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Posttraumatic stress disorder symptoms and injury: the moderating role of perceived social support and coping for young adults
Personality and Individual Differences 42 (2007) 1187–1198 www.elsevier.com/locate/paid
Posttraumatic stress disorder symptoms and injury: the moderating role of perceived social support and coping for young adults Sara C. Haden *, Angela Scarpa, Russell T. Jones, Thomas H. Ollendick Virginia Polytechnic Institute and State University, Blacksburg, VA 24061-0436, USA Received 15 March 2006; received in revised form 9 September 2006; accepted 26 September 2006 Available online 17 November 2006
Abstract Individuals who experience a traumatic event are at risk of developing posttraumatic stress disorder (PTSD). The present investigation examined (1) the relationship between PTSD symptoms and perceived injury sustained during a traumatic event, and (2) the moderational roles of the survivor’s coping behaviors and perceived support on the injury-PTSD relationship. A sample of college students completed self-report measures describing the trauma, coping styles, support, and PTSD symptoms. Results indicated that the degree of perceived injury significantly predicted levels of PTSD symptoms. Furthermore, individuals who self-reported more severe levels of injury reported less severe PTSD symptoms when they also perceived more friend support or utilized interpersonal styles of coping. These findings emphasize the value of perceiving and seeking support for survivors of traumatic events. Ó 2006 Elsevier Ltd. All rights reserved. Keywords: Posttraumatic stress; Injury; Social support; Coping
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Corresponding author. Present address: Department of Psychology, 109 Williams Hall, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, 24061-0436. USA. Tel.: +540 231 8034; fax: +540 231 3652. E-mail address: [email protected] (S.C. Haden). 0191-8869/$ - see front matter Ó 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2006.09.030
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0. Introduction It has been estimated that 10–40% of individuals who experience trauma will subsequently develop post-traumatic stress disorder (PTSD) (Michaels et al., 1999). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association[APA], 2000) defines a traumatic event as something that causes serious threat to one’s life and that elicits a fear and/or helpless response from the individual. Specific traumatic experiences can include natural or technological disasters, violent crimes, abusive relationships, and sexual assaults. It is estimated that 50–60% of the United States population will experience a traumatic event (Ozer, Best, Lipsey, & Weiss, 2003). Given that the prevalence of PTSD is considered one of the most common anxiety disorders experienced among young adults (Breslau, Davis, Andreski, & Peterson, 1991), an examination of potential risk and protective factors of PTSD, and interactions among these variables, is warranted. The present investigation focused on three factors that have been found to be related to PTSD symptoms: (1) level of perceived injury sustained during the traumatic event, (2) coping strategies, and (3) level of perceived social support. Unlike previous studies, the goal of the present study was to evaluate coping strategies and perceived social support as variables that might moderate the relationship between perceived severity of injury, as a trauma characteristic, and PTSD symptoms. An exploration of these relationships may account for individual differences in posttraumatic stress reactions in young adults.
1. Conceptual model In an effort to determine how perceived injury severity, coping behavior, and social support are related to one another and subsequent PTSD symptomatology, it is important to review how these factors have been incorporated into developmental models of PTSD. Green, Wilson, and Lindy (1985) proposed a widely accepted psychosocial model of adult PTSD (Peterson, Prout, & Schwarz, 1991). Their conceptual model describes how the event, in consideration with the processing of that event, is the essential factor influencing the development of positive or negative psychological outcomes. Specifically, Green and her colleagues explain the development of PTSD in terms of the interaction between the trauma experience, the survivor’s characteristics, cognitive processing, and the recovery environment. This psychosocial framework focuses on unique experiences such as those who survive identical traumas and yet have different outcomes. Although the model helps researchers understand why certain individuals are more likely to develop PTSD than others, it does not consider the direct interactions between trauma characteristics (i.e., injury) and dispositional factors (i.e., coping and social support). Differences in young adults’ PTSD symptomatology may be better explained by their appraisal and response to the event, as well as their subsequent resistance and vulnerability to specific trauma characteristics. As will be described in the following section, researchers have found that injury, coping behavior, and support are related to the development of PTSD in adults; however, the interactions among these variables have not been explored adequately.
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1.1. Trauma factor: injury Typically, the more severe the injury, the more probable it is that the individual will develop PTSD symptoms. Green’s (1993) discussion of the generic dimensions of trauma indicates that severe physical harm or injury and receipt of intentional injury/harm have been associated with psychological distress. Although the psychosocial perspective presented by Green et al. (1985) posits that cognitive appraisal mediates the trauma-distress relationship, dose of trauma also has a direct impact on PTSD severity. This relationship has been reported across a variety of traumas including natural disasters (Briere & Elliott, 2000) and women’s traumatic sexual experiences (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). However, certain factors may affect the influential ‘‘power’’ that sustained injury has on PTSD severity. For example, it has been shown that the individual’s coping styles after an event and the received social support play meaningful roles in the prediction of PTSD severity. 1.2. Coping behaviors The psychosocial model of PTSD (Green et al., 1985) represents coping mechanisms (i.e., responses to event) and cognitive processing (i.e., appraisal of the stressor based on prior experiences) as reciprocally related. It is the impact of these factors together which help predict psychological outcomes. In support of this model, it has been found that participants who viewed their situation as amenable to change tended to engage in active coping and experienced less psychological distress (Carver, Scheier, & Weintraub, 1989). It is not clear in the literature which type of coping strategy, or combination of coping strategies, is most beneficial for individuals who experience a trauma. For example, in a review of factors mediating the relationship between trauma and psychopathology, it was concluded that coping styles that entail more approach behavior in targeting and minimizing post-trauma symptoms are more effective in decreasing negative psychological outcomes than coping that is more avoidant in nature (Gibbs, 1989). Similarly, children who suffered from a higher dose of trauma during a residential fire were more likely to experience PTSD symptoms when they engaged in avoidant coping styles (Jones & Ollendick, 2002). On the other hand, in a study of political prisoners, specific coping strategies were not linked to overall posttraumatic stress reactions (Schu¨tzwohl, Maercker, & Manz, 1999). In summary, active coping strategies seem to predict better outcomes relative to avoidant coping strategies, though these findings are not conclusive. 1.3. Social support Research on social support highlights its contribution to an individual’s well-being and the reduction of psychological disorders (Schu¨tzwohl et al., 1999; Zimet, Dahlem, Zimet, & Farley, 1988). In general, it appears that support from family and friends has a positive influence on the ability to cope with trauma. In fact, social support was the strongest predictor found in a meta-analysis by Brewin, Andrews, and Valentine (2000), accounting for 40% of variance in PTSD severity. The perceptions of social support are also important in the prediction of PTSD.
