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AN EXAMINATION OF THE EFFECTS OF TRAUMATIC
EVENTS ON PSYCHOLOGICAL AND PHYSICAL HEALTH
SYMPTOMS: TESTING A TRANSACTIONAL MODEL

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MARIAM R. MOURAD

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AN EXAMINATION OF THE EFFECTS OF TRAUMATIC EVENTS ON
PSYCHOLOGICAL AND PHYSICAL HEALTH SYMPTOMS: TESTING
A TRANSACTIONAL APPROACH

By

Mariam R. Mourad

A DISSERTATION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Psychology
2009

ABSTRACT
AN EXAMINATION OF THE EFFECTS OF TRAUMATIC EVENTS ON
PSYCHOLOGICAL AND PHYSICAL HEALTH SYMPTOMS:
A TRANSACTIONAL APPROACH
By

Mariam R. Mourad

Objective: The main purpose of the current study was to examine the development of
psychological and physical health symptoms in female survivors of interpersonal
traumatic events using both a variable- and person-centered approach. The study assessed
the inﬂuential relationship of characteristics of the traumatic event, the survivor’s
personality and environmental stressors to the development of these health outcomes
(psychological and physical health symptoms) using Sameroﬁ’s transactional model.
Based on Herman’s trauma theory, this study also sought to determine if there was a
difference between the experience of interpersonal (IPT) and non-personal traumatic
events (N PT). Method: The current study examined a female college population from a
Midwestern university that had experienced IPT (N =279), NPT (N =1 165), and no trauma
(N=362). Due to the different methodological approaches used in this study, data was
analyzed using both structural equation models and cluster analyses. The transactional
model was examined using structural equation models to assess the relationship between
the different survivor domains and her psychological and physical health outcomes. An
exploratory cluster analysis was conducted using a combined approach (initial
agglomerative hierarchical and k-means iterative clustering procedures) for the person-

centered section of this study. Results: Study ﬁndings indicated that survivors Of IPT had

 

signiﬁcantly higher levels of all psychological and most physical health symptoms than

 

the NPT and no trauma group. However, signiﬁcant differences between the IPT and
NPT groups were not found for serious medical conditions. The transactional model was
rejected for all trauma models explored, instead mediation models best accounted for the
relationship between survivor characteristics and health outcomes. It was found that
characteristics of an IPT were predictive of physical health symptoms through the
presence of survivor personality, environmental stressors and psychological functioning.
Post hoc analyses demonstrated that there were no characteristics that predicted physical
health in the NPT survivor. Combination of the two forms of traumatic events was found
to yield differing results than when they are examined separately. In regards to
exploratory analyses, it was found that low levels of trauma characteristics,
environmental stress, and certain personality factors were associated with resilient groups
of IPT survivors. Conclusion: The current study suggests that the development of health
problems in the survivor of an IPT is based on their perceptions of the world and their
stressors after the traumatic event. Results indicate that there are signiﬁcantly different
consequences for survivors of IPT and NPT, suggesting a need to examine these groups
separately in future research. The current study provides information as to the physical
health repercussions Of IPT and its relationship to psychological symptoms. These
ﬁndings imply a need for clinicians to assess for physical health and as an indicator of the
impact of the IPT on the survivor. Naturally occurring proﬁles suggest that certain
constellations of the survivor’s personality and environmental stressors are associated
with a resilient proﬁle for these women. These groupings can inform the development of

useful clinical interventions for this population.

ACKNOWLEDGMENTS

There were many people who were important in the creation Of this work. First and
foremost, I would like to thank my dissertation chair, Alytia Levendosky, for all her
guidance, support, and patience during this entire process. Throughout the creation of this
paper, she not only provided me with mentorship regarding editing and formulation, she
also provided me with a wealth of encouragement and the conﬁdence I needed to keep
going not only in this endeavor but also throughout graduate school. I would like to
express my sincere gratitude to Alex von Eye for his statistical guidance. He not only
enhanced my knowledge but also gave me a new appreciation of statistics. I would also
like to thank my committee members, William Davidson and Marsha Carolan, for all
their support throughout this process. Finally, I could not have completed this project if
not for the help of my friends and family. They were always willing to provide me with
comforting words or solace during the times when I needed it most. Although there were
many to be thanked, there were two people that deserve special recognition. The ﬁrst is
my ﬁ'iend Archana Basu for her willingness to be my constant sounding board throughout
this process. The second, my brother Ayman Mourad for keeping me grounded
throughout this process and helping me to maintain perspective regardless of where I was

standing.

iv

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................ vii
LIST OF FIGURES ......................................................................................................... viii
Introduction ....................................................................................................................... 1
Definition of a Traumatic Event and Trauma ............................................................. 3
Type of Traumatic Event, Prevalence rate, and Gender Differences ......................... 4
Trauma Theory ............................................................................................................ 6
Psychological Health and Traumatic Events .............................................................. 8
Physical Health and Traumatic Events ..................................................................... l8
Transactional Model ................................................................................................. 23
Interpersonal Traumatic Event Characteristics ....................................................... 25
Personality Characteristics ...................................................................................... 34
Environmental Stress Characteristics ....................................................................... 42
Rationale ......................................................................................................................... 52
Hypotheses ...................................................................................................................... 55
Methods ........................................................................................................................... 57
Participants ............................................................................................................... 57
Procedures ................................................................................................................ 58
Measures ................................................................................................................... 58
Results ............................................................................................................................. 67
Missing Data ............................................................................................................. 67
Hypothesis Testing .................................................................................................... 68
[PT Model Testing ..................................................................................................... 68
Post Hoc Transactional Model Testing .................................................................... 71
NPT Model Testing .................................................................................................. 72
Full Trauma Model Testing ..................................................................................... 74
Group Comparison Model ................... _ ..................................................................... 75
Cluster Analytic Plan ................................................................................................ 76
Trauma Characteristics ............................................................................................ 77
Personality Characteristics ...................................................................................... 79
Environmental Stress Characteristics ....................................................................... 81
Discussion ....................................................................................................................... 83
Trauma Group Diﬂerences ....................................................................................... 84
Transactional Model Testing for [P T ....................................................................... 87
Health Outcomes for NPT Group ............................................................................. 91
Health Outcomes for All Trauma Group .................................................................. 93
Person Centered Approach for Survivors of IPT ...................................................... 96

Cluster Analysis Conclusion ................................................................................... 107

Limitations and Future Directions .......................................................................... 108
Clinical Implications ............................................................................................... 1 14
Conclusion .............................................................................................................. 1 15
Appendix A: Tables ...................................................................................................... 117
Appendix B: Figures ..................................................................................................... 134
Appendix C: Measures .................................................................................................. 151
References ..................................................................................................................... 188

vi

Table 1:
Table 2:
Table 3:
Table 4:
Table 5:
Table 6:

Table 7:

Table 8:

Table 9:

Table 10:

Table l 1:

Table 12:

LIST OF TABLES

Demographic percentages for each trauma group .................................. 118
Age by trauma group .............................................................................. 119
Percent of women in each group with psychological disorders ............. 120
Descriptives for all variables before and after estimation ...................... 121
Between Subjects Effects: MANOVA for all groups ............................. 124
Mental health outcome means by group ................................................. 127
Trauma Characteristics Final Iterative Cluster Analysis (F our-Cluster
Solution) .................................................................................................. 128
Between Subjects Effects for Trauma Characteristic Proﬁles ................ 129
Personality Characteristics Final Iterative Cluster Analysis (Four-Cluster
Solution) .................................................................................................. 130
Between Subjects Effects for Personality Characteristic Proﬁles .......... 131

Environmental Stress Characteristics Final Iterative Cluster Analysis
(Three-Cluster Solution) ......................................................................... 132

Between Subjects Effects for Environmental Stress Characteristic Proﬁles
................................................................................................................. 133

vii

Figure 1:
Figure 2:
Figure 3:
Figure 4:
Figure 5:
Figure 6:
Figure 7:
Figure 8:

Figure 9:

Figure 10:
Figure 11:
Figure 12:
Figure 13:
Figure 14:

Figure 15:

Figure 16:

LIST OF FIGURES

Interpersonal Traumatic Event Group Transactional Model .................. 135
Interpersonal Traumatic Events SEM Model ......................................... 136
Non-personal Traumatic Events SEM Model ......................................... 137
All Types of Traumatic Events SEM Model .......................................... 138
Trauma Characteristics Dendogram ....................................................... 139
Trauma Characteristics Clusters ............................................................. 140
Psychological symptoms for Trauma Characteristics Clusters ............... 141
Physical Health symptoms for Trauma Characteristics Clusters ........... 142
Personality Characteristics Dendogram ................................................. 143
Personality Characteristics Clusters ....................................................... 144
Psychological symptoms for Personality Characteristics Clusters ......... 145
Physical Health symptoms for Trauma Characteristics Clusters ............ 146
Environmental Stress Characteristics Dendogram .................................. 147
Environmental Stress Characteristics Clusters ....................................... 148

Psychological symptoms for Environmental Stress Characteristics Clusters
................................................................................................................. 149

Physical Health symptoms for Environmental Stress Characteristics
Clusters ................................................................................................... 150

viii

INTRODUCTION

Prevalence rates of traumatic events in community samples indicate that more
than half of the individuals reported exposure to at least one traumatic event in their
lifetime (e.g., National Comorbidity Survey: Kessler, Sonnega, Bromet, Hughes, &
Nelson, 1995). Some of the most common traumatic events experienced by both men and
women were accidents, natural disaster with ﬁre, and witnessing someone being killed or
badly injured, and for women, speciﬁcally, rape and sexual molestation (Kessler et al.,
1995). The experience of a traumatic event can have many detrimental consequences on
the well-being of the survivor, including effects on psychological and physical health.

Most of the research regarding the effects of traumatic experiences on survivors
has been on psychological reactions to traumatic events. Traumatic experiences are
associated with symptoms of not only post-traumatic stress disorder (PTSD: Herman,
1992; Levendosky & Graham-Berman, 2001) and acute stress disorder (ASD: Kaplan,
Matar, Kamin, Sadan, & Cohen, 2005), but also other anxiety disorders (Freeman et al.,
2002; Leskin & Sheikh, 2002; Maes, Mylle, Delmeire, & Altamura, 2000; Zayfert,
DeViva, & Hofmann, 2005), and depression (Carlson, McNutt, & Choi, 2003; Herman,
1992). A burgeoning literature has begun to discuss the relationship between physical
health problems and exposure to traumatic events (e.g. Gill & Page, 2006; Spertus,
Yehuda, Wong, Halligan, & Seremetis, 2003). Individuals with a history of tramnatic
experiences are more likely to report somatic and/or medical problems than individuals
without such histories (Gill & Page, 2006; Leserman et al., 1996). Some of the medical
problems found to be associated with the experience of a traumatic event include

gastrointestinal, cardiopulmonary conditions (Golding, 1994), and bodily pains

(Leserman et al., 1996). These physical health consequences may be due to lower
immune system functioning in persons with a history Of traumatic experiences (Gill &
Page, 2006).

While it is clear that exposure to a traumatic event is associated with
psychological and physical health problems (health outcomes), there has been relatively
little research examining the two symptom domains simultaneously (e. g. Dirkzwager,
Grievink, van der Velden, & Yzermans, 2006; Gill & Page, 2006; Zoellner, Goodwin, &
Foa, 2000). A major question that arises is what are the characteristics associated with the
traumatic event, the individual, and the environment and their relationships to one
another that differentially predict psychological versus physical health problems in
survivors of traumatic events.

The current study examines the relationship between traumatic events and
psychological and physical health consequences in a female college sample. This study
explores which characteristics of the individual, the environment, and the traumatic event
contribute to these consequences using both a variable-centered and a person-centered
approach. In addition, this study explores the differences in psychological and physical
health consequences based on the type of traumatic event experienced, interpersonal or
non-personal (see next section for deﬁnition). Of speciﬁc interest in this study are women
who have experienced interpersonal traumatic event(s). Although all traumatic events
can have negative effects on the survivor and can affect the survivor’s beliefs, the
intentional harm caused by another person in an interpersonal traumatic event is theorized
to have more detrimental effects on the way the person views herself, others, and her

environment (Herman, 1992). The transactional model of development (Sameroff, 2000)

is utilized as a framework for conceptualizing the way the characteristics Of interpersonal
traumatic event transact with characteristics of the individual and environmental to
inﬂuence the manifestation of psychological and/or physical health problems. A variable-
centered approach is utilized for this component of the project. In addition, exploratory
cluster analyses are conducted to determine survivor groupings which naturally arise
based on particular proﬁles of the characteristics of the interpersonal traumatic event, the
individual, and the environment. This is a person-centered approach to examining the
differential effects Of interpersonal traumatic events on female survivors.
Deﬁnition of a Traumatic Event and Trauma

This study is using the DSM-IV-TR deﬁnition of a traumatic event which is as
follows: “experienced, witnessed, or was confronted with an event or events that involved
actual or threatened death or serious injury, or a threat to the physical integrity of self or
others ” (American Psychological Association, 2000). Events that can be classiﬁed as
traumatic can fall into one of two categories: interpersonal and non-personal. An
interpersonal traumatic event (IPT) includes direct perpetration by another person
towards the survivor such as childhood sexual or physical abuse, rape, sexual assault,
experiencing or witnessing intimate partner violence. A non-personal traumatic event
(N PT) does not include intentional or direct perpetration by others, e.g. accidents and
natural disasters (Ford, Stockton, Kaltman, & Green, 2006).

The term trauma is commonly utilized to describe the experience of psychological
distress within the literature. However the experience of a traumatic event can be
conceptualized as differing from trauma. As will be discussed, although exposure to a

traumatic event is common, not all survivors of these events display the detrimental

reaction to the event. It is thus important to distinguish between persons that have
experienced a traumatic event and those that are traumatized, thus displaying negative
consequences from the experience. The current study will deﬁne trauma as the
experience of a traumatic event followed by the presence of negative outcomes for the
survivor. Although psychological consequences are most commonly examined in the
literature assessing the inﬂuence of traumatic events on survivors, the current study will
also examine physical health consequences. Trauma will thus be deﬁned as the display of
psychological and/or physical health consequences after the experience of a traumatic
event.
Type of traumatic event, prevalence rate, and gender diﬂerences

It was previously noted in the Diagnostic Statistical Manual-IIIR (DSM-IIIR:
American Psychological Association, 1987) that the experience of a traumatic event
based on the above deﬁnition would be outside of the normal human experience.
However, surveys assessing rates of traumatic events have since disputed this idea. In the
National Comorbidity Sample, Kessler and colleagues (1995) found that 61% of men and
51% of women have been exposed to at least one traumatic event in their lifetime. They
found that 5-14% of women and 10-15% of men reported exposure to two or more
traumatic events. Their sample endorsed a range of traumatic events, and gender
differences were found regarding type of trauma. Men reported signiﬁcantly more
exposure to witnessing someone being harmed or killed, being in a life-threatening
accident, natural disaster, and being threatened with a weapon or physically attacked. In
contrast, women reported signiﬁcantly higher levels of sexual molestation, rape,

childhood abuse or neglect. Thus, women were more likely to have experiences involving

perpetration of violence against her by another person, i.e. interpersonal traumatic events
(Breslau, Chilcoat, Kessler, Peterson, & Lucia, 1999a; Bureau of Justice Statistics, 2002;
Kessler et al., 1995; Moser, Hajcak, Simons, & Foa, 2007). In addition, women were
more likely than men to know the perpetrator of the IPT they experienced. For example,
84% of sexual assaults against women are found to be perpetrated by persons that the
victim knows (Saunders, Kilpatn'ck, Hanson, Resnick, & Walker, 1999).

According to the National Comorbidity Survey, the most common traumatic
events experienced for both men and women were accidents and natural disasters
involving ﬁre (Kessler et al., 1995). Similar to women exposed to IPTs, women exposed
to NPTS have also been found to display higher negative health outcomes than men
(Benight, Swift, Sanger, Smith, & Zepplin, 1999; Briere & Elliott, 2000; Wolfe, Schnurr,
Brown, & Furey, 1994; Yehuda, Schmeidler, Siever, Binder-Brynes, & Elkin, 1997).
These studies all provided support that women are also more likely to experience
psychological and physical health symptoms as a result of the traumatic event than men.
Kessler et al. (1995) found that women were twice as likely to be diagnosed with the
traumatic event related disorder, i.e. PTSD, than men. The effect of a traumatic event on
women is also found regarding physical health conditions. Studies found that women
suffering from PTSD were 2.5 to 4.5 times more likely to experience medical problems
than women without a PTSD diagnosis (Brewin, Andrews, & Valentine, 2000; Gill &
Page, 2006).

Considering the high rates of negative consequences for women exposed to a
traumatic event, it would be beneﬁcial to focus on women to understand the inﬂuence of

the traumatic event type on psychological or physical health symptoms. Identiﬁcation of

differences in symptoms for women based on the domain for which the traumatic event
falls, interpersonal or non-personal could provide further understanding of the way in
which women respond to trauma. In light of recent traumatic national events for which
US. residents have been exposed, e. g. Hurricane Katrina, the attack on the World Trade
Center on 9/11/01, examining the different health responses displayed from types of
traumatic events would be valuable for intervention.
Trauma Theory

Trauma theory, as developed by Herman (1992), can be applied to understand
why physical and/or psychological health consequences arise for individuals exposed to
traumatic events. According to the DSM-IV-TR, a traumatic event involves a situation in
which the person perceives a threat to the life of or physical integrity of the self or others.
As a result of this perception, in order to receive a diagnosis of PTSD, the person must
experience intense fear, helplessness, or horror (American Psychological Association,
2000). Herman (1992) proposes that the level of fear experienced from the event may
alter the survivor’s sense of self and level of functioning (Herman, 1992). During the
traumatic event the person may become conscious that she is vulnerable to injury or
death, through natural disasters or at the hands of others. The nature of the relationship
with the perpetrator prior to the event can also affect the survivor’s reaction. If the person
was a once-trusted individual, the abuse may raise confusion for the person in the way
that she perceives roles in relationships and identiﬁcation of safety in the environment. It
is through the realization of the tenuous nature of one’s own safety that the survivor may
begin to doubt her own perceptions, trust in others, and the environment in general (Ebert

& Dyck, 2004; Herman, 1992).

The level of fear experienced at the time of the traumatic event can be a great
shock to the person’s state of mind and can shatter the person’s fundamental assumptions
such as, people are ultimately good and would not harm others, or the world is a safe
place (Ebert & Dyck, 2004; Herman, 1992). Violation of these basic beliefs due to a
traumatic experience can lead to a variety of questions including how and why the
traumatic event occurred. The experience of being hurt by others may also make the
survivor wonder if she is vulnerable to further harm or in the case of perpetrated trauma-
if people are ultimately untrustworthy (Ebert & Dyck, 2004).

These stark fears can corrupt the survivor’s previously held fundamental truths
which may eventually lead to a dramatic change in her deﬁnition of the self or others
(Bloom, 1997). Thus, the traumatic event may leave the survivor with the struggle of how
to perceive the world in light of her experiences. The overwhelming fear associated with
these cognitions can alter the survivor’s willingness to trust her own intuition about
people or her trust of others. The internalization of the blame or fear possibly from the
traumatic experience may lead to the development of other psychological disturbances
(Olff‘, Langeland, & Gersons, 2005).

Trauma theory can also be applied to explain the physiological responses to the
traumatic experience. The experience of a traumatic event can inﬂuence the survivor’s
physical state and responses to the environment. Exposure to average levels of stress
results in the activation of the sympathetic nervous system (SNS), however a traumatic
event places the human body and mind in a more severely stressed state. Such a shock to
the human system can inﬂuence the functioning of different arousal mechanisms

(Tosevski & Milovancevic, 2006; Woods et al., 2005). The body may release abnormally

high levels of biochemical messengers such as adrenaline, cortisol, and endorphins which
function to suppress the autoimmune system. This may explain the somatic/medical
problems reported by persons who had suffered a traumatic event.

In terms of traumatic events that occur at critical development periods such as
childhood, Bloom (1997) suggests the survivor’s reaction to the traumatic event may be
inﬂuenced by her post-traumatic event environment. Considering the extreme stress of a
traumatic event, its arousal of the SNS, and children’s developing coping mechanisms,
children may not be able to soothe themselves after such an experience. Thus it is
important for caretaking adults to provide soothing responses for the child at this time.
The lack of such aid may result in chronic hyperarousal of SNS leading to physical health
problems. This component of trauma theory explains the effects of the traumatic events
on physical health, in addition to the importance of adequate parenting/social support on
the traumatized individual’s health outcomes. This perspective can also be applied to
survivors of adulthood traumatic events. The survivor of an interpersonal traumatic event
is more likely to have a fear of others since her experiences were perpetrated by another
person, possibly a close relationship. As such, the support received from a social network
after the high level of stress and fear associated with a traumatic event, may aid the
survivor to decrease their fears of others and arousal of the SNS. Based on this theory, the
survivor’s experiences after the traumatic event can have a large impact on the
psychological and physical health outcomes.

Psychological Health and Tramtic Events
Based on trauma theory the distress caused by the experience of a traumatic event

can alter the survivor’s psychological functioning. The psychological disruption can

manifest itself in different ways for the survivor. According to trauma research the four
psychological conditions most associated with the experience of a traumatic event
include PTSD, ASD, anxiety, or depression (Carlson et al., 2003; Freeman et al., 2002;
Herman, 1992; Kaplan et al., 2005; Levendosky & Graham-Berman, 2001; Zayfert et al.,
2005)

Posttraumatic Stress Disorder

The psychological condition discussed most frequently in trauma literature is that
of PTSD. This condition PTSD was developed to classify symptoms speciﬁc to the
experience of a traumatic event (APA, 2000). These disturbances are categorized into
three domains including reexperiencing elements of the traumatic event, avoidance of
traumatic event related stimuli, and hyperarousal to reminders of the event. Although
PTSD symptoms may commonly appear directly after exposure to a traumatic event, the
persistence of these symptoms for at least one month after the event is necessary for
diagnosis of PTSD (APA, 2000).

The rates of PTSD in women from the National Comorbidity sample that have
experienced a traumatic event are 10.4% (Kessler et al., 1995). These rates were similar
to the 13.8% found in another study examining PTSD rates solely in women (Breslau,
Davis, Peterson, & Schultz, 1997). Numerous studies have focused on the development
of PTSD in women ﬁ'om interpersonal traumatic events, e. g. childhood sexual and
physical abuse, adult sexual abuse, and domestic violence (Breslau et al., 1999b; Darves-
Bomoz et al., 1998; Johnson, Pike, & Chard, 2001) and from non-personal traumas e.g.
ﬂood, coal mining accidents, and motor-vehicle accidents (Macs et al., 2000; Strelau &

Zawadski, 2005; Yehuda et al., 1997).

When examining prevalence rates of PTSD, Kessler et al. (1995) reported that all
forms of trauma, interpersonal and non-personal, were qualifying events for the
development of PTSD. However, the likelihood of developing PTSD from IPT in
comparison to NPT has rarely been examined in the literature (Breslau et al., 1999a). In
the few instances where it has been assessed, signiﬁcant differences were found between
the trauma types and their relation to PTSD. Breslau and colleagues found that a single
incident of IPT had a higher likelihood of resulting in PTSD while only repeated NPT
experiences were related to higher risk for PTSD (1999a). These ﬁndings contributed to
the recognition that not all experiences of traumatic events have the same consequences
for the survivor. More literature is needed to examine the differences between these two
groups in regards to PTSD symptoms and other health consequences for the trauma
survivors.

Clearly, based on the prevalence rates of PTSD, most individuals exposed to a
traumatic event do not meet criteria for PTSD (Kessler et al., 1995). Fewer studies have
examined the effects of various forms of traumatic events on the development of PTSD
symptoms, rather than the actual diagnosis (Lauterbach & Vrana, 2001 ). However, there
has been research to suggest that although traumatized individuals may not meet full
criteria for PTSD, they may display PTSD symptoms (Amir, Kaplan, & Kotler, 1996;
Bramsen, Dirkzwager, & van der Ploeg, 2000; Lauterbach & Vrana, 2001). Research has
found that PTSD symptoms can also arise after the experience of an interpersonal
(Lucenko, Gold, & Cott, 2000; Nisith, Mechanic, & Resick, 2000) or a non-personal
traumatic event (Strelau & Zawadski, 2005; Yehuda et al., 1997). The high rates of PTSD

symptoms associated with various forms of traumatic events along with the low rates of

10

full PTSD diagnosis in traumatized samples indicate a need to examine symptoms as well
as the full-blown clinical syndrome in future research.

For example, one prospective study, Cortes and colleagues (2005) examined the
effects Of interpersonal traumatic events on PTSD symptoms on children and adolescents.
They reported that the presence of avoidance/numbing and hyperarousal cluster of PTSD
symptoms were most predictive of further psychological disturbances, i.e. another
anxiety disorder diagnosis after the traumatic event. In addition, the persistence of re-
experiencing symptoms at later assessment times was predictive of future anxiety
disorders (Cortes et al., 2005). These ﬁndings indicate that examination of the separate
PTSD symptoms can be informative regarding the survivor’s future psychological
functioning. Previous research has indicated that children and adolescents may display
PTSD symptoms differently than adults (APA, 2000; Terr, 1981). As this study only
examined PTSD symptoms in children and adolescents, it would be useful to also assess
the display of PTSD symptoms in adult samples in relation to further psychological
functioning.

