Trait rumination predicts onset of Post-Traumatic Stress Disorder through trauma-related cognitive appraisals: A 4-year longitudinal study
Introduction
Trauma-related rumination, defined as repetitive and recurrent thinking about the trauma and its consequences (Michael, Halligan, Clark, & Ehlers, 2007), has been proposed as a maladaptive cognitive coping strategy that maintains symptom levels or a diagnosis of PTSD (Ehlers and Clark, 2000, Wells and Sembi, 2004). In accordance with this presupposition, in numerous cross-sectional studies significant and moderately strong associations of trauma-related rumination with PTSD (symptoms) following different types of traumatic events have been found (Bennett and Wells, 2010, Clohessy and Ehlers, 1999, Ehlers et al., 1998, Ehring et al., 2008, Halligan et al., 2006, Hussain and Bhushan, 2011, Michael et al., 2007, Razik et al., 2013). Moreover, some prospective studies showed that trauma-related rumination assessed shortly after the trauma predicts PTSD some months later, also after controlling for initial symptom levels and/or other established predictors of PTSD (Ehring and Ehlers, 2014, Ehring et al., 2008, Kleim et al., 2007, Michael et al., 2007). Lastly, experimental studies have demonstrated that the induction of rumination about a traumatic film or real-life stressor results in significantly more analogue PTSD symptoms and/or a significantly slower recovery from the stressor than control conditions (Ehring et al., 2009, Zetsche et al., 2009).
Worry, defined as “an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes …” (Borkovec, Robinson, Pruzinsky, & DePree, 1983), constitutes another form of repetitive negative thinking (Watkins, 2008) and has been found to be associated with PTSD symptom severity following different types of traumatic events (Bardeen et al., 2013, Bennett et al., 2009, Pietrzak et al., 2011, Rosenthal et al., 2006, Warda and Bryant, 1998). Moreover, worry was predictive of the development of PTSD in traffic accident survivors (Holeva, Tarrier, & Wells, 2001) and in college students exposed to a significant life stressor (Roussis & Wells, 2008). Finally, worrying about an experimental stressor for a period of 4 min after exposure led to significantly more intrusions in the next 3 days than a settle-down control condition (Wells & Papageorgiou, 1995).
Taken together, these studies suggest that trauma-related rumination and worry constitute important cognitive risk factors for the maintenance of PTSD. We are not aware of studies that examined whether the propensity to repetitive negative thinking in the form of rumination or worry constitutes a pre-trauma cognitive risk factor for onset of PTSD and whether this effect of repetitive negative thinking on onset of PTSD is mediated by more negative cognitive appraisals of exposure to trauma. Individual differences in repetitive negative thinking as a transdiagnostic risk factor may not only be relevant for the onset and maintenance of depression and anxiety (Ehring & Watkins, 2008), but given the high levels of comorbidity and symptom similarity between depression, anxiety and PTSD (Brady et al., 2000, Spinhoven et al., 2014) this established risk factor for anxiety and depression may also serve as a risk factor for PTSD.
In a comprehensive review of cognitive risk factors for onset of PTSD (Elwood, Hahn, Olatunji, & Williams, 2009), reliance on cross-sectional designs and use of retrospective self-report measures are identified as a major study limitation of the extant literature. Ideally, studies of cognitive risk factors would include pre-trauma, peri-trauma, and post trauma assessments in order to improve our understanding of temporal relationships. Studies relying only on retrospective self-report data should include and control for measures of distress at the time of measurement. Finally, research examining cognitive risk factors will need to demonstrate that it can contribute above and beyond previously identified risk factors for PTSD (Elwood et al., 2009).
Risk-factor research may have clinical relevance and can inform the development of indicated and targeted prevention programs (Zvolensky, Schmidt, Bernstein, & Keough, 2006). In order to understand this translational link, some operational definitions of risk factors are necessary. Following Kraemer (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001) a risk factor can be defined as a factor that is related to, and temporarily precedes, a negative outcome. Causal risk factors are factors that when modified (e.g., by treatment) result in changes in outcome. Proxy risk factors are also related to a negative outcome, but this association is due to the proxy risk factor's relation with another causal risk factor. When a risk factor (e.g., gender) cannot be changed it is defined as a fixed marker of risk and not as a malleable risk factor. Our first study aim was to examine whether the inclination to repetitive negative thinking in the form of trait rumination and trait worry is a risk factor for the onset of PTSD and not a proxy risk factor due to its association with demographic and clinical severity and history variables. Moreover, we wanted to examine whether the predictive value of the inclination to repetitive negative thinking for onset of PTSD is mediated by cognitive rather than affective reactions to trauma exposure over and above the effect of other risk factors. Identification of repetitive negative thinking as a risk factor would pave the way for further studies examining whether it also constitutes a malleable causal risk factor (i.e., a factor when modified by treatment reduces the risk of post-traumatic stress reactions). We hypothesized that the inclination to repetitive negative thinking would independently predict PTSD onset and that cognitive reactions to trauma exposure would partly mediate this effect.
Section snippets
Sample
The Netherlands Study of Depression and Anxiety (NESDA) is an ongoing cohort study designed to investigate determinants, course and consequences of depressive and anxiety disorders. The NESDA sample of 2981 adults (18–65 years) includes participants with a life time and/or current anxiety and/or depressive disorder (n = 2329; 78%) and healthy controls (persons without depressive or anxiety disorders; n = 652; 22%). To include various developmental stages of disorders and different levels of
Sample characteristics
We examined whether sample attrition had introduced potential selection bias. Study dropouts between baseline and 4-yr follow-up (n = 579) did not differ from study completers (n = 2402) regarding gender distribution, age and level of rumination. However, in comparison to completers dropouts were significantly less educated (Cohen's d = .33) and showed higher levels of depressive (d = .43) and anxiety symptoms (d = .40) and trait worry (d = .27). Moreover, dropout showed a higher proportion of
Discussion
The first aim of the present study was to examine to what extent the inclination to repetitive negative thinking in the form of trait rumination and trait worry predicts the onset of PTSD over and above the effect of other risk factors. In the present study among persons without and with past or current depressive and anxiety disorders, 15% reported exposure to a traumatic event during the follow-up period of whom 14% developed PTSD according to strict diagnostic criteria for PTSD (Brewin
Conflict of interest
The authors have no conflict of interests to declare.
Acknowledgments
The infrastructure for the NESDA study (www.nesda.nl) is funded through the Geestkracht program of the Netherlands Organisation for Health Research and Development (Zon-Mw, grant number 10-000-1002) and is supported by participating universities and mental health care organizations (VU University Medical Center, GGZ inGeest, Arkin, Leiden University Medical Center, GGZ Rivierduinen, University Medical Center Groningen, Lentis, GGZ Friesland, GGZ Drenthe, Scientific Institute for Quality of
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