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It has been suggested that trauma survivors who perceive inadequate social support may be more at risk of negative outcomes (Raphael & Wilson, 1993). However, perceived social support may be directly affected by severity of the trauma. In some cases, support decreases with increases in trauma severity (Norris & Kaniasty, 1996). On the other hand, researchers have also reported a positive relationship with higher support given to survivors who have sustained more severe trauma (Solomon, Mikulincer, & Avitzur, 1988). It is difficult to determine the directional relationship between exposure dose and the adequacy of support.
2. Present study In sum, previous research has found significant relationships between injury sustained, coping behavior, and perceived social support and PTSD. The purpose of the current study was to focus on these variables in an effort to assess whether perceived social support and coping behavior moderate the relationship between perceived injury severity and subsequent PTSD reactions. It is also essential that these variables be adequately assessed in a young adult sample given the prevalence of this particular anxiety disorder (Breslau et al., 1991). Although Green et al.’s (1985) psychosocial model predicts that injury, coping behavior, and social support are mediated by cognitive appraisals, we were interested in determining if general styles of overall levels of perceived coping behavior and support were directly related to the injury-PTSD relationship in that they might serve to diminish the strong positive relationship. First, in accordance with past research, it was hypothesized that perceptions of more severe injury would predict higher PTSD symptomatology. Second, we predicted that active coping styles (i.e., interpersonal and problem-focused) would predict less severe PTSD symptoms and that avoidant styles of coping (i.e., disengagement) would be associated with more PTSD symptoms. Third, we hypothesized that higher perceived social support from family and friends would predict less severe symptoms of PTSD. The fourth hypothesis predicted that social support and coping behavior would serve independent moderational roles as protective factors in the relationship between perceptions of injury and PTSD reactions. Specifically, we predicted that individuals who perceived high degrees of injury would require high social support or high active coping behaviors in order to lessen PTSD symptoms. 2.1. Method 2.1.1. Participants Participants were 150 undergraduate students (50 male, 100 female) who reported experiencing different types of trauma. The majority of these participants were between the ages of 17 and 22 (93%). The mean age was 19.33 (SD = 1.31). Participants were primarily Caucasian (81%), followed by Asian (7.5%), African-American (5.5%), Hispanic (2.5%), and other ethnicities. Participants reported experiencing a range of traumas including technological accidents (e.g., car accidents, 30%), natural disasters (24%), violent crimes (16%), unwanted adult sexual experiences (14%), childhood abuse (10%), and abusive relationships (6%). The number of years since participants experienced the reported trauma ranged from a few months to 18 years with an average time of 5 years and 6 months (SD = 4 years, 5 months).
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2.1.2. Measures and procedure Individuals were asked to complete various self-report measures assessing the trauma’s characteristics, perceived social support, coping behavior, and PTSD symptoms. Regarding trauma exposure, participants completed the Events Scale (ES, Vrana & Lauterbach, 1994). The ES assesses participants’ exposure to various types of stressful events. In addition, participants reported different aspects of the trauma including when it had occurred, how traumatic it had been for them, and how much injury they sustained. Level of perceived injury was measured by the question, ‘‘Were you injured?’’ and was answered on a 7-point Likert type scale ranging from ‘‘not at all’’ to ‘‘severely.’’ Respondents indicated sustained injury levels ranging from 0 to 7 (M = 1.80, SD = 1.37). Participants’ PTSD-related symptoms were measured by their responses on the Purdue Post Traumatic Stress Disorder -Revised questionnaire (PPTSD-R, Lauterbach & Vrana, 1996). They were instructed to respond based on the most traumatic event they had experienced. The PPTSDR includes 17 items that comprise three scales, (1) reexperiencing the trauma, (2) avoidance, and (3) arousal based on DSM-IV symptomatology for PTSD. Participants responded to each item on a 5-point Likert type scale ranging from ‘‘not at all’’ to ‘‘often’’ regarding the frequency of each symptom during the previous month. The cumulative PTSD severity score was calculated and ranged from 17 to 69 (M = 30.31, SD = 13.34). The unstandardized Cronbach alpha for this scale was .91. In order to assess coping responses, participants were asked to complete the COPE Inventory (Carver et al., 1989). The COPE consists of 60 items answered on a 4-point Likert type scale, ranging from ‘‘I usually don’t do this at all’’ to ‘‘I usually do this a lot.’’ Items comprise 15 scales with Cronbach alpha reliabilities ranging from .45 to .92. The COPE has also shown moderate to high test-retest reliability (.46 to .77) suggesting that the measure identifies relatively stable ways that individuals cope. In an effort to reduce the number of scales and obtain more global measures of coping behavior, we factor analyzed the 15 scales using a principal component method of factor extraction with varimax rotation. In accordance with the principal component method, communalities were set at ‘1’ for the initial iteration of factors (Loehlin, 1998). Therefore, the communality of each original COPE scale was estimated by its squared multiple correlation with the remaining COPE scales. We also constrained the analysis to three factors, based upon the Scree plot showing three distinct factors with eigenvalues greater than 1.00 (Loehlin, 1998). In this analysis, 62% of the variance was accounted for and three orthogonal scales emerged regarding coping styles (described below): (1) disengagement, (2) interpersonal, and (3) problem-focused. Unstandardized Cronbach alphas were .69, .82, and .80, respectively. Disengagement coping consisted of mental and behavioral disengagement, denial, and substance use. This type of coping may be considered avoidant in nature. Interpersonal coping consisted of using emotional and social support, and venting emotions. Problem-focused coping consisted of active coping, restraining, positive reinterpretation and growth, acceptance, and planning. Participants’ mean score for each scale was calculated. Disengagement coping ranged from 4.00 to 13.23 (M = 7.39, SD = 1.90), while interpersonal coping ranged from 5.33 to 16.00 (M = 11.20, SD = 2.72) and problem-focused coping ranged from 6.40 to 15.60 (M = 11.15, SD = 1.87). The Multidimensional Scale of Perceived Social Support (MSPSS, Zimet et al., 1988) was used to assess perceived social support. Participants rated their agreement with four statements
