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Traumatology (Tallahass Fla). Author manuscript; available in PMC 2017 June 01. Published in final edited form as: Traumatology (Tallahass Fla). 2016 June ; 22(2): 85–93. doi:10.1037/trm0000063.
Examining the Relationship Between Trauma Centrality and Posttraumatic Stress Disorder Symptoms: A Moderated Mediation Approach
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Login S. George, Department of Psychology, University of Connecticut; Mailing Address: 406 Babbidge Road, Unit 1020, Storrs, CT 06269-1020; Phone #: 973-641-8851; [email protected] Crystal L. Park, and Department of Psychology, University of Connecticut; Mailing Address: 406 Babbidge Road, Unit 1020, Storrs, CT 06269-1020; Phone #: 860-486-3520; [email protected] Stephenie R. Chaudoir Department of Psychology, College of the Holy Cross; Mailing Address: 1 College Street, PO Box 38A, Worcester, MA, 01610; Phone #: 508-793-3620; [email protected]
Abstract
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Background and Objectives—The degree to which a traumatic event is seen as central to one's sense of self (trauma centrality) has been associated with posttraumatic stress disorder (PTSD) symptoms. Based on cognitive models of PTSD that highlight the role that maladaptive appraisals play in generating PTSD symptoms, we hypothesized that appraising a trauma as violating one's core beliefs and goals mediates the link between trauma centrality and PTSD symptoms. Further, we reasoned that coping ability moderates the direct and indirect link as those with better coping ability will have more adaptive appraisals. Design—Hypotheses were examined in a cross-sectional sample of 367 undergraduates who have experienced a traumatic event. Methods—Data were collected via an online survey. Results—Overall, results of the moderated mediation analysis were consistent with the hypothesized mediating role for appraised violations and moderating role for coping ability.
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Conclusions—Findings highlight the importance of considering individual differences and trauma appraisals in understanding the relationship between trauma centrality and PTSD — trauma centrality may be related to PTSD symptoms more so among people with poorer coping ability who appraise a trauma as violating their core beliefs and goals. Keywords trauma centrality; coping; PTSD; meaning making; stress
Correspondence to: Login S. George.
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Trauma centrality refers to the degree to which a traumatic event is seen as central to one's identity and sense of self (Berntsen & Rubin, 2006). Individuals who perceive greater centrality see the trauma as being an important part of who they are and an important part of their life story. Recent research has demonstrated that trauma centrality is positively associated with posttraumatic stress disorder (PTSD) symptoms. Such an association has been found among samples of college students (Berntsen & Rubin, 2006), older adults (Berntsen, Rubin, & Siegler, 2011), combat veterans (Brown, Antonius, Kramer, Root, & Hirst, 2010), and individuals involved in a bombing attack (Blix, Solberg, & Heir, 2013).
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Despite such accumulating evidence however, the literature is far from a well-developed understanding of the relationship between trauma centrality and PTSD. Research on this topic is relatively new (Berntsen & Rubin, 2006), and researchers have yet to gain an understanding of the mediating mechanisms and moderating factors of the relationship. In the current study, we examine potential mediators and moderators of this relationship to get a more detailed understanding of how trauma centrality may be associated with PTSD symptoms.
Appraised Violations as a Potential Mediator of the Trauma Centrality and PTSD Link
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Emotionally significant life events and experiences are important components of individuals' life stories. Major life experiences are strung together into a cohesive life narrative that informs one's sense of identity and sense of self (McAdams, 2001; McLean, Pasupathi, & Pals, 2007). While peoples' life stories appear to be biased towards positive life events, negative and traumatic events are also often incorporated (Walker, Skowronski, & Thompson, 2003). Due to their high emotional significance and impact to one's life, a traumatic event may come to be seen as central to one's sense of self (Berntsen & Rubin, 2006; Berntsen & Rubin, 2007). Existing research on centrality suggests that perceiving a trauma as central to one's sense of self is related to more PTSD symptomatology (e.g., Brown et al., 2010). However, could specific appraisals regarding the traumatic event be an important consideration when examining the trauma centrality-PTSD link? Appraisals regarding the event seems important considering that one feature of many cognitive models of PTSD is the idea that PTSD results from appraising traumatic events in non-adaptive ways (see Dalgleish, 2004, for a review). Non-adaptive appraisals are thought to generate and maintain distress while positive appraisals are thought to facilitate adjustment (Park, 2010).
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Across many models of trauma and recovery, one specific type of appraisal that is highlighted is that of violations (Park, 2010). Many cognitive models of PTSD posit that traumatic events violate individuals' core schemas, and these violations, in turn, generate and maintain distress (e.g., Cann et al., 2010; Janoff-Bulman, 1992). According to such models, individuals possess schemas — such as core beliefs and goals — that help them make sense of themselves and their lives. Traumatic events disrupt or violate these core schemas, thereby generating distress. In the aftermath of trauma, the degree to which one is able to reduce violations (by assimilating and accommodating the trauma into one’s schemas) is
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thought to alleviate PTSD symptoms (Park, 2010). Thus, in considering the link between trauma centrality and PTSD, the concept of appraisal of violations may be important.
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Due to the central role that violations are posited to play in cognitive models of PTSD and adjustment (Dalgleish, 2004), we hypothesized that appraised violations would be a key mediator through which trauma centrality predicts PTSD symptoms. Traumatic events are significant, emotional life experiences that may come to be seen as central to one's life story (Berntsen & Rubin, 2006). Due to their inherently violating nature however (Janoff-Bulman, 1992), traumatic events are also likely to be appraised as violating. That is, the traumatic event that is perceived to be central to the self is likely to be appraised as violating one's core beliefs and goals. For example, a traumatic event such as sexual assault that is seen as central to one's life story is likely to be appraised as violating one's core beliefs regarding the justness of the world (Janoff-Bulman, 1992). Such appraised violations may in turn generate and maintain PTSD symptoms such as rumination, intrusive thoughts, and negative affect (Horowitz, 1986; Park, 2010). Conceptualizing and measuring violations
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Individuals' global beliefs and goals are the core schemas through which they experience and understand the world. Global beliefs structure past experiences, convey what to expect in the future, and help people navigate their lives (Cann et al., 2010; Janoff-Bulman, 1992). Evidence suggests that the violation of one's core beliefs generates distress and motivates attempts to address the violation (Janoff-Bulman, 1992; Proulx & Inzlicht, 2012). Along with beliefs, important life goals add coherence and structure to experiences and behavior (Emmons, 1986; Little, 1983). Goals guide people’s efforts and determine the meaning and relevance of various life experiences. The violation or inability to progress on one's goals leads to negative emotions and ruminative thoughts, and has negative effects on wellbeing (Carver & Scheier, 1998; Moberly & Watkins, 2010).
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In the current study, violations was conceptualized as the perceived disruptions of one's core beliefs and goals by a traumatic event and measured by the Global Meaning Violations Scale (GMVS; Park et al., 2014; Park, Mills, & Edmondson, 2012). The GMVS explicitly asks participants to rate the degree to which a traumatic event has violated several important and common beliefs (e.g., the world is fair or just) and goals (e.g., intimacy, career related achievements). Factor analytic evidence indicates that the scale has three factors: belief violations, intrinsic goal violations, and extrinsic goal violations (Park et al., 2014). These three subscales refer to the degree to which a trauma is perceived to violate one's beliefs, intrinsic goals, and extrinsic goals, respectively. The distinction between intrinsic and extrinsic goals is important and is supported by other research on goal content and selfdetermination theory (Kasser & Ryan, 1996; Schmuck, Kasser, & Ryan, 2000). Intrinsic goals are of inherent value and intrinsically satisfying to individuals. In contrast, extrinsic goals are pursued because they represent rewards external to the individual such as positive evaluations from others. Research has shown that intrinsic and extrinsic goals show different patterns of relationships with relevant variables such as well-being (e.g., Van Hiel & Vansteenkiste, 2009; Schmuck et al., 2000).
