The impact of perceived injustice on pain and psychological outcomes after traumatic injury: a longitudinal analysis.

ABSTRACT: Individuals' appraisals regarding the injustice of their pain or physical injury have emerged as a significant risk factor for worse physical and psychological outcomes. Injustice appraisals are defined by perceptions of external blame for pain or injury and viewing pain or injury as a source of irreparable loss. To date, research on the impact of injustice appraisal has been primarily cross sectional, and existing longitudinal studies have examined injustice appraisals at only 2 time points in the context of rehabilitation treatment. This study examined the trajectory of injustice appraisals in 171 patients admitted for traumatic injury at admission, as well as 3, 6, and 12 months after discharge and examined injustice appraisals as a potential moderator of recovery after injury. Findings can be summarized as follows: First, injustice perception was largely stable in the 12 months after hospital discharge. Second, elevated injustice perception was associated with decreased recovery in pain intensity and depressive symptomatology over the study period but did not moderate changes in pain catastrophizing or posttraumatic stress symptomatology over time. This study is the first naturalistic prospective analysis of injustice appraisal following trauma admission within the American healthcare system. Findings indicate that injustice appraisals do not naturally decrease in the aftermath of traumatic injury and may be a risk factor for poorer physical and psychological recovery. Future research should examine additional sociodemographic and psychosocial factors that may contribute to elevated injustice appraisal, as well as ways of addressing the potential deleterious impact of injustice appraisals in treatment settings.

Illusory posttraumatic growth is common, but genuine posttraumatic growth is rare: A critical review and suggestions for a path forward.

Over the last 2.5 decades, trauma researchers have increasingly become interested in posttraumatic growth (PTG) - the concept that some people experience growth as a result of trauma exposure. I begin by reviewing extant research on PTG, with a focus on measurement and conceptual issues. Expanding on arguments made by others, I distinguish between three forms of PTG, 1) perceived PTG, which is an individual's beliefs about their own PTG, 2) genuine PTG, which is veridical growth following adversity, and 3) illusory PTG, which is motivated fabrications of PTG. Perceived PTG is extremely common, as over half of individuals exposed to a potentially traumatic event (PTE) report moderate or greater levels of PTG. I review evidence that most self-reports of PTG are greatly exaggerated and argue that perceived PTG is mostly illusory PTG. I propose five reasons for the disconnect between perceived PTG and genuine PTG, including design flaws in the current measurements, emotional biases that favor perceived PTG, the inherent appeal of PTG, cultural expectations, and problems of definition. I then review the empirical evidence concerning the prevalence rate of genuine PTG, coming to the bold conclusion that the occurrence of genuine PTG is very rare, contradicting current fundamental beliefs about PTG. I recommend researchers focus on the key areas of measurement and etiology of genuine PTG, which are necessary to create interventions that foster genuine PTG. I conclude by outlining a path to steer the scientific progression of PTG back in the right direction.

Encouraging inflated reports of posttraumatic growth: the presence of a wording effect on self-reports of posttraumatic growth.

BACKGROUND AND OBJECTIVES: Posttraumatic growth (PTG) refers to positive psychological changes that result from a traumatic experience. The Posttraumatic Growth Inventory (PTGI) and the Stress-Related Growth Scale (SRGS) are the two most commonly used measures of PTG. One criticism of these measures is that all their items are positively worded (for example, "I have a greater feeling of self-reliance"). DESIGN AND METHODS: In the current paper, we conducted two studies that examined a possible wording effect in these two measures. RESULTS: In Study 1, we found that positively worded items on the PTGI are positively correlated with the negatively worded version of the same items. Additionally, the positively and negatively worded versions of these items formed two separate factors, further suggesting a wording effect. In Study 2, we conducted an experimental design by comparing self-reports of PTG when randomly assigned to complete either positively- or neutrally worded versions of the items. We found that participants reported 27% less PTG when given neutrally worded items. CONCLUSIONS: The combined results strongly suggest a wording effect that encourages overreporting of self-reports of PTG.

Self-control, coping styles, and alcohol outcomes in college students.