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pertaining to the perceived support they received from family and four statements referring to the perceived support they received from friends, on a 7-point Likert scale ranging from ‘‘very strongly disagree’’ to ‘‘very strongly agree.’’ Unstandardized Cronbach alphas were .92 for both scales and scores could range from 0 to 28. Participants’ mean scale scores were used for family and friend support. Family (M = 19.19, SD = 5.24) and friend support (M = 19.32, SD = 4.84) ranged from 0 to 24. 2.2. Results Zero-order correlations were computed to determine how demographic characteristics (i.e., sex, years since trauma), perceived injury severity, coping styles, and perceived support were associated with PTSD symptomatology (Table 1). Women tended to report more PTSD symptoms. There was also a significant negative association between the years since the traumatic event had occurred and the PTSD severity. Since these variables were significantly associated with PTSD severity and research has consistently reported these variables as strong predictors of PTSD (Brewin et al., 2000), they were included as covariates in the subsequent regression models. 2.2.1. Hierarchical regressions Data were screened and all hierarchical regression assumptions were met. A series of five hierarchical regressions were conducted to test for significant main effects for perceived injury, coping, and social support, as well as the moderating effect of coping and social support predicting PTSD severity. All regressions were run separately for each coping (disengagement, interpersonal, problem-focused) and social support (family, friends) variable. Variables were centered in order to reduce multicollinearity and five interaction terms were computed (disengagement, interpersonal, problem-focused, family support, and friend support by perceived injury). After controlling for participants’ sex and years since the trauma in block one of the hierarchical regression, the main effect for perceived injury was tested in block two and the main effect for the moderator (one at a time) was tested in block three. The corresponding interaction term was entered in block four (Holmbeck, 1997, 2002). Post-hoc probing techniques (Aiken & West, 1991; Table 1 Zero-order correlations among all variables 1. 2. 3. 4. 5. 6. 7. 8. 9.
Sex Years Since Perceived Injury Family Support Friend Support Disengagement Interpersonal Problem-focused PTSD
1
2
3
4
5
6
7
8
9
1.000 .20** .06 .08 .35** .03 .28** .11 .19**
1.000 .23** .20** .00 .11 .04 .13 .23**
1.000 .00 .03 .12 .08 .13 .41**
1.000 .44** .11 .30** .32** .24**
1.000 .22** .35** .13 .10
1.000 .06 .07 .27**
1.000 .39** .12
1.000 .02
1.000
Note. Sex: Male = 0, Female = 1. *p < .05 (2-tailed). ** p < .01 (2-tailed).
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Holmbeck, 2002) were conducted using conditional moderator variables to determine whether the moderational effect was significant. The three main effects that were tested in each of the five hierarchical regressions (sex, years since trauma, and perceived injury) were significant. Women reported more PTSD symptoms than men, b = .18, t (148) = 2.23, p = .027. Manifestations of PTSD were also more severe for individuals who had experienced a traumatic event more recently, b = .20, t (148) = 2.46, p = .015. After controlling for sex and years since trauma, block two tested the main effect for perceived injury and also provided a significant contribution to PTSD symptoms, b = .39, partial t (147) = 5.23, p < .01. After controlling for sex, years since trauma, and perceived injury severity, the main effect for the moderator variables (i.e., the coping or social support scales) was entered in block three in each of the five hierarchical regressions. Two of the main effects were significant, including family support, b = .24, partial t (146) = 3.33, p < .001, and disengagement coping behavior, b = .21, partial t (146) = 2.90, p = .004. Higher levels of support from family were significantly related to less severe PTSD symptoms, while engaging in avoidance behaviors was associated with more symptoms. Two of the interaction terms were significant after controlling for the main effects and included friend support by injury, (b = .17, partial t (145) = 2.34, p = .021) and interpersonal coping behavior by injury, (b = .15, partial t (145) = 2.03, p = .044). Post-hoc probing was conducted for these possible moderators as recommended by Aiken and West (1991) and Holmbeck (2002). High and low variables for interpersonal coping and perceived friend support were computed by adding and subtracting one standard deviation from the centered value for each participant. These new variables (high/low interpersonal coping and high/low friend support) were entered into separate simultaneous regressions along with sex of the participant, years since the trauma, perceived injury, and their corresponding interaction term with perceived injury. Their regression lines were graphed based on the equations from the separate models including the simple slopes for the moderator variables and y-intercepts (see Figs. 1 and 2). These additional analyses supported the significant moderational effects for both variables on the relationship between perceived injury and PTSD symptoms. As illustrated in Fig. 1, the relationship between perceived
PTSD Symptomatology
80 70 60 Low Interpersonal Coping (b = .56)**
50 40 30 20 10
High Interpersonal Coping (b = .25)*
0 -1 SD
Mean
+1 SD
Injury
Fig. 1. Regression lines for injury-PTSD relationship as moderated by interpersonal coping behavior, b = unstandardized regression coefficient for perceived injury in each sample. SD = standard deviation.