Acute Stress Disorder and Dissociation

The DSM-IV diagnosis of acute stress disorder (ASD: APA, 2000) was also
developed to categorize symptoms speciﬁc to the experience of a traumatic event. Some
ASD diagnostic criteria are similar to those of PTSD, such as exposure to a traumatic
event, reexperiencing, avoidance, and hyperarousal symptoms, however there are two
main distinctions. The ﬁrst is that a diagnosis of ASD requires the presence of
dissociative symptoms during or after the traumatic event (APA, 2000). Second, the

duration of all presented symptoms must be less than 4 weeks aﬁer exposure to the

11

traumatic event, since persistence of most of these symptoms past 4 weeks can translate
to a diagnosis of PTSD. Some research states that ASD is considered a predecessor to the
development of PTSD (Elklit & Brink, 2004). In an assessment of the predictive ability
of ASD for PTSD in physical assault victims, it was found that ASD symptoms were
predictive of 79% of subsequent PTSD cases (Elklit & Brink, 2004), indicating the
importance of assessing for ASD in addition to PTSD. These rates indicate that there is a
group of individuals who do not develop PTSD after experiencing ASD. Hence it is still
important to assess for ASD separate from PTSD symptoms.

As a major distinctive symptom of ASD is the presence of dissociation during or
after the event, there have been numerous studies that have examined this key symptom
in relation to the experience of a traumatic event (Banyard & Williams, 1996; Johnson et
al., 2001; Leahy, Pretty, & Tenenbaum, 2004; Maercker, Beauducel, & Schutzwohl,
2000; Sanders & Moore, 1999). Dissociation has been consistently found to be associated
with the severity of the traumatic event (Johnson et al., 2001; Leahy et al., 2004;
Maercker et al., 2000). For example, Johnson and colleagues (2001) examined the
relationship between dissociation, psychological symptoms of PTSD, and depression in
childhood sexual abuse survivors. They found that dissociation signiﬁcantly predicted
psychological symptom severity for both PTSD and depression and that traumatic event
severity was predictive of dissociation. However, this study did not examine the other
symptoms of ASD in relation to PTSD and depressive symptoms.

Although not everyone meets for full diagnosis of ASD, display of the symptoms
of ASD such as dissociation can be indicative of other poor health functioning in the

survivor. These ﬁndings support the need to examine symptoms of acute stress disorder

12

rather than only the full diagnosis. Many of the studies examining ASD symptoms have
discussed it in relation to IPTs. Although there has been some research regarding ASD
symptoms in NPTS (Marmar et al., 1994; Ursano et al., 1999; van der Velden et al., 2006;
Wittrnann, Moergeli, & Schnyder, 2006) there is no research comparing ASD symptom
levels for IPT and NPT both traumatic event groups. It is important to assess if there are
differences between the levels of ASD displayed by persons that have experienced
different traumatic experiences.
Anxiety

According to the DSM-IV, PTSD and ASD are categorized as anxiety disorders
(APA, 2000), however they are the only two disorders speciﬁc to the experience of a
traumatic event, thus they are often examined separately in the trauma literature from
other forms of anxiety. The experience of a traumatic event has also been related to the
development of non-trauma speciﬁc anxiety disorders and symptoms such as generalized
anxiety disorder, social phobia, and panic disorder (Freeman et al., 2002; Leskin &
Sheikh, 2002; Macs et al., 2000; Zayfert et al., 2005). For example, one study reported
that traumatized children experiencing PTSD symptoms were 25 times more likely to
develop an anxiety disorder than the children that did not display PTSD symptoms
(Cortes et al., 2005). As a result, some studies have examined anxiety disorders and
symptoms in survivors in relation to the presence or absence of a PTSD diagnosis or
PTSD symptoms.

Some of the trauma research focused on anxiety has examined the presence of
PTSD with the development Of speciﬁc anxiety disorders. Leskin and Sheikh (2002)

found that more than half of the women that displayed panic disorder and PTSD together

13

reported histories of sexual abuse. These ﬁndings indicate that IPT, especially sexual
abuse, is highly related to the development of panic disorder as well as PTSD. Although
rates of sexual victimization were reported for the sample, analyses were conducted using
all forms of traumatic events. Another anxiety disorder examined in relation to traumatic
events and PTSD is social phobia. Zayfert, DeViva, and Hofmann (2005) found that in a
sample Of individuals exposed to a traumatic event 43% of individuals diagnosed with
PTSD later developed social phobia. These results suggest that a relationship between
anxiety disorders and traumatic events when PTSD is present.

Research has also examined the association between anxiety disorders and non-
pcrsonal traumatic events (Freeman et al., 2002; Macs ct al., 2000). Macs and colleagues
(2000) examined the risk factors associated with the development of newly diagnosed
anxiety disorders after the experience of a ﬁre or motor-vehicle accident. They found that
about 23% of the sample could be diagnosed with a new onset of generalized anxiety
disorder or agoraphobia. These rates increased to 46% when limiting the sample to
persons that also met criteria for PTSD. Surprisingly, the presence of a PTSD diagnosis
was not one of the strongest predictors of a new-onset anxiety disorder diagnosis. Further
examination of risk factors for the new-onset of an anxiety disorder was horror from the
traumatic event, extent of physical injury, loss of control during event, and female sex.
The increased incidence of new-onset anxiety disorders suggests that the risk factors for
generalized anxiety disorder and agoraphobia are similar to those for PTSD. These
ﬁndings support the importance of examining speciﬁc characteristics of tramnatic events

in relation to psychological functioning. Results from this study also provide evidence for

14

the need to examine anxiety disorders as the experience of a traumatic event itself can
inﬂuence anxiety symptoms regardless of the presence of PTSD.

As demonstrated by the previous research, characteristics of the events may also
inﬂuence the anxiety symptoms in survivors; the current study will examine the
relationship between traumatic event characteristics and anxiety symptoms. In addition,
many Of the studies conducted regarding anxiety have examined speciﬁcdisorders in
relation to speciﬁc traumatic events, e. g. sexual abuse. Few studies have also examined if
exposure to different types of traumatic events are related to different levels of anxiety
symptoms (Cortes et al., 2005). Due to the high rates of exposure to traumatic events and
low prevalence rates of full anxiety disorders in non-clinical samples, it is important to
assess for anxiety symptoms in survivors.

Depression

In addition to conditionscategorized as anxiety disorders, survivors of traumatic
events have also been found to display depressive symptoms and disorders (Breslau et al.,
1997; Johnson et al., 2001; Kessler et al., 1995). Studies of childhood abuse have
consistently noted the development of depression in survivors (e.g., Bemet & Stein,
1999; Gladstone et al., 2004; Lang et al., 2003; Saunders et al., 1999). For example, a
study examining incidence rates of psychological disorders in victims of childhood
sexual abuse (CSA) found that victims were 2 times more likely to have a lifetime
diagnosis of depression and 3 times more likely to suffer from depression at the time of
the interview than non-CSA victims (Saunders et al., 1999). These ﬁndings were also
found for victims of childhood physical abuse (Bemet & Stein, 1999). These rates

suggest that there is an association between the experience of a traumatic event and the

15

presence of depressive symptoms. Results were corroborated by Saunders and colleagues
(1999) who found that depression is not only linked to traumatic experiences at the time
of the event but also over the lifetime. However, this study focused solely on the
traumatic event of CSA. It is important to expand on this research and examine the
relationship between more types of interpersonal (and non-personal) traumatic events and
depression.

As is the case for anxiety disorders, depressive symptoms in traumatized
individuals are also often assessed in relation to the presence or absence of PTSD
throughout the literature. Breslau and colleagues (1997) found depression to be the most
prevalent comorbid disorder with PTSD. 43.2% of the women exposed to traumatic
events in this sample met criteria for PTSD and Major Depressive Disorder. The presence
of PTSD has also been found to increase depression ratings in a sample diagnosed with
Maj or Depressive Disorder (Oquendo et al., 2005). Other studies have found that
preexisting depression inﬂuenced rates of PTSD through an increased probability of
traumatic event exposure (Breslau et al., 1997). These ﬁndings suggest that the
depression is not only affected by the experience of a traumatic event but can also serve
an inﬂuential role in regards to the development of other psychological conditions. Due
to the strong relationship between these two conditions, it is important to examine both
depression and PTSD together.

Based on past research, the presence of depression appears to be highly associated
with the experience of a traumatic event (e. g. Saunders et al., 1999). However, as with
other disorders, it is important to assess for symptoms rather than mere diagnosis. In

addition, more research on the effects of various forms of traumatic events on depressive

l6

symptoms is needed to understand the relationship between those experiences and the
survivors functioning.

There has been an abundance of research that has demonstrated that the
experience of a traumatic event can affect the survivor’s psychological well-being in the
form of trauma speciﬁc anxiety or depressive symptoms. Although it is beyond the scope
of the current study to attempt to distinguish between the common symptoms of each
disorder, it is recognized that many co-occur with one another especially after a traumatic
event. Due to the high levels of comorbidty between psychological symptoms, the current
study proposes to examine the symptoms from all of these categories and to assess what
characteristics of the traumatic event and the survivor’s experiences inﬂuence the overall
psychological functioning of survivors.

It has been evident from trauma literature that different forms of traumatic events
can inﬂuence the development of psychological conditions and their symptoms for both
IPT and NPT. However, there has been little consideration as to whether these symptoms
occur at different levels for each group or what factors are associated with their
development. The few studies that have compared them have found that psychological
consequences Of IPT occur at higher levels than from NPT (Breslau et al., 1999). But as
noted before, these comparisons have not been made with regards to all psychological
conditions associated with traumatic experiences. Therefore it is important to determine if
the type of traumatic event will inﬂuence the levels of these psychological conditions.
Based on trauma theory’s postulation that IPT can have more detrimental consequences
than NPT because of the perpetration by others it is hypothesized that IPT will result in

higher levels of psychological symptoms than NPT. Although there is research that

17

examines the different factors associated with the psychological functioning of IPT
survivors, there are still many questions as to which factors are associated with the
development of these symptoms. The current study examines how characteristics of the
traumatic event as well as the individual inﬂuence the psychological health of the
survivors.
Physical Health and Traumatic Events

In addition to the possible psychological impact of a traumatic event, recently
there have been numerous studies that have examined and found a negative relationship
between traumatic experiences and physical health (F inestone et al., 2000; Leserman,
2005; Newman et al., 2000; Sickel, Noll, Moore, Putnam, & Trickett, 2002; Ullman,
2007; Walker et al., 1999; Woods et al., 2005). A review of the literature reported that
across studies, women suffering from PTSD after the experience of a traumatic event
were 2.5 to 4.5 times more likely to experience more severe medical conditions (Gill &
Page, 2006). Studies have found a negative relationship between various traumatic events
and gastrointestinal symptoms (Golding, 1994; Leserman, 2005; Sickel et al., 2002),
cardiopulmonary symptoms (F rayne et al., 1999; Golding, 1994; Lown & Vega, 2001),
gynecological problems (Golding, 1994; Leserman, 2005; Sickel et al., 2002), bodily pain
(Finestone et al., 2000; Golding, 1999; Suris, Lind, Kashner, & Borman, 2007), and poor
health perceptions (Lown & Vega, 2001; Thompson, Arias, Baslie, & Desai, 2002).

The association between the experience of a traumatic event and physical health
problems has also been demonstrated by the examination of medical utilization. In a
study examining inpatient and outpatient medical utilization among women with and

without a history of CSA, survivors of CSA with psychological distress had higher rates

18

of outpatient medical utilization than survivors of CSA without psychological distress
(Amow et al., 1999). These ﬁndings were also found when examining survivors of CSA
over a 2-year period (Newman et al., 2000). Newman and colleagues (2000) reported that
women with CSA and a current diagnosis of depression reported higher rates of physician
and emergency room visits. These ﬁndings raise the question of how a traumatic event
and subsequent PTSD or other mental heath disorders affect physical health.

An explanation of how physical health symptoms can be related to a traumatic
experience is the event’s inﬂuence on the immune system. The experience of stress has
been found to activate biological stress mechanisms related to the “ﬁght or ﬂight
response” such as the hypothalamic-pituitary-adrenal (HPA) and structures associated
with the sympathetic nervous system (Green & Kimerling, 2004; Woods ct al., 2005).
During this experience, the energy of all the biological mechanisms is utilized to maintain
homeostasis (Friedman & McEwen, 2004). The experience of one (or more) acute
stressors such as a traumatic event is considered to be extremely taxing on these systems
and may result in the dysregulation of immune parameters (Tosevski & Milovancevic,
2006)

Studies have also assessed the inﬂuence of traumatic experiences on immune
parameters in survivors of traumatic events and comparison groups. For example, Woods
and colleagues (2005) attempted to address this matter empirically in a study examining
the predictive ability of childhood and adulthood interpersonal violence on immune status
in a female sample. They utilized white blood cell count and different types of
lymphocytes (including helper/inducer and suppressor/cytotoxic cells) to assess immune

status. Interpersonal violence in adulthood was found to both directly and indirectly (i.e.

l9

through PTSD) to be predictive of lower immune status (Woods et al., 2005). These
ﬁndings indicate that a traumatic event may have a direct inﬂuence on the traumatized
woman’s immune status which would affect the person’s vulnerability to physical health
problems. The common limitation of all of these studies is that they only assess the
vulnerability to health problems, not the physical health consequences of the immune
system dysregulation. The current study assesses the physical health problems rather than
vulnerability to these problems.

Some research has assessed physical health problems in survivors of traumatic
events. In a study examining medical symptoms in sexually abused versus non-abused
women, Golding (1994) reported higher rates of physical health symptoms in the sexually
abused group such as gastrointestinal (abdominal pain and intolerances of food), pain
(especially during urination), cardiopulmonary, neurological, sexual (burning or pain in
genitals and painful intercourse) and reproductive symptoms (excessive menstrual
bleeding). Examination of physical health symptoms in women that were sexually
assaulted in the military reported higher rates of experiencing a heart attack in the last
year, hypertension, and diabetes (Frayne et al., 1999). This population was also recently
found to report more bodily pain than the comparison female veteran group. Findings
from these studies suggest that there is an association between experiences of sexual
assault and physical health symptoms (Suris et al., 2007). The assessment of actual
symptoms provides further understanding of the way in which the experience of a
traumatic event can manifest itself. However the previously discussed studies have

focused on one type Of traumatic experience at a time.

20

Studies examining a combination of interpersonal traumatic events have found
conﬂicting results. Walker and colleagues (1999) found that a history of childhood
maltreatment, physical and/or sexual, was associated with signiﬁcantly poorer physical
health than psychological symptoms. In comparison, a study examining the effects of
CSA and childhood physical abuse (CPA) on adult women, found that childhood
traumatic events were related to poorer perceptions of general health, but not related to
actual adulthood physical health conditions (Thompson et al., 2002). This may be related
to their measurement of chronic physical health problems. Physical health was assessed
by asking for problems that interfere with normal activities. It is possible that symptoms
that do not fulﬁll this criterion were not captured in this study. The presence of physical
health problems experienced overall may be a better way to assess for health problems.

These ﬁndings were corroborated by another study assessing group differences of
irritable bowel syndrome and CSA/CPA (I-Ieitkemper et al., 2001). The presence of
childhood and adult sexual and physical abuse were not found to predict higher levels of
irritable bowel syndrome. The conﬂicting ﬁndings across studies for the impact of
various forms Of traumatic events on physical health raises questions as to which factors
are inﬂuential for physical health symptoms. However, it should be noted that individuals
with irritable bowel syndrome reported more psychological distress than those without
in'itable bowel syndrome. These ﬁndings reinforce the need to examine both physical and
psychological health symptoms in order to capture the way in which the inﬂuence of a
traumatic event is manifested in survivors.

The literature presented in this section raises important measurement issues in this

population. Further research is needed to examine physical health problems exhibited by

21

women that have experienced various forms of traumatic events. The effect of traumatic
experiences on physical health is a burgeoning area of research. Considering the previous
focus on psychological functioning for trauma survivors, the main question raised by this
relatively new area of research asks what factors are associated with development Of
physical health problems. In addition, questions arise regarding which factors are
associated with the development of one domain of functioning over another if at all.

The combination of past and recent literature regarding health functioning after a
traumatic event has raised the question of why some survivors display psychological
symptoms or physical health problems, both symptoms and no symptoms. Studies have
only begun to assess this relationship and utilize other characteristics to distinguish
between the presence and absence of these symptoms. It is theorized that there are
differences in the way that the health outcomes develop for the two types of traumatic
events, speciﬁcally that IPT is more detrimental to the survivor than NPT (Herman,
1992). Characteristics of the traumatic event, the survivor’s environmental stress and
personality have been examined in the literature as predictors of these different health
outcomes. The relationship between these characteristics however, is still not fully
understood. The current study will examine the characteristics associated with the
presence of psychological and physical health outcomes for survivors of IPT. A model of
development utilized in the current study to understand the relationship between
traumatic events and symptoms for survivors is the transactional model of development

(Sameroff & Chandler, 1975).

22

Mctioml model

According to trauma theory, the experience of a traumatic event inﬂuences the
perception of self and the environment. The individual’s perceptions are believed to
possibly affect her psychological and physical health functioning. However, this raises
questions as to how these factors inﬂuence one another in relation to health outcomes for
the survivor. Sameroff and Chandler’s transactional model (1975) proposes that human
functioning is based on the operation of factors from multiple levels of ecology on one
another. This ﬁ'amework proposes that there are transactions between characteristics of
the environment and the individual which produce development and symptoms.

According to this model, health outcomes (psychological and physical) are based
on the way these levels of the ecology transact with one another. For example, particular
qualities of the environment may inﬂuence the individual characteristics displayed.
Individual characteristics possessed by the person may also inﬂuence the likelihood of
being exposed to a particular environment. In addition, the individual characteristics
exhibited by the person are inﬂuenced by her genetic makeup, the characteristics she is
predisposed to display. Thus, the characteristics of the individual and environmental
levels are important to examine in relation to one another as they inﬂuence one another.

In this study, characteristics of the traumatic event are also proposed to transact
with the individual and environmental characteristics and to be associated with
psychological and physical health symptoms. Herman’s trauma theory (1992) maintains
that the intentional harm caused by another person for IPT may have more detrimental
effects on the way the person views herself, others, and her environment. Thus,

characteristics of the interpersonal traumatic event may be especially pertinent to how the

23

experience is interpreted and can possibly transact with other characteristics related to the
person such as feature of her personality and the environment. Previous literature has
utilized this model to explain the sequelae Of an interpersonal traumatic event on the
survivor (e.g., Sarneroff & Mackenzie, 2003; Shields, Ryan, & Cicchetti, 2001;
Spaccarelli & Kim, 1995).

In accordance with the transactional model, interpersonal traumatic event
characteristics may also be unintentional products of the environment or individual
characteristics. In the case of a person that has had abuse inﬂicted on them by a family
member, she may view her environment as unsupportive and harmful from an early age.
Due to the blurring of the lines between family member and perpetrator the survivor may
not know how to protect herself from or avoid dangerous situations in which she can be
victimized (Spaccarelli, 1994). The experience of a previous interpersonal traumatic
event for this individual without advances in an understanding Of how to protect oneself
from danger based on the environment and individual can result in the experience of
another traumatic event or the revictirnization of the same type of event.

Much of trauma research continues to clarify what factors inﬂuence the
development of different health outcomes. According to the transactional model, it is not
merely the presence of the various factors, but also the way in which they transact with
one another. Thus, it is more likely that differing relationships between the domains will
contribute to the different psychological or physical health problems seen in survivors.
This model of functioning also stresses the need to assess characteristics from various
domains of the person’s life, such as individual and environmental, as well as those of the

interpersonal traumatic event. The current study examines characteristics associated with

24

the different domains discussed by Sameroff and Chandler (1975) as well as interpersonal
traumatic event characteristics to explain the psychological and physical health
consequences. For the purpose of this study, the different domains in the transactional
model are based on factors associated with poorer or better functioning for survivors of
traumatic events in trauma literature. The individual characteristics domain is redeﬁned
as personality characteristics Often associated with psychological functioning while the
environmental domain is categorized by stressors in the survivor’s past and present
environment.
Interpersonal Traumatic Event Characteristics

When discussing the health outcomes of IPTs on survivors, there are several
characteristics of the traumatic event that can inﬂuence the way in which the survivor
experiences the traumatic event. Research has explored how the different characteristics
of the traumatic event can predict the development of various psychological or physical
health symptoms. Some Of the characteristics that have been cited to inﬂuence symptoms
for traumatized individuals include relationship to perpetrator in the case of interpersonal
trauma, severity of the traumatic event, and ﬁnally the experience of multiple traumatic
events.
Relationship to Perpetrator

The deﬁning characteristic of an interpersonal traumatic event is the perpetration
of the event by another person. It is also considered the most salient element of the event
as it is clear that the harm inﬂicted on the survivor was intentional and possibly
maliciously caused by someone else (Herman, 1992). The survivor’s perceptions and

reactions to the traumatic event can be further complicated by her relationship with the

25

perpetrator (e.g., Ketring & Feinauer, 1999; Leahy et al., 2004; Lucenko et al., 2000).
The perpetration of a traumatic event by someone that the person cares for may result in
extreme confusion for the traumatized individual. It is theorized that it may be too
difficult for the traumatized person to process the atrocity committed by someone she is
supposed to trust, sometimes resulting in the need to dissociate from the event (Freyd,
1994,1996)

A large area of literature in which the relationship to the perpetrator has been
examined is that of CSA. A national survey of child rape found that 48% were
perpetrated by a trusted non-relative, 41% by relatives, and 11% by strangers (Saunders
et al., 1999). A number of studies have examined the inﬂuence of perpetrator identity or
relationship characteristics to later psychological symptoms for survivors of CSA (e.g.,
Beitchman et al., 1992; Johnson et al., 2001). In Banyard and Williams’ (1996)
prospective study they found that the relationship to the perpetrator was not signiﬁcantly
associated with negative symptoms soon after the incident. However, it was the only
signiﬁcant predictor of adult emotional distress such as Sleep problems, dissociative
experiences, and overall psychological symptoms 20 years later (Banyard & Williams,
1996). These ﬁndings were further supported in Leahy et al.’s (2004) study on survivors
of CSA. Despite the small sample size (N=39), they were able to detect a signiﬁcantly
higher level of PTSD symptoms and dissociative symptoms for survivors of CSA by
trusted individuals, guardians/caretakers compared to CSA by persons lacking these
relationship qualities. Further examination of perpetrator identity reported that CSA
perpetrated by a father ﬁgure predicted the highest levels of psychological symptoms in

adulthood, followed by family members and acquaintances, and ﬁnally strangers (Ketring

26

& Feinauer, 1999). Findings from these studies suggest that the survivor’s relationship
with the perpetrator could inﬂuence adult psychological symptoms.

Despite this evidence, there has also been some research on perpetrator identity
that has refuted the hypothesis that perpetration of sexual abuse by a trusted individual or
caretaker has a negative impact on psychological symptoms. In one study, the effects of
perpetrator relationship, caregiving duties, and residential proximity (i.e. if the
perpetrator resides with the victim) in adult survivors of CSA were examined in relation
to PTSD symptoms (Lucenko et al., 2000). The authors reported that PTSD symptoms
were found to be higher in survivors of CSA perpetrated by persons that did not have
caretaking responsibilities for the victims. Another study by Johnson and colleagues
(2001) found that the relationship and level of trust with the perpetrator was not
signiﬁcantly related to PTSD, depression, or dissociation symptom severity. These results
contradict previous ﬁndings that CSA by a trusted individual or caretaker would have a
more negative impact on victims of CSA.

It should be noted that the contradictory results may be related to sample
selection. The two studies that did not ﬁnd signiﬁcant results regarding relationship with
the perpetrator recruited their sample from a treatment seeking population. Thus, these
results may not be representative of all survivors of CSA. It is possible that their sample
was more severe than CSA survivors that are not seeking treatment for their experiences
regardless of perpetrator identity. In comparison, studies that found signiﬁcant
differences in psychological symptoms based on relationship to the perpetrator were
recruited from random surveys. Future studies assessing the perpetrator identity should be

aware of this potential methodological confound.

27

Although perpetration is an integral part of interpersonal traumatic events, the
inﬂuence of the relationship to the perpetrator is most commonly examined in CSA
literature. However, there has been little research examining the perpetrator relationship
for other forms of interpersonal traumatic events. As it is a deﬁning characteristic of an
IPT, it is important to examine the relationship with the perpetrator for all forms of this
traumatic event category. Currently there are no studies that examine the relationship to
the perpetrator and how that inﬂuences both psychological and physical health outcomes.
Severity of Traumatic Event

It has been theorized that the severity of the traumatic event has a negative
inﬂuence on the survivor’s functioning. Studies examining the inﬂuence of traumatic
event severity have often sampled speciﬁc types of events to assess the effect of events
such as war combat and torture on the psychological health of the survivor (Gold et al.,
2000; Maercker et al., 2000; McFarlane & dc Girolamo, 1996). For example, Gold et a1.
(2000) found severity of the traumatic event to be the best predictor of PTSD symptoms
in prisoners of war. In contrast, a study conducted by Maercker and colleagues (2000)
examined traumatic event severity of former political prisoners that had suffered various
forms of torture during their detainment. These researchers found that severity was a
good predictor of dissociative symptoms in their sample.

