The relationship between multiple traumatic events and the severity of posttraumatic stress disorder symptoms – evidence for a cognitive link

Figures & data

Figure 1. Assumed linear structural equation model with the three latent variables dysfunctional cognitions, dysfunctional expectations and PTSD symptom severity and their manifestations.

Table 1. Results of the intercorrelations of all scales and the PTES subscales.

	PTES_SUM	PTES_A	PTES_B	PTES_C	PTES_D	PTES_E	PTES_F	PTES_G	PTES_H	PTES_I	PTCI_SUM
IES-R_SUM	.54*	.05	.35	.31	.40	.52*	.42*	.36	.28	.52*	.58*
IES-R_Intrus	.43*	.00	.26	.22	.31	.42*	.26	.32	.30	.50*	.51*
IES-R_Avoid	.38	.07	.31	.17	.31	.41*	.32	.15	.17	.29	.37
IES-R_Hyper	.43*	.03	.22	.35	.28	.36	.37	.37	.17	.42*	.48*
PTCI_SUM	.66*	.10	.55*	.44*	.56*	.60*	.55*	.52*	.22	.47*	-
PHQ-9_SUM	.63*	.18	.49*	.47*	.39*	.52*	.49*	.47*	.34	.55*	.57*

Note. IES-R_SUM = Total sum score of the Impact-of-event-Scale-revised; IES-R_Intrus = Intrusion subscale; IES-R_Avoid = Avoidance subscale; IES-R_Hyper = Hyperarousal subscale; PTCI_SUM = Total sum score of the Posttraumatic Cognitions Inventory and the Interpretation of PTSD Symptoms Inventory; PTES_SUM = Total sum score of the Posttraumatic Expectations Scale (PTES); PTES_A = Subscale A: General treatment expectations; PTES_B = Subscale B: Expectations related to the exposure to the traumatic event during psychotherapy; PTES_C = Subscale C: Expectations related to talking about the traumatic event in psychotherapy; PTES_D = Subscale D: Expectations regarding reexperiencing symptoms; PTES_E = Subscale E: Expectations regarding emotion regulation; PTES_F = Subscale F: Expectations regarding openness to other people; PTES_G = Subscale G: Expectations regarding encounters with strangers; PTES_H = Subscale H: Expectations regarding avoidance behaviour; PTES_I = Subscale I: General disorder-specific expectations; PHQ-9_SUM = Sum score of the Patient Health Questionnaire – 9

* p < .05. All p-values were corrected according to the Holm method for multiple comparisons.

Table 2. Estimated effects from the structural equation model.

	β	B	p	S.E. (B)	C.R.
Dysfunctional general cognitions
Neg. self^a	.99	1.00	-	-	-
Neg. world^a	.79	0.82	< .001	.08	10.24
Self-blame	.55	0.76	< .001	.14	5.34
IPSI^b	.86	0.98	< .001	.07	13.13
Dysfunctional expectations
PTES A^c	.38	0.44	.004	.15	2.86
PTES B^c	.72	0.76	< .001	.16	4.78
PTES C^c	.62	0.54	< .001	.12	4.31
PTES D^c	.75	1.04	< .001	.21	4.88
PTES E^c	.81	1.03	< .001	.20	5.26
PTES F^c	.64	1.03	< .001	.24	4.38
PTES G^c	.65	1.03	< .001	.23	4.47
PTES H^c	.61	1.00	.001	.23	4.54
PTES I^c	.77	1.09	< .001	.21	5.18
PTSD symptoms
Hyperarousal^d	.77	1.00	-	-	-
Avoidance^d	.42	0.63	.002	.21	2.97
Intrusions^d	.79	1.02	< .001	.20	5.15

Note. β = standardised regression weight. B = unstandardised regression weight. S.E.(B) = standard error. C.R. = critical ratio. ^aSubscale of the Post- Trauma Cognition Inventory (Ehlers, 1999): Negative Cognitions About the Self (Neg. Self), Negative Cognitions About the World (Neg. World) and Self-Blame.

^b Interpretation of PTSD Symptoms Inventory (IPSI; Dunmore et al., 1999). ^cSubscale of the Post Traumatic Expectation Scale: Scale A general treatment expectations, Scale B expectations regarding exposure to the traumatic event in psychotherapy, Scale C expectations regarding talking about the traumatic event in psychotherapy, Scale D expectations regarding reexperiencing symptoms, Scale E expectations regarding emotion regulation, Scale F expectations regarding openness to other people, Scale G expectations regarding encounters with strangers, Scale H expectations regarding avoidance behaviour, and Scale I general PTSD-specific expectations. ^dSubscales of the Impact of Event Scale- Revised (Maercker & Schützwohl, 1998).

Figure 2. Results of the structural equation model. The model illustrates the four direct effects. The direct effect of multiple traumatic events on PTSD symptom severity was not significant. Instead, the indirect effect via dysfunctional general cognitions and situational expectations was significant, speaking to a cognitive mediation model. ⁺ p < .10, *** p < .001.

Ehlers, A. (1999). Posttraumatische Belastungsstörung. Hogrefe.

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Dunmore, E., Clark, D. M., & Ehlers, A. (1999). Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy, 37(9), 809–829. https://doi.org/10.1016/S0005-7967(98)00181-8

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Maercker, A., & Schützwohl, M. (1998). Erfassung von psychischen Belastungsfolgen: Die Impact of Event Skala-revidierte Version (IES-R). [Assessment of post-traumatic stress reactions: The impact of event scale-revised (IES-R)]. Diagnostica, 44(3), 130–141.

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Data availability statement

Data can be made available upon request. Data cannot be made freely available because this was not part of the informed consent that was approved by the institutional review board back in 2018.