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PTSD Syptomatology
80 70 60
Low Friend Support (b = 1.06)**
50 40 30 High Friend Support (b = .81)**
20 10 0 -1 SD
Mean Injury
+1 SD
Fig. 2. Regression lines for injury-PTSD relationship as moderated by friend support. b = unstandardized regression coefficient for perceived injury in each sample. SD = standard deviation.
injury severity and PTSD severity is stronger for those individuals with generally low interpersonal coping styles than those with high interpersonal coping styles. As illustrated in Fig. 2, the relationship between perceived injury severity and PTSD severity is stronger for those individuals who perceive lower, rather than higher, support from their friends.1
3. Discussion This study investigated the importance of perceived injury severity, perceived social support, and coping behaviors in young adults’ PTSD symptomatology. Consistent with our hypotheses, more severe perceived injury predicted PTSD severity while high support from family contributed to significantly fewer symptoms. Regarding coping styles, avoidant forms of coping, specifically disengagement coping behavior, contributed significantly to the severity of PTSD, while no significant main effects for active coping behaviors were found. Two significant moderating relationships were also detected. In particular, individuals who perceived more severe injury during their trauma reported fewer PTSD symptoms when they perceived high levels of support from friends or when they used interpersonal coping behavior as a coping mechanism. These findings help elucidate the impact of dispositional variables (i.e., coping styles and perceived support) and trauma characteristics on PTSD symptomatology in young adults. 3.1. Family support, injury, and disengagement coping styles Consistent with previous literature (Brewin et al., 2000), when trauma survivors perceived strong support from their families, they tended to experience less severe PTSD. Although several 1
The analyses were repeated using only the 62 participants who reported some levels of injury. Findings were identical to those of the larger sample such that the relationship between perceived injury levels and PTSD severity was strongest for those who engaged in low levels of interpersonal coping. A somewhat stronger relationship for those perceiving low support from friends was also found.
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studies have found some type of significant association between injury and social support (e.g., Norris & Kaniasty, 1996), we found that perceived injury was not significantly related to social support from friends and family. Thus, it seems that perceived injury and family support had direct independent effects on PTSD severity. Supportive interactions between family members and the trauma survivor may provide the individual with a valuable opportunity to talk through the event and explain the meaning of what has happened. It is possible that family members were part of some events that help to expedite recovery and provide a cathartic experience for the survivors (Raphael & Wilson, 1993). Although the type of support was not measured in the present investigation, in previous studies Ozer et al. (2003) found that emotional support has been most critical. It may be instructive to examine the types of support perceived by trauma survivors that help predict PTSD severity. This information would inform intervention strategies and help target areas that curb the development, not just the cause, of PTSD. The present investigation also found that perceived injury and disengagement behaviors contributed to more severe levels of PTSD. The negative effects of injury on the psychological outcomes of trauma have been highly cited in other studies as well and lend support to the dose-response nature of PTSD (Gibbs, 1989; Jones & Ollendick, 2002). However, the research regarding avoidant styles of coping has not been consistent. In our sample, young adult trauma survivors who tended to deny that the event had occurred, participated in activities intended to distract them, or drank alcohol in response to the trauma had more severe PTSD than those who spent time thinking about their experience. Given that these are general coping styles, it is not certain that these were the styles used following the traumatic event. Regardless, the findings suggest that continuing to use such coping styles may not be helpful. It is also important to highlight that avoidant (i.e., disengagement) rather than active (i.e., problem-focused, interpersonal) styles of coping were associated with PTSD severity. Green et al. (1985) predicted that active coping strategies would serve to protect the individual from experiencing psychic overload, which thereby would minimize PTSD severity. In the current study, however, a direct effect was not found regarding the active interpersonal and problem-focused coping strategies. Therefore, it cannot be argued that purposeful cognitive processing of the event is directly beneficial to young adults’ outcome. Rather, as discussed in the next section, such styles of coping become more influential when one considers the survivor’s injury level. 3.2. Injury moderated by interpersonal coping behaviors In the present study interpersonal coping behaviors consisted of asking for advice from others, speaking to others about feelings, and voicing emotions to others. Individuals who sustained high levels of injury during their traumatic experiences suffered from less severe PTSD symptoms when they utilized this type of coping behavior. Those who engaged in low levels of interpersonal coping behavior, who also perceived more severe injury, developed more severe PTSD than those who employed high levels of interpersonal coping. These findings suggest that positive active coping behavior, in the form of interpersonal coping, can indeed help to ameliorate PTSD severity. However, this association was uncovered only when explored in relation to amount of perceived injury suggesting that its influence depends on the level of perceived injury sustained by the trauma survivor.
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Perhaps this result helps explain the inconsistent findings regarding the role of coping behavior in predicting PTSD. Although we found that disengagement behaviors directly led to more severe PTSD, more positive and active coping styles were not directly predictive. Future research might choose to explore other types of coping styles in an effort to help understand their contradictory findings regarding coping behaviors. Conceivably, by exploring their moderated effects with risk factors, individual differences in the exact mechanisms of coping on PTSD manifestations may be revealed. 3.3. Injury moderated by friend support When highly injured trauma survivors perceived high support from their friends, they were less likely to develop severe PTSD than those who perceived less support. Thus, perceptions of support from friends help alleviate the strong positive association between injury and PTSD severity and thus serve as a powerful protective factor to those individuals. Unlike support from family, our results suggest that friend support becomes more influential when one examines its relationship vis a vis the level of injury. Thus, it seems that perceived friend support serves a more complex role than other forms of support. As previously discussed, future research might examine the nature of the support and its interactions with risk factors in the prediction of PTSD. 3.4. Limitations and future research While the present study contributed to adult PTSD literature by examining smaller components within larger conceptual models, several limitations should be noted. First, the sample was one of convenience comprised of undergraduate students and therefore may not be able to be generalized directly to a clinical sample. It would be favorable to examine these moderating relationships using a clinical population sample. Second, all questionnaires were self-report and therefore prone to such biases. Third, the coping and social support measures pertained to general lifestyle coping styles and perceived support and were not specific to the trauma. Although it can be argued that participants most likely dealt with the traumas using the coping they reported and perceiving similar amounts of support, it would be worthwhile to examine specific post-trauma factors. Lastly, some participants experienced traumas some time ago; therefore, their reports may not be as accurate as those who experienced their traumas more recently. 3.5. Conclusion This study was designed to explore the interaction between the trauma characteristic of injury and factors related to expressions of PTSD. Consistent with previous research, we found that (1) injury and disengagement styles of coping predict more severe PTSD and (2) support from family helped minimize PTSD. Though sustaining high levels of injury during a trauma may maximize the chances of developing PTSD, two variables were found to serve as protective factors and buffered this relationship, (1) perceiving strong support from friends and (2) interpersonal coping. As such, it is crucial that trauma survivors seek support from friends (and family) who provide it. It may be productive for future research to examine other nested interactions between support and
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other variables (i.e., pretrauma experiences, type of trauma, appraisal of event). The concept of support, perceiving it or seeking it out, may be considered one of the most powerful variables essential for minimizing the severity of PTSD in young adults. It may also be one of the easiest tools to provide a trauma survivor.