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Consistent with the rationale presented here, previous research has found that violations as measured by the GMVS were associated with greater PTSD symptoms and poorer adjustment (Park et al., 2012). Considering such evidence in support of the important role of violations, in the current study, we hypothesized that the three subscales of the GMVS would mediate the relationship between trauma centrality and PTSD.
Coping Ability as a Potential Moderator of the Trauma Centrality and PTSD Link
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In the above section, we reasoned that individuals may appraise a trauma that is central to their identities as violating their core schemas, which may in turn generate or maintain PTSD symptoms. However, this process may be influenced by individual differences in how people respond to and appraise traumatic events. In fact, individual differences in cognitive biases such as attributional styles and ruminative tendencies have been suggested to be risk factors for developing PTSD (Bomyea, Risbrough, & Lang, 2012). More specifically, one recent study found that individual differences in negative affectivity moderated the link between centrality of a stressful event and stress symptoms (Rubin, Boals, & Hoyle, 2014). Such literature indicates that individual differences could lead to important differences in how a trauma is appraised and thus on the negative impact that trauma has on PTSD symptoms.
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In the present study, we hypothesized that one important factor that has been shown to be protective for individuals facing stressful experiences — coping ability (e.g., Burton et al., 2012) — may moderate the relationship between trauma centrality and violations. We predicted that individuals with better coping ability will appraise the traumatic event in more adaptive ways than will those with poorer coping ability. That is, while the event may be central, those with better coping may be able to see the trauma in less threatening ways (i.e., as less disruptive to their global beliefs and goals). Through these more benign appraisals, those with better coping ability may thus experience traumatic events that are central to their lives in less distressing ways.
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Here, we examine the construct of constructive thinking as a potential moderator because it represents coping ability broadly. Constructive thinking refers to an individual’s ability to solve problems in everyday life at a minimal cost in stress (Epstein, 1992) and consists of problem-solving skills such as thinking about alternatives and staying focused on tasks rather than getting distracted. Better constructive thinking is related to higher psychological functioning and self-esteem along with fewer emotional and physical symptoms and health problems (Scheuer & Epstein, 1997). Good constructive thinkers react less defensively and appraise events more positively, leading to less cognitive distortion (Epstein & Meier, 1989; Scheuer & Epstein, 1997). Although researchers have only recently begun to examine the role of constructive thinking in the context of highly stressful events (e.g., Moore et al., 2014), researchers have long demonstrated that constructive thinking relates to less distress following laboratory stressors and daily life stressors (e.g., Katz & Epstein, 1991; Park & Grant, 2005)
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In this study, we reasoned that the links — both direct and indirect — between trauma centrality and PTSD will be moderated by constructive thinking such that the direct and indirect effects will be stronger among those with weaker constructive thinking. Participants with better constructive thinking will appraise their central trauma in more adaptive ways. Specifically, better constructive thinkers will appraise the trauma as violating their beliefs and goals to a lesser degree.
Putting the Pieces Together: A Moderated Mediation Hypothesis
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Thus far, we have hypothesized that the relationship between centrality and PTSD would be mediated by violations — that is, the trauma that is seen as central to one's sense of self is likely to be appraised as violating one's core beliefs and goals, which may in turn lead to PTSD symptoms. Further, the mediated effects via the three types of violations and any direct effect of centrality on PTSD would be moderated by individuals' coping ability. This leads us to the hypothesized moderated mediation model depicted in Figure 1. Specifically, we reasoned that those with better coping ability will be able to appraise their central traumas as violating their core beliefs and goals to a lesser degree and thus experience less PTSD symptoms. Thus, we expected the indirect and direct effects of centrality on PTSD to be lower for those with better coping ability.
Method
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Data for this study came from the baseline data of a larger study of narrative writing following traumatic events. Participants were recruited through the psychology department research pool at a large university in the Northeastern United States and earned partial course credit for their participation. Eligible participants indicated having at least one DSMlevel trauma (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) at a mass prescreening session held at the beginning of the semester. Enrolled participants provided informed consent and completed questionnaires and demographic questions using an online survey. Out of the 367 enrolled participants, sixty six percent were women and mean age was 18.79 years (SD = 1.18). Most participants (76%) identified their racial/ethnic background as Caucasian and approximately 50 percent of the sample reported a yearly family income of $70,000 or more.
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Participants were asked to choose from a list of traumatic events one event that they have experienced that they find most distressing. They were directed to answer the trauma related questionnaires (discussed below) in regard to this particular event. The type of trauma that participants experienced varied. Approximately 42% of participants had experienced sudden death of a friend or loved one, 21% endorsed the "other category," and 10% experienced a motor vehicle accident. The remaining categories of trauma (e.g., natural disaster, life threatening illness, assault, unwanted sexual contact) were selected by between .5 and 2.7 percent of participants. Measures PTSD symptoms—PTSD symptoms were measured using the Posttraumatic Stress Diagnostic Scale (PTDS; Foa, Cashman, Jaycox, & Perry, 1997). The PTDS is a commonly
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used measure that assesses symptoms of PTSD as laid out in the DSM-IV. The PTDS consists of 17-items that tap different symptoms such as bad dreams, physical reactions to reminders of the trauma, and avoidance. Participants rated how much they were bothered by each symptom in the last month on a four-point scale from 0 (not at all/ only once) to 3 (5 or more times a week/almost always). A total score was calculated on which higher scores represented greater PTSD symptom severity (α = .91). The PTDS has been validated in a sample of individuals dealing with a variety of traumas and scores on the PTDS has been found to have adequate validity and reliability (Foa et al., 1997).
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Constructive thinking—Global constructive thinking was measured by the Constructive Thinking Inventory (CTI; Epstein & Meier, 1989), a 29-item measure of the extent to which people employ adaptive cognitive and behavioral coping in response to stressors (e.g., “I look at challenges not as something to fear, but as an opportunity to test myself and learn”). Participants rated each item on a five-point scale ranging from 1 (not at all true) to 5 (extremely true), so that higher scores indicate better coping skills. Previous research with the CTI has demonstrated good reliability and construct and predictive validity (e.g., Epstein & Meier, 1989; Park, Edmondson, & Lee, 2012). Cronbach’s alpha in the present sample was .89.