Another study sampling torture victims found that severity of the traumatic event
was associated with PTSD symptoms, but not of anxiety and depressive symptoms
(Basoglu & Paker, 1995). This array of results suggests that severity was not necessarily
the best predictor for all mental health symptoms for survivors of IPT. However, the

discrepancy in ﬁndings may be related to different deﬁnitions of severity utilized in each

28

study. Severity was deﬁned as number of events experienced and duration of
imprisonment in the Maerker et al. (2000) study. In comparison, Basolgu and Paker’s
study (1995) also deﬁned torture severity using participant ratings of the event and did
not include duration Of speciﬁc torture events. These differences point out problems
associated with having varying deﬁnitions of traumatic event severity across studies.
With regard to sexual abuse, severity is often characterized in the literature by
level of abuse such as penetration (Johnson et al., 2001). Higher levels of abuse such as
penetration were found to be associated with higher levels of peritraumatic dissociation,
which was also fOund to be related to symptom severity of PTSD, depression, and
dissociative symptoms in adulthood. Another study found that only severe CSA (not mild
or moderate levels) was predictive of depressive, anxious, and dissociative symptoms
(Ketring & F einauer, 1999). These ﬁndings were corroborated by a meta-analysis
examining the impact of CSA on survivors (Kendall-Tackett, Meyer Williams, &
Finkelhor, 1993). In addition, to severity scales, Johnson et al. (2001) found that the
belief that she could be killed or seriously injured during the CSA was also associated
With more severe PTSD and depressive symptoms. Findings also suggest that perceived
severity of the CSA is related to negative adult psychological symptoms.

There has been some research examining the inﬂuence of event severity on
physical health symptoms survivors Of traumatic events relationship (Leserman, 2005;
Leserman et al., 1996). A study examining the effect Of CSA and physical abuse on
physical health found that severity, deﬁned as rape or physical abuse involving life

threatening force, was predictive of physical health problems such as gastrointestinal

29

symptoms (Leserman et al., 1996). More research is needed to assess the relationship
between severity of traumatic event and physical health problems.

Another element of traumatic event severity is the level of physical injury caused
by the experience. Studies have found that the injuries sustained due to the traumatic
event were related to the development of PTSD (Koren, Norman, Cohen, Bennan, &
Klein, 2005) and depression (Macs ct al., 2000; Rasmussen, Rosenfeld, Reeves, & Keller,
2008). Previous ﬁndings suggested that people were 8 times more likely to develop
PTSD after experiencing trauma-related injury (Koren et al., 2005). A study examining
chronic physical injury from torture found that the effects of traumatic event on PTSD
and depression were fully mediated by chronic physical injury (Rasmussen et al., 2007).
In comparison, a study examining NPT found that physical injury did not increase the
prevalence of depressive symptoms but rather this was associated with the different types
of trauma assessed in these studies. It is beyond the scope of this study to examine the
predictive value of psychological symptoms with one another. These ﬁndings indicate the
importance of assessing physical injury as an indicator of traumatic event severity.

There has also been some confusion due to the varying deﬁnitions of severity.
Previous studies examining severity of the traumatic event have focused on researcher
based criteria. However severity of the traumatic event can be associated with different
aspects of the experiences such as a life threatening force (Leserman et al., 1996) or
physical injuries (Macs et al., 2000). A recent study examining domestic violence and
negative life events discussed the need to assess for participant based ratings of the
traumatic event severity rather than imposing researcher ratings onto the event (Mourad,

Levendosky, Bogat, & Von Eye, 2008). The current study assessed for both Objective

30

(physical injury) and subjective (participant ratings) traumatic event severity scores in
relation to psychological and physical health symptoms.
Multiple T raumas

One of the difﬁcult aspects of research on the inﬂuence of traumatic events on
health outcomes is the high rate of multiple traumatic experiences in survivors. Kessler
and colleagues (1995) reported that 14% of all women in their sample experienced two
traumatic events, 5% experienced three, and 6.4% experienced four or more traumatic
events. According to the cumulative risk model (Sameroff & Seifer, 1983), the number of
risk factors or stressors an individual is exposed to or possesses can inﬂuence her
psychological ﬁmctioning. A traumatic event is considered the most extreme form of
stress that a person can endure (e.g., Gill & Page, 2006; Tosevski & Milovancevic, 2006),
suggesting that similar effects may occur regarding cumulative traumatic experiences.
Studies have found that the experience of more than one traumatic event may have
detrimental effects on a survivor’s psychological and physical health symptoms
(Banyard, Williams, & Siegel, 2001; Breslau et al., 1997; Feerick & Haugaard, 1999;
Kaltman, Krupnick, Stockton, Hooper, & Green, 2005; Ullman & Brecklin, 2003).
Breslau et a1. (1997) reported that subsequent traumatic events resulted in an increase in
lifetime prevalence rates of PTSD: one traumatic event- 11.6%, two traumatic event-
13.6%, and three traumatic events- 13.8%.

Several studies have examined the relationship between PTSD and multiple
traumatic events. Higher rates of PTSD symptoms have been found in relation to multiple
traumatic events than single event survivors when examining survivors of CSA and adult

sexual abuse (Kaltrnan et al., 2005; Nisith et al., 2000), witnessing Of parental domestic

31

violence (Feerick & Haugaard, 1999), community violence (Scarpa, Haden, & Hurley,
2006) and the Holocaust (Yehuda et al., 1997). In a study of Holocaust survivors, Yehuda
and colleagues (1997) found that the number of cumulative lifetime traumatic events was
positively associated with PTSD symptoms of avoidance. Findings from a study
conducted 50 years after the Holocaust suggest that the accumulation of traumatic events
can have long-term effects of psychological functioning. However, few of these studies
examined non-PTSD psychological symptoms in relation to multiple traumatic events.

Recently, studies have begun to examine the effects of multiple traumatic events
on physical health problems. Examination of the effects of CSA or adult sexual abuse on
physical health suggested that there were different factors based on age at the time of the
sexual abuse (U llman &'Brecklin, 2003). The authors utilized the National Comorbidity
Survey to assess the effects of sexual abuse on physical health. They found that for
survivors of adult sexual assault (with no CSA) higher numbers of traumatic events
experienced in life were predictive of chronic medical problems over a l-year span.
Surprisingly, the experience of CSA and adult sexual assault was not signiﬁcantly
predictive of medical problems (U llman & Brecklin, 2003). Examination of medical
problems over l-year may have been too brief of a period to examine CSA effects.
Further research on the relationship between multiple traumatic events and physical
health over a longer period of time is still needed.

The issue of multiple traumas also raises some complications in the literature.
There is an abundance of research that discusses the way in which previous traumatic
events, especially during childhood, can increase the likelihood for future revictimization

for the survivor (e.g., Banyard et al., 2001; Nishith et al., 2000). This is a particularly

32

salient issue regarding CSA and later sexual victimization. Empirical research purports
higher revictimization rates among CSA survivors than non-CSA survivors (e.g.,
Banyard et al., 2001; Kaltman et al., 2005; Lang et al., 2003; Nisith et al., 2000; Sanders
& Moore, 1999). Various theories explore the possible reasons for this situation including
attachment theory. According to this theory, the violation caused by CSA results in
difficulty feeling secure with attachment ﬁgures and thus feeling safe in the world. These
impaired attachment schemas can result in difﬁculty for the child to properly assess a safe
environment and persons thus leaving them more vulnerable to further harm (Alexander,
1992; James, 1994).

Similar results were found when examining the long-term effects of witnessing
parental domestic violence (Feerick & Haugaard, 1999). They found that women who
endorsed witnessing domestic violence between their parents were also more likely to
endure CSA, childhood physical abuse, and adult physical assault by partners and
strangers. However, these results may be related to the experience of a previous traumatic
event, especially CSA, or by psychosocial factors of a home environment in which there
is parental domestic violence. These ﬁndings corroborate the idea that people who
experience an IPT during childhood are more likely to experience another traumatic
experience.

Based on past literature, it appears that the experience of a traumatic event may
leave the person more vulnerable for further victimization, thus complicating our
understanding Of why survivors of IPT are likely to experience high rates of trauma. It is
beyond the scope of this study to provide an explanation for the connection between the

experiences of multiple traumatic events; the current study is interested in examining the

33

effect of the multiple traumatic experiences on the survivor. Overall, the experience of
multiple traumatic events appears to be frequent and to be predictive of poor
psychological functioning. It is important to assess for other factors such as traumatic
event characteristics and environment when examining the experience of multiple
traumatic event. More studies are also needed to determine the relationship between this
occurrence and physical health symptoms.

Previous meta-analyses examining the effects of traumatic events on survivors
have reported that there are a range of characteristics that predict development of
symptoms for survivors (Brewin et al., 2000; Ozer, Best, Lipsey, & Weiss, 2003). They
found that characteristics speciﬁc to the traumatic event do not unifonnly predict the
development of symptoms for survivors. This suggests that there are other factors that
may be related to the development of mental health and physical health problems.
According to the Sameroff’s transactional model, the development of pathology is related
to transactions between the different domains of characteristics.

Personality Chalcteristics

The transactional model proposes that there are characteristics speciﬁc to the
survivor that relate to her functioning. Research examining individual differences
between survivors has found that there are several aspects of the survivor’s personality
that may inﬂuence health symptoms after the traumatic event. Personality characteristics
have been studied in research as related to the development of both psychological and
physical health problems.

5-factor model

34

A major model of personality characteristics is the 5-factor model, which purports
there are 5 main personality dimensions: neuroticism, extraversion, agreeableness,
conscientiousness, and openness (Costa & McCrae, 1985). These dimensions have been
examined in relation to a wide variety of experiences including traumatic event
consequences (Lauterbach & Vrana, 2001; Linley & Joseph, 2004; Nightingale &
Williams, 2000; Smith, 2006). Considering that personality characteristics inﬂuence our
perceptions and experiences of the world, it is possible that they may also have a
protective or vulnerability inﬂuence regarding psychological health. The personality
characteristics most commonly associated with psychological health problems is
neuroticism (Bramsen, van der Ploeg, van der Kamp, & Ader, 2002; Lauterbach &
Vrana, 2001; Lee, Vaillant, Torrey, & Elder, 1995; Strelau & Zawadski, 2005).
Individuals that score high on the neuroticism scale are categorized as anxious, hostile,
self-conscious, insecure, and vulnerable (Brarnsen et al., 2002; Smith, 2006; Spindler &
Elklit, 2003). Since the traits for this personality domain resemble symptoms of
psychological disorders (e.g., depression and anxiety) it is likely that possession of these
traits may increase the likelihood of psychological symptoms (Brarnsen et al., 2002;
Engelhard, van den Hout, & Kindt, 2003; Kendler, Kuhn, & Prescott, 2004; Lauterbach
& Vrana, 2001; Roy, 2002; Tosevski & Milovancevic, 2006; Woods et al., 2005).

For example, a review of the 5-factor model research found that neuroticism was
the only personality trait higher in traumatized individuals versus non-traumatized
individuals (Bunce, Larsen, & Peterson, 1995). Other research studies reported that
neuroticism predicted PTSD symptoms (Brarnsen et al., 2002; Engelhard et al., 2003;

Lauterbach &Vrana, 2001) and depression and traumatic event severity (Kendler et al.,

35

2004; Roy, 2002). Most of these studies examined neuroticism in relation to one type of
traumatic event (e.g. CSA or wartime trauma). One study examined it in relation to all
types of traumatic events (Lauterbach & Vrana, 2001). They found that high neuroticism
was positively related to PTSD symptoms variables and traumatic event intensity and
accounted for 43% of variance for PTSD severity (Lauterbach & Vrana, 2001). Further
examination of personality characteristics determined that there was an interaction
between high neuroticism and traumatic event intensity. According to these ﬁndings, the
presence of high neuroticism was related to the survivor’s reaction to the event. It is
possible that individuals with neuroticism are less likely to have adequate coping
mechanisms to minimize the impact of a traumatic event.

A major limitation of their study is that they examined both non-personal and
interpersonal traumatic events together. Herman argues that there is a difference in how
interpersonal traumatic events and non-personal traumatic events can affect personality
characteristics due to the feeling of betrayal and harm at the hands of another person
(1992). Thus it is important to examine them separately.

In addition to personality characteristics that serve as risk factors, there has been
some research conducted regarding the protective quality using the S-factor model, e. g.
extraversion (Lauterbach & Vrana, 2001; Nightingale & Williams, 2000). Individuals
that score high on extraversion are described as being warm, assertive, and positive
attitudes to emotional expression (Nightingale & Williams, 2000). Extraversion is
associated with chronically low levels of arousal compared to neuroticism which is
associated with high levels of arousal (Strelau & Zawadski 2005). Extraverted individuals

have been found to display lower levels of PTSD after the experience of a traumatic

36

event (Nightingale & Williams, 2000). However there has been little research regarding
psychological functioning (Nightingale & Williams, 2000) relatively no research on its

relationship to development to physical health symptoms despite discussions of arousal
levels.

As the experience of a traumatic event is already associated with the activation of
arousal mechanisms (Tosevski & Milovancevic, 2006; Woods et al., 2005), the authors
hypothesize that the presence of personality traits also associated with arousal systems
may interact with the development of psychological symptoms, speciﬁcally anxiety ones
related to PTSD symptoms. As it is theorized that both of these personality traits are
associated with arousal symptoms it will be useful to examine their relationship to
physical health as well as psychological outcomes.

Optimism

Another personality factor associated with symptoms for traumatized individuals
is optimism. One of the main personality characteristics that Herman (1992) described as
being affected by the traumatic event is the survivor’s perception of the self, others, and
world. Thus, the existence of optimistic personality traits may serve as an adaptive
mechanism in order to reinstate previously shaken beliefs after the traumatic experience
or may be used to rebuild beliefs without damage to ﬁrnctioning. Research on personality
characteristics has cited levels of Optimism to inﬂuence health symptoms for survivors
(Benight et al., 1999; Brodhagen & Wise, 2008; Bunce et al., 1995; Lauterbach, Vora, &
Rakow, 2005; Segerstrom, 2001).

Studies have found that individuals displaying optimism experienced less distress

associated with the traumatic event (Benight et al., 1999; Brodhagen & Wise, 2008).

37

These ﬁndings correspond to trauma theory’s belief that characteristics of the survivor
inﬂuence psychological functioning after traumatic event. In comparison, studies
examining negative perceptions held by individuals in relation to health have found that
pessimism (the opposite of optimism) or negativism (Bunce et al., 1995; Segerstrom,
2001) has a negative inﬂuence on the person’s well being. Bonanno (2004) indicated that
positive emotion is beneﬁcial in reducing the aversive effects of a traumatic event. A
study examining the relationship between the survivor’s, the experience of a traumatic
event, and PTSD symptoms found that negativism was a strong predictor of high PTSD
symptoms (Linley & Joseph, 2004). The compilation of these ﬁndings suggests that low
Optimism in a traumatic event survivor may lead to increased psychological symptoms
such as for PTSD.

In recent years, there has been a growing literature that examines the relationship
between the individual characteristic of optimism in relation to immune system
functioning (Segerstrom, 2001). This literature focuses on the effects of optimism on
immune system functions in the face of stress. Among the research examining the effects
of optimism on immune system functions, there is also literature that argues that
optimism can lead to poorer immunity during stressful events (Cohen et al., 1999; Nes,
Segerstrom, & Sephton, 2005; Segerstrom, 2006). These studies note that optimism
appears to have positive effects for the individual regarding brief stressors. However,
these results are reversed in relation to prolonged stress. In a recent study, Segerstrom
(2006) examined characteristics of stressors in relation to optimism and immunity. She
found that optimism predicted higher immune parameters for individuals facing brief,

controllable stressors. In contrast, individuals with high optimism facing difﬁcult,

38

prolonged stressors had lower immune parameters. Similar ﬁndings were also found in a
prospective study by Cohen and colleagues (1999) when examining life stressors in 39
healthy women for 3 months. They found that optimism was associated with better
immune parameters for brief stress. In comparison, optimism was associated with
decreased immunity for women experiencing persistent stress at high levels (Cohen et al.,
1999).

An explanation for this phenomenon may be the biological processes associated
with prolonged stress. Nes et a1. (2005) found that the sympathetic nervous system and
HPA- axis were activated while problem solving in stressful situations thus the
continuous activity of these systems during prolonged stress for optimists can be
physiologically taxing for the immune system. These results suggest that although
optimism may be beneﬁcial for handling problems in the long term, it can have negative
consequences for the optimistic individual during the process.

These ﬁndings may be especially pertinent to research on survivors of traumatic
events. Such experiences result in increased levels of arousal and stress response.
Although the event may not necessarily be long in duration, the symptoms that normally
follow a traumatic experience, e. g. reexperiencing or intrusive thoughts, may inﬂuence
the survivor. For example, it was reported that 94% of rape victims experienced PTSD
symptoms 1 week after the event (Foa & Rothbaum, 1989). Thus, providing more support
that the experience of a traumatic event, regardless of actual duration may evoke a longer
physiological stress response than average stressors. There is currently no research on the
effects of optimism on physical health conditions in connection with traumatic events.

The current study proposes to examine this relationship based on ﬁndings reported in

39

stress literature. It is believed that high optimism may have negative effects on physical
health and positive effects on psychological symptoms.
Locus of Control

A major feature of a traumatic event is the fear that one can be harmed or killed
during the event (APA, 2000). When a person’s physical integrity is at risk, the
individual probably does not have control over what is occurring to her. After the
traumatic experience, it is not uncommon for the survivor to be concerned over the level
of control possessed in relation to their environment (Herman, 1992). The level at which
the survivor feels that she may have had control over the event or that her vulnerability
was outside of her control can contribute to the feelings of distress after the event (Foa,
1995; Herman, 1992). The distress experienced as a result of these feelings may be
detrimental to the survivor’s psychological and physical health.

A personality characteristic which is associated with these perceptions is locus Of
control, which is conceptualized as the way in which an individual perceives control for
life events or stressors (Rotter, 1966). Rotter conceptualized locus Of control as Operating
on a continuum, with the two extremes being: internal (control held by self) and external
(control source is outside of individual). The locus of control construct has since been
reconceptualized by Levenson (1973) as having three independent dimensions:
internality, powerful others (these two embody Rotter’s internal control and external
control respectively), and chance. According to Levenson’s conceptualization, these
dimensions are not mutually exclusive, but rather could be endorsed by one individual.

For the purpose of this study, these terms will be deﬁned as internal and external control.

40

There has been some research suggesting that the relative strength of external
versus internal locus of control held by the individual can inﬂuence her ability to manage
the stressful experiences (Blocker & Copeland, 1994; Regehr, Cadel, & Jansen, 1999;
Regehr, Hill, & Glancy, 2000; Walsh, Blaustein, Knight, Spinazzola, & van der Kolk,
2007). Internal locus of control permits the individual to believe that she has control over
what happens to her versus external locus of control in which she believes that what
happens to her is in the control of others.

In the event of high stress such as trauma, studies suggest that the relative strength
of external versus internal locus of control can help determine the way the person handles
the event. One study attempted to address this by examining the effect of publicized
traumatic event on PTSD (Dyb, Holen, Steinberg, Rodriquez, & Pynoos, 2003).
Participants were parents of children sexually abused at a daycare center in Norway. The
story was highly publicized in the area and the trial received a lot of media attention.
Parents that reported high levels of external locus of control also displayed higher levels
of PTSD symptoms, while high levels of internal control were not associated with PTSD
symptoms. These ﬁndings suggest that parent perception that they personally had little
control over what happened to their children, whether to prevent or protect them after the
trial, resulted in higher intrusive and avoidance symptoms.

Although an internal or external locus of control approach can be beneﬁcial in
different situations, high levels of internal locus of control has been found to be a
protective personality characteristic in the event of a traumatic experience. For example,
one study examining predictors of PTSD symptoms and depression in 164 traumatized

ﬁreﬁghters found a lack of internal control was predictive of depression (Regehr et al.,

41

2000). In another study examining predictors of adjustment in college students that had
experienced a traumatic event during their lifetime, locus of control was examined in
relation to psychological well-being. Using Rotter’s locus of control continuum, they
found that internal locus of control was associated with better psychological symptoms
for these college students (Banyard & Cantor, 2004). However, the study’s deﬁnition of
psychological well-being consisted of items such as autonomy, environmental mastery,
and purpose in life, but not for symptoms of psychological disorders. More research is
needed to assess the relationship between levels of internal locus of control and
symptoms of psychological disorders for individual’s that have experienced traumatic
events.

Examination of locus of control in relation to a traumatic event experience
suggests that the survivor’s dominant perception of control can serve as a protective or
vulnerability factor. Until now, locus of control has only been examined in relation to
psychological functioning. Based on Herman’s theory, it maybe that the perception of
internal locus of control decreases survivor’s hypervigilance resulting in a decrease in
SNS activation. Research is needed to assess the relationship of locus of control on
physical health. Examination Of both dimensions of locus of control along with the two
health outcome domains at the same time will provide more information about the
inﬂuences of survivor’s perception of control.

Environmental Stress CMeristics

According to the transactional model, the survivor’s environment also plays an

inﬂuential role in her functioning after a traumatic event. This model suggests that

aspects of a person’s environment can inﬂuence the likelihood of displaying

42

psychological or physical health symptoms. Environmental stressors may increase
vulnerability to these symptoms through the lack of protection from harm or by
increasing response levels to trigger symptoms. For a survivor of a traumatic event,
environmental characteristics, before and after event may also inﬂuence the way in which
she reacts to the experience and determine her level of functioning. Some characteristics
which may be inﬂuential for a survivor are her social support network, life stressors, and
a family history of psychological disorders.
Social Support

One of the most commonly discussed environmental characteristics related to
functioning after an interpersonal traumatic event is that of social support. Members of
the social support network can include family members, relatives, friends, and peers
(Rosenthal, Feiring, & Taska, 2003). The experience of a traumatic event can result in
loss of trust in self and others (Herman, 1992). As a result, the individual may be cautious
of trusting others due to fear of being-further harmed or victimized. In order for the
survivor to reestablish trust in other persons and the environment, she would need to have
an adequate support network to bolster this development. Herman (1992) postulates that
positive social support is an integral part of the recovery process from trauma. Social
support after the interpersonal traumatic event may aid the survivor in beginning to trust
that others will not cause her harm but rather will provide support when she is distressed.

Numerous studies have examined the inﬂuence of social support on psychological
symptoms (e.g., Bal, De Bourdeauhuj, Crombez, & van Oost, 2005; Banyard & Cantor,
2004; Gold et al., 2000; King, King, Foy, Keane, & Fairbank, 1999; Levendosky et al.,

2004; O'Doughcrty Wright, Fopma-Loy, & Fischer, 2005; Regehr et al., 2000). Much of I

43

the literature assessing the utility of social support has found that it is Often serves as a
protective factor from the development of future mental health problems. For example, in
the study examining adjustment to college among students that had suffered a variety of
interpersonal and non-personal traumas found that higher levels of social support was
linked to more positive adjustment in this sample (Banyard & Cantor, 2004). However, a
major limitation of the study is that they only examined current social support in relation
to positive adjustment, ignoring the type of social support at the time of the traumatic
event. According to trauma theory, recovery from a traumatic event is associated with the
type of support received in relation to the event. Examining current social support may
not capture how much support the survivor received in relation to the traumatic event.
Other studies have examined the quality of social support in relation to the
experience of the traumatic event. Davis and Brickman (1991) examined whether the
type of social support inﬂuenced psychological adjustment for rape survivors. They
found that unsupportive social networks were associated with poor psychological
outcomes, but that positive social support was not related to better outcomes. Thus,
indicating that although positive social networks did not inﬂuence psychological
symptoms in either direction, unsupportive social networks were detrimental to
psychological functioning. A major limitation Of that study was that it did not take into
account traumatic event characteristics such as event severity, in relation to survivor’s
functioning. It may be that individuals receiving positive support had more severe
traumatic event symptoms than those receiving negative social support explaining the

differences between psychological outcomes (Davis & Brickman, 1991).

44

Levendosky and colleagues (2004) also examined quality of social support in
relation to domestic violence. They found differences in outcomes based on the quality of
social support reported by pregnant abused women: social support networks. In this study
having a high ratio Of social support network members who had also experienced
domestic violence compared to members who had not experienced DV was predictive of
impaired quality of support among battered women. These ﬁndings suggest that social
support networks of women suffering from the same problems do not provide sufﬁcient
support for the individual in order to develop a healthier perception of the world, self, and
others. It may be that person’s who have poor functioning do not provide sufﬁcient
support for survivor’s of IPT and thus the quality of support received is just as important
as the social support itself.

