Chard et al., 2010).

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Wells and Davies (1994) identified six common thought control strategies that individuals may use to manage unpleasant thoughts that arise in response to negative life events. These include strategies such as worry (e.g., dwelling on the negative thought), self-punishment (e.g., feeling angry at oneself for thinking about a negative event), reappraisal (e.g., assessing the meaning of the thought), cognitive distraction (e.g., redirecting attention to another thought), behavioral distraction (e.g., engaging in another behavior), and social control (e.g., disclosing the thought to someone). Thought control strategies have been examined in individuals with PTSD (Roussis and Wells, 2008; Bennett et al., 2009; Scarpa et al., 2009), as well as acute stress disorder (Warda and Bryant, 1998; Guthrie and Bryant, 2000), generalized anxiety disorder (Barahmand, 2009), major depression (Reynolds and Wells, 1999; Barahmand, 2009), obsessive–compulsive disorder (Amir et al., 1997; Rassin and Diepstraten, 2003; Barahmand, 2009; Belloch et al., 2009), schizophrenia (Morrison and Wells, 2000), and borderline personality disorder (Rosenthal et al., 2006). Results of these studies suggest that worry and self-punishment strategies are commonly employed in all of these clinical groups. They further suggest that these strategies may mediate the association between PTSD symptoms and dysfunctional cognitions, thereby contributing to the persistence of these symptoms (Bennett et al., 2009). Avoidance coping responses have been conceptualized as cognitive or behavioral in nature, and consisting of approach or avoidance responses (Moos and Schaefer, 1993). Cognitive avoidance coping consists of denying, minimizing, or trying not to think about a stressful situation and its consequences. Behavioral avoidance coping consists of social withdrawal, escape, and avoidance of stressful activities. A large body of research has found that avoidance symptoms are associated with increased severity and chronicity of PTSD (Benotsch et al., 2000; Orcutt et al., 2004; Marx and Sloan, 2005; Morina, 2007; Solomon and Mikulincer, 2007; Solomon et al., 2009), as well as increased psychosocial difficulties and decreased social support (Pietrzak et al., 2010b). For example, studies of Gulf War Veterans (Benotsch et al., 2000) and treatment-seeking Veterans (Tiet et al., 2006) have found that greater avoidance symptoms at an initial evaluation predicted increased severity of PTSD symptoms 10– 13 months later. While it is known that avoidance may contribute to the chronicity of PTSD and related difficulties, little research has examined specific avoidance strategies that may be related to this disorder. For example, avoidance strategies may be cognitive social (e.g., failing to discuss or address tension that builds in a friendship); cognitive nonsocial (e.g., failing to sit down and think about one's future); behavioral social (e.g., making up excuses to get out of social activities); or behavioral nonsocial (e.g., sitting at home and watching TV instead of going out and doing things) in nature. Characterization of specific avoidance strategies associated with combat-related PTSD in treatment-seeking OEF–OIF Veterans will provide a more detailed understanding of maladaptive thoughts and behaviors associated with PTSD in this population, which may help identify potential targets for psychotherapeutic intervention. Meta-analyses of risk factors for posttraumatic stress disorder (PTSD) have suggested that low social support following a traumatic event is one of the strongest predictors of PTSD (Brewin et al., 2000; Ozer et al., 2003). For example, a study of a national sample of 1632 Vietnam Veterans found that greater perceived postwar functional social support and hardiness were the most important mediators of risk for PTSD compared to other variables such as war zone stressors, stressful life events, and structural social support (King et al., 1998). Greater levels of perceived social support have also been associated with reduced risk for PTSD in other trauma-exposed populations (Engdahl et al., 1997; Kaspersen et al., 2003; Ahern et al., 2004). Studies of OEF–OIF Veterans have found that greater postdeployment social support is negatively associated with PTSD and depressive symptoms, as well as suicidal ideation and psychosocial difficulties

