Rumination and PTSD symptoms among trauma-exposed Latinos in primary care: Is mindful attention helpful?
Introduction
Latinos represent a large and rapidly growing sector in the United States. It is estimated that by 2060 Latinos will comprise almost 30% of the population (Colby and Ortman, 2014), and yet in regard to mental health, Latinos remain a vastly understudied group (Alegría and Woo, 2009, Cochran et al., 2007). The studies that are available, however, report higher rates of posttraumatic stress symptoms (PTS) and posttraumatic stress disorder (PTSD) among Latinos relative to non-Latino Whites (Perilla et al., 2002, Pole et al., 2001, Pole et al., 2008, Schlenger et al., 1992, Zvolensky et al., 2015c). Given the well-documented comorbidity between PTS and PTSD with various forms of psychopathology and overall disability (Goldberg et al., 2014), a clearer understanding of the cognitive-affective processes that place trauma-exposed Latinos at greatest risk for higher PTSD symptoms is both scientifically and clinically important.
One factor apt to be associated with increased PTSD symptoms among trauma-exposed Latinos is rumination, a maladaptive cognitive coping strategy characterized by repetitive and focused attention on the causes and consequences of one's negative feelings (Brewin and Holmes, 2003, Morrow and Nolen-Hoeksema, 1990, Seligowski et al., 2015). Importantly, rumination is malleable and hence an optimal treatment target (Morrow and Nolen-Hoeksema, 1990). Cognitive models for the development and maintenance of PTSD suggest that rumination may be commonly used as cognitive avoidance strategy, wherein the person who has experienced a traumatic event engages in perseverative thinking regarding the causes and meaning of the trauma to escape or avoid dealing with emotionally painful memories (Ehlers and Clark, 2000, Ehlers and Steil, 1995). Rather than providing long-term relief, empirical investigations have found that rumination about the trauma is related to more severe traumatic memories and increased PTSD symptomology (Michael et al., 2007). Similarly, longitudinal investigations have found that rumination predicted PTSD symptom severity 6 months later, even after controlling for initial PTSD symptom levels (Ehring et al., 2008). Although extant findings for the role of rumination in the etiology and maintenance of PTSD symptoms are compelling, little is known about these associations among Latinos, and the factors that may weaken or strengthen this relationship are yet to be explored.
To the extent rumination is associated with increased PTSD symptomatology (Ehring et al., 2008, Roley et al., 2015), it is reasonable to suggest that mindful attention—the conscious and nonjudgmental appraisal of what is occurring in the present moment, both internally and externally (Brown and Ryan, 2003)—may be an important (malleable) protective factor (i.e., a moderator) among trauma-exposed individuals. Specifically, mindful attention may facilitate disengaging from ruminative thoughts and related maladaptive behavioral patterns. Consistent with this proposition, several investigations have found that higher levels of mindful attention are negatively related to the intensity and frequency of psychopathology symptoms (Brown and Ryan, 2003, Carlson and Brown, 2005, Gonzalez et al., 2009, Vujanovic et al., 2007, Zvolensky et al., 2006), including PTSD (Bormann et al., 2014, Vujanovic et al., 2009). Yet again, with few exceptions (Zvolensky et al., 2015a), investigations examining the role of mindful attention in PTSD symptoms among Latinos are scarce. No interactive models between rumination and mindful attention, constructs which theoretically may be at work at the same time (Vujanovic et al., 2007), have been explored in general or among Latinos specifically.
Available work suggests that rumination and mindful attention may interact (concurrently) in clinically meaningful ways among trauma-exposed Latinos. In particular, a Latino(a) with a heightened tendency to ruminate about his or her traumatic experience may likely reduce the severity of his or her PTSD symptoms to the extent that he or she is able to consolidate cognitive resources on the present moment, without assigning a judgment value to the emotions experienced. This concurrent willingness to “be in the moment” with various thoughts and emotions may, in turn, lead to more approach-oriented coping when individuals are triggered by external trauma reminders, and therefore, reduced experiential avoidance and thus more effective cognitive-affective processing of the traumatic memory by way of greater exposure to trauma cues and memories (Vujanovic et al., 2014). Heightened mindful attention and awareness may also foster psychological flexibility, such that individuals may better evaluate and adapt to circumstances wherein it may be adaptive to sit with distressing internal experiences or learn to shift attention away from ruminative thoughts (Vujanovic et al., 2014).
The present investigation examined the moderating role of mindful attention in the relation between rumination and PTSD symptoms (i.e., re-experiencing, avoidance, arousal, and total PTSD symptoms) among trauma-exposed Latinos in a primary care medical setting—wherein treatment for health problems in general, and mental health specifically, is often sought by Latinos (Vega and Lopez, 2001) because of it reduces stigma associated with seeking mental health services (Jimenez et al., 2013) separate tests for each PTSD symptom cluster (in addition to total PTSD symptoms) were conducted because dimensions of PTSD symptoms have shown differential relations with rumination (Claycomb et al., 2015). It was hypothesized that mindful attention would moderate, or lessen, the relation between rumination and all facets of PTSD symptoms, including re-experiencing, avoidance, and hyperarousal symptom clusters. Specifically, it was expected that the relation between rumination and all facets of PTSD symptoms would be significant among participants with low (versus high) levels of mindful attention, after controlling for several theoretically relevant covariates, including trauma load, negative affectivity, gender, marital status, employment status, years of education, and years in the United States. Of note, although other psychopathology symptoms such as depression and anxiety may be just as likely to emerge following trauma exposure, we focused on PTSD symptoms as outcome given evidence that ruminative and unproductive thoughts regarding the trauma (e.g., “why” questions) may serve as a form of cognitive avoidance (Ehlers and Steil, 1995) that worsens PTSD symptoms (Michael et al., 2007).
Section snippets
Participants
Participants included 182 trauma-exposed adult Latinos (89.0% female; Mage = 37.8, SD = 10.6% and 95.1% reported Spanish as their first language) attending a community-based integrated healthcare clinic in the Southwestern United States. Potential participants (18–64 years of age) were eligible for participation if they were able to read, write and communicate in Spanish and endorsed at least one traumatic event on the Posttraumatic Diagnostic Scale (PDS; Foa, 1995). Participants were excluded
Descriptive data
Participants endorsed a range of traumatic events, as defined by the PDS (Foa, 1995). The most commonly endorsed events were: natural disaster (45.1%), serious accident, fire, or explosion (30.2%), non-sexual assault by a stranger (22.5%), and sexual contact before the age of 18 by someone 5 (or more) years older (22.0%). The average number of traumas endorsed by participants was 2.0 (SD = 1.6).
Data were normally distributed with acceptable levels of skewness (−1.03 – 1.4) and kurtosis
Discussion
The present investigation examined the moderating role of mindful attention in the relation between rumination and PTSD symptoms (i.e., re-experiencing, avoidance, arousal, and total PTSD symptoms) among trauma-exposed Latinos in a primary care medical setting. Consistent with hypotheses, mindful attention was a significant moderator of relations between rumination and all facets of PTSD symptoms. Specifically, rumination and PTSD symptoms were significantly related yet only in the context of
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