Previous ﬁndings are corroborated by studies examining the survivor’s subjective
perception and the role of the social support. Rosenthal and colleagues (Rosenthal et al.,
2003) examined the relationship of support from various social ﬁgures in the lives of
sexually abused children and adolescents as related to the survivor’s satisfaction with the
support provided. They found that satisfaction with support provided by caregivers or
friends inﬂuenced depressive symptoms, self-esteem, and sexual anxiety (Rosenthal et
al., 2003). These results suggest that survivor perceptions of satisfaction from the support
network can also inﬂuence the survivor’s mental health outcomes. The survivor’s
perception of the support provided can also inﬂuence the way she reestablishcs trust in
others during the recovery process.

The presence of social support can have a positive impact on mental health

outcomes of interpersonal trauma survivors. Similar results were found regarding the

45

relationship between social support and physical health problems in CSA survivors; they
reported that social support was the strongest predictor of physical health (J onzon &
Lindblad, 2006). However, more research is needed to examine social support and
physical health problems in survivors of traumatic events.

According to trauma theory, social support is most relevant to the IPT survivor’s
functioning as it is indicative of a healing environment after the experience of a traumatic
event. As such, it is important to not only examine current social support systems, but
also those that were present after the experience of a traumatic event. Both time periods
are theorized to inﬂuence the woman’s environment and thus her perceptions of the
world as a safe place. In addition, based on previous literature it is important to assess the
perceived quality of the social support received by the survivor. However few studies
have examined the quality of social support in relation to health outcomes, especially
physical health. The current study will assess the survivor’s perception of social support
networks and its relationship to the IPT survivor’s health outcomes. As there has been
little research examining social support and physical health more research is needed to
address this relationship in addition to psychological symptoms.

Life Stressors

The inﬂuence of other stressors in the lives of a traumatized individual has also
been assessed as an environmental characteristic related to the health outcomes.
Traumatic events activate the same biological and coping mechanisms as stress, however
at a much more extreme level (Shalev, 1996). Both systems activate the sympathetic
nervous system and produce a physiological response, however due to the higher level of

fear associated with traumatic event there may be a greater response to it compared to

46

stress. Based on the Similar mechanisms underlying traumatic events and stressors, it is
possible that additional stress in the presence of a traumatic event may also increase the
person’s vulnerability to health problems. For example, a study examining a sample of
women who have experienced the interpersonal traumatic event of domestic violence
found that daily hassles and negative life events served as a mediator for the relationship
between physical abuse and their physical health as well as in the relationship between
abuse and their depression (Sutherland, Bybee, & Sullivan, 2002).

Several studies have examined the relationship between history of traumatic event
and life stressors such as daily hassles and negative life events (Glaser, van Os, Portegijs,
& Myin-Germeys, 2006; Kendler et al., 2004; Koopman, Gore-Felton, Classen, Kim, &
Spiegel, 2001; Sutherland et al., 2002; Thakaar & McCanne, 2000; Ullman & Brecklin,
2003). One major question in this literature is how survivors interpret the stressful events.
Female survivors of CSA with PTSD were found to experience more ASD symptoms
related to everyday stressful events than non-CSA survivors. As these events were
categorized as non-traumatizing to other people, it is theorized that stressful life events
are perceived as more distressing for survivors of IPT (Koopman et al., 2001). This
corresponds to trauma theories supervision that survivors of IPT view themselves as more
vulnerable to harm.

Similar results were reported in a study using experience sampling to examine
daily life stress in survivors of childhood traumatic events found that survivors of
childhood traumatic events endorsed higher levels of emotional reactivity to daily
stresses (Glaser et al., 2006). Emotional reactivity in this study was deﬁned as a change

in negative affect, thus survivors of childhood traumatic event mood changed more than

47

those not exposed to childhood traumatic events. However, there were no signiﬁcant
differences between both groups in regards to their rating of stressfulness from the
events. All participants for this study were recruited based on frequent attendance status
at a health organization. Thus, both groups appeared to display problems related to health
regardless of traumatic event status. This unfortunately was also a limitation of the study
as it only examined a sample with frequent medical problems and thus could not assess
for physical health symptoms. In addition, the sample may not generalize to other
populations as both groups already displayed medical problems.

Other studies that examined non-clinical samples found differences in relation to
stress perceptions between groups exposed to childhood traumatic events and those that
were not (Kendler et al., 2004; Thakaar & McCanne, 2000). A study examining daily life
stress and a history of CSA in female college students found that the experience of CSA
was associated with higher levels of stress and physical health problems (Thakaar &
McCanne, 2000). However, the authors included participants that only experienced
childhood sexual abuse for the CSA group, thus participants that endorsed adult sexual
assault were excluded from the study completely. Due to the high rates of revictimization
in CSA populations, this sample may not be representative of other CSA and
interpersonal trauma samples.

In another study examining stressful life events in survivors, Kendler and
colleagues (2004) found the CSA survivor group experienced more depressive symptoms
from stressful life events than the no-CSA group. However, no clear deﬁnition of
exclusion or inclusion criteria based on history of CSA or other traumatic events was

presented for this study. The two studies that recruited non-clinical samples, reported

48

high endorsement of perceived stress from life events in comparison to the clinical
sample presented in Glaser and colleagues’ study (2006). These differences suggest that
there may be differences in perceived stress related to the severity of the sample. Future
research Should be aware of these possible differences when choosing participants.

Based on the ﬁndings discussed, the experience of negative life events for a
survivor of traumatic experience may be difﬁcult to handle. Survivors appear to have
stronger reactions to the events and are more vulnerable to display depressive or physical
health symptoms in response to these stressors than non-survivors (Koopman et al.,
2001). This may be related speciﬁcally to a treatment of an IPT. The current study
examines a non-clinical sample will be more generalizable and examines one domain of
traumatic experiences.
Family Psychiatric History

Numerous studies have discussed the role of family psychiatric history Of
psychological disorders as a predictor of psychological disorders and symptoms in
Offspring (King, King, Foy, & Gudanowski, 1996; Koenen et al., 2002; Koenen, Mofﬁtt,
Poulton, Martin, & Caspi, 2007; McKenzie, Marks, & Liness, 2001; Ozer et al., 2003;
Yehuda, 1999). The presence of such a family history is believed to increase the
biological vulnerability to the developing the same or related symptoms or disorders. For
example, one study found that 51.4% of women with mothers that had a mental disorder
experienced lifetime depression, 46.2% for women whose fathers had a disorder, and
75% for women with both parents affected by mental illness (Rowe, Fleming, Barry,

Manwell, & Kropp, 1995). Yehuda and colleagues (1998) also found that there was a

49

signiﬁcant relationship between the presence of PTSD in Holocaust survivors and their
offspring.

Similar results were found in a study of family history of mental illness’ inﬂuence
on women that experienced sexual assault (Davidson, Tupler, Wilson, & Connor, 1998).
In this study, family history was obtained by assessing the ﬁrst generation relatives of all
participants. Women with a history of sexual assault and that suffered from PTSD were
found to have a higher rate of family history of psychological disorders than sexually
assaulted women that did not develop PTSD. The rates of familial psychological
disorders for the women with a history of sexual assault and PTSD were similar to those
of a comparison group of non-traumatized women with a history of depression (Davidson
et al., 1998). Salicoglu and colleagues (2003) also examined the inﬂuence of risk factors
for psychological disorders on the traumatic event of an earthquake. They found that
family history of psychiatric illness in the event of a traumatic experience was associated
with more severe symptoms of depression. These ﬁndings suggest a strong vulnerability
to psychological symptoms such as depression in the presence of familial history of
psychological disorders.

Research ﬁndings have also suggested it may serve as a psychosocial risk factor
for the person that experienced a traumatic event (Kellerrnan, 2001; Koenen et al., 2002;
Koenen et al., 2007; Yehuda, 1999). This is best exempliﬁed in studies of the
transmission of trauma symptoms from Holocaust survivors to their offspring. In their
examination of the offspring of Holocaust survivors, Yehuda and colleagues (2001)
found that parental exposure to the Holocaust was a strong predictor of a lifetime

diagnosis of depression. They also found that the offspring of Holocaust survivors with

50

PTSD were found to have increased rates Of PTSD than Offspring of Holocaust survivors
without PTSD (Yehuda, Halligan, & Bierer, 2001). According to these ﬁndings, the
experience of such a traumatic event by parents with or without the diagnosis of PTSD,
lead to an increased risk of personal psychological problems for the offspring.

Familial psychiatric history has also been found to be an inﬂuential factor in
exposure to a traumatic event. Studies have found that a family history of psychological
disorders have inﬂuenced the risk of exposure to a traumatic event (Koenen et al., 2002;
Koenen et al., 2007). In a longitudinal study examining the development of PTSD,
factors that were found to inﬂuence the exposure to trauma included family psychiatric
history, externalizing behaviors during childhood, and family adversity (Koenen et al.,
2007). Another study examining the effects of family history on trauma exposure in twins
that served in the military during the Vietnam War found that parental antisocial behavior
was associated with higher risk of trauma exposure and the development of PTSD. In
addition, exposure to traumatic event was signiﬁcantly associated with parental
depression (Koenen et al., 2002). It is suspected that the risk of personal traumatic event
exposure for family members of relatives with familial psychological disorders may be
related to matters of safety provided to the individual prior to a traumatic event or the
support provided post-traumatic event. Parents that are struggling with their own
psychological problems may not be able to protect their children from potentially
dangerous situations. These parents may also not be able to provide adequate support to
help their children cope with the stressors that may arise in their lives (Bloom, 1997).

Some offspring of Holocaust survivors reported feelings of emotional neglect due to their

51

parents’ frequent concern with the children and loved ones lost in the concentration
camps rather than their surviving children (Kellerman, 2001).

Based on the ﬁndings from presented studies, a family psychiatric history may
also inﬂuence the presence of psychological problems for relatives. Although the increase
may be due to genetic vulnerability, there is also evidence to suggest that it may inﬂuence
psychosocial enviromnental factors. This is particularly demonstrated through the
increase in trauma experiences for offspring of relatives with psychological problems.
This may be due to the lack of nurture or protection within family environments. It is
important to examine family history of psychological disorders as an environmental
characteristic that can inﬂuence the development of psychological symptoms for
individuals that experienced a traumatic event.

Rationale

The trauma literature has often focused on the presence of psychological
symptoms in relation to the experience of a traumatic event. Recent studies have begun
examining the effects of a traumatic event on physical health in addition to psychological
health. Although there have been some studies that have examined the relationship
between physical health problems and symptoms of PTSD (Woods et al., 2005; Zoellner
et al., 2000), there has been substantially less research that examines the effects of trauma
on the symptoms from other psychological conditions and physical health problems. The
current study will examine the relationship between traumatic experiences and the
presence of psychological and/or physical health outcomes.

Unlike other studies that have examined immune system responses to traumatic

events, the current study proposes to examine the expression of physical health outcomes

52

through participant reports of lifetime health problems. The present study will also
examine the presence of psychological symptoms in order to assess if there is a presence
of symptoms related to the traumatic event. Examination of psychological symptoms will
enable the current study to assess if there are higher rates of certain types of symptoms in
survivors of traumatic events.

Trauma research has either examined the effect Of various forms Of traumatic
events, separately or collapsed with one another, on the presence of health symptoms
(psychological and physical health). However, it is important to understand the different
characteristics of the traumatic event that may be associated with health consequences.
There have not been any studies that have assessed the difference between the type of
traumatic event experienced, interpersonal or non-personal, and the survivor’s health
symptoms. A comparison of interpersonal and non-personal traumatic events will be
made for both psychological and physical health symptoms.

Past research has also examined characteristics of trauma, individual, and the
environment as predictors of health symptoms for individuals that with traumatic
experiences. However, most studies have examined these characteristics using a variable-
oriented approach. The person-oriented approach holds that behavior and development
are person-speciﬁc and enables researchers to identify proﬁles of survivors based on
patterns related to the independent and dependent variables (von Eye & Bergman, 2003).
In the current study, the characteristics of the 3 domains in relationship to the health
symptoms will be examined using both a variable and person-oriented approach.

As this part of the study was exploratory, previous hypotheses were made based

on variable-centered research. Previous studies have examined the health outcomes

53

associated with proﬁles that occur from different types of interpersonal traumatic events
(e.g. Campbell, Greeson, Raja, & Bybee, 2008, Pimlott-Kubiak & Cortina, 2003).
However, there have not been studies that have examined the health outcomes associated
with the characteristics of the survivor of an IPT. It has been well documented in the
variable-centered approach that there are characteristics Of the survivor’s environment
and personality as well as attributes of the trauma endured that are associated with the
development of psychological and physical health outcomes (e.g., Bramsen et al., 2002;
Reghr et al., 2000; Rosenthal et al., 2003; Segerstrom, 2001). Understanding the
combination of the female survivor’s characteristics associated with their health
outcomes can provide a more detailed and interactive description of which survivor of
IPT is more likely to experience the different health problems.

For the variable-oriented approach, the present study proposes to utilize the
transactional model of functioning to examine the relationship between traumatic events,
individual, environmental characteristics, and psychological and physical health
symptoms. The use of this model allows the examination of individual, environmental,
and trauma characteristics and provides a conceptualization of the way they may
inﬂuence one another in relation to the health symptoms.

For the person-oriented approach, this study will explore the proﬁles of
characteristics associated with the women and their experiences that are related to their
health symptoms. The use of this approach will enable the current study to examine the
characteristics related to women who have experienced a traumatic event that can

inﬂuence their psychological and physical health ﬁrnctioning. This study is especially

54

interested to see if there are proﬁles of characteristic for women who display different
health symptoms or no symptoms.
HYPOTI-IESES

Hypothesis 1 a: According to trauma theory the experience of a traumatic event
along with the shock and fear of harm or injury to one’s physical integrity is what
inﬂuences the development of health symptoms in survivors. Either type of trauma,
interpersonal or non—personal, may have detrimental effects on the survivor. It is
hypothesized that traumatized women will experience signiﬁcantly higher levels of
psychological and physical health symptoms than non-traumatized women. However, it is
assumed that there are differences between the health outcomes for the two trauma
groups. The experience of a traumatic event at the hands of another person is theorized to
rupture the foundations for which the survivor’s world is based on, thus it is also
hypothesized that women who experience interpersonal traumatic event(s) will have
higher levels of psychological and physical health symptoms than those who only
experience non-personal traumatic events

Hypothesis 2: Prior studies have demonstrated that there are many characteristics
of the traumatic event, the survivor and her environment which inﬂuence the
development of health outcomes. However, the relationship between these characteristics
and how they contribute to the functioning of the survivor of a traumatic event is still not
fully understood. Sameroff and Chandler’s transactional model of development proposes
that characteristics of the individual and environment transact with one another and
inﬂuence health outcomes. Using this model, and our theoretical understanding of IPTs,

it is believed that the intensity levels of such a traumatic event will transact with

55

characteristics of the individual and the environment to inﬂuence health (psychological
and physical) symptoms for the survivor (see Figure 1). In accordance with this model, it
is also hypothesized that characteristics of the individual and environmental will
signiﬁcantly predict each other and that all Of these domains will transact with one
another and predict both psychological and physical health outcomes.

Hypothesis 3: In the current study, three domains have been identiﬁed as
inﬂuencing health outcomes for survivors of IPT: trauma, personality, and environmental
characteristics. In addition to examining the relationships between these domains with
health outcomes, this study examines the way the agglomeration of each domain’s
characteristics as well as the health proﬁles associated with these clusters. As there has
been no literature on this matter, these analyses will be exploratory. It is hypothesized
that there will be a group created with no symptoms, one with psychological symptoms
alone, and one with both psychological and physical health symptoms. Proposed proﬁles
for the group of women who do not display any psychological and physical health
symptoms include lower severity levels of the traumatic event, high levels of
extraversion, an internal locus of control, and high levels of social support at the time of
the traumatic event. The group of women who only display psychological symptoms are
proposed to have experienced multiple traumatic events, perpetration by a family member
or family acquaintance, and a family history of psychological problems. Based on
theoretical conceptualization and previous research the proﬁle proposed for the group of
women who experience both psychological and physical health symptoms include higher
severity of the traumatic event, higher levels of neuroticism, an external locus of control,

and low levels of social support at the time of the traumatic event.

56

METHODS
Participants

Participants included 1806 female undergraduates enrolled at Michigan State
University (MSU). All participants were recruited from the Psychology department
undergraduate subject pool; thus they were all enrolled in a psychology course that
required research participation credits. Inclusion criteria for the study included being
female and being at least 18 years of age. A total Of 2251 completed consent forms for
participation. Several hundred were not included in the ﬁnal sample: 169 because they
were male1 and 276 due to incomplete data.

Trauma incidence was calculated for participants based on the traumatic event
that they reported as being the most upsetting event on the list of traumatic events that
they have experienced; that trauma labeled their primary traumatic event. Participants
were divided into different trauma groups based on this response. The interpersonal
traumatic event group consisted of 15% (N =279) of the sample, the non-personal
traumatic event group was the largest at 65% (N=1 165), and the ﬁnal 20% (N=362)
reported no experience of a traumatic event in their lifetime and thus were placed in the
non-traumatic event group. The demographic characteristics for each group are provided
in Tables 1 and 2. Endorsement of clinical levels of psychological conditions was also

measured for each group and was reported in Table 3.

 

' All materials used for the current study clearly stated that only females were allowed to participate,
including the introductory description of the study from which participants chose the projects they could
participate in as well as the consent form. Despite these instructions, 169 identiﬁed males participated in
this study. Their information was removed from the present databases.

57

Procedures

Participants were recnrited from psychology classes at a Midwestern University
and received course credit for their participation in the study. Participants were provided
a brief description of the study prior to completing the questionnaires so as to inform
them of the study purposes. Participants were informed that they must be female and
above the age of 18 in order to participate in the study. The study was conducted
completely online and consisted of self-report questionnaires. The study was designed to
be completely anonymous in order to protect the privacy of the women that endorsed
traumatic experiences and to encourage full disclosure on the questionnaires. At the end
of the study, participants were provided with a feedback sheet to explain the purpose of
this study in more detail and a resource list for mental health services in the community if
needed.

All participants for the study were asked to complete questionnaires assessing
demographic information, measures assessing their psychological health, physical health,
personality characteristics, non-trauma related environmental stress measures, and a
screener for traumatic experiences (see measure descriptions below). Women that
endorsed a history of at least one traumatic event, interpersonal or non-personal, were
instructed to complete the remaining measures assessing characteristics of the traumatic
event, PTSD symptoms, ASD symptoms, and social support directly after the trauma
experience.

Measures

Demographics

58

Participants were asked to complete a short questionnaire, 4-items, to identify
their age, race/ethnicity, education level, and family income (parents’ income for those
supported by parents). An additional item was added to the end of the questionnaire to
identify participant’s sex in order to screen for possible males that may have participated
in the study. Gender was imputed to assess for persons that were male and did not answer
the question. Participants were categorized as male were removed from the database. All
identiﬁed males were removed from the database. See appendix A for copies of all
measures.

Physical Health Symptoms

National Health Interview Survey (NHIS: Centers for Disease Control, 2005).
This 28-item measure was designed to assess health concepts in clinical and research
settings. For the purposes of this study, it was adapted to include more medical conditions
discussed in the physical health and trauma experience literature such as gastrointestinal
and gynecological conditions. Participants were asked about the presence or absence of
medical conditions diagnosed by a medical practitioner at any time in their life. Medical
conditions assessed in this measure include cardiopulmonary, gastrointestinal, and
gynecological. Moderate reliability was found for this measure in the current study
(alpha= .70).

Miller Abuse Physical Symptom and Injury Scale (MAPSAIS: Miller &
Campbell, 1993). This is a 47-item measure that assesses physical ailments endured over
the past year and lifetime. Lifetime symptoms were assessed by presence or absence and
current year symptoms will be assessed using a 4-point Likert scale ranging from “Not at

all” to “Often.” This measure was originally designed to assess physical health problems

59

directly related to interpersonal violence and general physical health problems. It
included 40-items that assess health ailments speciﬁc to immune functioning such as
allergies (e. g. hay fever, asthma), infections (e. g. urinary tract, respiratory, viral) and
chronic pain Greadache, back pain, chest pain, abdominal pain). Woods and colleagues
(2005) found that this measure to have high reliability (alpha=.84) and validity as related
to all medical charts for their participants. High reliability was found for this section of
the measure in the current study (alpha= .90).

The remaining 8-items are speciﬁc to physical conditions related to interpersonal
violence. These items were reworded to encompass physical health problems directly
related to the traumatic event that bothered them the most. Examples of these items
include “Hospitalized due to injuries from the traumatic event” and “Facial injuries due
to the traumatic event.” Participants were instructed to only complete this section if they
had already endorsed the experience of a traumatic event. The sum of these questions was
used as physical health severity for traumatic characteristics. This section of the measure
yielded high reliability (alpha= .84).

Measures of Psychological Symptoms

Center for Epidemiologic Studies Depression Scale (CED-S: Radloff, 1977). This
is a 20—item self-report instrument that assesses the presence of current depressive
symptoms in the past week. Examples of items include: “I did not feel like eating; my
appetite was poor,” “I felt lonely,” and “I felt sad.” Participants were asked to report how
Often they experienced each item in the past week using a 4-item Likert scale ranging
from “Rarely or none of the time” to “Most or all of the time.” CED-S total scores range

from 0-60 with higher scores indicating more depressive symptoms. Scores of 16 or

60

higher were indicative of clinical levels of depression (Radloff, 1977) and were used as to
classify participants in the current study. The CED-S was reported to have internal
consistency in the general population with an alpha of.85 and a psychiatric inpatient
population with an alpha of .90. It was also reported to have moderate to high levels Of
convergent validity (Radloff, 1977). The current study found high reliability for this
measure (alpha= .90).

Beck Anxiety Inventory (BAI: Beck, Epstein, Brown, & Steer, 1988). This is a
21 -item self-report instrument that assesses the presence of current panic—like anxiety
symptoms in the past week. Examples of items include: “Unable to relax,” “Hands
trembling,” and “Difﬁculty breathing.” Participants will be asked to report how Often
they experienced each item in the past week using a 4-item Likert scale ranging from
“Not at all” to “Severely, I could barely stand it.” BAI total scores range from 0-63 with
higher scores indicating more anxiety symptoms. Scores of 16-63 were determined to
represent moderate to severe levels of anxiety according to past research (Beck et al.,
1988) and were used to classify presence of clinical levels of anxiety in the current study.
Authors of the BAI reported high internal consistency (alpha=.92) and high content
validity of .92 for panic disorder without agoraphobia, .91 for social phobia, and .85 for
generalized anxiety disorder (Beck et al., 1988). High reliability was found for this
measure in the current study (alpha= .90).

Posttraumatic Diagnostic Scale (PDS: Foa, 1995). This 38-item self-report scale
assesses all symptoms from all 6 criteria sets of PTSD based on the DSM-IV. Below is a

description of each section of the PDS.

61

Screener for Traumatic Event: The PDS begins with a list of l3-items that screen
for the experience of a traumatic event including sexual victimization during
childhood or adulthood, accident/ﬁre, torture, and life threatening illness. If more
than one event was endorsed, participants were asked to identify the traumatic
event that bothered her the most; for the purpose of this study, this was considered
the primary traumatic event. The information collected in this section was utilized
for three areas of data analysis. The events endorsed in this section were used to
screen for the experience of a traumatic event. Events considered the most
distressing traumatic experience were used to categorize the women based on
interpersonal or non-personal traumatic event experience into groups for analysis.
Participants that did not endorse any items in this section were directed to skip the
following sections of the PDS.

Characteristics of Traumatic Events: To assess for psychological severity of the
traumatic event, participants were also asked to report how upsetting the event
was at the time it occurred. Each item was measured on a 4-point Likert scale
ranging from “Not at all” to “A lot.” Items were summed for the primary
traumatic event to produce a psychological severity score. To assess for
relationship to the perpetrator, participants were asked to report the number of
times each interpersonal traumatic event was perpetrated by a family member

(e. g. father, brother, step-father), family friend or neighbor, or stranger. The
category and number of times the event was perpetrated by for the primary
traumatic event was used for analysis. Finally the number of events reported by

the participants, and the number of times each one occurred, was summed to

62

 

Cla

produce a total trauma exposure score to assess for multiple traumatic event

exposure.

- Trauma Symptoms: Participants who endorsed an experience Of a traumatic event
were asked to complete 17-items that correspond to the DSM-IV-TR PTSD
symptoms of reexperiencing, avoidance, and arousal. Participants were directed to
complete these questionnaires based on their primary traumatic event. The
experience of each symptom in the past month will be measured using a 4-point
Likert scale ranging from “Not at all” to “5 or more times a week/Almost
Always.” The frequency of symptoms was summed to create a sum score for each
cluster of PTSD symptoms.

The PDS is reported to have high test-rest reliability for total symptom severity
(alpha=.82) and for each of the symptoms clusters (alpha range= .77-.85). It was also
found to have high convergent validity with the PTSD portion of the SCID, kappa=.65
(Foa, 1995). High reliability was found in the current study for trauma symptoms (alpha=
.92).