Objective: Research indicates that coping styles mediate self-control and health outcomes. Emotion- and problem-focused coping strategies (eg, getting advice or planning) are used to address stressors. In contrast, avoidance-focused strategies (eg, substance use) are used to escape distress and are associated with greater alcohol problems. The purpose of this study was to examine associations between college students' levels of self-control, coping styles, and alcohol use and problems. Participants and Methods: 183 undergraduates completed questionnaires regarding self-control, coping styles, and alcohol consumption and problems. We hypothesized that self-control would be associated with alcohol problems through avoidance-focused coping, but not emotion- or problem-focused coping. Results: Our results were consistent with our hypothesis with and without controlling for alcohol consumption. Undergraduates lower in self-control who engage in avoidance-focused coping may experience greater alcohol problems. Conclusions: University programs dedicated to addressing substance use among undergraduates may develop workshops that promote problem- or emotion-focused coping strategies as alternatives to avoidance-focused strategies.

Can respondents accurately self-report posttraumatic growth when coached through the required cognitive steps?

BACKGROUND: Coyne and Tennen [(2010). Positive psychology in cancer care: Bad science, exaggerated claims, and unproven medicine. Annals of Behavioral Medicine, 39(1), 16-26. https://doi.org/10.1007/s12160-009-9154-z] argue that completing self-reports of posttraumatic growth (PTG) requires four complicated cognitive steps. DESIGN: We conducted two experiments designed to (1) use mental chronometry (i.e., reaction times on cognitive tasks) to test whether respondents engage in multiple cognitive steps when completing self-reports of PTG, and (2) determine whether coaching participants to take these steps results in a more valid assessment. METHOD: In Experiment 1, 310 undergraduates were randomly assigned to complete either the Posttraumatic Growth Inventory (PTGI) or Stress-Related Growth Scale (SRGS), and its corresponding current version that requires only one cognitive step. In Experiment 2, 306 undergraduates were randomly assigned to complete either a guided-steps version of the SRGS or the original SRGS. RESULTS: Experiment 1 indicated a very small difference in completion time for the PTGI, but not the SRGS, in comparison to the current versions, suggesting respondents do not engage in the four required cognitive steps. In Experiment 2, participants reported less PTG when coached to go through the four cognitive steps, but the resulting scores were generally unrelated to measures of convergent and predictive validity. CONCLUSION: We conclude that individuals cannot accurately report PTG, even when explicitly coached.

Event centrality and posttraumatic stress symptoms after traumatic injury: A longitudinal investigation.

The development of posttraumatic stress symptoms (PTSS) can occur following a traumatic injury, which may include an increase in negative cognitions. One cognitive construct shown to be associated with the development of PTSS is event centrality, or the degree to which an individual views a traumatic experience as central to their life story. Although cross-sectional work has demonstrated a robust connection between event centrality and PTSS, the directionality of this association remains unclear. Most previous work has investigated centrality as a predictor of PTSS, although one recent study suggests that PTSS may, in fact, predict event centrality. The current longitudinal study enrolled adult civilian participants (N = 191) from a Level 1 trauma center following a traumatic injury and assessed both event centrality and PTSS at three points posttrauma (3, 12, and 18 months). A time-constrained random intercept cross-lagged panel analysis showed that PTSS predicted event centrality over the 18-month follow-up period, B = 0.16, p = .021, but event centrality did not predict PTSS, B = -0.27, p = .340. These findings suggest that the development of PTSS following trauma exposure may lead to the perception of the traumatic event as central to an individual's story over time. Further longitudinal research is necessary to determine what variables may influence the connection between PTSS and event centrality.

Resolving the paradox of posttraumatic growth and event centrality in trauma survivors.

When a traumatic experience is central to an individual's identity and worldview, it can result in either severe posttraumatic stress disorder (PTSD) symptoms, perceived posttraumatic growth (PTG), or, paradoxically, both. To resolve this apparent paradox, we used network analytic methods to estimate the relations among components of event centrality (EC), PTSD symptoms, and PTG in 1,136 undergraduates who had experienced trauma. Participants completed surveys on their experiences with traumatic events as well as the degree to which they experienced PTSD symptoms, components of EC, and components of PTG. We performed network analysis to examine EC, PTSD, and PTG and identify which components of EC were most conducive to its associations with PTSD versus those with PTG. We found that the components of EC most associated with PTSD, the extent to which trauma serves as a script for the future, were markedly distinct from the components associated with PTG, the extent to which trauma is seen as a turning point in one's life. The combined findings suggest that EC may be a catalyst for subsequent positive or negative effects contingent upon how an individual interprets the centrality of their traumatic experience.