(Pietrzak et al., 2009, 2010a,c). In contrast, low levels of social support have been found to be associated with increased avoidant thoughts and behaviors, which may increase risk for PTSD in trauma survivors (Solomon et al., 1988; Benotsch et al., 2000; North et al., 2001; Silver et al., 2002). A possible mechanism by which social support may be protective is that individuals with greater levels of support may be less likely to engage in avoidance coping (i.e., worry, behavioral withdrawal, emotional disengagement), which may reduce the likelihood of developing PTSD (Irwin, 1996; Runtz and Schallow, 1997; Charuvastra and Cloitre, 2008). However, few studies have examined specific avoidance coping strategies (e.g., worry, selfpunishment, cognitive and behavioral avoidance) that may mediate the relation between social support and PTSD symptoms, and no study of which we are aware has examined them in treatment-seeking OEF– OIF Veterans. The purpose of the present study was to provide a detailed examination of thought control and avoidance coping strategies associated with both a probable diagnosis and symptom severity of combat-related PTSD in a sample of treatment-seeking OEF–OIF Veterans. Based on previous research (Irwin, 1996; Runtz and Schallow, 1997; Marx and Sloan, 2005; Morina, 2007; Solomon and Mikulincer, 2007; Charuvastra and Cloitre, 2008; Bennett et al., 2009; Scarpa et al., 2009), we hypothesized that thought control strategies of worry and punishment, and greater use of avoidant coping strategies, particularly social avoidance strategies, would be associated with both a probable diagnosis and increased severity of PTSD symptoms, even after adjustment for combat exposure, comorbid depression and alcohol use problems, and level of postdeployment social support. We further expected that greater perceptions of emotional support (e.g., understanding from others) would be negatively related to these outcomes. Finally, we hypothesized that maladaptive thought control strategies (e.g., worry, self-punishment) and avoidance coping strategies (e.g., social and nonsocial cognitive and behavioral avoidance) would mediate the relation between postdeployment social support and combat-related PTSD symptoms. 2. Methods 2.1. Participants Participants were 167 OEF–OIF Veterans recruited from mental health (N = 102; 61.1%) or primary care (N = 65; 38.9%) clinics at VA Connecticut Healthcare System in West Haven, CT, USA. Veterans recruited from mental health clinics were slightly younger than those recruited from primary care clinics (28.4 ± 0.6 vs. 30.9 ± 1.0 years; t(164) = 2.05, P = 0.042), but did not differ with respect to any other demographic or psychosocial variables (all t's b 1.83; all p's N 0.07). Thus, these groups were combined for analyses. All Veterans were within a year of returning from their only or most recent deployment. The participation rate was high, with more than 80% of those who were approached agreeing to participate in the survey. Participants were not compensated for their participation. Institutional review boards of VA Connecticut Healthcare System and Yale University approved this study. All participants provided written informed consent. 2.2. Assessments The Thought Control Questionnaire (TCQ; Wells and Davies, 1994) is a 30-item selfreport measure that assesses the frequency of use of six thought control strategies: worry (“When I experience an unpleasant/unwanted thought, I dwell on other worries”; α in current sample = 0.80); self-punishment (“When I experience an unpleasant/unwanted thought, I get angry at myself for having the thought”; α = 0.76); reappraisal (“When I experience an unpleasant/unwanted thought, I try a different way of thinking about it”; α = 0.79); behavioral distraction (“When I experience an unpleasant/unwanted thought, I occupy myself with work instead”; α = 0.67); cognitive distraction (“When I experience an unpleasant/unwanted thought, I call to mind positive images instead”; α = 0.62); and social control (“When I experience an unpleasant/unwanted thought, I find out how my friends deal with these thoughts”; α = 0.60). Items are rated on a 4-point Likert scale, from “1” (“Never”) to “4” (“Almost always”). The Cognitive-Behavioral Avoidance Scale (CBAS; Ottenbreit and Dobson, 2004) is a 31-item self-report instrument that assesses avoidance strategies. CBAS items are rated on a 5-point Likert scale ranging from “Not at all true for me” to “Extremely true for me.” Four subscales, which reflect different avoidance strategies, are derived:

R.H. Pietrzak et al. / Psychiatry Research 189 (2011) 251–258 cognitive social (sample item: “I fail to discuss/address tension that builds in a friendship;” Cronbach's α = 0.88); cognitive nonsocial (sample item: “When uncertain about my future, I fail to sit down and think about what I really want;” Cronbach's α = 0.92); behavioral social (sample item: “I tend to make up excuses to get out of social activities;” Cronbach's α = 0.93); and behavioral nonsocial (sample item: “Rather than getting out and doing things, I just sit at home and watch TV;” Cronbach's α = 0.86). The Combat Experiences Scale (CES) is a 15-item self-report instrument from the Deployment Risk and Resilience Inventory (DRRI; King et al., 2006; Vogt et al., 2008). It assesses exposure to combat, such as firing a weapon, being fired on by enemy or friendly fire, and witnessing injury and death. Higher scores represent greater combat exposure. A previous validation study in OIF veterans found that CES scores correlated positively with measures of PTSD and depression symptoms, and negatively with mental health functioning (Vogt et al., 2008). Cronbach's α on CES items was 0.81. Posttraumatic Stress Disorder Checklist-Military Version (PCL-M; Weathers et al., 1993). The PCL-M is a 17-item screening instrument based on DSM-IV criteria for PTSD. It was developed by the National Center for PTSD and contains items relevant to stressful military experiences. Scores range from 17 to 85. Probable PTSD was identified by a total PCL-M score ≥ 50 and endorsement of “moderate,” “quite a bit,” or “extreme” degree of symptoms that comprise each of three DSM-IV criteria required for a diagnosis of PTSD (cluster B: intrusive; cluster C: avoidance/numbing; and cluster D: hyperarousal). Cronbach's α on PCL-M items was 0.96. The Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) is a 9-item selfreport depression screening instrument derived from the clinician-administered Primary Care Evaluation of Mental Disorders. Higher scores indicate greater depressive symptoms, with scores ≥10 indicative of a positive screen for depression. Cronbach's α on PHQ-9 items was 0.92. The CAGE Questionnaire (Ewing, 1984) is a 4-item instrument used to identify individuals with a possible alcohol problem. Despite its brevity, it has been shown to have good validity in screening large populations. A score of 2 or higher is indicative of a possible alcohol problem. In this sample, Cronbach's α on CAGE items was 0.70. The Postdeployment Social Support Scale (PSSS) is a 15-item self-report measure from the DRRI that assesses postdeployment emotional support and instrumental assistance provided by family, friends, coworkers, employers, and community. As reported elsewhere (Pietrzak et al., 2010d), factor analysis in the current sample revealed a 4-factor solution: (1) Instrumental support (example item: “My friends or relatives would lend me money if I needed it”); (2) Community support (example item: “The American people made me feel at home when I returned”); (3) Accessibility of family and friends (example item: “I have people I can talk to about my deployment”); and (4) Understanding from others (example item, reverse scored: “People at home do not understand what I have been through”). Cronbach's α on PSSS items was 0.86. 2.3. Data analysis Shapiro–Wilk normality tests were conducted to examine distributions of all variables. Non-normally distributed variables were transformed using logarithmic base 10 transformations prior to analysis. Pearson correlations were then computed to examine associations between scores on all measures. To examine cognitive-behavioral coping strategies associated with a positive screen for combat-related PTSD, a multivariate analysis of covariance (MANCOVA) analysis was conducted. PTSD, depression, and alcohol use problem screening status (positive vs. negative) were entered as fixed factors, CES and PSSS scores as covariates, and TCQ and CBAS subscale scores as dependent variables. Depression and alcohol use problem screening status, and CES and PSSS scores were entered into this model in order to examine thought control and avoidance coping strategies associated specifically with combat-related PTSD. Magnitudes of differences in TCQ and CBAS scores by PTSD status were estimated

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using Cohen's d ([Meangroup1 − Meangroup2]/pooled standard deviation; (Cohen, 1988). To examine coping strategies associated with combat-related PTSD symptoms in the full sample, a hierarchical linear regression analysis was conducted. CES scores were entered in Step 1; scores on TCQ and CBAS subscales associated with PTSD symptoms at the p b 0.05 level in bivariate analyses were entered in Step 2; and scores on the PSSS were entered in Step 3. If total scores on an independent variable (e.g., PSSS scores) were significantly associated with PCL-M scores, post hoc linear regression analyses were conducted to examine associations between subscales of that measure and PCL-M scores; α was set to 0.01 for these analyses to reduce the likelihood of making a Type I error. A structural equation analysis using maximum likelihood estimation was conducted to examine whether maladaptive thought control (e.g., worry, selfpunishment) and avoidance coping strategies mediated the relation between perceived social support and PTSD symptoms. Three alternative models were also evaluated: (1) direct effects of postdeployment social support on maladaptive thought control, avoidance coping strategies, and combat-related PTSD symptoms; (2) direct effects of combat-related PTSD symptoms on maladaptive thought control, avoidance coping strategies, and postdeployment social support; and (3) direct effects of maladaptive thought control and avoidance coping strategies on combat-related PTSD symptoms and postdeployment social support. Given the high magnitudes of bivariate correlations between worry and self-punishment (r = 0.50, P b 0.001), and among avoidance coping strategies (all r's N 0.70, all P's b 0.001), scores on measures of maladaptive thought control strategies and avoidance coping strategies that correlated with combat-related PTSD symptoms at the p b 0.05 level in bivariate analyses were modeled as latent factors (scores on the TCQ social control subscale were specified to load on the “maladaptive cognitive coping” latent factor, but because their loading was significantly lower than loadings for worry and self-punishment [β = 0.36 vs. β = 0.70 and 0.72, respectively], they were not included as part of this factor). Combat exposure was entered as a covariate in this model. Summary scores on the CES, PSSS, TCQ, CBAS, and PCL-M were entered into this analysis. Model fit was evaluated using several fit statistics: χ2, root-mean-square error of approximation (RMSEA), comparative fit index (CFI), Tucker–Lewis Index (TLI), and Akaike Information Criterion (AIC). By convention, lower χ2 and AIC values, RMSEA ≤ 0.08, and CFI and TLI ≥ 0.90 are indicative of good model fit (Kline, 2005).