The Stanford Acute Stress Reaction Questionnaire (SASRQ: Cardena, Koopman,
Classen, Waelde, & Spiegel, 2000). This is a 30-item self-report questionnaire that
measures symptoms of ASD such as dissociation, reexperiencing avoidance, and
hyperarousal. For example, “I experienced myself as though I were a stranger,” “I felt
hypervigilant or on edge,” and “had repeated and unwanted memories of the event.” Each
item is measured on a 5-point Likert scales ranging from “Not experienced” to “Very
often experienced.” Participants were directed to respond to questions in this measure

based on their primary traumatic event. Participants were asked to report if they had

63

experienced these symptoms during the most traumatic event or up to 4 weeks afterward.
Their ratings were used to produce one total ASD score. This measure has been utilized
in previous studies to assess symptoms of ASD based on different traumas such as
earthquakes, ﬁrestorms, and witnessing someone else’s death (Cardena & Spiegel, I993;
Freinkel, Koopman, & Spiegel, 1994; Koopman, Classen, & Spiegel, 1994). The SASRQ
was reported to have high internal consistency (alpha=.93). The current study found high
reliability for this measure (alpha= .97).
Measures of Individual Characteristics
Eysenck Personality Questionnaire- Revised and Abbreviated (EPQR-S: Eysenck,
Eysenck, & Barrett, 1985). This measure is a 24-item assessment of abbreviated version
of the revised Eysenck Personality Questionnaire (Eysenck et al., 1985). The items assess
for extraversion and neuroticism. The EPQR-S has been widely used throughout the
literature to assess personality dimensions. Examples of items in the extraversion scale
include, “Are you an irritable person,” “Are you a talkative Person,” and “Have you ever
said anything bad or nasty about someone.” Items were reverse coded as needed and
summed to determine total score for each domain; only neuroticism and extraversion will
be used in analyses for this study. The EPQR-S was reported to have high test-retest
reliability for females, .80 for neuroticism and .84 for extraversion (Eysenck et al., 1985).
This measure yielded high reliability scores of .82 for neuroticism and .86 for
extraversion in this study.
Life Orientation Test- Revised (LOT-R: Scheier, Carver, & Bridges, 1994). This
is a lO-item scale that measures positive outcome expectancies. It is utilized to assess for

0ll>timistic and pessimistic attitudes. It provides 3 statements that are positively stated, 3

64

 

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that are negatively stated, and 4 ﬁller items used to disguise the intent of the scale.
Examples of items in the LOT-R include “In uncertain times, I usually expect the best,”
“I’m always optimistic about my future,” and “I rarely count on good things happening to
me.” Participants were asked to respond how much each item reﬂects their own attitudes
using a 5-point Likert scale ranging from “I agree a lot” to “I disagree a lot.” Responses
denoting pessimistic values were reversed scored. Items were summed to create one total
optimistic score and ranged from 0-32 with high scores reﬂecting more optimistic beliefs.
Internal consistency for the LOT-R was found to be .78 for the optimism items and test-
retest scores taken over 4-28 months ranged from .59-.79 (Segerstrom, 2006). The LOT-
R was also reported to have adequate discriminant validity (Scheier et al., 1994). High
reliability was found for this measure in the current study (alpha= .79).

Levenson’s Locus of Control Scale- Brief version (LOC-B: Sapp & Harrod,
1993). This 9-item measure is the abbreviated version of Levenson’s Locus of Control
Scale (1974) which is designed to assess perceptions of locus of control. Participants
were asked to rate a statement using a 5-point Likert scale ranging from “ Strongly
Agree” to “ Strongly Disagree.” Statements utilized in this measure were designed to
assess 3 categories of control: internal control, chance, and powerfulness of others (i.e.
external control). The 6 —items assessing internal and external control were utilized in the
analyses for this study. Examples of items include: “My life is determined by my own
actions” and “My life is chieﬂy controlled by powerful others.” Sapp and Howard report
moderate reliability coefﬁcients for internal control .58, chance .65, and powerfulness of
others .72. They also reported signiﬁcant (p<.01 level) predictive and construct validity

in relation to other Locus of Control measures. Inter-item correlations for internal fall in

65

 

 

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the optimal range of .32 to .44. Inter-item correlations for external control falls in a
slightly lower range of .10 to .40 with a mean of .20.
Measures of Environmental Characteristics

Crisis Support Scale (CSS: Joseph, Andrews, Williams, & Yule, 1992). This 7-
item scale assesses survivor perceptions of received social support after a traumatic
event. Participants were asked to rate their perceptions of social support right after the
primary traumatic event and current social support. A 7-point Likert scale ranging from
“Never” to “Always” is utilized to assess the reception of social support after the
experience of a traumatic event. Examples of the items in the CSS are “Someone willing
to listen,” “Sympathy and support from others,” and “Feeling let down.” Items were
summed to create two total social support scores, one at the time of the traumatic event
and for current social support. They were reverse coded so that high items reﬂect less
social support related to the traumatic event. Elklit and colleagues (2001) reported good
internal consistency and discriminatory power in their review of 11 studies (N=4213) that
used the CSS and reported an alpha of .74 (Elklit et al., 2001). High reliability was found
for both current and past social support (alpha=.90 and .91 respectively).

Life Experiences Survey (LES: Sarason, Johnson, & Siegel, 1978). This 37-item
questionnaire asks about life events experienced in the last year that may have caused
changes in the participant’s life. If an event occurred, the participant was instructed to
report whether they view the event as positive or negative on a 7-point Likert scale
ranging from —3 for extremely negative impact to +3 for extremely positive impact. Some
examples of items are “death of a close family member,” “trouble with employer,” and

“marital separation.” Items endorsed were multiplied by their impact rating and only

66

items rated as negative scores were summed to create one total score for negative life
events. This measure was found to have high reliability for the current study (alpha= .77
to .81).

Family History Questionnaire (F HQ: Klump, 2001). In this measure, the
participant was asked to indicate if any relatives have major internalizing psychological
problems such as depression, post-traumatic stress disorder, anxiety, alcoholism, or
suicide and/or attempts (they will be provided with deﬁnitions of each disorder in case
there were any questions about the diagnostic terms). If the participant answers positively
to any of the mental health problems, they were asked to identify the family members’
relation to themselves (e. g. mother, brother, father’s sister) and asked if that individual
was treated or hospitalized for the condition. Family psychiatric history score was
composed of the total number of family members (e. g. mother, father, or siblings) that the
participant identiﬁed as having an internalizing disorder.

RESULTS
Missing Data

Due to the nature of the data collection, there were many checks conducted to
assess for completion and accuracy of the data. All participants that did not complete the
PDS screening section were removed from the database prior to analyses. As previously
mentioned, data were checked for accuracy and participants identiﬁed as male or with
incomplete data were removed from the database to ensure that only data from
participants that understood the questionnaires were included in the study. Any remaining
missing data were imputed using the EM estimation method (SYSTAT 12). This

statistical algorithm is used to ﬁnd the maximum-likelihood estimate of the parameters of

67

the distribution from the data set with missing values. Estimates were rounded to the
nearest full value and used to replace the missing values in the data set. See table 4 for
percent of data imputed and descriptive statistics of the variables before and after
imputation.

Hypothesis Testing

Hypothesis 1

The ﬁrst hypothesis addressed whether there was a difference in psychological
and physical health outcomes for the different groups based on trauma experiences.
Multivariate Analysis of Variance (MANOVA) demonstrated a signiﬁcant difference
between the no trauma, IPT, and NPT groups (A=. 647, F18,1806 = 48.444, p < .01) for both
types of outcomes (see table 5). Further post hoc tests were conducted using Tukey HSD
to assess for signiﬁcant differences between the groups.

The IPT group was found to be signiﬁcantly different than the no trauma and NPT
groups for depressive and anxious symptoms, however, there were no signiﬁcant
differences between the no trauma and NPT groups (see table 6). The IPT and NPT
groups were also signiﬁcantly different from one another for PTSD and ASD symptoms.
In addition, all three groups were signiﬁcantly different from one another for serious
medical conditions, lifetime and past year physical ailments. The IPT group had the
highest means for all mental health outcomes, NPT had the second highest, and the no
trauma group had the lowest.

Hypothesis 2: Structural Model

IPT Model Testing

68

In 'order to test the transactional model for trauma, a structural equation model
(SEM) was estimated based on group membership; groups were created based on the
primary traumatic event endorsed. All SEM analyses were conducted with LISREL,
version 8.72 (Joreskog & Sorbom, 2005). The IPT hypothesized model ﬁt was )8 (184,
N = 279) =341.38, p <.01, Goodness Of Fit Index (GFI) = 0.90, Comparative Fit Index
(CPI) = 0.96, Normed Fit Index (NNF I) = 0.95, Root Mean Square Error of
Approximation (RMSEA) = 0.055, 90 Percent Conﬁdence Interval for RMSEA = (0.046;
0.065), and Standardized Root Mean Square Residual (RMR) = 0.071. Thus, the model
showed a good ﬁt to the data.

In regards to personality characteristics, it was found that neuroticism and
external control loaded negatively on the latent variable, while the other three factors
loaded positively onto the latent variable. Based on these ﬁndings and previous literature
that these two factors were categorized as risk factors for psychological symptoms
(Bramsen et al., 2002; Dyb et al., 2003; Lauterbach & Vrana, 2001; Lee, Vaillant, Torrey,
& Elder, 1995; Regehr et al., 2000) and physical health consequences of traumatic
experiences, it appears that the factor loaded as protective personality characteristics. As
a result, the personality characteristics latent variable will be referred to as protective
personality characteristics for this analysis.

Further examination of the path coefﬁcients indicated that only some of the
hypothesized relationships were signiﬁcant. The transactional model was tested and, as
hypothesized, it was found that high levels of trauma characteristics were predictive of
high levels of environmental stress (t= 3.16, p < .05) and negatively predictive of

protective personality characteristics (t= -2.67, p < .05). Contrary to other hypotheses in

69

 

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the transactional model, trauma characteristics were not directly predictive of
psychological or physical health symptoms. Protective personality characteristics were
negatively predictive of environmental stress (t= -4.29, p < .05) and psychological
symptoms (t= -3.47, p < .05) but not signiﬁcantly predictive of physical health
symptoms. As hypothesized, environmental stress was found to be predictive of
psychological symptoms (t= 3.47, p < .05) but not of physical health symptoms. Finally,
psychological symptoms were found to be predictive of physical health symptoms (t=
2.50, p < .05). Overall, these ﬁndings do not offer strong support of the hypothesized
transactional model for the traumatic event situation. However, further examination of
these results suggests the presence of a mediation model of trauma characteristics and
health outcomes through environmental stress. See ﬁgure 2. Additional analyses were
conducted to test this mediation model.

The presence of a mediation model among the trauma characteristics of IPT and
health outcomes was assessed by removing the pathways from trauma characteristics to
both psychological and physical health symptoms. The model ﬁt was x2 (186, N = 279)
=342.6l , p <.01, Goodness of Fit Index (GFI) = 0.90, Comparative Fit Index (CFI) =
0.96, Normed Fit Index (NN F I) = 0.95, Root Mean Square Error of Approximation
(RMSEA) = 0.055, 90 Percent Conﬁdence Interval for RMSEA = (0.046; 0.064), and
Standardized Root Mean Square Residual (RMR) = 0.070. The ﬁt statistics indicate a
good ﬁt to the data and are similar to the ﬁt indices from the previous model. A chi-
square test of difference was conducted between these two models and determined that

the models were not signiﬁcantly different from one another.

70

 

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Post Hoc Tran_sacti0n_al Model Testing

As previously noted the primary focus of this study has been to examine the
relationship of characteristics of IPT survivors in relation to psychological and physical
health outcomes. Results from the preceding analyses indicate that there are signiﬁcant
differences between the reactions of IPT and NPT survivors. Based on these ﬁndings and
the lack of support for the transactional model with survivors of IPT the question was
raised as to whether this model would be a good ﬁt for survivors of NPTS. Previous
studies have found that aspects Of the traumatic event (e.g., physical injury: Koren et al.,
2005; Macs et al., 2000) personality (e.g., Nightingale & Williams, 2000) and
environmental characteristics (e.g., Benight et al., 1999) are also predictive of health
outcomes for survivors of NPT. Thus, I proposed post hoc hypotheses to examine if the
transactional model was well suited to survivors of non-personal traumatic events. The
following exploratory analyses reﬂect the hypothesis that the transactional model may
better depict the relationships between different survivor domains for a NPT group
compared to an IPT group.

In addition, the current study also raised the question of the differences between
examining the trauma groups separately compared to collectively. Since signiﬁcant
differences were found for almost all health outcomes between the IPT and the NPT
survivors, the question of what happens when the different trauma groups are combined
arises. As noted in the review of trauma literature, it is common to examine the
experience of trauma either together (e. g. Lauterbach & Vrana, 2001) or separately (e. g.
Banyard & Williams, 1996), however, it is not common to compare these approaches.

Thus, I also proposed the combination of these groups in order to compare the

71

 

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relationships that emerge based on this approach compared to the premise of this study,
that they need to be separated from one another. Due to the nature of the different
traumas experiences it is hypothesized that there will be differences between in the
relationships between survivor characteristics and health outcomes when the traumatic
event types are combined versus separated. The following analyses reﬂect these
additional research questions.
NPT Model Testing

Based on the MANOVA ﬁndings discussed earlier, there were signiﬁcant
differences between the IPT and NPT groups for psychological and physical health
symptoms. Thus, the transactional model was also assessed using structural equation
modeling for the NPT sample in addition to the IPT sample. According to SEM analyses,
the NPT model ﬁt was x2 (151, N = 1165) =738.81, p <.Ol, Goodness of Fit Index (GFI)
= 0.94, Comparative Fit Index (CPI) = 0.96, Normed Fit Index (NNFI) = 0.95, Root
Mean Square Error Of Approximation (RMSEA) = 0.058, 90 Percent Conﬁdence Interval
for RMSEA = (0.054; 0.062), and Standardized Root Mean Square Residual (RMR) =
0.060. Thus, the model was a moderate ﬁt to the data.

As with the survivors of IPT, personality characteristics also loaded on the latent
variable in the direction of protective personality characteristics. As predicted, there were
several signiﬁcant path coefficients within the path model. It was found that high levels
of trauma characteristics were predictive of high levels of environmental stress (t= 6.54, p
< .05) and negatively predictive of protective personality characteristics (t= -3.66, p <
.05). As was the case for the IPT model, trauma characteristics were not directly

predictive of psychological or physical health symptoms. Protective personality

72

characteristics were negatively predictive of enviromnental stress (t= -9.27, p < .05) but
not signiﬁcantly predictive of psychological or physical health symptoms (see ﬁgure 3).
Environmental stress was found to be predictive of psychological symptoms (t= 2.67, p <
.05) but not of physical health symptoms. Unlike in the IPT model, psychological
symptoms were not predictive of physical health symptoms.

Based on these ﬁndings, the transactional model was not supported in the NPT
model. Findings indicate that in the NPT group there are no factors that predict physical
health symptoms, however, trauma characteristics appear to indirectly predict
psychological health symptoms through environmental stress factors. A full mediation
model of trauma characteristics through environmental stress to psychological symptoms
was found and tested.

The possible presence of a mediation process among the trauma characteristics of
NPT and health outcomes was assessed by removing the pathways from trauma
characteristics to both psychological and physical health symptoms. The model ﬁt was x2
(153, N = 1165) = 739.91, p <.01, Goodness of Fit Index (GFI) = 0.94, Comparative Fit
Index (CFI) = 0.96, Normed Fit Index (NNFI) = 0.95, Root Mean Square Error of
Approximation (RMSEA) = 0.057, 90 Percent Conﬁdence Interval for RMSEA = (0.053;
0.062), and Standardized Root Mean Square Residual (RMR) = 0.060. The ﬁt statistics
indicate a moderate ﬁt to the data and are similar to the ﬁt indices from the previous
model. The mediation was upheld after the removal of the non-signiﬁcant parameters
from trauma characteristics to the health outcome variables. In addition, two previously
non-signiﬁcant paths became signiﬁcant when these paths were removed: personality

characteristics were positively predictive of psychological symptoms (t= 2.34, p < .05)

73

and environmental stress was signiﬁcantly predictive of physical health symptoms (t=
2.87, p < .05). Despite these differences, a chi-square test of difference determined that
the models were not signiﬁcantly different from one another.

Full Trauma Model

As discussed, a model was also estimated for all women that reported any form of
traumatic event to assess if the transactional model was valid for the combined trauma
group. In regards to the full trauma model, the model ﬁt was x2 (176, N = 1444) =919.67,
p <.01, Goodness of Fit Index (GFI) = 0.94, Comparative F it Index (CFI) = 0.97, Normed
F it Index (NNFI) = 0.95, Root Mean Square Error of Approximation (RMSEA) = 0.054,
90 Percent Conﬁdence Interval for RMSEA = (0.051; 0.058), and Standardized Root
Mean Square Residual (RMR) = 0.056. Thus, the model was a good ﬁt to the data.

As in the previous models, personality characteristics also loaded on the latent
variable in the direction of protective personality characteristics. In regard to the
relationships of the different characteristics, trauma characteristics were found to be
predictive of environmental stress (t= 6.48, p < .05) and negatively predictive of
protective personality characteristics (t= -5.80, p < .05) but not directly predictive of
psychological or physical health symptoms (see ﬁgure 4). In regard to protective
personality characteristics, as in the previous models, they were found to be negatively
predictive of environmental stress (t= -6.75, p < .05). Unlike in the previous models, they
were also found to be positively predictive of physical health symptoms (t= -3.89, p <
.05) and not predictive of psychological symptoms. As with the previous models,
environmental stress was found to be predictive of psychological symptoms (F 7.91 , p <

.05) and physical health symptoms (F 3.47, p < .05). Finally, psychological symptoms

74

were not predictive of physical health symptoms. The full trauma model supports the
transactional model for protective personality characteristics. Additional analyses were
conducted to test this mediation model.

The presence of mediation model among the trauma characteristics of full trauma
model and health outcomes was assessed by removing the pathways from trauma
characteristics to both psychological and physical health symptoms. The model ﬁt was x2
(178, N = 1444) =922.99, p <.01, Goodness of Fit Index (GFI) = 0.95, Comparative Fit
Index (CPI) = 0.97, Normed Fit Index (NNFI) = 0.96, Root Mean Square Error of
Approximation (RMSEA) = 0.054, 90 Percent Conﬁdence Interval for RMSEA = (0.050;
0.057), and Standardized Root Mean Square Residual (RMR) = 0.056. The ﬁt statistics
indicate a good ﬁt to the data and are similar to the ﬁt indices from the previous model. A
chi-square test of difference was conducted between these two models and determined
that the models were not signiﬁcantly different from one another.

Group Comparison Model

Multiple-group analyses were attempted to compare the three different groups for
this study. The full trauma group could not be compared to the IPT or NPT groups
because the participants from the IPT and NPT groups were the participants in the Full
Trauma group. A comparison between the IPT and NPT models was attempted. The NPT
model did not include the manifest variable of perpetration due to the nature of the
traumatic events experienced, thus making comparison of the two-group model difficult.
The IPT and NPT group was compared by ﬁxing the missing variable in the IPT model
and setting it equal to zero in the second model, however the model did not converge thus

indicating that the models are not comparable to one another.

75

Hypothesis 3: Exploratory Cluster Analyses
CMerAnalvtic PIE

As proposed in the hypotheses, only the IPT group was examined in this
exploratory person-centered approach. Prior to clustering, all scores in the IPT group
were standardized to account for the different scales and ranges used (Hair & Black,
2000). The data were divided based on the categories represented in the previous
structural equation models: trauma characteristics, environmental stress characteristics,
personality characteristics. Thus, three sets of clusters were used for this study.
Psychological and physical health symptoms were compared across clusters to determine
whether or not differences existed.

For all clusters, a combined approach was used. An initial agglomerative
hierarchical cluster analysis was conducted using Ward’s method and squared Euclidean
distances as the measure of proximity. Ward’s method was selected because it maximizes
within-group homogeneity by minimizing the within-cluster error sum of squares (Hair &
Black, 2000). Squared Euclidean distances were then used because they provide the
distance between the individuals in clusters (Hair & Black, 2000). The stability of these
cluster solutions were examined using a split-half test (Hair & Black, 2000). Second,
stable solutions were submitted to a K-means iterative clustering procedure. The K-
means clusters were then conducted to determine the ﬁnal solution for the cluster
categories. Finally, MAN OVAs were conducted for the cluster solutions to assess if the
psychological and physical health symptoms were signiﬁcantly different from one

another based on cluster membership.

76

A combined approach was chosen for this study, in Which both hierarchical and
iterative cluster procedures were conducted, to utilize the advantages and address the
disadvantages of each clustering procedure if used alone. The agglomerative hierarchical
procedure allows the data to determine the number of clusters based on naturally
occurring clustering. However, a disadvantage of this technique is that it is susceptible to
outliers which can distort the cluster solutions developed (Hair & Black, 2000). In
comparison, the K-means iterative procedure requires the researcher to determine the
number of clusters used for the analysis but is less susceptible to outliers. Thus a
combined approach is useful way to deal with the problems that each procedure raises
and was used in the current study (Hair & Black, 2000).

Trauma Characteristics

Preliminary hierarchical clusters were used to determine the number of clusters
that form from the data based on 4 trauma characteristic variables: physical severity,
psychological severity, cumulative multiple traumas, and perpetration of traumatic events
by family member. The cluster analysis produced a dendogram with an 11, 6, 5, 4, 3, 2,
l-cluster solution (see ﬁgure 5). The 3-cluster solution was determined to be the most
appropriate solution based on group size, conceptual meaning for the study, and stability
of results. An iterative clustering procedure was then conducted for the 3—cluster solution
(see table 7 for means).

In the ﬁrst cluster (N=158), women displayed low levels of all trauma
characteristics (see ﬁgures 6-8). It was thus categorized as the low risk group. Women in

this group displayed low levels of all physical health and psychological health symptoms.

77

In the second cluster, (N =90), women displayed high levels of multiple traumas
and moderate levels of perpetration of traumatic events by family members. Women in
this group also reported moderate levels of psychological severity and low levels of
physical severity. Based on this proﬁle, this group was labeled the multiple trauma group.
In regards to physical health symptoms, women with this proﬁle reported high levels of
physical ailments in the past year and over their lifetime. They also reported moderate
levels of serious medical conditions. Women with this proﬁle of trauma characteristics
displayed relatively moderate levels of all psychological symptoms.

The ﬁnal cluster (N=31), was categorized by the highest levels of physical health
severity and minimal levels of all other trauma characteristics. This cluster was
categorized as the high injuries group. Women with this proﬁle displayed high levels of
all physical health symptoms. They also displayed high levels of anxiety and PTSD
symptoms, moderate levels of ASD symptoms, and low levels of depressive symptoms.

MANOVAS were conducted to assess for statistical differences regarding
psychological and physical health symptoms between the 3 clusters. Multivariate
analyses indicated a signiﬁcant difference between the clusters (A=. 835, F 14,279 = 3.628,
p < .01). Further examination of the between-subjects ﬁndings indicated a signiﬁcant
difference for all psychological and physical health symptoms excluding serious medical
conditions, p < .01 (see table 8). Further post hoc tests were conducted using Tukey HSD
to assess for signiﬁcant differences between the groups (see ﬁgures 6-8).

Examination of the 3 proﬁles in post hoc tests indicated that the low risk group
(cluster 1) was found to be signiﬁcantly lower than the multiple trauma group (cluster 2)

and the high injuries from trauma group (cluster 3) for physical ailments in past year and

78

over lifetime, anxiety, ASD, and PTSD symptoms. Cluster 1 was also found to be
signiﬁcantly lower than cluster 2 for depressive symptoms, but not cluster 3. As
mentioned in the MANOVA results, there were no signiﬁcant differences found between
the clusters for serious medical conditions.

Personality Characteristics

Women in the IPT group were also clustered based on personality characteristics.
Preliminary hierarchical clusters were conducted using the 5 variables: optimism,
neuroticism, extraversion, internal control, and external control. The cluster analysis
produced a dendogram which showed a 16, 10, 7, 6, 5, 4, 2, l-cluster solution (see ﬁgure
9). The 4-cluster solution was suggested as the most appropriate solution based on group
size, conceptual meaning for the study, and stability of results. An iterative clustering
procedure was then conducted for the 4-cluster solution (see table 9 for means).

The ﬁrst cluster (N =95) was categorized by the highest levels of optimism of the
4 proﬁles. These women also displayed moderate levels of extraversion and internal
control; low levels of both neuroticism and external control. See ﬁgure 10-12. This
cluster was thus labeled the high optimism and low neuroticism group. Women who
clustered into this group displayed low levels of both psychological and physical health
problems.

In the second cluster (N =89), women displayed moderate levels Of both
neuroticism and extraversion, and minimal levels of internal and external control, and
low levels of optimism. Thus, this proﬁle was labeled the average personality
characteristics group. The women that had this proﬁle displayed the highest level of

physical health symptoms of all 4 groups, especially physical ailments in their lifetime

79

and the past year. These women also displayed moderate levels of all the psychological
symptoms.