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Goal violations—Violations were measured using the Global Meaning Violations Scale (Park et al., 2014; Park, Mills, & Edmondson, 2012; Steger, Owens, & Park, 2015) which explicitly asks participants if their traumatic event has violated their core beliefs and goals. The GMVS consists of three subscales (belief violations, intrinsic goal violations, and extrinsic goal violations) and a mean score was calculated for all three subscales. The belief violations subscale consisted of three items regarding the extent to which trauma violated belief regarding fairness or justness of the world, belief regarding control over one's life, and belief regarding God's control over one's life (e.g., "How much does your most stressful or traumatic life event violate your sense of the world as fair or just?"). On the intrinsic and extrinsic goal violations subscales, participants were given a list of commonly pursued goals and asked to rate the extent to which their trauma interferes with the pursuit of each goal. The intrinsic goal violations subscale consisted of five items (e.g., "intimacy (emotional closeness)", "social support and community," "inner peace," "self-acceptance") and the extrinsic goal violations subscale consisted of three items (e.g., "achievement in my career," "education achievement"). Participants rated all items on the GMVS on a five-point scale that ranged from 1 (not at all) to 5 (completely). The GMVS has demonstrated desirable psychometric properties such as a consistent factor structure, good reliability, and concurrent and predictive validity (Park et al., 2012). Cronbach's alphas for the belief violations, intrinsic goal violations, and extrinsic goal violations subscales in the present study were . 69, .87, and .89 respectively. The alpha value for the belief violations subscale was relatively low (.69), which is not surprising given that the subscale has only three items. This alpha value found here is similar to what has been found in previous research (e.g., .72; Park et al., 2014). Centrality—We used the four-item Importance to Identity subscale of the Collective Self-Esteem scale (Luhtanen & Crocker, 1992) to examine the centrality of the traumatic
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event. Questions were modified to refer to respondents’ most stressful or traumatic life experience (e.g., “The most stressful or traumatic life event I experienced is an important reflection of who I am”). Each item was answered on a seven-point response scale that ranged from 1 (strongly disagree) to 7 (strongly agree) and negatively-worded items (e.g., “The most stressful or traumatic life event I experienced is unimportant to my sense of what kind of a person I am”) were reverse coded (α = .73). This scale has demonstrated strong psychometric properties among a variety of identities, including stressful and traumatic identities that are stigmatized (Quinn et al., 2014; Quinn & Chaudoir, 2009).
Results
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Descriptive statistics and bivariate correlations between the variables of interest can be found in Table 1. Results showed that greater centrality was associated with greater violations of core beliefs and goals and greater PTSD symptoms. To the contrary, constructive thinking was negatively associated with centrality, violations, and PTSD symptoms. Bivariate analyses also indicated that PTSD symptoms were not correlated with demographic variables such as gender, race, age, or income, and therefore, these demographic variables were not controlled for in the moderated mediation analysis. Moderated Mediation Analysis The moderated mediation analysis was executed using PROCESS (Hayes, 2013a) in SPSS, which uses a regression-based path analytical framework. In the following analyses, model eight of the PROCESS model templates was used, variables used to create interaction terms were mean centered, and bias corrected boot strap confidence intervals were generated using 10,000 bootstrap samples.
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Testing for moderated mediation—Hayes (2013b) introduces the index of moderated mediation as a new formal statistical test to establish moderated mediation. Often, a mediated path is said to be moderated if one of the constituent paths is significantly moderated by the moderating variable. Hayes (2013b) argues that this approach is problematic, because showing that a constituent path of an indirect effect is moderated does not establish that the indirect effect is moderated (since the indirect path is a result of multiplying the constituent paths). In a similar vein, an indirect effect can be moderated even if neither of the constituent paths appear to be moderated. He elaborates that a claim regarding moderation of the indirect effect should be based on a quantification of the effect of the moderator on the indirect effect (and not just on one of the constituent paths). If the size of the effect of the moderator on the indirect effect is significantly different from zero, then one can conclude that the indirect effect is moderated. In the following analyses, this index was used to determine if moderated mediation was present. Table 2 contains results from the four regression models that were part of the moderated mediation analysis. The index for moderated mediation (Hayes, 2013b) showed that the effect of constructive thinking on the indirect effect via intrinsic goal violations was significantly different from zero (index = −.0209; SE = .0095; 95% CI = [−.0438, −.0059]). In contrast, the effects of constructive thinking on the indirect effect via belief violations (index = −.0039; SE = .0069; 95%CI = [−.0184, .0093]) and via extrinsic goal violations Traumatology (Tallahass Fla). Author manuscript; available in PMC 2017 June 01.
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paths were not significantly different from zero (index = −.0007; SE = .0035; 95%CI = [−. 0131, .0033]). Thus, constructive thinking moderated the mediated path via intrinsic goal violations but not the mediated path via belief violations or extrinsic goal violations. In moderated mediation analyses, as the indirect effects are hypothesized to vary as a function of the moderator, no one value represents the magnitude of the effect; rather, a range of indirect effects are estimated across the range of the moderator. Below we further probe the estimated indirect and direct effects to better understand the nature of the relationship between the variables. In order to facilitate interpretation of the moderated effects, Table 3 consists of estimates of the indirect effects and direct effect at one standard deviation below the mean, at the mean, and at one standard deviation above the mean on the moderator (constructive thinking).
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The mediated path via belief violations—As mentioned above, constructive thinking did not moderate the mediated path via belief violations. Estimates of the indirect effect (Table 3) were significantly greater than zero and positive suggesting that belief violations mediated the path between centrality and PTSD symptoms, and this mediated effect was constant across levels of constructive thinking.
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The mediated path via intrinsic goal violations—The mediated path via intrinsic goal violations was significantly moderated by constructive thinking, indicating that the magnitude of the mediated path varies at different levels of constructive thinking. Estimates of the indirect effect (Table 3) showed that as constructive thinking increased, the indirect effect decreased. That is, the indirect effect between trauma centrality and PTSD via intrinsic goal violations was highest for those with low constructive thinking. Among those with high constructive thinking, the indirect effect was lower. Across low, average and high levels of constructive thinking, the indirect effects were significantly different from zero and in the positive direction, indicating that greater centrality was associated with greater PTSD symptoms. The mediated path via extrinsic goal violations—The index of moderated mediation showed that the mediated path via extrinsic goal violations was not moderated by constructive thinking. The estimates of the indirect effect at various levels of constructive thinking (Table 3) were not significantly different from zero, indicating that extrinsic goal violation was not a mediator of centrality and PTSD symptoms.
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The direct path between centrality and PTSD and its moderation—Examining the coefficients from regression model four (see Table 2) where PTSD was the dependent variable showed that the interaction term was marginally significant, indicating that the direct effect was being moderated. That is, constructive thinking moderated the direct relationship between centrality and PTSD. The fourth column of Table 3 shows how the direct effect changed as a function of low, average, and high constructive thinking. Trauma centrality has the largest direct effect at low levels of constructive thinking, and this effect gets smaller as constructive thinking increases. The direct effect becomes smaller to the extent that, at high constructive thinking, the direct effect is not significantly different from zero and there exists no direct effect between centrality and PTSD symptoms. Traumatology (Tallahass Fla). Author manuscript; available in PMC 2017 June 01.
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In summary, results showed that out of the three hypothesized mediators, intrinsic goal violations showed a moderated mediation effect, indicating that intrinsic goal violations mediated the link between centrality and PTSD symptoms, and this mediated effect was highest among individuals with poor constructive thinking abilities. Belief violations also mediated the relationship between centrality and PTSD; however, this mediated path was constant across levels of constructive thinking. In contrast to belief violations and intrinsic goal violations, extrinsic goal violations was not a mediator. Finally, the direct effect between centrality and PTSD was also moderated by constructive thinking such that centrality was not as strongly related to PTSD symptoms among individuals high on constructive thinking.
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We tested a moderated mediation model to examine if there is evidence to suggest that perceiving violations is a mediator of the centrality-PTSD link and if coping ability moderates this mediation. Results indicated that two of the hypothesized mediators, belief violations and intrinsic goal violations, partially mediated the effect of trauma centrality on PTSD symptoms. Further, individual differences in coping ability moderated the direct link between centrality and PTSD and the indirect effect via intrinsic goal violations (but not via belief violations); the moderation was such that the link between centrality and PTSD was highest for those with poor constructive thinking abilities. The Mediated Paths and Their Moderation
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The three hypothesized mediators seemed to play slightly different roles in the trauma-PTSD link. Intrinsic goal violation was a significant mediator of the centrality-PTSD link, and this mediated path was moderated by constructive thinking. Thus, the results were consistent with the idea that traumas that are central to one's identity may be appraised as violating intrinsically valued goals, and this may generate and maintain PTSD symptoms. Further, the moderation effects showed that the magnitude of the mediated path decreased for individuals higher on constructive thinking. Thus, better coping abilities were associated with trauma appraisals wherein individuals perceived less violation of intrinsic goals. Such results are consistent with the notion that people with different levels of coping ability may appraise a trauma that is central to their sense of self as violating of their schemas to different degrees, and such differences in appraised violations may in turn lead to differences in the extent to which people experience PTSD symptoms (Dalgleish, 2004; Park, 2010).
