Posttraumatic growth moderates the effect of posttraumatic stress on quality of life in U.S. military veterans with life-threatening illness or injury
Introduction
Posttraumatic stress disorder (PTSD) has been a focal point of much war-related trauma research [43,71,87]. For several decades, a large body of research has examined the relationship between PTSD and physical impairment, disability, and functionality [3,49,50,72]. Wiseman, Foster, and Curtis [88] conducted a review of 41 publications on the topic of traumatic physical injury and mental health. They noted that PTSD was the most frequently researched mental health issue following a traumatic physical injury and that the incidence of PTSD ranged from 30% to 93% in individuals who survived a traumatic physical injury. Schweininger and colleagues [69] suggested that “there is something uniquely damaging about high levels of PTSD symptoms in the aftermath of injury” (p. 5). PTSD also has been associated with a lower quality of life (QoL) among war Veterans [68]. In view of the detrimental impact of PTSD on individuals' lives, the present research focused on investigating what factors may increase QoL in the context of PTSD and severe injury or disability among Veterans, in order to promote mental health for this population.
Epidemiological studies on PTSD among Veterans have indicated that not everyone experiencing traumatic events will develop PTSD symptoms. In the National Vietnam Veterans Readjustment Study, Kulka et al. [43] reported that fifteen or more years after their service, 15.2% of males and 8.1% of females who were Vietnam theater Veterans had a current diagnosis of PTSD, indicating that about 85% of the males and 92% of the females did not have PTSD. These PTSD studies among Veterans and other trauma survivors inevitably led to questions about why people experience PTSD after trauma and how resilience and posttraumatic growth (PTG) may mitigate the experience of PTSD.
PTG refers to positive personal changes that result from the survivor's struggle to cope with trauma and its psychological consequences [78]. PTG is distinct from resilience in that individuals experiencing PTG do not merely return to a pre-trauma baseline, but, in fact, advance to higher than pre-trauma levels in one or more life domains, such as self-perception, relationships with others, greater emotional expressiveness, greater appreciation and enjoyment of life, a more meaningful life, and heightened spirituality [76,77,79]. Tedeschi and Calhoun [10,76,77,79] noted that the PTG process does not necessarily decrease emotional distress, because growth after extreme life crises may require an existential struggle for people to rebuild their worldviews. Tedeschi and Calhoun [77] emphasized that “For most trauma survivors, posttraumatic growth and distress will coexist, and the growth emerges from the struggle with coping, not from the trauma itself” (p. 60).
Recent research has explored PTG among Veterans who reported PTSD. Pietrzak and colleagues ([[81], [82], [83]]) conducted a nationally representative study (N = 3157) called the National Health and Resilience in Veterans Study (NHRVS), which assessed PTG, resilience, PTSD, and other variables among Veterans. Of all potentially traumatic events, experiencing a life-threatening illness or injury was significantly and positively related to PTG, while experiencing a natural disaster was significantly and negatively related to PTG among the full NHRVS sample that included Veterans exposed to a broad range of potentially traumatic life events [81]. These particular findings from the full NHRVS sample suggested that the relationship between life-threatening illness or injury and PTG warrants a more in-depth examination. This information could help elucidate the role of PTG—both directly and as a potential moderator of illness/injury-related PTSD symptoms—in relation to functioning and QoL in Veterans with life-threatening illness or injury.
Section snippets
Quality of life and chronic illness and disability
QoL, which is the focus of the present study, has been used as both an outcome variable and a therapeutic goal in literature on coping with life traumas, and more specifically psychosocial adaptation to chronic illness and disability (CID; [5,20,24,45,66]). QoL has been viewed rather consistently as an outcome of these and related psychosocial models of adaptation to CID, trauma, and crisis. QoL is also depicted as a complex, multidimensional, and dynamic construct that incorporates both
Aims of study
The present study has three aims. The first aim is to examine the predictive ability of PTSD and PTG on individuals' QoL among a sample who experienced a range of life-threatening illnesses or injuries. The second aim is to examine whether PTG acts as a protective factor that moderates the effect of PTSD on QoL among this sample with diverse life-threatening illnesses or injuries. The third aim of this study, as an extension of the second aim, is to examine the specific role played by each of
Research hypotheses
- 1.
PTSD symptoms will be negatively associated and PTG positively associated with perceived QoL among Veterans who have experienced life-threatening illnesses and injuries.
- 2.
PTG will moderate the effect of PTSD symptoms on QoL among Veterans who have experienced life-threatening illnesses or injuries, such that Veterans with greater PTG will report greater QoL than Veterans with lower PTG.
- 3.
Each of the five PTG components (subscales) will moderate the effect of PTSD on QoL among Veterans who have
Participants
The NHRVS is a nationally representative survey of U.S. Veterans (N = 3157). This internet-based survey was conducted from October to December 2011. The present cross-sectional study focused on a subsample of the NHRVS (N = 418), which consisted only of individuals who reported a life-threatening illness or injury as their ‘worst’ traumatic life event. Prior to initiating the proposed analyses, a power analysis was conducted. In order to detect a medium effect size (R2 = 0.15) for linear
Results
The following continuous control variables were significantly correlated with QoL: 1) Age, r = 0.314, p < 0.001; 2) sum of number of lifetime traumas, r = − 0.405 p < 0.001; 3) sum of disabilities in activities of daily living (ADL): r = −0.358 p < 0.001; 4) sum of disabilities in instrumental activities of daily living (IADL), r = −0.571 p < 0.001; and 5) household income, r = −0.219, p < 0.001. TSI was not significantly correlated with QoL, r = 0.015 p = 0.761. The following categorical
Discussion
The aims of this research were to investigate whether PTSD and PTG influenced individuals' QoL, whether PTG moderated the hypothesized association between PTSD and QoL, and whether all five PTG factors moderated the PTSD and QoL association. The results of this cross-sectional study indicated, not surprisingly, that PTSD was inversely associated with QoL. The finding that PTG was associated positively with QoL in the fully adjusted models is consistent with prior work. In research with a larger
Conclusion
Notwithstanding these limitations, results of this study suggest that PTG moderates the relation between PTSD symptoms and QoL in U.S. Veterans who reported a life-threatening illness or injury as their ‘worst’ traumatic event. While severity of illness/injury-related PTSD symptoms were strongly and negatively related to QoL, greater perceptions of PTG, particularly relating to others, new possibilities, and personal strength, were positively related to QoL and moderated the effect of PTSD
Conflicts of interest
There are no conflicts of interests to report.
Disclaimer
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
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