3. Results Table 1 displays correlations between measures of combat exposure (CES), combat-related PTSD symptoms (PCL-M), and thought control (TCQ), avoidance coping (CBAS), and postdeployment social support (PSSS) scores. CES scores correlated positively with TCQ-self-punishment and CBAS-behavioral social avoidance scores. PCL-M scores correlated positively with TCQ worry, selfpunishment, social control, and all CBAS subscales; and negatively with PSSS scores. PHQ-9 scores correlated positively with TCQ worry, self-punishment, and all CBAS subscales; and negatively with cognitive distraction and PSSS scores. CAGE scores correlated positively with TCQ worry, self-punishment, and social control subscales; and all CBAS subscales. PSSS scores correlated negatively with TCQ-worry and self-punishment, and all CBAS-avoidance subscales; and positively with TCQ-cognitive distraction scores. The mean age of the full sample was 29.4 (standard error of the mean [SEM] = 0.6), 95.8% were male, 63.5% were white, 59.3%

Table 1 Mean scores and correlation matrix of all study variables.

1. Combat exposure 2. PTSD symptoms 3. Depressive symptoms 4. Alcohol abuse symptoms 5. Postdeployment support 6. Worry 7. Self-punishment 8. Reappraisal 9. Behavioral distraction 10. Cognitive distraction 11. Social control 12. Cognitive social 13. Cognitive non-social 14. Behavioral social 15. Behavioral non-social

Mean (SE) 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

8.4 (0.3) 52.1 (1.4) 10.5 (0.5) 1.3 (0.1) 52.0 (0.8) 10.4 (0.3) 9.6 (0.3) 10.4 (0.2) 4.9 (0.1) 10.8 (0.2) 13.0 (0.2) 16.3 (0.5) 21.3 (0.8) 19.3 (0.7) 13.4 (0.4)

0.73*** 0.24** − 0.61*** 0.49*** 0.48*** − 0.02 0.14 − 0.06 0.27** 0.68*** 0.61*** 0.65*** 0.56***

0.27** − 0.57*** 0.45*** 0.43*** − 0.04 − 0.04 − 0.18* 0.15 0.60*** 0.61*** 0.62*** 0.58***

− 0.11 0.49*** 0.48*** − 0.02 − 0.02 − 0.04 0.16* 0.27** 0.34*** 0.26** 0.27**

− 0.29*** − 0.31*** 0.10 − 0.04 0.28*** − 0.13 − 0.54*** − 0.48*** − 0.46*** − 0.49***

0.50*** 0.18* 0.10 0.01 0.23** 0.56*** 0.56*** 0.42*** 0.54***

0.23** 0.15* 0.05 0.31*** 0.43*** 0.43*** 0.44*** 0.37***

0.16* 0.41*** 0.23** − 0.06 − 0.02 0.05 − 0.07

0.33*** 0.32*** 0.00 0.00 0.08 − 0.01

0.18* − 0.16 − 0.15 − 0.09 − 0.16*

0.29*** 0.24** 0.85*** 0.26** 0.76*** 0.75*** 0.09 0.76*** 0.81*** 0.71***

0.29*** 0.22** 0.27** − 0.08 0.05 0.19* − 0.04 − .06 − 0.02 − 0.01 0.12 0.10 0.22** .11

Note. Statistically significant association, *P b 0.05; ** P b 0.01; ***P b 0.001. SE = standard error of the mean.

12.

13.

14.