Validation of the Injustice Experience Questionnaire (IEQ) in a spinal cord injury population.

STUDY DESIGN: Retrospective analysis of cross-sectional data. OBJECTIVES: To verify the factor structure of the Injustice Experience Questionnaire (IEQ) using a sample of individuals with spinal cord injury (SCI) and to assess IEQ scale reliability and construct validity using the same population. SETTING: Two SCI rehabilitation sites in the United States. METHODS: Three datasets were combined to conduct this validation study. The sample consisted of 341 adults with SCI who completed the IEQ, measures of psychological distress and pain, and provided sociodemographic and injury-related information. A series of confirmatory factor analyses (CFA) and exploratory factor analyses (EFA) were conducted to verify the two-factor structure of the IEQ, Cronbach's alpha was used to demonstrate scale reliability, and correlations between the IEQ and measures of pain and psychological distress were examined to assess construct validity. RESULTS: Poor model fit was observed for the two-factor structure of the IEQ as well as for the subsequent factor-structures that were explored. The IEQ demonstrated strong scale reliability (α = 0.89) and correlations between the IEQ and measures of pain and psychological distress were in the expected direction, indicating good construct validity. CONCLUSIONS: In this preliminary validation study, we failed to confirm the two-factor structure of the IEQ in a population of individuals with SCI. Though good scale reliability and construct validity were observed, further study is needed to refine the IEQ for use in this population.

When Hindsight Is Not 20/20: Ecological Momentary Assessment of PTSD Symptoms Versus Retrospective Report.

Assessment of posttraumatic stress disorder (PTSD) has relied almost exclusively on retrospective memory of symptoms, sometimes over long intervals. This approach creates potential for recall bias and obscures the extent to which symptoms fluctuate. The aim of the present study was to examine the discrepancy between retrospective self-reporting of PTSD symptoms and ecological momentary assessment (EMA), which captures symptoms closer to when they occur. The study also sought to estimate the degree to which PTSD symptoms vary or are stable in the short-term. World Trade Center responders (N = 202) oversampled for current PTSD (19.3% met criteria in past month) were assessed three times a day for 7 consecutive days. Retrospective assessment of past week symptoms at the end of the reporting period were compared with daily EMA reports. There was correspondence between two approaches, but retrospective reports most closely reflected symptom severity on the worst day of the reporting period rather than average severity across the week. Symptoms varied significantly, even within the span of hours. Findings support intervention research efforts focused on exploiting significant, short-term variability of PTSD symptoms, and suggest that traditional assessments most reflect the worst day of symptoms over a given period of recall.

Heterogeneity in temporal self-appraisals following exposure to potentially traumatic life events: A latent profile analysis.

BACKGROUND: People tend to believe that they continuously improve over time. In fact, Temporal Self-Appraisal Theory ("Chump to Champ") has found that people are motivated to derogate their past selves in favor of their present selves. Studies on temporal self-appraisals following trauma is less clear, with some studies showing perceived improvement whereas other studies show appraisals of decline. METHOD: Utilizing Latent Profile Analysis (LPA), we tested for discrete patterns of temporal self-appraisals in undergraduate college students (N = 740) following trauma exposure. We then explored various trauma-related characteristics as predictors of profile membership. RESULTS: LPA revealed three distinct profiles of appraisal styles (Profile 1: optimistic, Profile 2: chump to champ, Profile 3: pessimistic). The optimistic profile was associated with lower levels of PTSD and depression symptoms, whereas the optimistic and chump to champ profiles were associated with greater trauma centrality. LIMITATIONS: Findings are limited in that this study utilized cross-sectional data from a sample of predominantly undergraduate females, thus conclusions regarding temporal relations among study constructs cannot be made and findings may not generalize to other populations. CONCLUSION: Temporal self-appraisals following trauma exposure may reflect prototypical patterns in which individual appraise adaptation to potentially traumatic stress and may confer risk for psychopathology. Such findings have implications for approaches to intervention with clinical and non-clinical populations following trauma exposure.