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Posttraumatic stress disorder symptoms and injury: the moderating role of perceived social support and coping for young adults Sara C. Haden *, Angela Scarpa, Russell T. Jones, Thomas H. Ollendick Virginia Polytechnic Institute and State University, Blacksburg, VA 24061-0436, USA Received 15 March 2006; received in revised form 9 September 2006; accepted 26 September 2006 Available online 17 November 2006
Abstract Individuals who experience a traumatic event are at risk of developing posttraumatic stress disorder (PTSD). The present investigation examined (1) the relationship between PTSD symptoms and perceived injury sustained during a traumatic event, and (2) the moderational roles of the survivor’s coping behaviors and perceived support on the injury-PTSD relationship. A sample of college students completed self-report measures describing the trauma, coping styles, support, and PTSD symptoms. Results indicated that the degree of perceived injury significantly predicted levels of PTSD symptoms. Furthermore, individuals who self-reported more severe levels of injury reported less severe PTSD symptoms when they also perceived more friend support or utilized interpersonal styles of coping. These findings emphasize the value of perceiving and seeking support for survivors of traumatic events. Ó 2006 Elsevier Ltd. All rights reserved. Keywords: Posttraumatic stress; Injury; Social support; Coping
*
Corresponding author. Present address: Department of Psychology, 109 Williams Hall, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, 24061-0436. USA. Tel.: +540 231 8034; fax: +540 231 3652. E-mail address: [email protected] (S.C. Haden). 0191-8869/$ - see front matter Ó 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2006.09.030
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0. Introduction It has been estimated that 10–40% of individuals who experience trauma will subsequently develop post-traumatic stress disorder (PTSD) (Michaels et al., 1999). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association[APA], 2000) defines a traumatic event as something that causes serious threat to one’s life and that elicits a fear and/or helpless response from the individual. Specific traumatic experiences can include natural or technological disasters, violent crimes, abusive relationships, and sexual assaults. It is estimated that 50–60% of the United States population will experience a traumatic event (Ozer, Best, Lipsey, & Weiss, 2003). Given that the prevalence of PTSD is considered one of the most common anxiety disorders experienced among young adults (Breslau, Davis, Andreski, & Peterson, 1991), an examination of potential risk and protective factors of PTSD, and interactions among these variables, is warranted. The present investigation focused on three factors that have been found to be related to PTSD symptoms: (1) level of perceived injury sustained during the traumatic event, (2) coping strategies, and (3) level of perceived social support. Unlike previous studies, the goal of the present study was to evaluate coping strategies and perceived social support as variables that might moderate the relationship between perceived severity of injury, as a trauma characteristic, and PTSD symptoms. An exploration of these relationships may account for individual differences in posttraumatic stress reactions in young adults.
1. Conceptual model In an effort to determine how perceived injury severity, coping behavior, and social support are related to one another and subsequent PTSD symptomatology, it is important to review how these factors have been incorporated into developmental models of PTSD. Green, Wilson, and Lindy (1985) proposed a widely accepted psychosocial model of adult PTSD (Peterson, Prout, & Schwarz, 1991). Their conceptual model describes how the event, in consideration with the processing of that event, is the essential factor influencing the development of positive or negative psychological outcomes. Specifically, Green and her colleagues explain the development of PTSD in terms of the interaction between the trauma experience, the survivor’s characteristics, cognitive processing, and the recovery environment. This psychosocial framework focuses on unique experiences such as those who survive identical traumas and yet have different outcomes. Although the model helps researchers understand why certain individuals are more likely to develop PTSD than others, it does not consider the direct interactions between trauma characteristics (i.e., injury) and dispositional factors (i.e., coping and social support). Differences in young adults’ PTSD symptomatology may be better explained by their appraisal and response to the event, as well as their subsequent resistance and vulnerability to specific trauma characteristics. As will be described in the following section, researchers have found that injury, coping behavior, and support are related to the development of PTSD in adults; however, the interactions among these variables have not been explored adequately.
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1.1. Trauma factor: injury Typically, the more severe the injury, the more probable it is that the individual will develop PTSD symptoms. Green’s (1993) discussion of the generic dimensions of trauma indicates that severe physical harm or injury and receipt of intentional injury/harm have been associated with psychological distress. Although the psychosocial perspective presented by Green et al. (1985) posits that cognitive appraisal mediates the trauma-distress relationship, dose of trauma also has a direct impact on PTSD severity. This relationship has been reported across a variety of traumas including natural disasters (Briere & Elliott, 2000) and women’s traumatic sexual experiences (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). However, certain factors may affect the influential ‘‘power’’ that sustained injury has on PTSD severity. For example, it has been shown that the individual’s coping styles after an event and the received social support play meaningful roles in the prediction of PTSD severity. 1.2. Coping behaviors The psychosocial model of PTSD (Green et al., 1985) represents coping mechanisms (i.e., responses to event) and cognitive processing (i.e., appraisal of the stressor based on prior experiences) as reciprocally related. It is the impact of these factors together which help predict psychological outcomes. In support of this model, it has been found that participants who viewed their situation as amenable to change tended to engage in active coping and experienced less psychological distress (Carver, Scheier, & Weintraub, 1989). It is not clear in the literature which type of coping strategy, or combination of coping strategies, is most beneficial for individuals who experience a trauma. For example, in a review of factors mediating the relationship between trauma and psychopathology, it was concluded that coping styles that entail more approach behavior in targeting and minimizing post-trauma symptoms are more effective in decreasing negative psychological outcomes than coping that is more avoidant in nature (Gibbs, 1989). Similarly, children who suffered from a higher dose of trauma during a residential fire were more likely to experience PTSD symptoms when they engaged in avoidant coping styles (Jones & Ollendick, 2002). On the other hand, in a study of political prisoners, specific coping strategies were not linked to overall posttraumatic stress reactions (Schu¨tzwohl, Maercker, & Manz, 1999). In summary, active coping strategies seem to predict better outcomes relative to avoidant coping strategies, though these findings are not conclusive. 1.3. Social support Research on social support highlights its contribution to an individual’s well-being and the reduction of psychological disorders (Schu¨tzwohl et al., 1999; Zimet, Dahlem, Zimet, & Farley, 1988). In general, it appears that support from family and friends has a positive influence on the ability to cope with trauma. In fact, social support was the strongest predictor found in a meta-analysis by Brewin, Andrews, and Valentine (2000), accounting for 40% of variance in PTSD severity. The perceptions of social support are also important in the prediction of PTSD.