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Table 2 Demographic, deployment, and psychosocial variables by PTSD screening status. No PTSD

PTSD

74

85

29.0 (0.8) 72 (97.3%)

29.8 (0.8) 86 (95.6%)

62 (74.7%) 12 (14.5%) 7 (8.4%) 2 (2.4%)

44 (56.4%) 20 (25.6%) 12 (15.4%) 2 (2.6%)

24 (28.6%) 53 (63.1%) 7 (8.3%)

25 (32.9%) 46 (60.5%) 5 (6.6%)

46 (54.1%) 28 (32.9%) 11 (12.9%)

42 (52.5%) 31 (38.8%) 7 (8.8%)

47 (55.3%) 38 (44.7%)

54 (66.7%) 27 (33.3%)

Deployment variables Service duty Active duty National Guard or Reserves Number of deployments Combat exposure score

49 (57.6%) 36 (42.4%) 1.5 (0.7) 7.6 (0.3)

52 (64.2%) 29 (35.8%) 1.7 (0.9) 9.3 (0.4)

Psychosocial variables Positive depression screen Positive alcohol use problem screen Postdeployment social support score

28 (32.9%) 30 (35.7%) 56.7 (1.0)

61 (76.2%) 38 (52.1%) 47.3 (9.2)

N Demographic variables Age Sex (% male) Race/ethnicity White Hispanic Black Other Education High school Some college/college graduate Graduate school Marital status Single Married/living with partner Divorced/separated Recruitment site Mental health clinic Primary care clinic

F or χ2

P

0.45 0.35 6.22

0.50 0.55 0.10

0.45

0.80

1.07

0.59

2.25

0.13

0.75

0.39

1.58 3.36

0.12 0.001

31.11 4.25 6.60

b 0.001 0.039 b 0.001

Note. Frequencies differ due to missing data.

completed at least some college education, and 60.5% were active duty. The mean number of deployments was 1.6 (SD = 0.8, range = 1 to 5). A total of 85 (50.9%) Veterans met screening criteria for probable PTSD, 89 (53.3%) for probable depression, and 68 (40.7%) for a probable alcohol use problem. Demographic, deployment, and psychosocial variables by PTSD screening status are shown in Table 2. None of the demographic variables differed between groups. Compared to respondents without PTSD, respondents with PTSD scored higher on the CES and lower on the PSSS; they were also more likely to screen positive for depression and an alcohol use problem. Table 3 shows results of a MANCOVA analysis that examined thought control and avoidance coping strategies by PTSD screening

status. After adjusting for depression and alcohol use problem screening status, as well as CES and PSSS scores, PTSD screening status emerged as a significant overall predictor of thought control and avoidance coping strategies (F(10,130) = 4.00, P b 0.001). Veterans with a positive screen for PTSD scored higher than Veterans without a positive screen for PTSD on the worry, self-punishment, social control, and behavioral distraction subscales, as well as on all CBAS avoidance subscales. PSSS scores (F(10,130) = 2.32, P = 0.015) and a positive depression screen (F(10,130) = 1.95, P = 0.044) were also significant in this analysis, but CES scores, positive screen for an alcohol use problem, and all interactions of psychiatric screening variables were not (all F's(10,130) b 1.41, all P's N 0.18). Effect sizes of group differences by PTSD status were medium-to-large for TCQ worry and self-punishment, and all CBAS subscale scores; and medium for TCQ social control and behavioral distraction scores; and small for TCQ cognitive distraction and reappraisal scores. Table 4 displays results of a hierarchical linear regression analysis that examined variables associated with combat-related PTSD symptoms. Combat exposure, TCQ-worry, and CBAS-behavioral social cognitive social avoidance scores were positively associated with PTSD symptoms, and postdeployment support scores were negatively associated with PTSD symptoms. A post-hoc regression analysis revealed that scores on the PSSS understanding from others subscale were negatively associated with PTSD symptoms (β = − 0.28, t = 5.03, P b 0.001), but scores on the other subscales were not significant (all β's b 0.11, all t's b 1.61, all P's N 0.10). Fig. 1 shows results of a structural equation model that evaluated whether maladaptive thought control and avoidance coping strategies mediated the relation between perceived social support and combat-related PTSD symptoms. Overall, this model provided a good fit to the data, χ2(24)= 36.21, P = 0.007; RMSEA = 0.072 (90% confidence interval= 0.034–0.108); CFI = 0.98; TLI = 0.96; AIC = 108.21. In this model, postdeployment social support scores were negatively associated with combat-related PTSD symptoms, and this association was partially mediated by maladaptive thought control strategies and avoidance coping strategies. The three alternative models tested did not fit the data as well as the model shown in Fig. 1: direct effects of postdeployment social support on maladaptive thought control, avoidance coping strategies, and combat-related PTSD symptoms [χ 2(24) = 101.15, P = b0.001; RMSEA = 0.156 (90% confidence interval = 0.127–0.187); CFI = 0.91; TLI = 0.79; AIC = 169.15]; direct effects of combat-related PTSD symptoms on maladaptive thought control, avoidance coping strategies, and postdeployment social support [χ 2(24) = 42.16, P = 0.003; RMSEA = 0.082 (90% confidence interval = 0.047–0.116); CFI = 0.97; TLI = 0.94; AIC = 110.16]; and direct effects of maladaptive thought