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The mediating role of intrinsic goal violations is consistent with previous literature on the relationship between disruption of valued goals and distress. Important life goals represent desired end points that add structure to one’s experiences and organize one’s behavior (Emmons, 1986). Difficulties in goal pursuit generate negative emotions and ruminative thoughts (Carver & Scheier, 1998; Moberly & Watkins, 2010). The moderation by constructive thinking is also consistent with previous literature showing that coping ability is associated with more adaptive appraisals (e.g., Epstein, 1992; Smith & Kirby, 2011). In the present results, belief violations was also a significant mediator of the centralityPTSD link. Similar to the mediation effect of intrinsic goal violation, the mediation effect of
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belief violation is consistent with the idea that centrality may lead to PTSD because individuals appraise the trauma that is central to their sense of self in ways in which they perceive violations of their core beliefs; and as discussed in many cognitive theories of PTSD (Dalgleish, 2004), such perceived violations to one's core beliefs may in turn lead to and maintain PTSD symptoms (Cann et al., 2010; Janoff-Bulman, 1992).
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Contrary to our expectations however, the mediated path via belief violations was not moderated by constructive thinking: the mediated effect stayed the same across levels of constructive thinking. This lack of moderation indicates that coping ability did not make a difference in regards to appraising a central trauma as violating one's beliefs to a lesser degree. Among individuals varying in their constructive thinking abilities, centrality was associated with the same level of perceived belief violations. It is interesting to speculate why the intrinsic goal violations path was moderated by constructive thinking but not the belief goal violations path. Why may constructive thinking abilities be associated with less intrinsic goal violations at a given level of centrality, but not less belief violations? This brings up the possibility that belief and intrinsic goal violations may play different roles in the context of trauma. For example, perhaps goal violations are more amenable to differential appraisals than belief violations. Perhaps the impact of the occurrence of trauma on one's core beliefs is more definitive than the impact on one's goals. Because of this difference in impact, there might be less room to appraise the trauma differentially when it comes to belief violations. Such reasoning would be mostly speculative at this point. Research on belief and goal violations in the context of trauma is relatively recent (Park et al., 2012) and more research is needed before we can parse out the differential roles that different types of violations play.
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In the present results, the extrinsic goal violations path was not a significant mediator of the relationship between centrality and PTSD. The results showed that although at the zeroorder correlation level extrinsic goal violations was linked to PTSD symptoms, in the regression model (see model 4 in Table 2) that included belief and intrinsic goal violations, extrinsic goal violations was not related, indicating that extrinsic goal violation has no unique association with PTSD symptoms aside from what is captured by belief and intrinsic goal violations. This finding is perhaps not so surprising in light of existing literature on goal content that highlights the difference between intrinsic and extrinsic goals and the relative importance of intrinsic goals for well-being (Kasser & Ryan, 1996; Schmuck et al., 2000). Intrinsic goals are of inherent value and satisfy individuals' psychological needs. Extrinsic goals, on the other hand, represent rewards external to the individual. Previous research has shown that intrinsic goal attainment contributed to subjective well-being but extrinsic goal attainment did not (Van Hiel & Vansteenkiste, 2009). Thus, in the context of trauma and PTSD symptoms, violation of one's intrinsic goals may be more central to driving distress than is violation of one’s extrinsic goals. The Direct Effect and its Moderation Centrality was directly related to PTSD symptoms after accounting for the mediators, and this direct path was moderated. The moderation was such that at higher constructive thinking, centrality was associated with PTSD to a lesser degree. Thus, trauma centrality
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was associated with PTSD more so for individuals with poor coping ability. The perspective that we have taken in this paper has been based on cognitive models of PTSD that highlight the role of maladaptive appraisals in leading to PTSD symptoms (Dalgleish, 2004). Our perspective has been that individuals may appraise a trauma that is central to their sense of self in maladaptive ways, which would lead to PTSD symptoms; further, individual differences in coping ability would moderate how individuals appraise the trauma (Park, 2010). The direct effect that remained after accounting for violations suggest that there may be other appraisals besides the ones that we measured (violations) that could account for the relationship between centrality and PTSD. Further, constructive thinking may moderate these other mediators as well such that those with poor coping abilities may have more nonadaptive appraisals of the trauma and this may lead to PTSD.
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It is worth noting that the direct effect between centrality and PTSD symptoms was no longer significant at high constructive thinking (see Table 3). The direct effect at one standard deviation above average constructive thinking shows that the direct effect diminishes to the extent that at one standard deviation above average, there is no direct effect between centrality and PTSD symptoms. This lack of direct effect at high levels of constructive thinking highlights the importance of considering individual differences in understanding the trauma centrality-PTSD link. Numerous studies have at this point found associations between centrality and PTSD (e.g., Berntsen & Rubin, 2006; Brown et al., 2010). Focusing on such main effects may lead one to conclude that centrality is inherently negative for psychological health as it is associated with PTSD. However, the moderating (and mediating) effects that we found in the current study highlight the notion that we should pay particular attention to individual differences such as coping ability and the specific ways in which a trauma is appraised when making conclusions regarding the centrality-PTSD link. The current results could be taken to mean that centrality is associated with PTSD symptoms more so among individuals with poor coping ability, who appraise a traumatic event in more maladaptive ways where they perceive a greater degree of violations. Limitations
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The present study findings should be interpreted in the context of several limitations. A cross-sectional study design precludes us from drawing stronger conclusions about the causal associations among study variables. Additional longitudinal research is needed in order to more precisely measure the causal effects of centrality, goal violations, and constructive thinking on PTSD symptoms. Future research should also evaluate the degree to which the current study findings replicate among more socioeconomically and racially diverse samples of adults, and more importantly, among samples that have experienced a variety of traumas (e.g., sexual assault, abuse). A test of these effects among a clinical sample of participants seeking treatment for PTSD would also strengthen the generalizability of the present study findings.
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Conclusions The results of the current study was consistent with the mediational role of violations that is often suggested by cognitive theories of PTSD (Dalgleish, 2004) and also indicative of the moderating role of coping ability in individuals' response to trauma. Present results suggest that in trying to understand the relationship between trauma centrality and PTSD, researchers and clinicians should attend to individual differences and the specific ways in which a trauma is appraised. A trauma being central to one's sense of self may not be unequivocally related to PTSD. Rather, the relationship may change as a function of individuals' coping skills and the adaptiveness of their trauma appraisals. Specifically, centrality may be related to PTSD symptoms more so among individuals with poor coping abilities who perceive the trauma as violating their core schemas about the world.
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Acknowledgments This project was supported by Grant 5R21MH75737-2 from the National Institute of Mental Health awarded to Crystal L. Park.
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Figure 1.
Conceptual model: Perceived violations of beliefs and goals mediate the effect of centrality on PTSD symptoms and constructive thinking moderates these mediated effects
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(4) Intrinsic goal violations
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Traumatology (Tallahass Fla). Author manuscript; available in PMC 2017 June 01. Published in final edited form as: Traumatology (Tallahass Fla). 2016 June ; 22(2): 85–93. doi:10.1037/trm0000063.