The third cluster Of women (N =49) displayed the highest levels of neuroticism
and the lowest levels of extraversion of the four proﬁles. Women in this group also
displayed minimal levels of internal control, and low levels of optimism and external
control. This cluster was thus labeled the high neuroticism group. Women with this
proﬁle displayed average levels of all physical health symptoms and psychological
symptoms with the exception of depression. Women in this group displayed the highest
levels of depression of all 4 groups.

For the ﬁnal cluster (N =46), women exhibited the highest levels of external
control and the lowest levels of internal control and optimism of the 4 groups. Women in
this group also displayed average levels of both neuroticism and extraversion. This
proﬁle was thus labeled the high external control group. Women with this proﬁle
displayed high levels of physical ailments in the past year, but minimal levels of both
serious medical conditions and lifetime physical ailments. Women in this group also
displayed high levels of depression and anxiety, but minimal levels of PTSD or ASD
symptoms.

Further analyses were conducted to assess if the proﬁles were signiﬁcantly
different than one another in regards to their psychological and physical health outcomes.
Multivariate analyses indicated a signiﬁcant difference between the clusters (A=. 670,

F 21 ,279 = 5.516, p < .01). Further examination of the between-subjects ﬁndings indicated a

signiﬁcant difference for all psychological and physical health symptoms excluding

80

serious medical conditions, p < .01 (see table 10). Post hoc tests were conducted using
Tukey HSD to assess for signiﬁcant differences between the groups (see ﬁgures 10-12).

Examination of the 4 proﬁles in post hoc tests for lifetime physical ailments and
ASD symptoms for women in cluster 1 were signiﬁcantly lower than women in cluster 2.
However, there were no signiﬁcant differences between women in cluster 3 and 4 for
these outcomes. Women in cluster 1 displayed signiﬁcantly lower PTSD symptoms than
women in clusters 2 and 4. Finally, the Physical ailments for the last year, depressive and
anxiety symptoms for women in cluster 1 were signiﬁcantly lower than those of all the
women in other clusters.
Environmengl Stress

Women in the IPT group were ﬁnally clustered based on their environmental
factors. Preliminary hierarchal clusters were conducted using the 4 variables: negative
life events, family psychiatric history, and social support (current and at the time of the
traumatic event). The cluster analysis produced a dendogram which showed a 22, 14, 9,
6, 5, 4, 3, 2, l-cluster solution (see ﬁgure 13). The 3-cluster solution was determined to
be the most appropriate solution based on group size, conceptual meaning for the study,
and stability of results. An iterative clustering k-means procedure was then conducted for
the 3-cluster solution (see table 11 for means). Social support in the current study was
coded for presence of social support rather than the lack of social support and was
graphically represented accordingly in ﬁgure 14. Thus low levels of social support
actually represent high levels of social support problems in the present analysis and will

be discussed based on the latter deﬁnition.

81

The ﬁrst cluster (N =68) was categorized by high levels of negative life events and
social support, both past and current. This group displayed low levels of family
psychiatric history. See ﬁgures 14-16. It was thus labeled the high environmental stress
group. In regards to the physical health, women in this group were categorized by the
highest levels of physical ailments in the past year and minimal levels of lifetime physical
ailments and serious medical problems. In regard to psychological health, women with
this proﬁle reported the highest levels of depressed symptoms and moderate levels of
anxiety, ASD, and PTSD symptoms.

Women in the second cluster (N =145), were categorized by low levels of all
forms of environmental stress, past and present. This group was thus labeled as the low
environmental stress group. Women with this proﬁle were also found to display low
levels of all physical health and psychological health symptoms.

Women in the ﬁnal cluster (N =66) displayed very high levels of family
psychiatric history. In comparison, these women displayed minimal levels of other forms
of environmental stress examined in this study. Thus, this group was labeled the high
family psychiatric history group. Women in this group displayed high levels of physical
ailments currently and over their lifetime. They reported minimal levels of serious
medical conditions in their lifetime. In regard to psychological health, women with this
proﬁle reported high levels of ASD symptoms, moderate levels of PTSD and anxiety
symptoms, and low levels of depressive symptoms.

MAN OVAS were conducted to assess for statistical differences regarding
psychological and physical health symptoms between the 3 clusters. Multivariate

analyses indicated a signiﬁcant difference between the clusters (A=. 738, F 14,279 = 6.321,

82

p < .01). Further examination of the between-subjects ﬁndings indicated a signiﬁcant
difference for all psychological and physical health symptoms excluding serious medical
conditions, p < .01 (see table 12). Further post hoc tests were conducted using Tukey
HSD to assess for signiﬁcant differences between the groups (see ﬁgures 14-16). I

Examination of the 3 proﬁles in post hoc tests for depressive symptoms indicated
that all three clusters differed from one another on a signiﬁcant level. The low
environmental stress group (cluster 2) was found to be signiﬁcantly lower than the high
family history group (clusters 3) for lifetime physical health ailments. Cluster 2 was also
found to be signiﬁcantly lower than clusters 1 and 3 for physical ailments in the past
year, anxiety, ASD, and PTSD symptoms. As previously mentioned, there were no
signiﬁcant differences between the three groups for serious medical conditions.

DISCUSSION

Overall, the ﬁndings from this study offered support for differences between the
psychological and physical health outcomes for survivors of interpersonal compared with
non-personal traumatic events. These differences were found both for the magnitude of
the outcomes as well as the survivor characteristics that inﬂuence the development of
these health outcomes. While the proposed transactional model was not supported for the
interpersonal survivor population, mediation models were found to explain the
relationship between these survivor characteristics and health outcomes. As was the case
for the IPT survivor group, the transactional model was not supported for post hoc
analyses conducted with survivors of both non-personal and all forms of traumatic
events. Rather a mediation model was found for all survivor types. However, the

relationship between survivor characteristics in relation to health outcomes differed based

83

on the type of traumatic event examined. In general, study ﬁndings support Herman’s
(1992) trauma theory that the experience of an interpersonal traumatic event has a
different impact on the survivor than a non-personal traumatic event. Current ﬁndings
suggest a need to differentiate between types of traumatic events when examining the
consequences for psychological and physical health.

Person-centered analyses were also conducted to examine the groupings of
interpersonal traumatic event and survivor characteristics. The health proﬁles that
correspond to these groupings were then examined. Cluster analyses indicate that there
are multiple health symptom proﬁles of women who have suffered IPT and that these
symptom proﬁles differed meaningfully based on characteristics of the trauma,
personality, and environmental stress. A group with low levels of psychological and
physical health problems was found in each cluster analysis and this group Was
associated with low risk characteristics. These ﬁndings suggest that the combination of
certain risk and protective factors in survivors of interpersonal traumatic events is related
to resilience. Interpretations of the speciﬁc ﬁndings are discussed below.
1m Group Differences

Results from MANOVA analyses indicate that there were differences between the
psychological and physical health repercussions for female survivors of IPT, survivors of
NPT, and women that did not report the experience of a traumatic event. Women that
experienced IPT as their primary traumatic event consistently endorsed higher levels of
each psychological symptom than the NPT and no trauma groups. This supports

Herman’s trauma theory (1992) which postulates that the experience of an interpersonal

84

traumatic event has more negative repercussions for the survivor over other forms of
traumatic events due to the nature of the event.

The IPT group was found to have signiﬁcantly higher levels of depressive and
anxiety symptoms than both other groups, while there were no signiﬁcant differences
between the NPT and no trauma groups for these symptoms. These ﬁndings suggest that
not all forms of trauma are related to the presence of internalizing mental health
problems. Although the experience of any form of tramnatic event may affect the
survivor’s understanding of her vulnerability to harm in the world, the experience of a
traumatic event at the hands of another person differentially exposes the survivor to risk
for mental health problems. The experience of an NPT may result in the activation of a
state anxiety response when a situation arises that was related to traumatic event, e. g.
trauma associated to a tornado may result in fear when a tornado approaches or other
forms of inclement weather. In contrast, the experience of an IPT may result in chronic
fear of further harm by close relationships or other people in general and be associated
with a feeling of vulnerability and anxiety in relation to other people. This experience
may also result in negative interpretations of situations associated with other people due
to the IPT survivor’s fear of vulnerability which has been associated with the
development of depressive symptoms (Beck, 1972).

In regard to physical health, supportive of my hypothesis, the IPT group reported
signiﬁcantly higher levels of recent and lifetime physical ailments, such as colds/viruses,
than the NPT and no trauma groups. These ﬁndings may be explained by the theory that
the experience of a traumatic event may result in the activation of the sympathetic

nervous system which regulates the immune system response (Tosevski & Milovancevic,

85

2006). As described above, the experience of an interpersonal traumatic event may result
in constant activation of this nervous system through the chronic anxiety of being harmed
by others, thus affecting the survivor of an IPT’s immune system response.

In contrast, when examining serious medical conditions such as heart problems,
diabetes, or cancer, signiﬁcantly higher levels were exhibited by both groups that
experienced any form of traumatic event compared to the no trauma group. However, the
IPT and NPT groups reported statistically similar levels of serious medical conditions to
one another, even though the IPT group had higher levels of serious medical conditions.
Previous studies have found high levels of physical health conditions for survivors of
interpersonal traumatic events e. g. CSA (Amow et al., 1999; Newman et al., 2000),
childhood and adulthood interpersonal violence (Golding, 1994; Walker et al., 1999;
Woods et al., 2005). It may be that the lack of signiﬁcance between the trauma groups in
this study is related to the low endorsement of serious medical conditions in this study
overall. Most of the conditions categorized by this variable were chronic and had serious
health consequences for the individual suffering from them in comparison to the physical
ailments which were categorized as more transient medical conditions such as colds and
viruses. Younger women may not have developed these serious medical conditions yet
due to their age. It may also be that persons that have developed such serious medical
conditions would not be physically well enough to be enrolled in a 4-year university.
Thus, there was a restricted range on the number of serious medical conditions seen in the

current study.

86

T_ran_safction_al Model Testing for IPT

The current study was primarily concerned with the environmental and
personality characteristics associated with the presence of psychological and physical
health symptoms for the survivors of interpersonal traumatic events. Based on Sameroff’ s
transactional model (2000), it was hypothesized that the dynamic relationship between
the traumatic event, the survivor’s personality, and environmental stressors would
transact with one another to inﬂuence health outcomes. However, the ﬁndings do not
support the transactional premise that various domains of the IPT survivor’s life (past and
present) directly inﬂuence one another to explain the presence of mental and physical
health. Contrary to the hypotheses, it was found that neither psychological nor physical
health symptoms were directly predicted by trauma characteristics for any of the trauma
groups. Rather psychological and physical health symptoms were predicted by
environmental stress, personality, or other health outcomes which were inﬂuenced by
trauma characteristics. Thus, these ﬁndings are indicative of a mediation relationship for
the development of health outcomes in traumatic event survivors rather than a
transactional model.

The transactional model was rejected due to the lack of a direct relationship from
trauma characteristics to health outcomes. This may have been the result of my
interpretation of the inﬂuential factors for poor functioning. The current study took the
approach that one of the elements that affects these outcomes is the experience of the
traumatic event, thus implying that the different domains have the same level of inﬂuence
on the survivor of an IPT. This approach presumes that characteristics of the IPT are as

detrimental as the survivor’s world after the event, however, the lack of support for the

87

transactional model suggests otherwise. It can be inferred from study results that
characteristics of the IPT alone are not sufﬁcient for the development of health outcomes;
rather the key element is the appearance of the survivor’s world following the IPT.
Findings from this study suggest that after an IPT the survivor’s world is shaped by
external factors (i.e., stressors) and her interpretation of this world (i.e., her personality).
Although these ﬁndings do not support the transactional model, they do not necessarily
contradict the theoretical basis for this study. Herman’s trauma theory includes the
survivor’s environment as an important factor for the survivor’s healing process (1992).
Results from the current study suggest that the survivor’s environment and personality
are not just used for the healing process but also inﬂuence any health consequences
experienced by the survivor of an IPT.

Previous trauma literature has supported a mediational relationship between
traumatic experiences and psychological consequences through other factors such as
parenting (Levendosky, Leahy, Bogat, Davidson, & Von Eye, 2006), social support
(Levendosky et al., 2004), and psychosocial stressors (Oppedal, 2008). These results are
consistent with national surveys that found that only a subset of people who experience a
traumatic event develop psychological symptoms (Breslau et al., 1997; Kessler et al.,
1995). Thus, overall study ﬁndings support the concept that health consequences are
indirectly inﬂuenced by trauma characteristics through effects on environmental and
personality characteristics.

Further examination of the IPT group model demonstrated that protective
personality characteristics also negatively predicted by environmental stress

characteristics. Although protective personality characteristics had a direct relationship

88

with psychological symptoms for survivors of IPT, a path existed between protective
personality and environmental stress which then predicted psychological symptoms. This
corresponds with past trauma research indicating that personality inﬂuences the
survivor’s coping ability in regards to trauma or stress. People that have high risk
personality characteristics, e.g. pessimism, may be more likely to make negative
attributions to life events they have experienced and/or interpret their social networks as
being unsupportive (Brodhagen & Wise, 2008; Segerstrom ct al., 2005). A similar
relationship was found in a recent study examining optimism in IPT survivors. They
found that optimism was related to problems with interpersonal relations, school and
work (Brodhagen & Wise, 2008). Distorted thoughts about the world and self have also
been found to be deﬁning characteristics of depression as they may result in the
individual interpreting their abilities and other people’s relationships in a negative light
(Beck, 1972).

Previous literature examining the reason for the direct relationship between
personality characteristics and psychological distress has delved into the coping strategies
associated with these qualities. Researchers have found that the survivor’s belief of how
he/she would be able to cope with the stress of a traumatic event (coping self-efﬁcacy)
mediated the relationship between PTSD distress and optimism (Benight et al., 1999). It
is theorized that despite the experience of a traumatic event, a person who views the
world in a positive light would be more willing to believe that there are some good
people in the world and that they can develop positive relationships (Herman, 1992). This
view of the world and others could help the survivor in her healing process by refuting

the concern that she would be harmed again. These ﬁndings suggest that the survivor’s

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own perception of her coping ability inﬂuences the relationship between personality
characteristics and psychological distress.

Despite previous hypotheses, it was found that physical health symptoms are only
directly inﬂuenced by psychological symptoms rather than other proposed characteristics
of the environment, personality or traumatic event. Previous research has shown that
individuals with PTSD and other psychological conditions related to interpersonal
traumatic events were more likely to display problems with their physical health than
persons without psychological conditions (Amow et al., 1999; Cloitre, Cohen, Edelman,
& Han, 2001; Martin, Rosen, Durand, Knudson, & Stretch, 2000; Zoellner et al., 2000).
The presence of symptoms such as reexperiencing may result in the hyperactivation of
the sympathetic nervous system and lower the strength of the person’s immune response
(Tosevski & Milovancevic, 2006). Thus, physical health problems are related to the
survivor’s psychological reaction to the event. For example, a person that continues to
feel as though the event is occurring to her or being reminded of that experience may
have an overly activated ﬁght or ﬂight response in comparison to the person that does not
reexperience the event. Correspondingly, in response to the hyperactivation of the
sympathetic nervous system, the immune system then is chronically lowered. Since the
survivor’s psychological reaction is theorized to be inﬂuenced by her experience of
further life stressors as well as poor coping personality styles these characteristics may be
indirectly affecting physical health through psychological symptoms.

In general, this study ﬁnds that characteristics of the IPT indirectly affect the
survivor’s functioning through aspects of her personality and environment. According to

these ﬁndings, women that experience an IPT are not necessarily affected by the

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perpetrator, their perception of the event’s severity, or how Often this event or Similar
events occur, but rather by how these factors make them view themselves and the world.
Understanding this mediation is integral to modeling the dynamics between an IPT
survivor’s experience of the trauma and her subsequent health. The experience of any
traumatic event can be detrimental to the survivor’s health in that it alters the survivor’s
sense of safety. However, the experience of an IPT is most damaging as it affects the
survivor’s proﬁciency to see the world as safe afterwards. For these reasons a supportive
environment and positive attributions are essential for the IPT survivor’s functioning. As
such, these results also provide an explanation of why diminished functioning is not
universal for all survivors of IPT.
Health Outcomes for NPT Group

Although there was considerable overlap in the ﬁndings between the IPT and
NPT groups, there were two main differences found between these groups. The ﬁrst was
the lack of a signiﬁcant pathway from any domain to physical health symptoms. Thus,
physical health was not found to be related to characteristics of the traumatic event,
environmental stress, or personality. There has been some literature that has found a
relationship between non-personal traumatic events and physical health symptoms
(Dirkzwager et al., 2006; Taft, Stern, King, & King, 1999; Wagner, Wolfe, Rotnitsky,
Proctor, & Erickson, 2002). However, many of these studies were based on military
traumas. It is not always clear what was entailed in combat trauma, it is possible that
these traumas were more interpersonal in nature or were perceived as having a
perpetrator as the traumas were based on war-related experiences. A more clearly deﬁned

NPT population may not have similar physical health consequences as a military

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population which probably has considerable IPT experiences. Further research is needed
to provide more information about the characteristics of an NPT population.

Another reason these relationships may not have been found in the current study
refers to the low rates of PTSD endorsed within the NPT sample (see table 3). Past
studies examining physical health symptoms in relation to traumatic events consistently
indicated that the presence Of physical health symptoms were based on the level of PTSD
experienced by the survivor (e.g., Taft et al., 1999). Similar ﬁndings were reported for
IPT groups (Schnurr & Green, 2004; Zoellner et al., 2000). Thus it may be that physical
health symptoms are associated with PTSD symptom endorsement rather than all
psychological symptoms as is the case with IPT survivors. This may be a result of the
different types of trauma endured. Based on the immune system hypothesis, the
sympathetic nervous system would be more active for women who are reexperiencing
traumatic events either through PTSD reexperiencing symptoms or retraurnatization
(Woods, 2005). Previous studies have found that survivors of IPT are at higher risk for
revictimization compared to survivors of NPT (Banyard et al., 2001; Nisith et al., 2000).
It is possible that for those women that do not experience revictimization or multiple
traumas, high levels of reeexperiencing symptoms, as evidenced by meeting full criteria
for PTSD, would be necessary to for hyperactivation of the sympathetic system
associated with physical health problems. Future studies examining the immune
responses in survivors of traumatic events should assess for differences between the
different trauma groups.

The other difference found between the IPT and NPT models is that personality

characteristics did not directly predict psychological symptoms. It appears that in the

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NPT model, healthy personality characteristics have an indirect relationship with
psychological stress through environmental stress characteristics. This may be explained
by the nature of the NPT trauma versus the IPT trauma. Traumatic events can shatter the
survivor’s fundamental assumption that they are safe, leading in some cases to
personality changes (Herman, 1992). The development of a self-conscious, insecure, and
vulnerable personality type (Bramsen et al., 2002) may be more likely for someone who
has experienced a traumatic event at the hands of another person compared with someone
who experiences a natural disaster, as an interpersonal trauma may exacerbate the pre-
existing personality beliefs or Shatter prior fundamental assumptions about the self.

Results indicate that in addition to the difference in means between the two
groups discussed earlier, there are also differences in the health outcomes based on the
type of traumatic event endured. As it has been theorized, the psychological reaction of
the survivor of is predictive of physical health, lower levels of psychological symptoms
associated with the experience of a NPT may explain the lack of a prediction to physical
health problems for the survivors of NPT. Thus, these ﬁndings appear to be
complimentary to those found for IPT survivors.
Health Outcomes for All Trauma Group

For the ﬁnal SEM analysis, both trauma groups were combined in order to
examine the transactional model using the practice commonly found in trauma literature.
When examining the relationship of trauma, environmental stress, and personality
characteristics on health outcomes for all trauma survivors together, aspects Of the
survivor characteristic model changed. The full trauma group results shared some

similarities with the separate group models; for all three models, trauma characteristics

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predicted environmental stress and negatively predicted healthy personality
characteristics, but did not predict either health outcome (refer back to ﬁgures 2-4). Thus,
the mediation model arose for all types of trauma models. These ﬁndings supported
previous research which demonstrated a mediation model between various aspects of a
trauma survivor’s characteristics and their psychological and/or physical health
regardless of the type of traumatic event experienced (Levendosky et al., 2004;
Levendosky et al., 2006; Oppedal, 2008). The full trauma group also displayed similar
characteristics as the separate trauma group models regarding the inﬂuence of
environmental stress characteristics on psychological health and healthy personality
characteristics on environmental stress.

The consistent nature of these mediation ﬁndings suggested that there are certain
aspects of a trauma survivor’s experiences which can have detrimental inﬂuences on her
regardless of the type of trauma she endured. For example, it appeared that environmental
stress mediates the relationship between characteristics of the traumatic event and the
survivor’s psychological health symptoms for IPT, NPT, and when the two forms of
traumatic events are combined. These ﬁndings supported past research which has found
that the presence of environmental stress factors in the life of a survivor of a traumatic
event is associated with more psychological health problems than if these factors were
absent (Brewin et al., 1999; Glaser et al., 2006; Thakaar & McCanne, 2000). Traumatic
events have been described as severe forms of stressful events (Strelau & Zawadski,
2005) in some research. Based on this deﬁnition, the cumulative effect of several
stressors can have detrimental affects on the individual as the person’s sympathetic

nervous system is constantly reacting to the different stresses that it is experiencing

94

(Woods, 2005). Thus, it is understandable that the experience of further negative life
events would result in an increased likelihood for health problems.

The combination in this model of both forms of traumatic events also yielded
results which were not found in the separate trauma models. The current study found that
when IPT and NPT groups were combined environmental stress and healthy personality
characteristics were found to predict physical health symptoms. Unlike the previous
models, these ﬁndings suggest that when trauma types are combined, that trauma
characteristics indirectly inﬂuence the physical health symptoms through other survivor
characteristics. This is very different than the NPT model alone which did not predict
physical health symptoms at all or the IPT model which found that physical health
symptoms were only predicted through psychological symptoms. These ﬁndings indicate
that the combination of trauma groups alters the predictive relationships for physical
health but not psychological symptoms. The disparity in the current study between this
model and the separate IPT and NPT models may be a result of the low variance for
physical health symptoms in the NPT model alone. It may be that combining the two
models provided further variance for the physical health latent variable in the model.
However, the difference in variance may have been artifact of the different rates of
physical health symptoms that are actually endorsed in a population that has experienced
an NPT as their primary traumatic event compared to those that experienced an IPT.

These ﬁndings suggested that combining the two groups not only conceals the
distinct relationships associated with the development of physical health symptoms for
trauma survivors, it may also confuse the researcher’s understanding of the dynamics

associated with the development of physical health symptoms. It is important to be aware

95

of the differences in presentation when both groups are combined, especially since the
relationship between physical health and traumatic events is a relatively new area of
research.
Person-Centered Approach for Survivor’s of IPT

Previous trauma literature has predominantly focused on the relationship between
speciﬁc factors associated with the traumatic events and the survivor, classiﬁed as the
variable-centered approach (Levendosky, Bogat, & Von Eye, 2007). However these
studies do not necessarily give the sense of the survivor as a whole entity or what
elements categorize her experiences. In recent years, more trauma researchers have begun
to incorporate the person-centered approach into their analyses of the interpersonal
violence (Campbell et al., 2008; Levendosky et al., 2008; Mourad et al., 2008). The use
of cluster analysis has been one approach to this methodology. Past trauma studies using
this approach have examined if the different IPTs have distinct proﬁles from one another
(Campbell et al., 2008; Pimlott-Kubiak & Cortina, 2003). The current study was
interested in assessing the proﬁles of the survivor to gain a different perspective of how
characteristics of the survivor affect her psychological and physical health outcomes.

Characteristics of the interpersonal traumatic event (multiple traumas, physical
and psychological severity, and perpetration by family members), survivor’s personality,
and environmental stress were examined in separate cluster analyses to assess for the
constellation of characteristics that arose for each domain. Overall, a resilient group of
emerged for each domain of survivor characteristics. Psychological and physical health
symptoms corresponding to these survivor characteristic groupings were also examined.

Health proﬁles exhibited in this study did not fully support previous hypotheses that there

96

were would be four proﬁles displayed including the presence of only psychological
symptoms, only physical health symptoms, both forms of health symptoms and an
absence of symptoms. Instead, the health symptom proﬁles varied based on the speciﬁc
aspects of the trauma, environment and personality characteristics they corresponded to.
Most of the proﬁles included some psychological and physical health symptoms, but at ’
varying levels. Speciﬁc ﬁndings for clusters on each set of characteristics are discussed
below.
Traumatic Event Characteristics for survivors of IPT

Cluster analyses of the traumatic event characteristics determined that there were
three different proﬁles that formed based on the women’s experiences of multiple
traumatic events, perpetration of the traumatic event by a family member, and reported
psychological and physical severity of the traumatic event. Based on the characteristics of
each cluster, the proﬁles were deﬁned as low risk, multiple trauma, and high injury
groups. Examination of the psychological symptoms for these proﬁles found that the low
risk group had signiﬁcantly lower levels of anxiety, ASD, and PTSD symptoms than
women in the multiple trauma group or high injury group. The low risk group also
displayed signiﬁcantly lower depressive symptoms levels than the multiple trauma group
(refer to ﬁgures 9-11). Results suggest that the perceived severity of the interpersonal
traumatic event characteristics does inﬂuence the psychological and physical well being
of the female survivor after the experience of a traumatic event. These ﬁndings support
previous research indicating that different elements of the traumatic event itself, e. g.
perpetration by a family member can create a different health proﬁle than for women who

experience low levels of perpetration by other persons in the survivor’s life.