Table 3 Thought control and avoidance coping strategies by PTSD screening status.

N Thought control strategies Worry* Self-punishment* Social control* Behavioral distraction* Cognitive distraction Reappraisal Avoidance coping strategies Cognitive social avoidance* Behavioral social avoidance* Cognitive non-social avoidance* Behavioral non-social avoidance*

No PTSD

PTSD

74

85

9.02 (0.37) 8.45 (0.38) 12.53 (0.39) 4.64 (0.20) 10.68 (0.31) 9.96 (0.40) 13.77 16.27 18.42 11.51

(0.69) (0.94) (0.99) (0.60)

F (1, 139)

P

Cohen's d

11.57 (0.41) 10.78 (0.42) 14.14 (0.44) 5.46 (0.22) 11.34 (0.35) 10.76 (0.45)

21.07 16.64 7.40 7.25 1.95 1.80

b 0.001 b 0.001 0.007 0.008 0.17 0.18

0.76 0.67 0.45 0.45 0.23 0.22

19.70 22.34 24.71 15.11

32.04 18.21 17.54 15.40

b 0.001 b 0.001 b 0.001 b 0.001

0.93 0.70 0.69 0.65

(0.78) (1.06) (1.12) (0.68)

Note. Scores are adjusted for depression and alcohol use problem screens, and combat exposure (Combat Experiences Scale scores) and postdeployment social support (Postdeployment Social Support Scale scores). *Groups differ, P b 0.05; d = Cohen's d estimate of effect size of group difference.

R.H. Pietrzak et al. / Psychiatry Research 189 (2011) 251–258

self-punishment, social control, and behavioral distraction thought control strategies, and avoidance coping strategies to manage unwanted thoughts, feelings, and situations. This finding replicates and extends a growing body of research suggesting that strategies such as worry, self-punishment, and experiential avoidance are commonly employed to manage unwanted thoughts by individuals with PTSD (Roussis and Wells, 2008; Bennett et al., 2009; Scarpa et al., 2009), as well as several other psychiatric conditions (Amir et al., 1997; Warda and Bryant, 1998; Reynolds and Wells, 1999; Blalock and Joiner, 2000; Guthrie and Bryant, 2000; Morrison and Wells, 2000; Rassin et al., 2000; Rosenthal et al., 2006; Roussis and Wells, 2008; Barahmand, 2009). Consistent with cognitive therapy models (Wells, 2000), results of the current study suggest that OEF–OIF Veterans with PTSD are more likely than those without PTSD to engage in maladaptive cognitivebehavioral coping strategies that may decrease the cognitive flexibility needed for adaptive processing and recovery from trauma. While prospective studies are needed to evaluate the temporal association between PTSD and cognitive-behavioral coping strategies, results of the present study suggest that modification of maladaptive coping strategies such as worry and self-punishment, and avoidant coping behaviors through empirically supported interventions such as cognitive processing therapy (Monson et al., 2006; Macdonald et al., 2011) may be helpful in reducing combat-related PTSD symptoms in treatment-seeking OEF–OIF Veterans. Alternatively, amelioration of PTSD symptoms may help decrease maladaptive cognitive coping and promote engagement in more adaptive coping strategies (e.g., problem-focused coping). The finding that Veterans with PTSD were more likely than Veterans without PTSD to engage in thought control strategies characterized by worry and self-punishment, as well as several cognitive and behavioral avoidance coping strategies, replicates and extends previous research (Solomon et al., 1988; Benotsch et al., 2000; Blalock and Joiner, 2000; Rassin et al., 2000; North et al., 2001; Silver et al., 2002; Orcutt et al., 2004; Marx and Sloan, 2005; Morina, 2007; Solomon and Mikulincer, 2007). Social avoidance, in particular, was strongly associated with both a probable diagnosis and severity of

Table 4 Hierarchical regression analyses of association between thought control and avoidance coping strategies and severity of combat-related PTSD symptoms.