Examining the Relationship Between Trauma Centrality and Posttraumatic Stress Disorder Symptoms: A Moderated Mediation Approach
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Login S. George, Department of Psychology, University of Connecticut; Mailing Address: 406 Babbidge Road, Unit 1020, Storrs, CT 06269-1020; Phone #: 973-641-8851; [email protected] Crystal L. Park, and Department of Psychology, University of Connecticut; Mailing Address: 406 Babbidge Road, Unit 1020, Storrs, CT 06269-1020; Phone #: 860-486-3520; [email protected] Stephenie R. Chaudoir Department of Psychology, College of the Holy Cross; Mailing Address: 1 College Street, PO Box 38A, Worcester, MA, 01610; Phone #: 508-793-3620; [email protected]
Abstract
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Background and Objectives—The degree to which a traumatic event is seen as central to one's sense of self (trauma centrality) has been associated with posttraumatic stress disorder (PTSD) symptoms. Based on cognitive models of PTSD that highlight the role that maladaptive appraisals play in generating PTSD symptoms, we hypothesized that appraising a trauma as violating one's core beliefs and goals mediates the link between trauma centrality and PTSD symptoms. Further, we reasoned that coping ability moderates the direct and indirect link as those with better coping ability will have more adaptive appraisals. Design—Hypotheses were examined in a cross-sectional sample of 367 undergraduates who have experienced a traumatic event. Methods—Data were collected via an online survey. Results—Overall, results of the moderated mediation analysis were consistent with the hypothesized mediating role for appraised violations and moderating role for coping ability.
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Conclusions—Findings highlight the importance of considering individual differences and trauma appraisals in understanding the relationship between trauma centrality and PTSD — trauma centrality may be related to PTSD symptoms more so among people with poorer coping ability who appraise a trauma as violating their core beliefs and goals. Keywords trauma centrality; coping; PTSD; meaning making; stress
Correspondence to: Login S. George.
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Trauma centrality refers to the degree to which a traumatic event is seen as central to one's identity and sense of self (Berntsen & Rubin, 2006). Individuals who perceive greater centrality see the trauma as being an important part of who they are and an important part of their life story. Recent research has demonstrated that trauma centrality is positively associated with posttraumatic stress disorder (PTSD) symptoms. Such an association has been found among samples of college students (Berntsen & Rubin, 2006), older adults (Berntsen, Rubin, & Siegler, 2011), combat veterans (Brown, Antonius, Kramer, Root, & Hirst, 2010), and individuals involved in a bombing attack (Blix, Solberg, & Heir, 2013).
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Despite such accumulating evidence however, the literature is far from a well-developed understanding of the relationship between trauma centrality and PTSD. Research on this topic is relatively new (Berntsen & Rubin, 2006), and researchers have yet to gain an understanding of the mediating mechanisms and moderating factors of the relationship. In the current study, we examine potential mediators and moderators of this relationship to get a more detailed understanding of how trauma centrality may be associated with PTSD symptoms.
Appraised Violations as a Potential Mediator of the Trauma Centrality and PTSD Link
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Emotionally significant life events and experiences are important components of individuals' life stories. Major life experiences are strung together into a cohesive life narrative that informs one's sense of identity and sense of self (McAdams, 2001; McLean, Pasupathi, & Pals, 2007). While peoples' life stories appear to be biased towards positive life events, negative and traumatic events are also often incorporated (Walker, Skowronski, & Thompson, 2003). Due to their high emotional significance and impact to one's life, a traumatic event may come to be seen as central to one's sense of self (Berntsen & Rubin, 2006; Berntsen & Rubin, 2007). Existing research on centrality suggests that perceiving a trauma as central to one's sense of self is related to more PTSD symptomatology (e.g., Brown et al., 2010). However, could specific appraisals regarding the traumatic event be an important consideration when examining the trauma centrality-PTSD link? Appraisals regarding the event seems important considering that one feature of many cognitive models of PTSD is the idea that PTSD results from appraising traumatic events in non-adaptive ways (see Dalgleish, 2004, for a review). Non-adaptive appraisals are thought to generate and maintain distress while positive appraisals are thought to facilitate adjustment (Park, 2010).
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Across many models of trauma and recovery, one specific type of appraisal that is highlighted is that of violations (Park, 2010). Many cognitive models of PTSD posit that traumatic events violate individuals' core schemas, and these violations, in turn, generate and maintain distress (e.g., Cann et al., 2010; Janoff-Bulman, 1992). According to such models, individuals possess schemas — such as core beliefs and goals — that help them make sense of themselves and their lives. Traumatic events disrupt or violate these core schemas, thereby generating distress. In the aftermath of trauma, the degree to which one is able to reduce violations (by assimilating and accommodating the trauma into one’s schemas) is
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thought to alleviate PTSD symptoms (Park, 2010). Thus, in considering the link between trauma centrality and PTSD, the concept of appraisal of violations may be important.
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Due to the central role that violations are posited to play in cognitive models of PTSD and adjustment (Dalgleish, 2004), we hypothesized that appraised violations would be a key mediator through which trauma centrality predicts PTSD symptoms. Traumatic events are significant, emotional life experiences that may come to be seen as central to one's life story (Berntsen & Rubin, 2006). Due to their inherently violating nature however (Janoff-Bulman, 1992), traumatic events are also likely to be appraised as violating. That is, the traumatic event that is perceived to be central to the self is likely to be appraised as violating one's core beliefs and goals. For example, a traumatic event such as sexual assault that is seen as central to one's life story is likely to be appraised as violating one's core beliefs regarding the justness of the world (Janoff-Bulman, 1992). Such appraised violations may in turn generate and maintain PTSD symptoms such as rumination, intrusive thoughts, and negative affect (Horowitz, 1986; Park, 2010). Conceptualizing and measuring violations
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Individuals' global beliefs and goals are the core schemas through which they experience and understand the world. Global beliefs structure past experiences, convey what to expect in the future, and help people navigate their lives (Cann et al., 2010; Janoff-Bulman, 1992). Evidence suggests that the violation of one's core beliefs generates distress and motivates attempts to address the violation (Janoff-Bulman, 1992; Proulx & Inzlicht, 2012). Along with beliefs, important life goals add coherence and structure to experiences and behavior (Emmons, 1986; Little, 1983). Goals guide people’s efforts and determine the meaning and relevance of various life experiences. The violation or inability to progress on one's goals leads to negative emotions and ruminative thoughts, and has negative effects on wellbeing (Carver & Scheier, 1998; Moberly & Watkins, 2010).
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In the current study, violations was conceptualized as the perceived disruptions of one's core beliefs and goals by a traumatic event and measured by the Global Meaning Violations Scale (GMVS; Park et al., 2014; Park, Mills, & Edmondson, 2012). The GMVS explicitly asks participants to rate the degree to which a traumatic event has violated several important and common beliefs (e.g., the world is fair or just) and goals (e.g., intimacy, career related achievements). Factor analytic evidence indicates that the scale has three factors: belief violations, intrinsic goal violations, and extrinsic goal violations (Park et al., 2014). These three subscales refer to the degree to which a trauma is perceived to violate one's beliefs, intrinsic goals, and extrinsic goals, respectively. The distinction between intrinsic and extrinsic goals is important and is supported by other research on goal content and selfdetermination theory (Kasser & Ryan, 1996; Schmuck, Kasser, & Ryan, 2000). Intrinsic goals are of inherent value and intrinsically satisfying to individuals. In contrast, extrinsic goals are pursued because they represent rewards external to the individual such as positive evaluations from others. Research has shown that intrinsic and extrinsic goals show different patterns of relationships with relevant variables such as well-being (e.g., Van Hiel & Vansteenkiste, 2009; Schmuck et al., 2000).