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It has been suggested that trauma survivors who perceive inadequate social support may be more at risk of negative outcomes (Raphael & Wilson, 1993). However, perceived social support may be directly affected by severity of the trauma. In some cases, support decreases with increases in trauma severity (Norris & Kaniasty, 1996). On the other hand, researchers have also reported a positive relationship with higher support given to survivors who have sustained more severe trauma (Solomon, Mikulincer, & Avitzur, 1988). It is difficult to determine the directional relationship between exposure dose and the adequacy of support.
2. Present study In sum, previous research has found significant relationships between injury sustained, coping behavior, and perceived social support and PTSD. The purpose of the current study was to focus on these variables in an effort to assess whether perceived social support and coping behavior moderate the relationship between perceived injury severity and subsequent PTSD reactions. It is also essential that these variables be adequately assessed in a young adult sample given the prevalence of this particular anxiety disorder (Breslau et al., 1991). Although Green et al.’s (1985) psychosocial model predicts that injury, coping behavior, and social support are mediated by cognitive appraisals, we were interested in determining if general styles of overall levels of perceived coping behavior and support were directly related to the injury-PTSD relationship in that they might serve to diminish the strong positive relationship. First, in accordance with past research, it was hypothesized that perceptions of more severe injury would predict higher PTSD symptomatology. Second, we predicted that active coping styles (i.e., interpersonal and problem-focused) would predict less severe PTSD symptoms and that avoidant styles of coping (i.e., disengagement) would be associated with more PTSD symptoms. Third, we hypothesized that higher perceived social support from family and friends would predict less severe symptoms of PTSD. The fourth hypothesis predicted that social support and coping behavior would serve independent moderational roles as protective factors in the relationship between perceptions of injury and PTSD reactions. Specifically, we predicted that individuals who perceived high degrees of injury would require high social support or high active coping behaviors in order to lessen PTSD symptoms. 2.1. Method 2.1.1. Participants Participants were 150 undergraduate students (50 male, 100 female) who reported experiencing different types of trauma. The majority of these participants were between the ages of 17 and 22 (93%). The mean age was 19.33 (SD = 1.31). Participants were primarily Caucasian (81%), followed by Asian (7.5%), African-American (5.5%), Hispanic (2.5%), and other ethnicities. Participants reported experiencing a range of traumas including technological accidents (e.g., car accidents, 30%), natural disasters (24%), violent crimes (16%), unwanted adult sexual experiences (14%), childhood abuse (10%), and abusive relationships (6%). The number of years since participants experienced the reported trauma ranged from a few months to 18 years with an average time of 5 years and 6 months (SD = 4 years, 5 months).
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2.1.2. Measures and procedure Individuals were asked to complete various self-report measures assessing the trauma’s characteristics, perceived social support, coping behavior, and PTSD symptoms. Regarding trauma exposure, participants completed the Events Scale (ES, Vrana & Lauterbach, 1994). The ES assesses participants’ exposure to various types of stressful events. In addition, participants reported different aspects of the trauma including when it had occurred, how traumatic it had been for them, and how much injury they sustained. Level of perceived injury was measured by the question, ‘‘Were you injured?’’ and was answered on a 7-point Likert type scale ranging from ‘‘not at all’’ to ‘‘severely.’’ Respondents indicated sustained injury levels ranging from 0 to 7 (M = 1.80, SD = 1.37). Participants’ PTSD-related symptoms were measured by their responses on the Purdue Post Traumatic Stress Disorder -Revised questionnaire (PPTSD-R, Lauterbach & Vrana, 1996). They were instructed to respond based on the most traumatic event they had experienced. The PPTSDR includes 17 items that comprise three scales, (1) reexperiencing the trauma, (2) avoidance, and (3) arousal based on DSM-IV symptomatology for PTSD. Participants responded to each item on a 5-point Likert type scale ranging from ‘‘not at all’’ to ‘‘often’’ regarding the frequency of each symptom during the previous month. The cumulative PTSD severity score was calculated and ranged from 17 to 69 (M = 30.31, SD = 13.34). The unstandardized Cronbach alpha for this scale was .91. In order to assess coping responses, participants were asked to complete the COPE Inventory (Carver et al., 1989). The COPE consists of 60 items answered on a 4-point Likert type scale, ranging from ‘‘I usually don’t do this at all’’ to ‘‘I usually do this a lot.’’ Items comprise 15 scales with Cronbach alpha reliabilities ranging from .45 to .92. The COPE has also shown moderate to high test-retest reliability (.46 to .77) suggesting that the measure identifies relatively stable ways that individuals cope. In an effort to reduce the number of scales and obtain more global measures of coping behavior, we factor analyzed the 15 scales using a principal component method of factor extraction with varimax rotation. In accordance with the principal component method, communalities were set at ‘1’ for the initial iteration of factors (Loehlin, 1998). Therefore, the communality of each original COPE scale was estimated by its squared multiple correlation with the remaining COPE scales. We also constrained the analysis to three factors, based upon the Scree plot showing three distinct factors with eigenvalues greater than 1.00 (Loehlin, 1998). In this analysis, 62% of the variance was accounted for and three orthogonal scales emerged regarding coping styles (described below): (1) disengagement, (2) interpersonal, and (3) problem-focused. Unstandardized Cronbach alphas were .69, .82, and .80, respectively. Disengagement coping consisted of mental and behavioral disengagement, denial, and substance use. This type of coping may be considered avoidant in nature. Interpersonal coping consisted of using emotional and social support, and venting emotions. Problem-focused coping consisted of active coping, restraining, positive reinterpretation and growth, acceptance, and planning. Participants’ mean score for each scale was calculated. Disengagement coping ranged from 4.00 to 13.23 (M = 7.39, SD = 1.90), while interpersonal coping ranged from 5.33 to 16.00 (M = 11.20, SD = 2.72) and problem-focused coping ranged from 6.40 to 15.60 (M = 11.15, SD = 1.87). The Multidimensional Scale of Perceived Social Support (MSPSS, Zimet et al., 1988) was used to assess perceived social support. Participants rated their agreement with four statements