Step 1 Combat exposure* Step 2 Worry* Self-punishment Social control Behavioral social* Behavioral non-social Cognitive social* Cognitive non-social Step 3 Postdeployment support*

F

P

R2

10.52

0.001

0.06

23.76

b0.001

0.56

26.83

b0.001

β

t

P

0.14

2.55

0.012

0.15 0.08 − 0.04 0.31 0.10 0.32 0.10

2.14 1.23 0.80 3.43 0.98 2.94 0.81

0.034 0.22 0.43 0.001 0.33 0.004 0.42

− 0.30

4.69

b 0.001

255

0.62

Note. *Significant association with PTSD symptom severity, P b 0.05.

control and avoidance coping strategies on combat-related PTSD symptoms and postdeployment social support [χ 2(24) = 55.97, P = b0.001; RMSEA = 0.108 (90% confidence interval= 0.076–0.142); CFI = 0.96; TLI = 0.90; AIC = 125.97]). 4. Discussion The purpose of this study was twofold: first, we sought to provide a detailed examination of thought control and avoidance coping strategies associated with both a probable diagnosis and symptom severity of combat-related PTSD in treatment-seeking OEF–OIF Veterans; second, we evaluated whether maladaptive thought control strategies (e.g., worry, self-punishment) and avoidance coping strategies (e.g., social and nonsocial cognitive and behavioral avoidance) mediate the relation between postdeployment social support and combat-related PTSD symptoms in this population. Compared to OEF–OIF Veterans who did not screen positive for PTSD, those with a positive screen were more likely report using worry,

e6 Postdeployment Social Support

-.42

-.55

e1

Behavioral Social Avoidance

.83

e2

Behavioral Nonsocial Avoidance .92

e3

e9

Self-punishment

.72 .86

-.29

Maladaptive Thought Control

Avoidance coping

Cognitive Nonsocial Avoidance

.70

Worry

e10

.92

e4

Cognitive Social Avoidance

e11

e12

.39

e7

.28

PTSD Symptoms .20

e13

Combat Exposure

Fig. 1. Structural equation model of the role of cognitive-behavioral coping strategies in mediating the relation between postdeployment social support and combat-related PTSD symptoms.

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PTSD symptoms. This was evident in the larger effect sizes of group differences between Veterans with and without PTSD, as well as in the hierarchical regression analysis of PTSD symptoms in the full sample, which revealed that social avoidance strategies, but not non-social avoidance strategies, were associated with PTSD symptoms. These findings accord with results of a study of 178 treatment-seeking Veterans with PTSD, which similarly found that cognitive social avoidance predicted greater severity of PTSD symptoms (Tiet et al., 2006). Given that avoidance symptoms tend to remain stable over time (Marshall et al., 2006; Solomon et al., 2009) and are associated with increased severity and chronicity of PTSD (Blalock and Joiner, 2000; Marx and Sloan, 2005; Morina, 2007; Solomon and Mikulincer, 2007), as well as postdeployment readjustment difficulties (Pietrzak et al., 2010b), results of this study suggest underscore the importance of targeting maladaptive avoidance strategies, most notably social avoidance, in psychotherapeutic interventions for PTSD in OEF–OIF Veterans. In particular, increasing beliefs about one's ability to manage and control stressful life events may help facilitate more adaptive coping and mitigate trauma-related distress (Bandura, 1989; Benight and Bandura, 2004). Further, facilitation of a positive cognitive explanatory style, approach/active coping, and greater social resources and support may help decrease the severity of PTSD symptoms (King et al., 1998; Sharkansky et al., 2000; Southwick et al., 2005; Tiet et al., 2006; Charuvastra and Cloitre, 2008). Of note, in addition to being more likely to engage in worry and selfpunishment thought control strategies, Veterans with PTSD were more likely than their non-PTSD counterparts to also engage in social control and behavioral distraction strategies, which may be helpful in seeking knowledge regarding how to manage unwanted thoughts and interrupting ruminative and/or intrusive thoughts, respectively (Wells and Davies, 1994). In the current study, greater perceptions of understanding from others, in particular, were negatively associated with PTSD symptoms, even after controlling for combat exposure and maladaptive coping strategies. This finding, which is consistent with recent reports on the importance of interpersonal relationships, family cohesion, and understanding in PTSD treatment (Benotsch et al., 2000; Billette et al., 2008; Markowitz et al., 2009; Sautter et al., 2009), underscores the importance of psychoeducational interventions that inform family members and close friends about the postdeployment mental health needs of Veterans (e.g., Sherman et al., 2009), as well as cognitivebehavioral interventions that address interpersonal difficulties in this population (e.g., Erbes et al., 2008; Monson et al., 2008; Sautter et al., 2009). Perceived lack of understanding from others may negatively affect traumatized individuals' processing of traumatic memories and may reinforce avoidance coping. Interestingly, a prior study of former prisoners of war from World War II found that while those with PTSD sought out social support more frequently than those without PTSD, they were also more likely to use maladaptive avoidant coping skills such as self-isolation, wishful thinking, and self-blame (Fairbank et al., 1991). One explanation for this finding is that negative attitudes and expectations about the usefulness of one's support networks in coping with stress may mediate the relation between social support and PTSD (Clapp and Gayle Beck, 2009). Another possibility is that more severe PTSD symptoms may lead to an erosion of social support over time (Laffaye et al., 2008). Taken together, these findings suggest that despite the availability of social support, negative attitudes and expectations about the usefulness of one's support networks in coping with their symptoms (e.g., decreased perceptions of understanding from others) may be related to reduced reliance on support networks and an increase in avoidance coping, which may contribute to the persistence of PTSD symptoms. Additional research is needed to evaluate the processes by which symptomatic Veterans and other trauma-exposed individuals navigate their social support networks, and to assess which aspects of social support may be most helpful in facilitating successful recovery from PTSD.