The utility of college student samples in research on trauma and posttraumatic stress disorder: A critical review.

There is a widespread notion of the 'college sophomore problem' in social science research that posits that college student samples are samples of convenience with little generalizability to the general population. To address this concern, we conducted a critical review of the literature on college student samples in trauma research. Specifically, we reviewed how college student samples differ from non-college samples in four key areas of trauma research: (1) exposure rates to potentially traumatic events (PTEs), (2) prevalence of posttraumatic stress disorder (PTSD) symptoms, (3) factor structure of PTSD symptoms, and (4) PTSD's relation with common markers, correlates, and consequences. Lastly, we discussed the value and advantages of using college student samples in trauma research. Results of the critical review indicated similar trends of trauma-related findings (Points 1-4) between college student samples and both U.S. nationally collected and treatment-seeking samples; specifically, we identified a comparable lifetime PTE exposure rate, comparable rates of PTSD, a comparable factor structure of PTSD symptoms, and a comparable pattern of associations between PTSD symptoms and post-trauma markers/correlates/consequences. Although trauma-exposed college student samples are biased in some key areas, they may be no more biased than other commonly used trauma samples (e.g. epidemiological, treatment-seeking). Results of this critical review highlight the need to re-examine potentially unfounded biases on the part of the trauma research community, as well as the need to consider advantages of using college student samples in trauma research.

Stress and cognitive functioning during a pandemic: Thoughts from stress researchers.

In this commentary we discuss a downstream consequence of increases in stress and anxiety during the COVID-19 pandemic. Stress and anxiety can lead to mind wandering, which in turn competes for limited cognitive resources. We encourage researchers to be understanding and patient concerning the inevitable cognitive impact of the pandemic and subsequent reduced productivity levels from our students, colleagues, and ourselves. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Injustice is Served: Injustice Mediates the Effects of Interpersonal Physical Trauma on Posttraumatic Stress Symptoms and Depression Following Traumatic Injury.

Previous research has consistently found that traumas of an interpersonal nature are associated with elevated levels of posttraumatic stress symptoms (PTSS). In the current study, we examined whether feelings of injustice related to sustained physical trauma mediate the association between the interpersonal nature of a traumatic injury and two outcomes: PTSS and depressive symptoms. The sample consisted of 176 patients admitted to a Level 1 trauma center for traumatic injuries. Participants completed measures of PTSS, depressive symptoms, and injury-related injustice perception at baseline and again at 3- and 6-month postinjury follow-ups. The results revealed that, compared to noninterpersonal injuries, interpersonal injuries were related to significantly higher levels of perceived injustice, PTSS, and depressive symptoms at all three assessment points, except for PTSS at baseline, ds = 0.47-1.23. These associations remained significant after accounting for injury severity. It is important to note that higher levels of perceived injustice 3-month postinjury follow-up mediated the association between the interpersonal nature of the trauma and higher levels of PTSS and depressive symptoms at 6 months postinjury. Our results suggest injustice may be an important factor that helps explain why interpersonal traumas are associated with poorer mental health outcomes than noninterpersonal traumas. Additionally, the current study provides some of the first prospective analyses of injustice perception and trauma outcomes.

Perceived injustice after spinal cord injury: evidence for a distinct psychological construct.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To identify unique predictors of perceived injustice compared with depression symptoms within the first year after SCI. SETTING: Inpatient rehabilitation program in a large urban region in the Southwestern United States. METHODS: A sample of 74 participants with median time since injury of 52 days completed measures of perceived injustice, depression symptoms, posttraumatic stress symptoms, expected disability, pain intensity, and anger. RESULTS: Three unique predictors of perceived injustice as compared with depression symptoms were found-time since injury, state anger, and sex. These predictors had significantly different relationships with perceived injustice than with depression symptoms. CONCLUSIONS: Results replicate previous findings that perceived injustice is moderately correlated with depression symptoms. However, findings also reveal factors uniquely associated with perceived injustice than with depression symptoms, providing support that these are two separate constructs. Thus, these findings support development of novel interventions targeting perceptions of injustice.