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Consistent with the rationale presented here, previous research has found that violations as measured by the GMVS were associated with greater PTSD symptoms and poorer adjustment (Park et al., 2012). Considering such evidence in support of the important role of violations, in the current study, we hypothesized that the three subscales of the GMVS would mediate the relationship between trauma centrality and PTSD.
Coping Ability as a Potential Moderator of the Trauma Centrality and PTSD Link
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In the above section, we reasoned that individuals may appraise a trauma that is central to their identities as violating their core schemas, which may in turn generate or maintain PTSD symptoms. However, this process may be influenced by individual differences in how people respond to and appraise traumatic events. In fact, individual differences in cognitive biases such as attributional styles and ruminative tendencies have been suggested to be risk factors for developing PTSD (Bomyea, Risbrough, & Lang, 2012). More specifically, one recent study found that individual differences in negative affectivity moderated the link between centrality of a stressful event and stress symptoms (Rubin, Boals, & Hoyle, 2014). Such literature indicates that individual differences could lead to important differences in how a trauma is appraised and thus on the negative impact that trauma has on PTSD symptoms.
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In the present study, we hypothesized that one important factor that has been shown to be protective for individuals facing stressful experiences — coping ability (e.g., Burton et al., 2012) — may moderate the relationship between trauma centrality and violations. We predicted that individuals with better coping ability will appraise the traumatic event in more adaptive ways than will those with poorer coping ability. That is, while the event may be central, those with better coping may be able to see the trauma in less threatening ways (i.e., as less disruptive to their global beliefs and goals). Through these more benign appraisals, those with better coping ability may thus experience traumatic events that are central to their lives in less distressing ways.
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Here, we examine the construct of constructive thinking as a potential moderator because it represents coping ability broadly. Constructive thinking refers to an individual’s ability to solve problems in everyday life at a minimal cost in stress (Epstein, 1992) and consists of problem-solving skills such as thinking about alternatives and staying focused on tasks rather than getting distracted. Better constructive thinking is related to higher psychological functioning and self-esteem along with fewer emotional and physical symptoms and health problems (Scheuer & Epstein, 1997). Good constructive thinkers react less defensively and appraise events more positively, leading to less cognitive distortion (Epstein & Meier, 1989; Scheuer & Epstein, 1997). Although researchers have only recently begun to examine the role of constructive thinking in the context of highly stressful events (e.g., Moore et al., 2014), researchers have long demonstrated that constructive thinking relates to less distress following laboratory stressors and daily life stressors (e.g., Katz & Epstein, 1991; Park & Grant, 2005)
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In this study, we reasoned that the links — both direct and indirect — between trauma centrality and PTSD will be moderated by constructive thinking such that the direct and indirect effects will be stronger among those with weaker constructive thinking. Participants with better constructive thinking will appraise their central trauma in more adaptive ways. Specifically, better constructive thinkers will appraise the trauma as violating their beliefs and goals to a lesser degree.
Putting the Pieces Together: A Moderated Mediation Hypothesis
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Thus far, we have hypothesized that the relationship between centrality and PTSD would be mediated by violations — that is, the trauma that is seen as central to one's sense of self is likely to be appraised as violating one's core beliefs and goals, which may in turn lead to PTSD symptoms. Further, the mediated effects via the three types of violations and any direct effect of centrality on PTSD would be moderated by individuals' coping ability. This leads us to the hypothesized moderated mediation model depicted in Figure 1. Specifically, we reasoned that those with better coping ability will be able to appraise their central traumas as violating their core beliefs and goals to a lesser degree and thus experience less PTSD symptoms. Thus, we expected the indirect and direct effects of centrality on PTSD to be lower for those with better coping ability.
Method
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Data for this study came from the baseline data of a larger study of narrative writing following traumatic events. Participants were recruited through the psychology department research pool at a large university in the Northeastern United States and earned partial course credit for their participation. Eligible participants indicated having at least one DSMlevel trauma (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) at a mass prescreening session held at the beginning of the semester. Enrolled participants provided informed consent and completed questionnaires and demographic questions using an online survey. Out of the 367 enrolled participants, sixty six percent were women and mean age was 18.79 years (SD = 1.18). Most participants (76%) identified their racial/ethnic background as Caucasian and approximately 50 percent of the sample reported a yearly family income of $70,000 or more.
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Participants were asked to choose from a list of traumatic events one event that they have experienced that they find most distressing. They were directed to answer the trauma related questionnaires (discussed below) in regard to this particular event. The type of trauma that participants experienced varied. Approximately 42% of participants had experienced sudden death of a friend or loved one, 21% endorsed the "other category," and 10% experienced a motor vehicle accident. The remaining categories of trauma (e.g., natural disaster, life threatening illness, assault, unwanted sexual contact) were selected by between .5 and 2.7 percent of participants. Measures PTSD symptoms—PTSD symptoms were measured using the Posttraumatic Stress Diagnostic Scale (PTDS; Foa, Cashman, Jaycox, & Perry, 1997). The PTDS is a commonly
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used measure that assesses symptoms of PTSD as laid out in the DSM-IV. The PTDS consists of 17-items that tap different symptoms such as bad dreams, physical reactions to reminders of the trauma, and avoidance. Participants rated how much they were bothered by each symptom in the last month on a four-point scale from 0 (not at all/ only once) to 3 (5 or more times a week/almost always). A total score was calculated on which higher scores represented greater PTSD symptom severity (α = .91). The PTDS has been validated in a sample of individuals dealing with a variety of traumas and scores on the PTDS has been found to have adequate validity and reliability (Foa et al., 1997).
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Constructive thinking—Global constructive thinking was measured by the Constructive Thinking Inventory (CTI; Epstein & Meier, 1989), a 29-item measure of the extent to which people employ adaptive cognitive and behavioral coping in response to stressors (e.g., “I look at challenges not as something to fear, but as an opportunity to test myself and learn”). Participants rated each item on a five-point scale ranging from 1 (not at all true) to 5 (extremely true), so that higher scores indicate better coping skills. Previous research with the CTI has demonstrated good reliability and construct and predictive validity (e.g., Epstein & Meier, 1989; Park, Edmondson, & Lee, 2012). Cronbach’s alpha in the present sample was .89.
