Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: Experiential avoidance as a contributor to distress and quality of life

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Abstract

Few studies have been conducted on psychological disorders other than post-traumatic stress disorder (PTSD) in war survivors. The aim of this study was to examine PTSD, social anxiety disorder (SAD), and major depressive disorder (MDD) and their associations with distress and quality of life in 174 Albanian civilian survivors of the Kosovo War. This included testing of conceptual models suggesting that experiential avoidance might influence associations between anxiety and mood disorders with psychological functioning. Each of the three psychiatric disorders was associated with greater experiential avoidance and psychological distress, and lower quality of life. Being a refugee was associated with a higher likelihood of having SAD and MDD. We found evidence for experiential avoidance as a partial mediator of the respective effects of SAD and PTSD on quality of life; experiential avoidance did not mediate the effects of disorders on global distress. We also found support for a moderation model showing that only war survivors without SAD and low experiential avoidance reported elevated quality of life; people with either SAD or excessive reliance on experiential avoidance reported compromised, low quality of life. This is the third independent study, each using a different methodology, to find empirical support for this moderation model [Kashdan, T. B., & Breen, W. E. (2008). Social anxiety and positive emotions: a prospective examination of a self-regulatory model with tendencies to suppress or express emotions as a moderating variable. Behavior Therapy, 39, 1–12; Kashdan, T. B., & Steger, M. F. (2006). Expanding the topography of social anxiety: an experience sampling assessment of positive emotions and events, and emotion suppression. Psychological Science, 17, 120–128]. Overall, we provided initial evidence for the importance of addressing PTSD, SAD, MDD, and experiential avoidance in primarily civilian war survivors.

Section snippets

Experiential avoidance as a contributor to distress and quality of life

Psychiatric disorders widely studied in relation to trauma exposure include PTSD (by definition; American Psychiatric Association, 1994), social anxiety disorder (e.g., Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006; Green, Lindy, Grace, & Leonard, 1992; Orsillo, Heimberg, Juster, & Garrett, 1996), and depression (e.g., O’Donnell, Creamer, & Pattison, 2004; Shalev et al., 1998). Despite high rates of comorbidity among these conditions, there is evidence for some degree of independent onset and

Psychiatric conditions and experiential avoidance operating together in Kosovo War survivors

Existing data suggest that several psychiatric conditions and experiential avoidance contribute to the mental health of trauma survivors. Yet, nearly all of this work has been limited to the study of American male combat veterans. Despite several empirical studies of whether experiential avoidance mediates or moderates adverse consequences associated with psychiatric conditions, only a small body of work has focused on trauma survivors (Batten, Orsillo, & Walser, 2005).

To address gaps in the

Procedure and participants

The current study is part of a larger IRB-approved non-related project (Priebe et al., 2008). Our data collection occurred in 2006, 7 years after the war, across different regions of Kosovo. A random walk-in technique was utilized in the general population that had been exposed to war-related traumatic experiences in 1998 and 1999. First, 6 out of 30 possible administrative units or municipalities in Kosovo were randomly chosen. These six regions were Prishtina, Gllogovc, Fushë Kosova,

Preliminary analyses

As reported above, the current study is part of a larger multi-national project with more than 4100 respondents. For the 174 participants in the present study, only one data point was missing. We imputed the missing value with the mean item score for the specific questionnaire in question (BSI). Missing data was a minor problem in the study as a function of the interview format used to collect data. The entire interview was read to the participants by interviewers who at the end of the

Discussion

Drawing on a community sample of Albanian civilian survivors of the Kosovo War, we examined whether PTSD, SAD, MDD, and experiential avoidance were associated with mental health and quality of life outcomes. Extending previous findings on PTSD (e.g., Plumb et al., 2004; Valentiner, Foa, Riggs, & Gershuny, 1996), SAD (e.g., Frueh et al., 2006; Kashdan, Julian, Merritt, & Uswatte, 2006), and depression (e.g., Ottenbreit & Dobson, 2003; Zettle & Rains, 1989), each of these conditions was

Acknowledgements

This research was funded by commission of the European Community within the Framework Programme 6, contract N: INCO-CT-2004-509175, principal investigator: Stefan Priebe. Additional support was provided by National Institute of Mental Health grant MH-73937 to Todd B. Kashdan. We thank Matthew Tull for his helpful comments on an earlier draft.