Perceptions of Change after a Trauma and Perceived Posttraumatic Growth: A Prospective Examination.

Recent research has distinguished between actual posttraumatic growth (PTG) and perceived PTG. We used a prospective research design to measure both actual and perceived PTG in an attempt to replicate and extend previous findings. We examined college students (N = 64) who experienced a traumatic event between the start (Time 1) and end (Time 2) of a semester. We included three measures of change from pre- to post-trauma: (1) Actual PTG (change scores in measures of PTG domains), (2) perceived general growth (Time 2 ratings of functioning at Time 1 subtracted from actual ratings given at Time 1), and (3) perceived PTG (self-reports of PTG on the posttraumatic growth inventory). The results revealed perceived general growth and actual PTG were significantly correlated, suggesting that participants' perceptions of change were accurate. However, perceived PTG was not significantly related to either actual PTG or perceived general growth. Further, increases in actual PTG and perceived general growth were significantly related to decreases in distress and unrelated to coping. By contrast, higher levels of perceived PTG were significantly related to increases in distress and higher levels of avoidance coping. Our results suggest perceived PTG may be more of a coping process than an accurate recall of posttraumatic change.

Shattered cell phones, but not shattered lives: A comparison of reports of illusory posttraumatic growth on the Posttraumatic Growth Inventory and the Stress-Related Growth Scale-Revised.

OBJECTIVE: Existing measures of posttraumatic growth (PTG), such as the Posttraumatic Growth Inventory (PTGI), have been criticized on their ability to assess genuine PTG. Specifically, individuals tend to report illusory growth after a traumatic experience, when no true growth has taken place, as a coping mechanism. Recent evidence suggests a new measure, the Stress Related Growth Scale-Revised (SRGS-R), is less prone to reports of illusory PTG. The aim of the current study is to evaluate the extent to which participants report PTG on the PTGI and SRGS-R to an event that may be distressing, but incapable of resulting in genuine PTG-a cracked cell phone screen. METHOD: Participants (N = 613) who experienced a cracked cell phone screen were randomly assigned to complete either the SRGS-R or the PTGI, along with several measures of distress and coping. RESULTS: The results revealed that participants who completed the PTGI reported significantly higher levels of PTG, than did participants who completed the SRGS-R. In addition, scores on the PTGI were significantly correlated with PTSD symptoms, distress, anxiety, depression, avoidance coping, and denial coping. In contrast, scores on the SRGS-R were not significantly related to any of the aforementioned measures. CONCLUSIONS: These findings provide evidence that (a) existing measures of PTG can be contaminated with reports of illusory growth, and (b) the SRGS-R is less prone to such reports of illusory growth. The authors believe the SRGS-R is an important step forward in improving our ability to measure actual PTG. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Computer-Guided Problem-Solving Treatment for Depression, PTSD, and Insomnia Symptoms in Student Veterans: A Pilot Randomized Controlled Trial.

Depression is a highly prevalent psychological disorder experienced disproportionately by college student military veterans with many deleterious effects including risk for suicide. Treatment can help, but the debilitating nature of depression often makes seeking in-person treatment difficult and many are deterred by stigma, inconvenience, concerns about privacy, or a preference to manage problems themselves. The current study examines the efficacy of a computer-guided Problem-Solving Treatment (ePST®) for reducing symptoms of depression, posttraumatic stress disorder (PTSD), and insomnia in student military veterans. Twenty-four student veterans (Meanage = 32.7) with symptoms of depression were randomly assigned either to a treatment group receiving six weekly sessions of ePST or to a minimal contact control group (MCC). Participants completed the Patient Health Questionnaire-9 (PHQ-9) depression scale at baseline and then weekly through post-ePST or post-MCC. PTSD and insomnia questionnaires were also completed at baseline and posttreatment. A linear mixed model regression showed a statistically significant Group (ePST vs. MCC) × Time (pretreatment through posttreatment) interaction for depression, with the ePST showing substantial improvements in depressive symptoms over the 6-week period. Significant improvements were also seen in PTSD and insomnia symptoms. Results suggest that ePST can effectively treat depression, PTSD, and insomnia symptoms in student military veterans and may be a viable alternative for those who are not able to access live therapy. Future work should examine the durability of treatment effects and utility for more severe depression and suicide prevention.