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Goal violations—Violations were measured using the Global Meaning Violations Scale (Park et al., 2014; Park, Mills, & Edmondson, 2012; Steger, Owens, & Park, 2015) which explicitly asks participants if their traumatic event has violated their core beliefs and goals. The GMVS consists of three subscales (belief violations, intrinsic goal violations, and extrinsic goal violations) and a mean score was calculated for all three subscales. The belief violations subscale consisted of three items regarding the extent to which trauma violated belief regarding fairness or justness of the world, belief regarding control over one's life, and belief regarding God's control over one's life (e.g., "How much does your most stressful or traumatic life event violate your sense of the world as fair or just?"). On the intrinsic and extrinsic goal violations subscales, participants were given a list of commonly pursued goals and asked to rate the extent to which their trauma interferes with the pursuit of each goal. The intrinsic goal violations subscale consisted of five items (e.g., "intimacy (emotional closeness)", "social support and community," "inner peace," "self-acceptance") and the extrinsic goal violations subscale consisted of three items (e.g., "achievement in my career," "education achievement"). Participants rated all items on the GMVS on a five-point scale that ranged from 1 (not at all) to 5 (completely). The GMVS has demonstrated desirable psychometric properties such as a consistent factor structure, good reliability, and concurrent and predictive validity (Park et al., 2012). Cronbach's alphas for the belief violations, intrinsic goal violations, and extrinsic goal violations subscales in the present study were . 69, .87, and .89 respectively. The alpha value for the belief violations subscale was relatively low (.69), which is not surprising given that the subscale has only three items. This alpha value found here is similar to what has been found in previous research (e.g., .72; Park et al., 2014). Centrality—We used the four-item Importance to Identity subscale of the Collective Self-Esteem scale (Luhtanen & Crocker, 1992) to examine the centrality of the traumatic
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event. Questions were modified to refer to respondents’ most stressful or traumatic life experience (e.g., “The most stressful or traumatic life event I experienced is an important reflection of who I am”). Each item was answered on a seven-point response scale that ranged from 1 (strongly disagree) to 7 (strongly agree) and negatively-worded items (e.g., “The most stressful or traumatic life event I experienced is unimportant to my sense of what kind of a person I am”) were reverse coded (α = .73). This scale has demonstrated strong psychometric properties among a variety of identities, including stressful and traumatic identities that are stigmatized (Quinn et al., 2014; Quinn & Chaudoir, 2009).
Results
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Descriptive statistics and bivariate correlations between the variables of interest can be found in Table 1. Results showed that greater centrality was associated with greater violations of core beliefs and goals and greater PTSD symptoms. To the contrary, constructive thinking was negatively associated with centrality, violations, and PTSD symptoms. Bivariate analyses also indicated that PTSD symptoms were not correlated with demographic variables such as gender, race, age, or income, and therefore, these demographic variables were not controlled for in the moderated mediation analysis. Moderated Mediation Analysis The moderated mediation analysis was executed using PROCESS (Hayes, 2013a) in SPSS, which uses a regression-based path analytical framework. In the following analyses, model eight of the PROCESS model templates was used, variables used to create interaction terms were mean centered, and bias corrected boot strap confidence intervals were generated using 10,000 bootstrap samples.
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Testing for moderated mediation—Hayes (2013b) introduces the index of moderated mediation as a new formal statistical test to establish moderated mediation. Often, a mediated path is said to be moderated if one of the constituent paths is significantly moderated by the moderating variable. Hayes (2013b) argues that this approach is problematic, because showing that a constituent path of an indirect effect is moderated does not establish that the indirect effect is moderated (since the indirect path is a result of multiplying the constituent paths). In a similar vein, an indirect effect can be moderated even if neither of the constituent paths appear to be moderated. He elaborates that a claim regarding moderation of the indirect effect should be based on a quantification of the effect of the moderator on the indirect effect (and not just on one of the constituent paths). If the size of the effect of the moderator on the indirect effect is significantly different from zero, then one can conclude that the indirect effect is moderated. In the following analyses, this index was used to determine if moderated mediation was present. Table 2 contains results from the four regression models that were part of the moderated mediation analysis. The index for moderated mediation (Hayes, 2013b) showed that the effect of constructive thinking on the indirect effect via intrinsic goal violations was significantly different from zero (index = −.0209; SE = .0095; 95% CI = [−.0438, −.0059]). In contrast, the effects of constructive thinking on the indirect effect via belief violations (index = −.0039; SE = .0069; 95%CI = [−.0184, .0093]) and via extrinsic goal violations Traumatology (Tallahass Fla). Author manuscript; available in PMC 2017 June 01.
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paths were not significantly different from zero (index = −.0007; SE = .0035; 95%CI = [−. 0131, .0033]). Thus, constructive thinking moderated the mediated path via intrinsic goal violations but not the mediated path via belief violations or extrinsic goal violations. In moderated mediation analyses, as the indirect effects are hypothesized to vary as a function of the moderator, no one value represents the magnitude of the effect; rather, a range of indirect effects are estimated across the range of the moderator. Below we further probe the estimated indirect and direct effects to better understand the nature of the relationship between the variables. In order to facilitate interpretation of the moderated effects, Table 3 consists of estimates of the indirect effects and direct effect at one standard deviation below the mean, at the mean, and at one standard deviation above the mean on the moderator (constructive thinking).
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The mediated path via belief violations—As mentioned above, constructive thinking did not moderate the mediated path via belief violations. Estimates of the indirect effect (Table 3) were significantly greater than zero and positive suggesting that belief violations mediated the path between centrality and PTSD symptoms, and this mediated effect was constant across levels of constructive thinking.
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The mediated path via intrinsic goal violations—The mediated path via intrinsic goal violations was significantly moderated by constructive thinking, indicating that the magnitude of the mediated path varies at different levels of constructive thinking. Estimates of the indirect effect (Table 3) showed that as constructive thinking increased, the indirect effect decreased. That is, the indirect effect between trauma centrality and PTSD via intrinsic goal violations was highest for those with low constructive thinking. Among those with high constructive thinking, the indirect effect was lower. Across low, average and high levels of constructive thinking, the indirect effects were significantly different from zero and in the positive direction, indicating that greater centrality was associated with greater PTSD symptoms. The mediated path via extrinsic goal violations—The index of moderated mediation showed that the mediated path via extrinsic goal violations was not moderated by constructive thinking. The estimates of the indirect effect at various levels of constructive thinking (Table 3) were not significantly different from zero, indicating that extrinsic goal violation was not a mediator of centrality and PTSD symptoms.
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The direct path between centrality and PTSD and its moderation—Examining the coefficients from regression model four (see Table 2) where PTSD was the dependent variable showed that the interaction term was marginally significant, indicating that the direct effect was being moderated. That is, constructive thinking moderated the direct relationship between centrality and PTSD. The fourth column of Table 3 shows how the direct effect changed as a function of low, average, and high constructive thinking. Trauma centrality has the largest direct effect at low levels of constructive thinking, and this effect gets smaller as constructive thinking increases. The direct effect becomes smaller to the extent that, at high constructive thinking, the direct effect is not significantly different from zero and there exists no direct effect between centrality and PTSD symptoms. Traumatology (Tallahass Fla). Author manuscript; available in PMC 2017 June 01.
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In summary, results showed that out of the three hypothesized mediators, intrinsic goal violations showed a moderated mediation effect, indicating that intrinsic goal violations mediated the link between centrality and PTSD symptoms, and this mediated effect was highest among individuals with poor constructive thinking abilities. Belief violations also mediated the relationship between centrality and PTSD; however, this mediated path was constant across levels of constructive thinking. In contrast to belief violations and intrinsic goal violations, extrinsic goal violations was not a mediator. Finally, the direct effect between centrality and PTSD was also moderated by constructive thinking such that centrality was not as strongly related to PTSD symptoms among individuals high on constructive thinking.
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We tested a moderated mediation model to examine if there is evidence to suggest that perceiving violations is a mediator of the centrality-PTSD link and if coping ability moderates this mediation. Results indicated that two of the hypothesized mediators, belief violations and intrinsic goal violations, partially mediated the effect of trauma centrality on PTSD symptoms. Further, individual differences in coping ability moderated the direct link between centrality and PTSD and the indirect effect via intrinsic goal violations (but not via belief violations); the moderation was such that the link between centrality and PTSD was highest for those with poor constructive thinking abilities. The Mediated Paths and Their Moderation
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The three hypothesized mediators seemed to play slightly different roles in the trauma-PTSD link. Intrinsic goal violation was a significant mediator of the centrality-PTSD link, and this mediated path was moderated by constructive thinking. Thus, the results were consistent with the idea that traumas that are central to one's identity may be appraised as violating intrinsically valued goals, and this may generate and maintain PTSD symptoms. Further, the moderation effects showed that the magnitude of the mediated path decreased for individuals higher on constructive thinking. Thus, better coping abilities were associated with trauma appraisals wherein individuals perceived less violation of intrinsic goals. Such results are consistent with the notion that people with different levels of coping ability may appraise a trauma that is central to their sense of self as violating of their schemas to different degrees, and such differences in appraised violations may in turn lead to differences in the extent to which people experience PTSD symptoms (Dalgleish, 2004; Park, 2010).