Results of a structural equation model suggested that maladaptive thought control and avoidance coping strategies partially mediated the association between postdeployment social support and combatrelated PTSD symptoms. This finding replicates prior research demonstrating that traumatized individuals with greater levels of social support are less likely to engage in avoidance coping, which is in turn associated with decreased PTSD symptoms (Irwin, 1996; Runtz and Schallow, 1997; Charuvastra and Cloitre, 2008). It extends this finding and prior research on OEF–OIF Veterans (Pietrzak et al., 2009; Pietrzak et al., 2010c) to suggest that while postdeployment social support may help buffer against PTSD symptoms, this association may be partially mediated by engagement of maladaptive thought control and avoidance coping strategies. While longitudinal studies are needed to elucidate temporal associations among these variables, results of this analysis provide an initial step in moving toward a more comprehensive model of the relations among postdeployment social support, cognitive and behavioral coping strategies, and combatrelated PTSD symptoms in OEF–OIF Veterans. Methodological limitations of this study include a cross-sectional design, which does not permit examination of temporal associations between cognitive-behavioral coping strategies, PTSD, and social support, and longer term adjustment. Further limitations include recruitment of a sample of OEF–OIF Veterans from a single VA hospital and employment of a self-report methodology. Further research in larger, more representative samples of treatment-seeking OEF–OIF Veterans is needed to examine the generalizability of these study results. Notwithstanding these limitations, results of this study are the first to provide a systematic characterization of a broad range of cognitive and behavioral coping strategies associated with combat-related PTSD in treatment-seeking OEF–OIF Veterans. Results suggest that PTSD is associated with engagement in coping strategies characterized by worry, self-punishment, social control, behavioral distraction, as well as social and nonsocial avoidance. Increased perceptions of understanding from others were negatively associated with PTSD, suggesting that enhancement of shared understanding may help mitigate PTSD symptoms in OEF–OIF Veterans, or alternatively, that greater severity of PTSD symptoms may lead to an erosion of social support and decreased perceptions of understanding from others. Prospective studies are needed to examine whether maladaptive cognitive coping strategies are related to preexisting personality characteristics or whether they arise as a function of developing PTSD symptoms; determine the role of cognitive-behavioral coping strategies in predicting treatment and functional outcomes; and evaluate whether enhancement of social support (i.e., perceived understanding from others) may help reduce engagement in maladaptive coping strategies and promote successful outcomes in symptomatic OEF–OIF Veterans and other trauma-exposed populations.

Acknowledgements We thank the Veterans who participated in this survey. We also thank Douglas C. Johnson, Ph.D., for helping design the survey, and Amanda Russo, B.A., Alison Rivers, B.A., and Alicia Christensen, B.A. for their assistance with data collection and management. This work was supported by the Clinical Neurosciences Division of the National Center for Posttraumatic Stress Disorder and a private donation.

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