Reducing reports of illusory posttraumatic growth: A revised version of the Stress-Related Growth Scale (SRGS-R).

OBJECTIVE: We evaluated a revised version of the Stress-Related Growth Scale (SRGS-R) against the original version (SRGS) and the most commonly used measure of posttraumatic growth, the Posttraumatic Growth Inventory (PTGI). The SRGS-R differs from the SRGS in that (a) the wording of each item was modified from implying positive change to neutral wording and (b) the rating scale includes both positive and negative impacts, which we believe makes the SRGS-R less prone to reports of illusory growth. METHOD: Participants (N = 615) completed either the SRGS-R, the SRGS, or the PTGI, along with convergent (e.g., meaning in life), outcome (depression, anxiety, global distress, well-being, PTSD symptoms, and quality of life), and coping measures. RESULTS: The PTGI and the original SRGS yielded a similar pattern of results. We replicated past findings that the PTGI was unrelated to depression, anxiety, global distress, and quality of life, and positively related to PTSD symptoms. In stark contrast, the SRGS-R was significantly related to less depression, anxiety, global distress, and greater quality of life. Most notably, the SRGS-R was negatively related to PTSD symptoms. All 3 measures had acceptable associations with convergent measures and were related to use of emotion and problem-focused coping. However, the PTGI was positively related to venting and denial, whereas the SRGS-R was negatively associated with avoidance coping. CONCLUSIONS: Our findings suggest the SRGS-R is less prone to reports of illusory growth. Improved measurement of posttraumatic growth is vital to our understanding of how individuals grow from traumatic or stressful experiences. (PsycINFO Database Record

Severity of traumatic injuries predicting psychological outcomes: A surprising lack of empirical evidence.

Despite widespread beliefs that trauma severity is related to levels of posttraumatic stress symptoms (PTSS), the empirical evidence to support such beliefs is lacking. In the current study we examined Injury Severity Score (ISS), a medical measure of event severity for physical injuries, in a sample of 460 patients admitted to a Level 1 Trauma Center. Results revealed no significant relationship between ISS and PTSS, depression, pain, and general physical and mental health at baseline, three months, and six months post-injury. However, at 12 months post-injury, ISS significantly predicted depression, pain, and physical health, but was unrelated to PTSS. The effect sizes of these relationships were small and would not remain significant if any adjustments for multiple comparisons were employed. We conclude that the relationship between ISS and PTSS is, at best, weak and inconsistent. The results are discussed in the broader picture of event severity and psychological outcomes.

The effect of depressive symptoms on social support one year following traumatic injury.

BACKGROUND: Depression is a common mental health outcome after traumatic injury, negatively impacting physical outcomes and increasing the cost of care. Research shows that the presence and quality of support is a leading protective factor against depression post-injury; however, research is vague on the directional effects of both factors over the course of recovery. METHODS: 130 patients admitted to a Level I Trauma Center were recruited to a prospective study examining overall outcomes one-year after injury. Effects of social support and depression at baseline and 12-months post-injury were examined using correlational and cross-lagged path model analyses. Additional follow-up analyses were conducted for depression on specific types of social support. RESULTS: Findings replicated previous research suggesting depression and social support were inversely related. Initial depression at time of traumatic injury was predictive of social support 12-months after their injury, but initial social support levels did not significantly predict depression at 12-months. Additionally, initial depression significantly predicted attachment, social integration, reassurance of worth, and guidance 12-months later. LIMITATIONS: Findings of the analyses are limited by lack of experimentation and inability to control for other related variables. CONCLUSIONS: Findings of the present study support the notion that initial depression predicts poorer social support in recovery, in lieu of prevailing theory (i.e., initial support buffers against later depression) in a sample of trauma patients. These findings highlight the need for medical staff to target specific factors during inpatient stay, such as addressing depressive symptoms and preparing family members and caregivers prior to discharge.