97

Women in the low risk group and women in the high injury group did not differ
from one another on depressive symptoms level, despite signiﬁcant differences between
these groups based on other mental health symptoms (i.e. anxiety, ASD, and PTSD:
APA, 2000). Only the women in the multiple trauma group displayed high depressive
symptoms. These ﬁndings imply that women with high levels Of physical injury from IPT
present similarly to groups with other trauma characteristics for anxiety symptoms, but
not for depressive symptoms. It may be that the physical harm endured during the
traumatic event contributes to the appraisal of fear from potential harm. In this case, the
survivor has “physical” evidence that she could be harmed as she not only endured a life
threatening experience but also sustained injuries from this event. Hence she may be
more cognizant of further harm and exhibits this fear as different forms of anxiety.
Previous studies have found that physical injuries are associated with the development of
PTSD (Koren et al., 2005; Rasmussen et al., 2008). For example, a study examining
physical injuries in relation to survivors of torture found that injuries fully mediated the
relationship between torture and PTSD (Rasmussen et al., 2008). These ﬁndings
correspond with the idea that these injuries serve as reminder of the event and makes the
feeling of vulnerability more salient.

Research examining severity of traumatic events has also demonstrated that
severity of the traumatic event, as evidenced by events with the potential for more
physical injuries, can have negative consequences for the survivor as well (Johnson et al.,
2001; Leserman et al., 1996; Maercker et al., 2000). The issue of physical injuries can

add to the survivor’s perception of the traumatic event’s severity as well as her fear of

98

harm. Thus, women who experience high levels of physical injury are more likely to have
higher psychological symptoms, than the women who experience lower levels.

In regards to physical health symptoms, the low risk group was found to display
signiﬁcantly lower levels of lifetime and recent physical ailments than for women who
are characterized by multiple traumas or high physical severity. This is consistent with
previous ﬁndings that survivors of multiple IPTs were more likely to report chronic
health problems over the course of a year (U llman & Brecklin, 2003). These ﬁndings
may be explained by immune system functioning such that frequent reactivation of the
sympathetic nervous system can inﬂuence the physical health characteristics of female
IPT survivors (Woods et al., 2005).

Signiﬁcant differences were not found between the different proﬁles for serious
medical conditions. This may be a function of the low endorsement of these conditions in
general throughout the study. The smaller group sizes for the IPT group clusters may
have resulted in too small of an effect for differences to be estimated.

Personality Characteristics for survivors of IPT

Cluster analysis of the personality characteristics associated with survivors of IPT
led to four personality proﬁles for these women: the high optimism and low neuroticism
group, the average personality characteristics group, the high neuroticism group, and the
high external control group. The ﬁrst group displayed the highest level of optimism and
the lowest level Of neuroticism of all the different groups that emerged. Although all
personality characteristics examined in the present study have been associated with
survivor functioning after a traumatic event, the two most commonly discussed have been

optimism and neuroticism. Personality literature has consistently associated high levels of

99

optimism (Bunce et al., 1995; Lauterbach et al., 2005; Segerstrom et al., 2001) and low
levels of neuroticism (Bramsen et al., 2002; Lauterbach & Vrana, 2001; Strelau &
Zawaski, 2005) with better functioning for survivors of traumatic events. Research has
also identiﬁed high levels of external control or low levels of internal control as being
associated with poor survivor functioning (Banyard & Cantor, 2004; Dyb et al., 2003). In
the current study, high levels of the two risk factors, neuroticism and external control,
were classiﬁed as separate clusters. Thus, there were two risk groups, one resilient group
and one average group. The separate grouping of the two risk personality characteristics,
neuroticism and external control, suggests that there is a difference in between these
factors. As neuroticism is associated with anxiety and low self-esteem and external
control is associated with the perception that the person is at the whim Of the universe, it
is surprising that there is little overlap between these personality traits. It may be that
there are different underlying mechanisms pertaining to each of these factors. These
differences may be a result of the different personality areas being assessed, for example
the image they present of themselves to the world versus their perception of environment.
The differences between these realms of personality may also explain the variation in
health outcomes that arise for the different risk proﬁles. Finally an average personality
characteristics cluster formed which displayed equal levels Of neuroticism and
extraversion. This suggests that there is a subgroup of survivors that do not have elevated
levels Of the protective or risk personality factors. The clusters that formed in this
analysis were indicative of different levels of psychological and physical health proﬁles.
In regards to psychological health, women in the high optimism and low

neuroticism group were found to have signiﬁcantly lower levels of depression, and

100

anxiety symptoms than all of the other survivors of IPT. By deﬁnition, optimism,
expectation of positive outcomes (Brodhagen & Wise, 2008), is contradictory to the
characteristics of depression of negative perceptions of the self and world (Beck, 1972).
The same is true of the characteristics of neuroticism, deﬁned as anxious, self conscious
and insecure (Bramsen et al., 2002; Smith, 2006; Spindler & Elkhit, 2003). Thus lower
levels of depressive and anxiety symptoms are logical for the respective levels of these
personality factors. These ﬁndings are consistent with previous literature examining
neuroticism (Bunce et al., 1995).

Women with the high optimism and low neuroticism proﬁle were also found to
have signiﬁcantly lower levels of physical ailments in the past year than all of the other
survivors of IPT. It is possible that these ﬁndings are also a result of interpretation of
these events by optimistic persons. As optimism is associated with perceived stress levels
(Cohen et al., 1999; Segerstrom, 2001) and stress levels are associated with the activation
of the sympathetic nervous system (Tosevski & Milovancevic, 2006), it may be that
Optimism serves as a protective factor from health problems. The optimistic perception
that things will ultimately work out and that the world is not malicious can help the
survivor remain calm in the face of daily stressors explaining the lower rates of physical
health ailments in the past year.

The second group that emerged ﬁ'om the data was that of average levels of
personality characteristics. This group did not display high or low levels of any of the
ﬁve personality characteristics used in proﬁle formation. As indicated by this description,
this group displays the most balanced personality characteristics of the four proﬁles that

emerged from this study. Average personality characteristics are not commonly

101

considered in the literature. Interestingly, women with this proﬁle were found to display
the highest levels of ASD and PTSD and overall physical health symptoms (see ﬁgures
14 and 15). Past research has focused on high and low levels of the different personality
characteristics and which factors are associated with poor functioning (e. g. Segerstrom,
2001), however it may be that the lack of protective personality characteristics are
especially detrimental to Survivors of IPT. Trauma theory purports that due to the nature
of an IPT, a major element of the healing process for survivors is to learn to regain trust
in the world and themselves. It has been shown using variable-centered methodologies in
the current study that protective aspects of the survivor’s personality help to mediate this
relationship. Thus it may be that the lack of these characteristics associated with
resilience places the survivor at risk for future health problems, even in the absence of
personality risk factors. The formation and distinctive health characteristics of women
with this personality proﬁle suggest that it is important to consider all levels of
personality factors in relation to survivors of IPT rather than only the inﬂuence of high
levels.

Another proﬁle that emerged for female survivors of IPT was the high external
control group. The main distinguishing feature of this group was that the PTSD
symptoms for the high external control group were found to be signiﬁcantly higher than
the high optimism and low neuroticism group. Herman’s trauma theory (1992) suggests
that in order for the survivor of an IPT to heal, they need to develop the ability to view
the world as a safe place again. Experiencing oneself as being at the mercy of the whims
of the universe does not foster this belief. Rather may perpetuate the belief that one is

susceptible to further harm. This can result in symptoms of hypervigilance regarding

102

one’s environment; these behaviors can be categorized as hyperarousal associated with
both PTSD and ASD (APA, 2000). Thus, the development Of higher PTSD symptoms
for women that display this proﬁle compared to women who view the world as safe and
having positive qualities is consistent with the theory of how psychological distress
develops after the experience of an IPT.

The ﬁnal group formed from the personality cluster analysis of IPT survivors was
that of the high neuroticism group. Similarly to the high external control group, this
proﬁle also displayed the complimentary personality styles of low extraversion which is
often associated with high neuroticism (Costa & McCrae, 1985). Based on previous
research examining the effects of neuroticism and low extraversion on survivors of
trauma, it was expected that women with this proﬁle would display high rates of
psychological symptoms. However, study ﬁndings indicated that this group was not
signiﬁcantly different than other groups characterized by negative personality
characteristics. It may be that although there are women that experience high rates of
neuroticism it does not add to the IPT survivor’s psychological proﬁle. Rather other
personality characteristics are required to distinguish psychological repercussions of the
survivor. These ﬁndings may be indicative of a more systemic problem of the assessment
of neuroticism in relation to psychological conditions. The relationship between
neuroticism and psychological health found in the literature may be a result of the
overlapping deﬁnition of these conditions rather than an actual relationship (Bramsen et
al., 2002; Kendler et al., 2004; Tosevski & Milovancevic, 2006; Woods et al., 2005).
Further attempts to parse out the differences between may be needed in the future to

assess for the relationship between these factors for survivors of trauma.

103

 

 

ﬂ

Environmental Stress Characteristics for survivors of IPT

When examining the female survivors of IPT based on their environmental stress
proﬁles, three different groupings emerged from the data: high environmental stress, low
environmental stress, and high family psychiatric history (refer to ﬁgures 12-14). These
ﬁndings suggest that there is a low environmental stress group and then two distinct
groups that display high levels of environmental stress. The ﬁrst high environmental
stress group is categorized by high levels of current stressors including negative life
events in the past year and a current lack of social support. It appears that this group was
formed based on more recent difﬁculties in regards to their life circumstance and social
support. These factors may correspond with one another as difﬁculties with social
support network have been associated with poorer perceptions of life circumstances
(Brodhagen & Wise, 2008). In comparison, the second group of women with high
environmental stress only report high levels of family psychiatric history. Contrary to
hypotheses, women who report high levels of family psychiatric history do not appear to
be clustered with women that report other forms of environmental stressors. This
grouping suggests that the women who report a family psychiatric history are distinct
from the women who report more recent environmental stressors. As there appears to be
little overlap between the two groups, the emergence of these two proﬁles also suggests
that the presence of family psychiatric history does not inﬂuence the emergence of later
stressors. This helps explain ﬁndings from previous studies that found a stronger effect
on psychological outcomes for survivors experiencing low social support than family
psychiatric history (Brewin et al., 2000; Ozer et al., 2008). The separate clustering of

these stressors is an important contribution to the ﬁeld of trauma as it provides further

104

understanding that the groups of individuals experiencing these stressors may be
dissimilar and thus have different health consequences.

Upon further examination of the proﬁles that arose based on IPT survivors’
environmental stress experiences it was found that there were indeed differences between
the groups. In regards to psychological symptoms, it was found that the group with the
lowest level of environmental stress was signiﬁcantly different than the other two groups
in relation to anxiety, ASD, and PTSD symptoms. This is consistent with previous
ﬁndings that persons experiencing higher levels of environmental stressors such as less
social support (Brewin et al., 2000), negative life events (Glaser et al., 2006; Kendler et
al., 2004), and family history of psychological problems (Koenen et al., 2001; Ozer et al.,
2008) are more likely to display more psychological symptoms associated with the IPT
they have experienced. It has been theorized that the experience of more environmental
stressors can exacerbate the effects of a traumatic experience, resulting in higher
psychological symptoms than if the stressors are absent (Brewin et al., 2000).

Further examination of these proﬁles indicated that all of the groups had
signiﬁcantly different levels of depressive symptoms from one another. The low
environmental stress group had the lowest level, while the high environmental stress and
high family psychiatric history had the highest and second highest respectively. These
ﬁndings suggest that survivors of IPT with current stressors have higher levels of
depressive symptoms than those survivors with a family psychiatric history. Results
suggest that depressive levels are associated with the experience of stressors and the time
frame for which it occurred. For example, survivors that endorsed the experience of

recent environmental stressors, poor social support and high negative life events, also

105

exhibited the highest levels of depressive symptoms. In comparison, those that reported
past stressors experienced signiﬁcantly lower levels of depressive symptoms than those
experiencing recent stressors. Previous studies have found that the experience of current
stressors such as negative life events and domestic violence inﬂuences depressive
symptoms when there is a familial vulnerability for internalizing symptoms (Mourad et
al., 2008). However, as the groupings that emerged do not combine pat and current
stressors, it appears that there are differences in the levels of depressive symptoms that
are displayed. These ﬁndings may also be a function of the present study’s methodology
for assessing depressive symptoms; data on current depressive symptoms were collected
in the present study. Future research should assess for lifetime depressive symptoms
when examining environmental stressors so as to clarify this matter. However, it should
be noted that assessment of current depressive symptoms in relation to past events is a
common methodological issue in the trauma literature (e.g., Mourad et al., 2008). Thus,
in spite of these methodological concerns, the level of depressive symptoms provides
further support for the distinct grouping of the environmental stressors.

The low environmental stress group displayed signiﬁcantly lower physical health
ailments in the past year than both the other groups. These results indicate that moderate
to high levels of any environmental stressor inﬂuences the development of current
physical health ailments. Based on the immune system theory, it may be that current
stressors serve as an activator for the sympathetic nervous system for an immune system
that is already sensitive to arousal due to the experience of previous traumatic event. This
theory also explains the reason that women with high levels of family psychiatric history

displayed higher lifetime physical ailments. It may be that the prolonged stress endured

106

of this family environment contributed to frequent activation of the sympathetic nervous
system resulting in more health problems.

Both ﬁndings regarding the environmental stress proﬁles relationship to physical
health suggests that women who have experienced an IPT and experience moderate levels
of stress are more likely to develop physical health ailments (lifetime or present). Thus it
is important to be aware that these women’s stress levels can also inﬂuence their physical
health. As there has been little research conducted on the role that environmental stress
plays on physical health, these ﬁndings provide further information about the function of
environmental stress on physical health.

Cluster An_alysis Conclusion

Findings from the cluster analyses demonstrated that distinct proﬁles emerge for
female survivors of IPT based on their experiences with the traumatic event, features of
their personality, and the stressors they are exposed to. Examining the nature of these
proﬁles gives researchers a deeper understanding of the characteristics associated with a
survivor of IPT. Examination of all the clusters suggests that certain proﬁles from each
domain are associated with higher levels of psychological and physical health symptoms.
Overall results of the trauma characteristics indicate that the high physical injury proﬁle
exhibits are related to the highest level of anxiety disorder symptoms and physical health
problems. Results suggest that average personality characteristics were most indicative of
trauma condition symptoms (PTSD and ASD) and physical health problems. In
comparison, women with high environmental stress displayed the highest depressive and
anxiety levels, while women with a family psychiatric history displayed the highest

trauma condition symptoms (PTSD and ASD) and physical health problems.

107

It is very important to examine these naturally occurring proﬁles as they
demonstrate the constellation of personality and environmental stress emerge in female
survivors of IPT. These groupings can then help future researchers to assess what other
factors inﬂuence these speciﬁc collection of characteristics as well as provide
information regarding the health outcomes associated with these groupings. Recognizing
the proﬁles that emerge for these women provides us with more information as to why
some survivors of IPT have poorer health functioning than others after the experience of
a traumatic event. As this was the ﬁrst study to examine these characteristics using a
person-centered approach, this study provides the ﬁeld with insight regarding the reason
there are varying levels of functioning for female survivors of IPT.

Limitations and Future Directions

There were some limitations regarding the methodology of the present study that
may inﬂuence the generalizability of these ﬁndings. One limitation for this study is that it
was conducted with a college sample. There were several implications of using this
sample, the ﬁrst is that due to the collectively younger age, they may have been less
likely to report serious medical conditions than if the sample had a wider age range. The
low variance within each trauma group may have resulted in the lack of signiﬁcant
ﬁndings for this variable. Future studies will need to recruit a wider age range so as to
assess for the prevalence of serious medical conditions for each trauma group. Another
limitation of this sample for physical health assessment refers to likelihood of ﬁnding
persons with serious medical conditions enrolled in a university. It may be that the use of
a college sample naturally ﬁlters out persons with serious medical conditions due to the

taxing requirements of schoolwork. However, despite these limitations signiﬁcant

108

differences were found between the trauma and no trauma groups. These results could be
considered more meaningful as there was less endorsement of these conditions overall.

Second, it can be argued that trauma survivors who have been able to attend
college are a high-functioning group and may be qualitatively different than other trauma
survivors. This limitation may have contributed to the lower levels of actual
psychological disorders in the current study. Despite this limitation, this population still
showed signiﬁcant variability on the different symptoms assessed (with the exception of
serious medical conditions) and signiﬁcant differences were found based on these
symptoms. In addition, it Should be noted that students in the study were only asked their
education status, they were not asked for their course grades. As more than 60% of the
sample reported freshman or sophomore standing, it is unclear if they were successfully
matriculating through the university. Future studies that choose to use a college
population would be advised to collect information regarding their sample’s functioning
level.

There were also limitations associated with the IPT and NPT samples. First the
size of the IPT group (N =279) although sufficient for the SEM analyses conducted
resulted in small group sizes at times for the cluster analyses. This may have contributed
to fewer signiﬁcant differences between the survivor group health outcomes. Future
studies should try to recruit larger groups when conducting cluster analyses to assure the
ability to ﬁnd signiﬁcant ﬁndings when present. Another limitation of the sample size
was that the IPT and NPT samples were not proportionate in size. This may have affected
the model ﬁndings when both groups were combined together and ﬁndings when the two

groups were compared to one another. The disproportionate size of the groups is also

109

representative of the frequency of the two different trauma groups in the trauma
experiencing population (Kessler et al., 1995; Lauterbach & Vrana, 2001). This is also
indicative of the problem that trauma researchers may experience, without their
knowledge, when a general trauma group is sampled. Researchers should be aware of this
matter when sampling, as well as the blurring of results when these two trauma groups
are combined together.

As is generally the case when deciding on the event to assess for PTSD, the
primary traumatic event was determined solely by the participant. This raised some issues
regarding the grouping of the survivors, as reported in much of the trauma literature,
many of the survivors experienced more than one traumatic event. However, not all of the
events experienced fell into only one category, there were some people who reported
incidents Of both IPT and NPT. Hence the groups were not necessarily comprised of
survivors of only one form of traumatic event. This issue is not speciﬁc to the current
study; many trauma survivors have experienced both types of traumatic events. As
speciﬁed by the DSM-IV (APA, 2000) the event that is assessed for PTSD is the one that
the survivor considers the most severe. It important to notice the differences found
between the groups based on this deﬁnition.

Finally, there were some restrictions placed on the study due to the use of the
intemet for data collection. One restriction was that structured clinical interviews could
not be utilized for this study to assess for psychological symptoms. This limited the study
in the type of measures that could be used to assess for lifetime psychological symptoms.
The depression questionnaire used in the current study did not assess for lifetime

depression symptoms. It would have been useful to also assess for lifetime psychological

110

symptoms as the study examined different survivor characteristics associated with past
experiences (e. g. family psychiatric history). This method of data collection also limited
the study to only using self-report data, thus some of the data collected may have
represented single-reporter bias regarding their experiences. It may have been beneﬁcial
to obtain information from other persons such as family members’ to corroborate the
participant’s reports of family psychiatric history. Previous studies have reported that
self-reports have a low sensitivity level for diagnosing psychiatric illness in relatives
(Orvaschel et al., 1988). However, the current study was primarily concerned with the
survivor’s perception of their family members as well as all other information collected.
As noted earlier and through the ﬁndings of this study, the experience of a traumatic
event is based on the survivor’s perception of the experience as well as their views of the
world and themselves post-trauma. Thus, it was very important for the current study to
utilize self-report measures to assess the information pertaining to the survivor’s
experiences.

In addition there may be some concern over the validity of the answers provided
by the participants. This however is can be an issue for all self-report studies. Collecting
in-person self-report measures does not ensure correct the reporting of correct data either,
thus the use of the intemet is not necessarily a limitation. In contrast, there were
considerable beneﬁts to using this form of data collection. Due to the anonymous nature
of the data collection, the use of the intemet may have allowed participants to feel that
the data was more conﬁdential thus making them more comfortable to answer the
questions honestly. The use of the intemet format also allowed for a more convenient

data collection process as ofﬁce space and lab assistants were not required. It also

111

provided the participants with more ﬂexibility regarding when they could complete the
study.

Despite the limitations mentioned, there were several strengths of the current
study. There has been limited research examining the difference between IPT and NPT
on psychological symptoms for the survivor and no studies that have compared these
groups in relation to physical health symptoms. Other studies took the approach that all
traumatic events fall under one category and melded them altogether without comparing
the two groups. A comparison between the two trauma groups is important to recognize
and understand that there are different consequences resulting from the different types of
traumatic events. Without such a contrast present in the literature, many researchers may
continue to examine the two groups together unaware of how it may affect their results.
Assessment of the two different groups separately also allowed us to examine the distinct
relationships between survivor characteristics for each of trauma groups. It will be
important for future trauma researchers to be careful of combining these groups together
under the guise that all traumatic experiences can treated the same or will have the same
consequences for their survivors.

An important strength of this study is that it used different methodologies to
explore the characteristics and reasons that some female survivors exhibit poor health
functioning after the traumatic event and others do not. The use of both a variable-
centered and person-centered approach allowed this study to examine the inﬂuence of the
characteristics based on domain (personality or environmental) as well as the groupings

that emerge from the data to describe the women who have experienced an IPT. These

112

approaches not only allow us to understand what the women look like, but also to reﬂect
on their psychological and physical functioning.

Another important element of this study refers to its exploration of physical health
problems in relation to female survivors of IPT and other forms of traumatic events. The
effect Of trauma on physical health has been a relatively new area within the trauma
research. This has been the ﬁrst comprehensive study to examine physical health
consequences of trauma exposure across different domains, trauma groupings, traumatic
event characteristics, personality features, and environmental stressors. All of the
domains were found to be associated with the development Of physical health problems
for IPT survivors, but this study provided further information as to the route in which
these symptoms develop in relation to psychological symptoms. There is still much more
to learn regarding effects of this experience on survivors, future research will be needed
to examine more characteristics for trauma survivors discussed in the literature e. g. age
and race associated with the traumatic events, as well as different gender. The current
study was focused on the presence of actual physical health conditions rather than just
examining the immune system functioning. However many of the ﬁndings speculated
that the survivor’s experiences affected her immune functioning resulting in physical
health problems. It may be useful for ﬁrture studies to examine both the immune system
markers and physical health conditions to assess how the immune system actually
inﬂuences the development of physical health conditions. As the trauma ﬁeld continues
to grow, it will be more important for researchers to incorporate physical health
repercussions into the consequences of traumatic events to be assessed in order to

understand the full health repercussions of these events on its survivors.

113

Clinicalémﬂcatiorg

The differences between the two trauma domains may also have implications for
assessment and deﬁnition of trauma conditions for survivors. Based on study ﬁndings the
experience of an IPT is different than that of a NPT and can have different consequences,
including physical health problems, for survivors of IPT. Clinicians that are aware of the
relationship between psychological and physical health can begin to incorporate the
evaluation of physical health problems in their assessment of these clients. As trauma
research in this arena increases and assessment methods evolve it may become important
to weave physical health symptoms in present psychological diagnoses to understand the
severity of the survivor’s functioning.

Awareness of the connection between psychological and physical health
functioning suggests a need for clinical interventions to prevent the development of
physical health problems, in addition to poor psychological functioning. Results indicate
a need for psychological interventions before the development of medical conditions.
Early interventions may need to incorporate techniques to reduce the hyperactivation of
the nervous system. For example, these ﬁndings suggest that it is imperative for
clinicians to teach survivors of IPT relaxation techniques in response to their
reexperiencing symptoms. Varying trajectories for survivors of IPT and NPT also
suggests a need for trauma domain focused clinical interventions. For example, based on
these ﬁndings, it may be useful to incorporate support groups in the treatment of IPT
survivors to foster the development of a healing environment.

Study results can also be applied in a clinical setting to understand what

characteristics are related to poorer functioning for survivors of IPT. Person-centered

114

ﬁndings can be used to understand the different proﬁles of women that may seek
treatment after experiencing an IPT. Recognition of which proﬁle the client ﬁts can also
be used to alert the clinician of the potential health (psychological and physical) concerns
associated with those proﬁles. For example the assessment of personality characteristics
to aid in the understanding of the possible health proﬁles displayed in female clients with
a history of IPT. Although the ﬁndings from this study were informative, further research
is needed to examine the proﬁles of trauma survivors using a larger sample. It would be
useful to apply the person-centered approach for similar analyses in relation to women of
different ethnicities and males.

Conclusion

The current study set out to examine if theorized differences between survivors of
IPT and NPT were present and what the implications Of these differences were on health
outcomes. The study was also interested in examining the factors associated to the
development of health outcomes speciﬁc to survivors Of IPT using different approaches. I
was able to demonstrate that there were differences between the levels of the different
health outcomes, which also led me to examine the differences between the trajectories
for each of these types of traumatic events.