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pertaining to the perceived support they received from family and four statements referring to the perceived support they received from friends, on a 7-point Likert scale ranging from ‘‘very strongly disagree’’ to ‘‘very strongly agree.’’ Unstandardized Cronbach alphas were .92 for both scales and scores could range from 0 to 28. Participants’ mean scale scores were used for family and friend support. Family (M = 19.19, SD = 5.24) and friend support (M = 19.32, SD = 4.84) ranged from 0 to 24. 2.2. Results Zero-order correlations were computed to determine how demographic characteristics (i.e., sex, years since trauma), perceived injury severity, coping styles, and perceived support were associated with PTSD symptomatology (Table 1). Women tended to report more PTSD symptoms. There was also a significant negative association between the years since the traumatic event had occurred and the PTSD severity. Since these variables were significantly associated with PTSD severity and research has consistently reported these variables as strong predictors of PTSD (Brewin et al., 2000), they were included as covariates in the subsequent regression models. 2.2.1. Hierarchical regressions Data were screened and all hierarchical regression assumptions were met. A series of five hierarchical regressions were conducted to test for significant main effects for perceived injury, coping, and social support, as well as the moderating effect of coping and social support predicting PTSD severity. All regressions were run separately for each coping (disengagement, interpersonal, problem-focused) and social support (family, friends) variable. Variables were centered in order to reduce multicollinearity and five interaction terms were computed (disengagement, interpersonal, problem-focused, family support, and friend support by perceived injury). After controlling for participants’ sex and years since the trauma in block one of the hierarchical regression, the main effect for perceived injury was tested in block two and the main effect for the moderator (one at a time) was tested in block three. The corresponding interaction term was entered in block four (Holmbeck, 1997, 2002). Post-hoc probing techniques (Aiken & West, 1991; Table 1 Zero-order correlations among all variables 1. 2. 3. 4. 5. 6. 7. 8. 9.
Sex Years Since Perceived Injury Family Support Friend Support Disengagement Interpersonal Problem-focused PTSD
1
2
3
4
5
6
7
8
9
1.000 .20** .06 .08 .35** .03 .28** .11 .19**
1.000 .23** .20** .00 .11 .04 .13 .23**
1.000 .00 .03 .12 .08 .13 .41**
1.000 .44** .11 .30** .32** .24**
1.000 .22** .35** .13 .10
1.000 .06 .07 .27**
1.000 .39** .12
1.000 .02
1.000
Note. Sex: Male = 0, Female = 1. *p < .05 (2-tailed). ** p < .01 (2-tailed).
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Holmbeck, 2002) were conducted using conditional moderator variables to determine whether the moderational effect was significant. The three main effects that were tested in each of the five hierarchical regressions (sex, years since trauma, and perceived injury) were significant. Women reported more PTSD symptoms than men, b = .18, t (148) = 2.23, p = .027. Manifestations of PTSD were also more severe for individuals who had experienced a traumatic event more recently, b = .20, t (148) = 2.46, p = .015. After controlling for sex and years since trauma, block two tested the main effect for perceived injury and also provided a significant contribution to PTSD symptoms, b = .39, partial t (147) = 5.23, p < .01. After controlling for sex, years since trauma, and perceived injury severity, the main effect for the moderator variables (i.e., the coping or social support scales) was entered in block three in each of the five hierarchical regressions. Two of the main effects were significant, including family support, b = .24, partial t (146) = 3.33, p < .001, and disengagement coping behavior, b = .21, partial t (146) = 2.90, p = .004. Higher levels of support from family were significantly related to less severe PTSD symptoms, while engaging in avoidance behaviors was associated with more symptoms. Two of the interaction terms were significant after controlling for the main effects and included friend support by injury, (b = .17, partial t (145) = 2.34, p = .021) and interpersonal coping behavior by injury, (b = .15, partial t (145) = 2.03, p = .044). Post-hoc probing was conducted for these possible moderators as recommended by Aiken and West (1991) and Holmbeck (2002). High and low variables for interpersonal coping and perceived friend support were computed by adding and subtracting one standard deviation from the centered value for each participant. These new variables (high/low interpersonal coping and high/low friend support) were entered into separate simultaneous regressions along with sex of the participant, years since the trauma, perceived injury, and their corresponding interaction term with perceived injury. Their regression lines were graphed based on the equations from the separate models including the simple slopes for the moderator variables and y-intercepts (see Figs. 1 and 2). These additional analyses supported the significant moderational effects for both variables on the relationship between perceived injury and PTSD symptoms. As illustrated in Fig. 1, the relationship between perceived
PTSD Symptomatology
80 70 60 Low Interpersonal Coping (b = .56)**
50 40 30 20 10
High Interpersonal Coping (b = .25)*
0 -1 SD
Mean
+1 SD
Injury
Fig. 1. Regression lines for injury-PTSD relationship as moderated by interpersonal coping behavior, b = unstandardized regression coefficient for perceived injury in each sample. SD = standard deviation.
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PTSD Syptomatology
80 70 60
Low Friend Support (b = 1.06)**
50 40 30 High Friend Support (b = .81)**
20 10 0 -1 SD
Mean Injury
+1 SD
Fig. 2. Regression lines for injury-PTSD relationship as moderated by friend support. b = unstandardized regression coefficient for perceived injury in each sample. SD = standard deviation.
injury severity and PTSD severity is stronger for those individuals with generally low interpersonal coping styles than those with high interpersonal coping styles. As illustrated in Fig. 2, the relationship between perceived injury severity and PTSD severity is stronger for those individuals who perceive lower, rather than higher, support from their friends.1
3. Discussion This study investigated the importance of perceived injury severity, perceived social support, and coping behaviors in young adults’ PTSD symptomatology. Consistent with our hypotheses, more severe perceived injury predicted PTSD severity while high support from family contributed to significantly fewer symptoms. Regarding coping styles, avoidant forms of coping, specifically disengagement coping behavior, contributed significantly to the severity of PTSD, while no significant main effects for active coping behaviors were found. Two significant moderating relationships were also detected. In particular, individuals who perceived more severe injury during their trauma reported fewer PTSD symptoms when they perceived high levels of support from friends or when they used interpersonal coping behavior as a coping mechanism. These findings help elucidate the impact of dispositional variables (i.e., coping styles and perceived support) and trauma characteristics on PTSD symptomatology in young adults. 3.1. Family support, injury, and disengagement coping styles Consistent with previous literature (Brewin et al., 2000), when trauma survivors perceived strong support from their families, they tended to experience less severe PTSD. Although several 1
The analyses were repeated using only the 62 participants who reported some levels of injury. Findings were identical to those of the larger sample such that the relationship between perceived injury levels and PTSD severity was strongest for those who engaged in low levels of interpersonal coping. A somewhat stronger relationship for those perceiving low support from friends was also found.