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The mediating role of intrinsic goal violations is consistent with previous literature on the relationship between disruption of valued goals and distress. Important life goals represent desired end points that add structure to one’s experiences and organize one’s behavior (Emmons, 1986). Difficulties in goal pursuit generate negative emotions and ruminative thoughts (Carver & Scheier, 1998; Moberly & Watkins, 2010). The moderation by constructive thinking is also consistent with previous literature showing that coping ability is associated with more adaptive appraisals (e.g., Epstein, 1992; Smith & Kirby, 2011). In the present results, belief violations was also a significant mediator of the centralityPTSD link. Similar to the mediation effect of intrinsic goal violation, the mediation effect of
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belief violation is consistent with the idea that centrality may lead to PTSD because individuals appraise the trauma that is central to their sense of self in ways in which they perceive violations of their core beliefs; and as discussed in many cognitive theories of PTSD (Dalgleish, 2004), such perceived violations to one's core beliefs may in turn lead to and maintain PTSD symptoms (Cann et al., 2010; Janoff-Bulman, 1992).
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Contrary to our expectations however, the mediated path via belief violations was not moderated by constructive thinking: the mediated effect stayed the same across levels of constructive thinking. This lack of moderation indicates that coping ability did not make a difference in regards to appraising a central trauma as violating one's beliefs to a lesser degree. Among individuals varying in their constructive thinking abilities, centrality was associated with the same level of perceived belief violations. It is interesting to speculate why the intrinsic goal violations path was moderated by constructive thinking but not the belief goal violations path. Why may constructive thinking abilities be associated with less intrinsic goal violations at a given level of centrality, but not less belief violations? This brings up the possibility that belief and intrinsic goal violations may play different roles in the context of trauma. For example, perhaps goal violations are more amenable to differential appraisals than belief violations. Perhaps the impact of the occurrence of trauma on one's core beliefs is more definitive than the impact on one's goals. Because of this difference in impact, there might be less room to appraise the trauma differentially when it comes to belief violations. Such reasoning would be mostly speculative at this point. Research on belief and goal violations in the context of trauma is relatively recent (Park et al., 2012) and more research is needed before we can parse out the differential roles that different types of violations play.
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In the present results, the extrinsic goal violations path was not a significant mediator of the relationship between centrality and PTSD. The results showed that although at the zeroorder correlation level extrinsic goal violations was linked to PTSD symptoms, in the regression model (see model 4 in Table 2) that included belief and intrinsic goal violations, extrinsic goal violations was not related, indicating that extrinsic goal violation has no unique association with PTSD symptoms aside from what is captured by belief and intrinsic goal violations. This finding is perhaps not so surprising in light of existing literature on goal content that highlights the difference between intrinsic and extrinsic goals and the relative importance of intrinsic goals for well-being (Kasser & Ryan, 1996; Schmuck et al., 2000). Intrinsic goals are of inherent value and satisfy individuals' psychological needs. Extrinsic goals, on the other hand, represent rewards external to the individual. Previous research has shown that intrinsic goal attainment contributed to subjective well-being but extrinsic goal attainment did not (Van Hiel & Vansteenkiste, 2009). Thus, in the context of trauma and PTSD symptoms, violation of one's intrinsic goals may be more central to driving distress than is violation of one’s extrinsic goals. The Direct Effect and its Moderation Centrality was directly related to PTSD symptoms after accounting for the mediators, and this direct path was moderated. The moderation was such that at higher constructive thinking, centrality was associated with PTSD to a lesser degree. Thus, trauma centrality
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was associated with PTSD more so for individuals with poor coping ability. The perspective that we have taken in this paper has been based on cognitive models of PTSD that highlight the role of maladaptive appraisals in leading to PTSD symptoms (Dalgleish, 2004). Our perspective has been that individuals may appraise a trauma that is central to their sense of self in maladaptive ways, which would lead to PTSD symptoms; further, individual differences in coping ability would moderate how individuals appraise the trauma (Park, 2010). The direct effect that remained after accounting for violations suggest that there may be other appraisals besides the ones that we measured (violations) that could account for the relationship between centrality and PTSD. Further, constructive thinking may moderate these other mediators as well such that those with poor coping abilities may have more nonadaptive appraisals of the trauma and this may lead to PTSD.
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It is worth noting that the direct effect between centrality and PTSD symptoms was no longer significant at high constructive thinking (see Table 3). The direct effect at one standard deviation above average constructive thinking shows that the direct effect diminishes to the extent that at one standard deviation above average, there is no direct effect between centrality and PTSD symptoms. This lack of direct effect at high levels of constructive thinking highlights the importance of considering individual differences in understanding the trauma centrality-PTSD link. Numerous studies have at this point found associations between centrality and PTSD (e.g., Berntsen & Rubin, 2006; Brown et al., 2010). Focusing on such main effects may lead one to conclude that centrality is inherently negative for psychological health as it is associated with PTSD. However, the moderating (and mediating) effects that we found in the current study highlight the notion that we should pay particular attention to individual differences such as coping ability and the specific ways in which a trauma is appraised when making conclusions regarding the centrality-PTSD link. The current results could be taken to mean that centrality is associated with PTSD symptoms more so among individuals with poor coping ability, who appraise a traumatic event in more maladaptive ways where they perceive a greater degree of violations. Limitations
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The present study findings should be interpreted in the context of several limitations. A cross-sectional study design precludes us from drawing stronger conclusions about the causal associations among study variables. Additional longitudinal research is needed in order to more precisely measure the causal effects of centrality, goal violations, and constructive thinking on PTSD symptoms. Future research should also evaluate the degree to which the current study findings replicate among more socioeconomically and racially diverse samples of adults, and more importantly, among samples that have experienced a variety of traumas (e.g., sexual assault, abuse). A test of these effects among a clinical sample of participants seeking treatment for PTSD would also strengthen the generalizability of the present study findings.
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Conclusions The results of the current study was consistent with the mediational role of violations that is often suggested by cognitive theories of PTSD (Dalgleish, 2004) and also indicative of the moderating role of coping ability in individuals' response to trauma. Present results suggest that in trying to understand the relationship between trauma centrality and PTSD, researchers and clinicians should attend to individual differences and the specific ways in which a trauma is appraised. A trauma being central to one's sense of self may not be unequivocally related to PTSD. Rather, the relationship may change as a function of individuals' coping skills and the adaptiveness of their trauma appraisals. Specifically, centrality may be related to PTSD symptoms more so among individuals with poor coping abilities who perceive the trauma as violating their core schemas about the world.
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Acknowledgments This project was supported by Grant 5R21MH75737-2 from the National Institute of Mental Health awarded to Crystal L. Park.
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Figure 1.
Conceptual model: Perceived violations of beliefs and goals mediate the effect of centrality on PTSD symptoms and constructive thinking moderates these mediated effects
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(3) Belief violations
(4) Intrinsic goal violations
(5) Extrinsic goal violations
(6) Constructive thinking
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