The relationship between maladaptive appraisals and posttraumatic stress disorder: a meta-analysis

Figures & data

Figure 1. PRISMA diagram outlining results from the study selection process.

Table 1. Results from overall and subgroup meta-analyses.

	K	n	r	LL	UL	Z	p	Q	df	p
TOTAL – ALL STUDIES*	147	29,812	0.53	0.51	0.56	30.88	<0.01	1382.37*	146	<0.0001; I^2 = 89.4%
Age Group
Child	25	9326	0.59	0.54	0.64	18.10	<0.01
Adult	120	19,795	0.52	0.49	0.55	24.66	<0.01
Subgroup analysis								5.73	1	<0.02
Population
Civilian	138	28,530	0.54	0.51	0.56	32.19	<0.01
Military	6	1159	0.44	0.05	0.71	2.19	0.03
Subgroup analysis								0.34	1	0.56
Data used
Cross-sectional	135	26,950	0.54	0.51	0.57	30.35	<0.01
Prospective	12	2862	0.48	0.37	0.57	7.58	<0.01
Subgroup analysis								1.39	1	0.24
Type of report
Peer reviewed	135	28,550	0.52	0.50	0.55	29.47	<0.01
Unpublished/dissertation	12	1262	0.65	0.56	0.72	11.04	<0.01
Subgroup analysis								6.63	1	<0.02
Validity of appraisal measure
Validated	124	23,640	0.54	0.51	0.57	28.42	<0.01
Un-validated	23	6172	0.51	0.43	0.58	11.04	<0.01
Subgroup analysis								0.66	1	0.42
Appraisal measure name
CPTCI	14	1636	0.65	0.55	0.72	10.20	<0.01
IPSI	3	211	0.70	0.63	0.77	12.22	<0.01
PBRS	3	259	0.59	0.50	0.67	10.72	<0.01
PTCI	90	19,800	0.55	0.52	0.58	29.51	<0.01
SBQ	4	70	0.25	0.00	0.47	1.93	0.05
TAQ	4	687	0.38	−0.01	0.67	1.93	0.05
WAS	4	708	0.15	0.08	0.22	4.00	<0.01
Subgroup analysis								159.40	6	<0.0001
Appraisal measure admin.
Interview	3	328	0.26	0.15	0.36	4.73	<0.01
Self-report	144	29,484	0.54	0.51	0.57	31.09	<0.01
Subgroup analysis								32.48	1	<0.0001
PTSD measure admin.
Interview	37	5056	0.51	0.44	0.57	12.70	<0.01
Self-report	110	24,756	0.54	0.51	0.57	28.09	<0.01
Subgroup analysis								1.02	1	0.31
PTSD measure type
Dichotomous	25	3442	0.52	0.43	0.59	10.36	<0.01
Continuous	122	26,370	0.54	0.51	0.57	29.00	<0.01
Subgroup analysis								0.21	1	0.64
Number of traumatic events
Single event	65	15,899	0.54	0.50	0.58	21.06	<0.01
Multiple event	8	1435	0.52	0.33	0.67	4.92	<0.01
Subgroup analysis								0.07	1	0.79
Intentionality of trauma
Intentional trauma	46	9910	0.48	0.43	0.53	15.81	<0.01
Unintentional trauma	44	10,094	0.51	0.46	0.56	16.31	<0.01
Subgroup analysis								0.66	1	0.42
Traumatic event type
Accident, illness or injury	36	5036	0.51	0.46	0.56	15.87	<0.01
Combat/war exposure	10	1429	0.42	0.30	0.53	6.34	<0.01
IPV/sexual abuse	25	4581	0.48	0.42	0.54	12.79	<0.01
Natural/human disaster	10	7950	0.51	0.39	0.61	7.57	<0.01
Subgroup analysis								2.27	3	0.52
Time trauma symptoms measured
> 1 month after trauma	80	16,575	0.54	0.50	0.58	22.42	<0.01
0–1 month after trauma	20	3594	0.56	0.48	0.64	11.34	<0.01
Subgroup analysis								0.31	1	0.58
Sensitivity analyses
No Beta co-efficient	141	28,538	0.54	0.52	0.57	32.07	<0.01	1210.58*	140	<0.01; I^2 = 88.4%
No low quality studies	109	25,240	0.52	0.49	0.55	25.87	<0.01	1175.78*	108	<0.01; I^2 = 90.8%
Outliers removed	96	16,706	0.54	0.52	0.55	47.53	<0.01	176.73*	95	<0.01; I^2 = 46.2%

* Not all items add up to 147 as not all studies reported information on the subgroups in question.

Table 2. Table of subgroup analysis and sensitivity analysis results for ptci and cptci studies only.