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studies have found some type of significant association between injury and social support (e.g., Norris & Kaniasty, 1996), we found that perceived injury was not significantly related to social support from friends and family. Thus, it seems that perceived injury and family support had direct independent effects on PTSD severity. Supportive interactions between family members and the trauma survivor may provide the individual with a valuable opportunity to talk through the event and explain the meaning of what has happened. It is possible that family members were part of some events that help to expedite recovery and provide a cathartic experience for the survivors (Raphael & Wilson, 1993). Although the type of support was not measured in the present investigation, in previous studies Ozer et al. (2003) found that emotional support has been most critical. It may be instructive to examine the types of support perceived by trauma survivors that help predict PTSD severity. This information would inform intervention strategies and help target areas that curb the development, not just the cause, of PTSD. The present investigation also found that perceived injury and disengagement behaviors contributed to more severe levels of PTSD. The negative effects of injury on the psychological outcomes of trauma have been highly cited in other studies as well and lend support to the dose-response nature of PTSD (Gibbs, 1989; Jones & Ollendick, 2002). However, the research regarding avoidant styles of coping has not been consistent. In our sample, young adult trauma survivors who tended to deny that the event had occurred, participated in activities intended to distract them, or drank alcohol in response to the trauma had more severe PTSD than those who spent time thinking about their experience. Given that these are general coping styles, it is not certain that these were the styles used following the traumatic event. Regardless, the findings suggest that continuing to use such coping styles may not be helpful. It is also important to highlight that avoidant (i.e., disengagement) rather than active (i.e., problem-focused, interpersonal) styles of coping were associated with PTSD severity. Green et al. (1985) predicted that active coping strategies would serve to protect the individual from experiencing psychic overload, which thereby would minimize PTSD severity. In the current study, however, a direct effect was not found regarding the active interpersonal and problem-focused coping strategies. Therefore, it cannot be argued that purposeful cognitive processing of the event is directly beneficial to young adults’ outcome. Rather, as discussed in the next section, such styles of coping become more influential when one considers the survivor’s injury level. 3.2. Injury moderated by interpersonal coping behaviors In the present study interpersonal coping behaviors consisted of asking for advice from others, speaking to others about feelings, and voicing emotions to others. Individuals who sustained high levels of injury during their traumatic experiences suffered from less severe PTSD symptoms when they utilized this type of coping behavior. Those who engaged in low levels of interpersonal coping behavior, who also perceived more severe injury, developed more severe PTSD than those who employed high levels of interpersonal coping. These findings suggest that positive active coping behavior, in the form of interpersonal coping, can indeed help to ameliorate PTSD severity. However, this association was uncovered only when explored in relation to amount of perceived injury suggesting that its influence depends on the level of perceived injury sustained by the trauma survivor.
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Perhaps this result helps explain the inconsistent findings regarding the role of coping behavior in predicting PTSD. Although we found that disengagement behaviors directly led to more severe PTSD, more positive and active coping styles were not directly predictive. Future research might choose to explore other types of coping styles in an effort to help understand their contradictory findings regarding coping behaviors. Conceivably, by exploring their moderated effects with risk factors, individual differences in the exact mechanisms of coping on PTSD manifestations may be revealed. 3.3. Injury moderated by friend support When highly injured trauma survivors perceived high support from their friends, they were less likely to develop severe PTSD than those who perceived less support. Thus, perceptions of support from friends help alleviate the strong positive association between injury and PTSD severity and thus serve as a powerful protective factor to those individuals. Unlike support from family, our results suggest that friend support becomes more influential when one examines its relationship vis a vis the level of injury. Thus, it seems that perceived friend support serves a more complex role than other forms of support. As previously discussed, future research might examine the nature of the support and its interactions with risk factors in the prediction of PTSD. 3.4. Limitations and future research While the present study contributed to adult PTSD literature by examining smaller components within larger conceptual models, several limitations should be noted. First, the sample was one of convenience comprised of undergraduate students and therefore may not be able to be generalized directly to a clinical sample. It would be favorable to examine these moderating relationships using a clinical population sample. Second, all questionnaires were self-report and therefore prone to such biases. Third, the coping and social support measures pertained to general lifestyle coping styles and perceived support and were not specific to the trauma. Although it can be argued that participants most likely dealt with the traumas using the coping they reported and perceiving similar amounts of support, it would be worthwhile to examine specific post-trauma factors. Lastly, some participants experienced traumas some time ago; therefore, their reports may not be as accurate as those who experienced their traumas more recently. 3.5. Conclusion This study was designed to explore the interaction between the trauma characteristic of injury and factors related to expressions of PTSD. Consistent with previous research, we found that (1) injury and disengagement styles of coping predict more severe PTSD and (2) support from family helped minimize PTSD. Though sustaining high levels of injury during a trauma may maximize the chances of developing PTSD, two variables were found to serve as protective factors and buffered this relationship, (1) perceiving strong support from friends and (2) interpersonal coping. As such, it is crucial that trauma survivors seek support from friends (and family) who provide it. It may be productive for future research to examine other nested interactions between support and
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other variables (i.e., pretrauma experiences, type of trauma, appraisal of event). The concept of support, perceiving it or seeking it out, may be considered one of the most powerful variables essential for minimizing the severity of PTSD in young adults. It may also be one of the easiest tools to provide a trauma survivor.
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