References (86)

  • Y. Lecrubier et al.

    The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI

    European Psychiatry

    (1997)
  • B.P. Marx et al.

    The role of emotion in the psychological functioning of adult survivors of childhood sexual abuse

    Behavior Therapy

    (2002)
  • B.P. Marx et al.

    Experiential avoidance, peritraumatic dissociation, and post-traumatic stress disorder

    Behaviour Research and Therapy

    (2005)
  • J.C. Plumb et al.

    A preliminary test of thee role of experiential avoidance in post-event functioning

    Journal of Behavior Therapy and Experimental Psychiatry

    (2004)
  • K. Salters-Pedneault et al.

    The role of avoidance of emotional material in the anxiety disorders

    Applied and Preventive Psychology

    (2004)
  • D.V. Sheehan et al.

    The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability

    European Psychiatry

    (1997)
  • S. Starr et al.

    The role of negative interpretations of intrusive memories in depression

    Journal of Affective Disorders

    (2006)
  • A.A. Vujanovic et al.

    A test of the interactive effects of anxiety sensitivity and mindfulness in the prediction of anxious arousal, agoraphobic cognitions, and body vigilance

    Behaviour Research and Therapy

    (2007)
  • R. Yehuda et al.

    Predicting the development of posttraumatic stress disorder from the acute response to a traumatic event

    Biological Psychiatry

    (1998)
  • J. Ahern et al.

    Gender, social support, and posttraumatic stress in postwar Kosovo

    Journal of Nervous and Mental Disease

    (2004)
  • L.S. Aiken et al.

    Multiple regression: testing and interpreting interactions

    (1991)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1994)
  • D.H. Barlow

    Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory

    American Psychologist

    (2000)
  • R.M. Baron et al.

    The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations

    Journal of Personality and Social Psychology

    (1986)
  • S.V. Batten et al.

    Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder

  • R.F. Baumeister

    Ego depletion and self-control failure: an energy model of the self's executive function

    Self and Identity

    (2002)
  • R.F. Baumeister et al.

    Ego-depletion: is the active self a limited resource

    Journal of Personality and Social Psychology

    (1998)
  • S.R. Bishop et al.

    Mindfulness: a proposed operational definition

    Clinical Psychology: Science and Practice

    (2004)
  • L. Campbell-Sills et al.

    Acceptability of negative emotion in anxiety and mood disorders

    Emotion

    (2006)
  • B.L. Cardozo et al.

    Mental health, social functioning, and feelings of hatred and revenge of Kosovar Albanians one year after the war in Kosovo

    Journal of Traumatic Stress

    (2003)
  • C.S. Carver et al.

    On the self-regulation of behavior

    (1998)
  • D.M. Clark et al.

    A cognitive model of social phobia

  • J. Cohen

    Statistical power analysis for the behavioral sciences

    (1977)
  • M.G. Craske et al.

    Facilitating symptom reduction and behavior change in GAD: the issue of control

    Clinical Psychology: Science and Practice

    (2002)
  • L.R. Derogatis et al.

    The Brief Symptom Inventory: an introductory report

    Psychological Medicine

    (1983)
  • D.E. Erickson et al.

    Posttraumatic stress disorder and depression symptomatology in a sample of Gulf War veterans: a prospective analysis

    Journal of Consulting and Clinical Psychology

    (2001)
  • E.B. Foa et al.

    The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale

    Psychological Assessment

    (1997)
  • J.P. Forsyth et al.

    Fear conditioning in an emotion regulation context: a fresh perspective on the origins of anxiety disorders

  • B.L. Fredrickson et al.

    What good are positive emotions in crises?: a prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001

    Journal of Personality and Social Psychology

    (2003)
  • B.L. Green et al.

    Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample

    Journal of Nervous and Mental Disease

    (1992)
  • S.C. Hayes et al.

    Measuring experiential avoidance: a preliminary test of a working model

    The Psychological Record

    (2004)
  • S.C. Hayes et al.

    Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment

    Journal of Consulting and Clinical Psychology

    (1996)
  • International Federation of Red Cross and Red Crescent Societies

    World disasters report 1993

    (1993)
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