	K	n	r	LL	UL	Z	p	Q	df	p
TOTAL CPTCI/PTCI ONLY	104	21,436	0.56	0.53	0.59	31.31	<0.01	748.21*	103	<0.0001
Age Group
Adult	84	13,020	0.55	0.51	0.58	25.09	<0.01
Child	18	7725	0.62	0.56	0.67	16.14	<0.01
Subgroup analysis								3.89	1	<0.049
Population
Civilian	99	20,633	0.56	0.53	0.58	32.84	<0.01
Military	3	680	0.64	0.22	0.86	2.77	0.028
Subgroup analysis								0.22	1	0.64
Data used
Cross-sectional	96	20,370	0.57	0.54	0.59	29.96	<0.01
Prospective	8	1066	0.50	0.44	0.56	7.91	<0.01
Subgroup analysis								2.67	1	0.10
Type of report
Peer reviewed	94	20,432	0.55	0.53	0.58	30.23	<0.01
Unpublished/dissertation	10	1004	0.64	0.54	0.73	9.09	<0.01
Subgroup analysis								2.57	1	0.12
PTSD measure administration
Interview	31	4426	0.51	0.44	0.58	11.75	<0.01
Self-report	73	17,010	0.58	0.55	0.61	30.54	<0.01
Subgroup analysis								3.61	1	0.06
PTSD measure type
Dichotomous	17	1368	0.56	0.47	0.64	10.05	<0.01
Continuous	87	20,068	0.56	0.53	0.59	29.31	<0.01
Subgroup analysis								0.00	1	0.99
Number of traumatic events
Multiple event	5	835	0.64	0.45	0.78	5.44	<0.01
Single event	48	12,320	0.58	0.53	0.61	21.53	<0.01
Subgroup analysis								0.57	1	0.45
Intentionality of trauma
Intentional trauma	25	6567	0.52	0.47	0.56	19.11	<0.01
Unintentional trauma	31	7154	0.54	0.48	0.59	14.50	<0.01
Subgroup analysis								0.31	1	0.58
Traumatic event type
Accident, illness or injury	24	2395	0.53	0.47	0.60	13.03	<0.01
Combat/war exposure	6	869	0.52	0.41	0.62	7.85	<0.01
IPV/sexual abuse	13	2364	0.50	0.45	0.56	14.55	<0.01
Natural/human disaster	8	7318	0.59	0.49	0.67	9.91	<0.01
Subgroup analysis								2.28	3	0.52
Time trauma symptoms measured
> 1 month after trauma	55	12,601	0.57	0.53	0.60	24.03	<0.01
0–1 month after trauma	16	2256	0.58	0.49	0.66	10.57	<0.01
Subgroup analysis								0.05	1	0.82
Sensitivity analyses
No Beta co-efficient	102	21,161	0.56	0.54	0.59	31.16	<0.01	732.60*	101	<0.01; I^2 = 86.2%
No low quality studies	77	17,822	0.55	0.52	0.58	26.12	<0.01	624.29*	76	<0.01; I^2 = 87.8%
Outliers removed	76	12,157	0.56	0.53	0.58	40.94	<0.01	158.12*	75	<0.01; I^2 = 52.6%

Figure 2. Forest plot showing effect sizes across different subtypes of maladaptive appraisal.

Key: PTCI-Self = Posttraumatic Cognitions Inventory Self subscale; PTCI-World = Posttraumatic Cognitions Inventory World subscale; PTCI-Self-blame = Posttraumatic Cognitions Inventory Self-Blame subscale; CPTCI – fragile/scary = Child Posttraumatic Cognitions Inventory Fragile Person/Scary World subscale; CPTCI- Permanent Change = Child Posttraumatic Cognitions Inventory Permanent Change subscale.

Figure 3. Forest plot showing effect size of relationship between acute appraisals and PTSD symptoms at 2–4 months, 6 months and 12 months since trauma.

Table 3. Estimates of publication bias for all analyses.

Meta-Analysis	Egger’s test of intercept	Fail Safe N	Duval & Tweedie’s Trim and Fill
All studies	t = 0.39, df = 145, two-tailed p = 0.70	5697	16 missing studies to the right of the mean; adjusted r = 0.57, 95% CI = 0.54–0.59, Q = 1982.20
PTCI/CPTCI only	t = 0.46, df = 102, two-tailed p = 0.65	3465	8 missing studies to right of the mean; adjusted r = 0.58, 95% CI = 0.55–0.61, Q = 867.48
Adult-Self	t = 0.70, df = 64, two-tailed p = 0.49	3635	11 missing studies to the right of the mean; adjusted r = 0.64, 95% CI = 0.61–0.67, Q = 599.80
Adult-World	t = 1.16, df = 60, two-tailed p = 0.25	9942	No missing studies
Adult- Self-Blame	t = 0.93, df = 57, two-tailed p = 0.36	9045	12 missing studies to right of the mean; adjusted r = 0.34, 95% CI = 0.30–0.39, Q = 456.00
Child- Perm Change	t = 0.28, df = 10, two-tailed p = 0.78	1836	No missing studies
Child-Fragile/Scary	t = 0.07, df = 10, two-tailed p = 0.94	1445	No missing studies
2–4 months	t = 0.07, df = 7, two-tailed p = 0.95	1299	No missing studies
6 months	t = 0.44, df = 11, two-tailed p = 0.67	1862	2 missing studies to left of mean; adjusted r = 0.51 (95% CI = .46 – .56, Q = 28.13
12 months	t = 1.30, df = 1, two-tailed p = 0.42	116	No missing studies

Figure 4. Funnel plot of standard error by Fisher’s Z for overall effect size (all studies included) showing the symmetry of the data in relation to publication bias.

Figure 5. Funnel plot of effect sizes exploring publication bias for meta-analysis of appraisals measured using only PTCI and CPTCI.