This study revealed differences in consequences between traumatic event
domains, IPT and NPT, as well as differences in the factors associated with these
outcomes. This study also provided further information regarding the trajectory of
psychological and physical health for survivors of IPT based on variable- and person-
centered approaches. These ﬁndings demonstrated that it is important to examine the

domains of traumatic events separately so as to prevent mistaken ﬁndings due to melding

115

of two distinct groups. Based on these ﬁndings, future studies should continue to examine
the effect of IPT on physical health problems and sample a wider range in age and
physical health functioning. Finally, this study suggests the need to develop assessment
and treatment plans based on the type of trauma experienced by the survivor and the

particular characteristics of the trauma, the survivor’s environment and personality.

116

APPENDIX A

117

Table 1.

Demographic percentages ior each trauma group

 

 

 

 

IPT NPT NO trauma
Ethnicity
White 75.3 83.5 73.5
Black 10.8 6.5 8.6
Asian/Paciﬁc Islander 5.7 4.5 11
Hispanic 2.9 2 1.7
Other 4.7 2.9 4.1
Income
0-18,500 10.8 5.2 7.5
19,000-30,000 10 5.2 5.2
30,500-50,000 12.2 11.7 10.5
50,500-75,000 20.8 18.3 13.3
75,500-100,000 20.1 24.2 19.3
100,500-200,000 17.6 24.7 26.8
200,000 and above 8.6 10.4 16.6
Education
Freshman 28 36.2 35.4
Sophomore 32.6 28.2 26.8
Junior 22.6 19.4 21.8
Senior 15.1 15.5 15.5
BA complete 1.4 0.6 0.3

118

Table 2.

 

Age by Trauma Group

Group Mean Median SD (range)
Interpersonal trauma 19.86 19 3.16 (18-53)
Non-personal trauma 19.50 19 1.664 (18-33)
No trauma 19.44 19 1.390 (18-27)

 

Note: Only includes persons that reported items

119

Table 3.

Percent of women in each group with psychological disorders

 

 

IPT NPT No trauma

Clinical levels of Depression (CD) 54.1 38 35.1
Moderate-Severe levels of anxiety (CA) 29.4 18.2 15.2
PTSD 14 4.2 na
ASD 36.9 17.5 Na
ASD and PTSD 10 2.3 Na
CD, ASD, and PTSD 7.2 1.9 Na
CA, ASD, and PTSD 5.4 1.3 Na
CA and CD 24.7 13.9 13
Presence of any psychological

diagnoses 69.2 49.5 37.3
Presence of all psychological diagnoses 4.3 1.0 Na

 

120

 

 

Table 4.

Descriptives for all variables before and after estimation

 

 

 

Mean SD Range Mean SD Percent
(after (after (before (before Impute
estimat estimat estimat estimatio d
ion) ion) ion) 11)
Trauma

Psychological 1.97 1.23 0-3 1.96 1 .24 .7

severity

Physical .56 1.25 0-7 .56 1.28 4.7

Severity

Multiple 2.81 2.84 0-23 2.81 2.84 0

trauma

Perpetrated by .23 1.14 0-20 .23 1.14 0

family

Perpetratedby .11 1.13 0-30 .11 1.13 0

friend

Stress

Negative life 4.24 3.26 0-30 4.24 3.26 0

events

Family History 1.18 1.73 0-11 1.18 1.73 0

Current Social 31.04 7.26 3-42 31.04 7.25 0

Support

121

‘x. ,4
t

Table 4. continued

 

 

 

Past Social 22.04 14.25 0-42 21.98 14.50 5.1
Support

Personality
Neuroticism 5.22 3.36 0-12 5.22 3.36 .1
Extraversion 9.24 3.06 0-12 9.24 3.06 .1
Optimism 14.52 4.14 0-24 14.52 4.14 0
Internal 8.67 1.79 0-12 8.67 1.79 0
Control
External 5.52 1.68 0-12 5.52 1.68 .1
Control

Psychological Symptoms
Depression 14.77 9.69 0—55 20.44 6.72 .1
Anxiety 9.62 8.39 0-51 9.62 8.39 .1
ASD 24.91 30.31 0-127 24.60 30.46 5.1
PTSD 6.90 8.61 0-54 6.90 8.77 0
Reexperiencin 2.08 2.70 0-15 2.48 2.83 4.5
8
Avoidance 2.31 3 .44 0-21 2.80 3 .65 4.6
Hyperarousal 1.74 2.66 0-15 2.13 2.84 4.8

Physical Health Symptoms

Medical 1.48 1.53 0-20 1.48 1.53 0
Conditions

122

ﬂ-J'I
“

Table 4. continued
Lifetime 18.92 5.84 0-39 18.92 5.84 0
Physical health
ailments
Past Year 23.91 10.47 065 23.91 10.47 0
Physical health

ailments

 

123

Table 5.

Between Subjects Effects: MANO VA for all groups

 

 

 

So
Dependent
urc df Mean Square F p n2 Power
Variable
e
Medical
1 2776.479 1192.626 .000 .398 1.000
Conditions
Lifetime
Phys. 1 445052.865 13593.98 .000 .883 1.000
ailments
Past Year
Phys. 1 729744.061 6867.808 .000 .792 1.000
’5. .
8 arlments
§
5 Depression 1 296824.999 3223.628 .000 .641 1.000
Anxiety 1 126677.699 1838.858 .000 .505 1.000
Reexperienci
1 3466.349 597.555 .000 .249 1.000
118
Avoidance 1 4416.696 435.308 .000 .194 1.000
Hyperarousal 1 2594.626 432.25 .000 .193 1.000
ASD 1 757885.934 1053.723 .000 .369 1.000
T“ Medical
5 2 16.757 7.198 .001 .008 .934
[3 Conditions

 

124

In; -

Table 5. continued

 

Lifetime
Phys. 2 1303.701 39.821 .000 .042 1.000
ailments
Past Year
Phys. 2 3180.584 29.933 .000 .032 1.000
ailments
Depression 2 1809.217 19.649 .000 .021 1.000
Anxiety 2 1409.361 20.458 .000 .022 1.000
Reexperienci
2 1006.459 173.501 .000 .161 1.000
“8
Avoidance 2 1308.613 128.977 .000 .125 1.000
Hyperarousal 2 729.113 121.466 .000 .119 1.000
ASD 2 180571.092 251.056 .000 .218 1.000
Medical
1803 2.328
Conditions
Lifetime 1803
Phys. 32.739
25
l: .
Lu arlments
Past Year 1803
Phys. 106.256
ailments

125

Table 5. continued
Depression
Anxiety
Reexperienci
ng
Avoidance
Hyperarousal

ASD

1803

1803

1803

1803

1803

1803

92.078

68.889

5.801

10.146

6.003

719.246

 

126

 

Table 6.

Mental health outcome means by group

 

 

No trauma mean IPT mean NPT mean

Depressive symptoms 13.93 18.07b 14.25
Anxiety Symptoms 8.46 12.44b 9.31
All PTSD Symptoms na 12.64’ll 7.66a

PTSD reexperiencing na 2.31 2.69

PTSD avoidance na 2.57 3.07

PTSD hyperarousal na 2.04 2.28
ASD Symptoms na 46.44a 27.55a
Serious Medical Conditions 1.26b 1.72 1.50
Lifetime Physical ailments 16.771’ 20.68“ 19.17a
Past Year Physical Ailments 21.12“ 27.47a 23.93a

 

Note: aMeans are signiﬁcantly different from all other groups on a p < .05 level.

t’Means are signiﬁcantly different from the other two groups on a p < .05 level.

127

 

Table 7.

Trauma Characteristics Final Iterative Cluster Analysis (F our-C luster Solution)

 

 

 

Cluster
(N=158) (N=90) (N=31)
Physical Severity -.342 -.212 2.357
Psych Severity -.256 .375 .216
Multiple trauma -.574 .916 .266
Perpetration by Family -.388 .673 .021

 

128

 

 

Table 8.

Be tween Subjects Effects for Trauma Characteristic Proﬁles

 

 

Dependent Mean

df F p 112 Power

Variable Square

Medical

2 2.293 2.314 .101 .016 .467
Conditions
Lifetime
Phys. 2 7.671 8.060 .000 .055 .956
ailments
Past Year
Phys. 2 8.686 9.198 .000 .062 .976
ailments
Depression

2 5.037 5.189 .006 .036 .826
symptoms
Anxiety

2 11.179 12.069 .000 .080 .995
Symptoms
ASD

2 10.431 11.196 .000 .075 .992
Symptoms
PTSD

2 14.123 15.607 .000 .102 .999
Symptoms

129

Table 9.

Personality Characteristics Final Iterative Cluster Analysis (F our-C luster Solution)

 

 

 

Cluster
(N=95) (N=89) (N=49) (N=46)
—Optimism .962 -.423 -.499 -.637
Neuroticism -.987 .485 .821 .226
Extraversion .497 .486 -l .561 -.303
Internal Control .359 .263 -.024 -1.225
External Control -.411 .063 -.473 1.232

 

130

Table 1 0.

Between Subjects Eﬂects for Personality Characteristic Proﬁles

 

 

Dependent Mean
df F p n2 Power
Variable Square
Medical
3 .701 .698 .554 .008 .198
Conditions
Lifetime
Phys. 3 3.763 3.880 .010 .041 .822
ailments
Past Year
Phys. 3 10.301 11.464 .000 .111 .999
ailments
Depression
3 24.194 32.389 .006 .261 1.000
symptoms
Anxiety
3 13.191 15.214 .000 .142 1.000
Syruptoms
ASD
3 4.603 4.792 .003 .050 .900
SymPtOms
PTSD
3 7.430 7.990 .000 .080 .990
Symptoms

\

 

131

Table 1 1.

Environmental Stress Characteristics Final Iterative Cluster Analysis
(T hree-Cl uster Solution)

 

 

 

Cluster
(N=68) (N=145) =66)
Negative Life Events .866 -.428 .047
Family History -.381 -.470 1.424
Current Social Support -.964 .509 -.123
Past Social Support -.771 .513 -.332

 

132

Table 12.

Between Subjects Effects for Environmental Stress Characteristic Proﬁles

 

 

Dependent Mean
df F p 112 Power
Variable Square
Medical
2 .612 .610 .554 .004 .151
Conditions
Lifetime
Phys. 2 9.684 10.335 .000 .070 .987
ailments
Past Year
Phys. 2 9.477 10.098 .000 .068 .985
ailments
Depression
2 25.492 30.993 .000 .183 1.000
symptoms
Anxiety
2 13.377 14.695 .000 .096 .999
SYUIptoms
ASD
2 14.677 16.291 .000 .106 1.000
Symptoms
PTSD
2 11.746 12.737 .000 .085 .997
SymPtOms
\

 

133

APPENDIX B

134

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139

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140

Figure 7.
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Note: Group marked with “a” is signiﬁcantly different from all other groups p < .05 level.
Groups marked with “b” are signiﬁcantly different from one another p < .05 level.

141

Figure 8.
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Note: Group marked with “a” is signiﬁcantly different from all other groups p < .05 level.

142

Figure 9.
Personality Characteristics Dendogram

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>1 =43 |——>[ N=43 l—bl N=43 H N=43
H N=20 —>{ N=20 l—Dl N=20

N=38 ﬂ N=38

 

 

 

 

 

 

 

 

N=ll N=ll

 

143

 

 
      

[ N=279 l

Figure 10.
Personality Characteristics Cluster

 

Fumnyf‘ ‘*“ 4.:.....‘.Krraa13

 

 

 

IQﬁnismlhbuuﬁdstEﬁaersimUhemalCaﬂdlEﬂdeatd

 

 

 

 

Figure 11.
Psychological symptoms for Personality Characteristics Cluster

 

Psycholodcd l-hdﬂiforParscrt4dLsher-lﬁmais

 

 

 

Inepessamumayumuprsoj

 

 

 

“ 3"

Note: Group marked with a 18 signiﬁcantly different from all other groups p < .05 level.
Groups marked with “b” are signiﬁcantly different from one another p < .05 level.
Groups marked with “c” are signiﬁcantly different from one another p < .05 level.

145

Figure 12.
Physical Health symptoms for Personality Characteristics Clusters

 

Plneicdl-bdthformsortntduaerm

 

 

I I serious medical oondﬁons I Ilhtirneailmerts Cl )ea'a'lmenls

 

 

 

‘6 ,"

Note: Group marked with a is signiﬁcantly different from all other groups p < .05 level.
Groups marked with “b” are signiﬁcantly different from one another p < .05 level.

146

Figure 13.
Environmental Stress Characteristics Dendogram

22-cluster 14- 9-cluster 6-cluster 5-cluster 4-cluster 3-cluster 2-cluster l-cluster

solution cluster solution solution solution solution solution solution solution
solution

N=l7

N-..

N=22

N=28
N=23 -N=23
N=48

 

 

N=2s
N=ll
N—7 N=42 liq—279
-N=l9 -N=19
N=12
N=10
N=l3 =
N 41
N= =6
N=6 N=l8 N=l49
N25
N=l
N=9
N=l9 N=28 N=28 N=28 N=28
N=lO N=66 N=66
N2” N=21 N=21
N=38 N=38
N=l6 N=l6 N—17
“=1 N=1

147

Figure 14.
Environmental Stress Characteristics Cluster

 

wmmmsdm

 

 

 

ll Negalhel'rfeaents I FaﬁlsttnyUQnentSS DTraInaSSl

 

 

Note: Current and Trauma social support in this graph represent levels of perceived
support by the survivor.

148

Figure 15.
Psychological symptoms for Environmental Stress Characteristics Cluster

 

W l-bdlhforﬁ'ess: 3dlﬂers-Krmals

 

 

lDeprassionlAmietyDAsonprsal

 

 

 

Note: Group marked with “a” is signiﬁcantly different from all other groups p < .05 level.
Groups marked with “b” are signiﬁcantly different ﬁ'om one another p < .05 level.

149

Figure 16.
Physical Health symptoms for Environmental Stress Characteristics Cluster

 

Physicd l-bdﬂrforSmssc3dtstars-Knaals

 

 

ll serious meticd oondtions I lifaimeailmerls Elyeaailmensl

 

 

 

Note: Group marked with “a” is signiﬁcantly different from all other groups p < .05 level.
Groups marked with “b” are signiﬁcantly different from one another p < .05 level.

150

APPENDIX C

 

 

151

Demographic Questionnaire

Below are some general questions about you.

For each question, please give the answer that best describes you.

Note: This study is open to females only. If you are a male, and have been assigned to
this study in error, please do not continue answering these questions

1. What is your current age (in years)?

2. How would you describe you race/ethnicity? (Please circle all that apply.)

a. White/Caucasian

b. Black/African-American

0. Asian/Paciﬁc Islander

(1. Hispanic/Latino

e. Native American/Alaskan Native
f. Bi-fMulti-racial

g. Other:

 

3. Which of the ranges below best describes your approximate annual family income?
(Please circle. For students supported by parents, include your parents’ income). Estimate
as needed.

$0-l 8,500
$19,000-30,000
$30,500-50,000
$50,000-75,000
$75,000-100,000
$100,000-$200,000
$200,000 and above

4. What is your level of education?
Freshman standing
Sophomore standing
Junior Standing

Senior Standing

Already completed BA

{DP-99"!”

152

National Health Interview Survey

Below are some questions about certain medical conditions.

 

Have you EVER been told by a doctor or YES NO Still Have
other health professional that you had... Condition?

 

1. Hypertension (high blood pressure)
If YES go to la

 

> la. Were you told
on 2 or more different visits N/A
that you had hypertension?

 

2. Coronary heart disease

 

3. A heart attack

 

4. Any other kind of heart condition or heart
disease (e. g. heart murmur)

 

5. A stroke

 

6. Emphysema

 

7. Asthma

 

8. An ulcer. This could be a stomach,
duodenal or peptic ulcer.

 

9. Cancer or a malignancy (tumor) of any
kind?

 

10. Diabetes or sugar diabetes

 

l l. Hay fever

 

12. Sinusitis

 

13. Chronic Bronchitis

 

14. Weak or failing kidneys (do not include
kidney stones, bladder infections or
incontinence)

 

15. Any kind of liver condition

 

16. Mononucleosis (i.e. mono)

 

l7. Irritable Bowel Syndrome

 

 

 

 

 

l8. Urinary Tract Infection

 

 

153

 

 

19. Human papillomavirus (HPV)

 

20. Pneumonia

 

 

 

 

 

 

21. DURING THE PAST 30 DAYS, have you had any symptoms of pain, aching, or
stiffness in or around a joint? Please do NOT include the back or neck. If YES go to 21a

1 Yes
2 No

>21a. Have you EVER seen a doctor or other health professional for
these joint symptoms?

1 Yes

2 No

22. Have you EVER been told by a doctor or other health professional that you have
some form of arthritis, rheumatoid arthritis, gout, lupus, or ﬁbromyalgia?

1 Yes
2 No

The following questions are about pain you may have experienced in the PAST THREE
MONTHS. Please refer to pain that LASTED A WHOLE DAY OR MORE. Do not
report aches and pains that are ﬂeeting or minor.

During the PAST THREE MONTHS, did you have...

 

YES NO

 

23. Neck pain

 

24. Lower back pain

 

25. Facial ache or pain in the jaw muscles
or the joint in front of the ear
26. Severe headache or migraine

 

 

 

 

 

 

27. Did you have a head cold or chest cold that started in the past TWO WEEKS?

1 Yes
2 No

154

28. Did you have a stomach or intestinal illness with vomiting or diarrhea that started in
the past TWO WEEKS?

1 Yes
2 No

155

MAPSAIS- I
Many people have experienced various physical ailments over their lifetime, please make
if you have EVER experienced any of the following in your lifetime AND in the past

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

year
Have you ever had YES NO If YES, how often in the past
any of the following year?
health problems in Not at Seldo Occasi Often
your life? all m onal 3
0 l 2
l. ‘ Nausea (upset
stomach/vomiting)
2. Back pain
1
3. Headache
4. Memory loss
5. Fainting/loss of
. consciousness
6. Ringing in ears
7. Dizzy spells
8. Seizures
l
9. Eye pain/vision loss
1
10. Shortness of Breath
11. Food intolerances
12. Difﬁculty
Swallowing
13. Loss of Voice
14. Ear pain/hearing loss
15. Difﬁculty
‘ concentrating
16.1 Insomnia

 

 

 

 

 

 

 

 

 

156

 

 

Have you egg had

any of the following

health problems in
your life?

YES

NO

If YES, how often in the past

year?

 

Not at
all
0

Seldo Occasi
m onal
1 2

Often
3

 

 

. Diarrhea

 

. Loss of Appetite

 

. Abdominal pain

 

20.

Chest pain

 

21.

High Blood Pressure

 

22.

Heart Palpitations

 

23.

Chronic fatigue
(always tired)

 

24.

Pelvic Pain

 

25.

Excessive Menstrual
Bleeding

 

26.

Vaginal discharge

 

27.

Missed menstrual
periods (do not
include for
pregnancy)

 

28.

Painful menstruation

 

29.

Painful intercourse

 

30.

Bloating (e.g. gassy)

 

31.

Sexually transmitted
diseases (STDs: e.g.,
herpes, AIDS,
CLAP)

 

 

32.

 

Burning pain in
sexual organs

 

 

 

 

 

 

 

157

 

 

Have you gel had

any of the following

health problems in
your life?

YES

NO

If YES, how often in the past

year?

 

Not at
all
0

Seldo

m
1

onal
2

Occasi

Often
3

 

33. .

Rectal bleeding

 

34. .

Bladder infection

 

35. .

l

Frequent urination
(peeing)

 

36. 4

Painful urination
(peeing)

 

37. 4

Cold/ﬂu

 

38. .

Viruses

 

 

39. 4

 

Swollen joints

 

 

 

 

 

 

 

158

 

CES-D

Below is a list of ways you might have felt or behaved. Please mark how often you have
felt this way during the past week.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rarely or Some or Occasiona Most or
none of a little lly or a all of the
the time of the moderate time (5-
During the past week.... (less than time (1- amount of 7 days)
1 day) 2 days) time (3-4
days)
1 I was bothered by things that
usually don’t bother me.
2 I did not feel like eating; my
appetite was poor
3 I felt that I could not shake
off the blues even with help
from my family or friends
4 I felt I was just as good as
other people
5 I had trouble keeping my
mind on what I was doing
6 I felt depressed
7 I felt that everything I did
was an effort
8 I felt hopeful about the future
9 I thought my life has been a
failure
10 I felt fearful
11 My sleep was restless
12 I was happy
13 I talked less than usual
14 I felt lonely
15 People were unfriendly
16 I enjoyed life
17 I had crying spells
18 I felt sad
19 I felt that people dislike me
20 I could not get “going”

 

 

 

159

 

BAI

Below is a list of common symptoms of anxiety. Please carefully read each item in the
list. Indicate how much you have been bothered by each symptom during the past week,
including today, and mark how bothered you were by each symptom.

 

 

 

 

 

Not at Mildly. Moderately. Severely.
all It did It was very I could
During the past week, how much not unpleasant barely
were you bothered by bother but I could stand it '
me stand it
much
Numbness or tingli_ng
Feelinghot
Wobbliness in legs

 

Unable to relax

 

Fear of the worst happening

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

5

6 Dizzy or lightheaded
7 Heart pounding or racing
8 Unsteady

9 Terriﬁed

10 Nervous

11 Feeligs of choking
12 Hands trembling

13 Shaky

14 Fear or losingcontrol
15 Difﬁculty breathing
16 Fear of dyinL

17 Scared

18

Indigestion or discomfort in
abdomen

 

 

 

 

 

19 Faint
20 Face flushed
21 Sweatingjnot due to heat)

 

 

 

 

 

160

 

EPQR—A

Please answer each question by marking YES or NO. There are no right or wrong
answers, and no trick questions. Work quickly and do not think too long about the
meaning of the questions.

 

Yes No

 

Does your mood often g9 up and down?

Are you a talkative person?

Do you ever feel ‘just miserable’ for no reason?

Are you rather lively?

Are you an irritable person?

Do you enjoy meeting new people?

Are your feelings easily hurt?

Can you usually let yourself go and enjoy yourself at a
lively party?

Do you often feel ‘fed up’?

10. Do you usually take the initiative in making new friends?
11. Would you call ﬂurself a nervous person?

12. Can you easily get some life into a rather dull party?

13. Are you a worrier?

Do you tend to keep in the background on social
occasions?

15. Would you call yourself tense or ‘highly-strug’?

16. Do you like mixing with people?

17. Do you worry too long:after an embarrassing experience?
18. Do you like plenty of hustle and excitement around you?
19. Do you suffer from ‘nerves’?

20. Are you mostly quiet when you are with other people?
21. Do you often feel lonely?

22. Do other people think of you as being very lively?

23. Are you often troubled about feeliﬂs of guilt?

24. Can you get a party going?

 

 

 

 

 

 

 

 

2° 9’ F999???

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

161

LOT-R

Please be as honest and accurate as you can throughout. Try not to let your response to
one statement inﬂuence your responses to other statements. There are no "correct" or
"incorrect" answers. Answer according to your own feelings, rather than how you think
"most people" would answer.

 

I I agree I neither I I

agree a little agree disagree disagree

a lot nor a little a lot
disagree

 

1. In uncertain times, I
usually expect the best.

 

2. It's easy for me to relax.
3. If something can go
wrongior me, it will.

4. I'm always optimistic
about my future.

5. I enjoy my friends a lot.
6. It's important for me to
keep busy.

7. I hardly ever expect
thinﬂtgo my way.

8. I don't get upset too
easily.

9. I rarely count on good
things happening to me.
10. Overall, I expect more
good things to happen to me
than bad.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

162

LOC-B

Please read each statement and mark how much you feel it characterizes you

 

Strongly Somewh Ineither Somewh Strongly

agree at agree agree at disagree
nor disagree
disagree

 

1. When I make
plans, I am
almost certain to
make them work.

 

2. When I get what
I want, it’s
usually because I
worked hard on
it

 

3. My life is
determined by
my own actions.

 

4. To a great extent,
my life is
controlled by
accidental
happenings.

 

5. When I get what
I want, it’s
actually because
I’m lucky.

 

6. I’ve often found
that what is going
to happen will
happen.

 

7. People like
myself have very
little chance of
protecting our
personal interests
where they
conﬂict with
those of strong
pressure groups.

 

8. My life is chieﬂy
controlled by
powerful others.

 

 

 

 

 

 

 

 

163

 

 

9. Getting what I
want requires
pleasing those
people above me.

 

 

 

164

 

 

 

 

CSS- I

Please report how you feel about your current social support network. Please refer to
support from friends and/or family in the past few weeks.

 

nally

Never
Rarely
Occasro
Half of
the
Time
Some of
the
Time
Most of
the
Time
Always

 

1. Someone willing to
listen

 

2. Contact with
people in a similar
situation

 

3. Able to talk about
thoughts and
feelings

 

4. Sympathy and
support from
others

 

5. Practical help

 

5"

Feeling let down

 

 

r)

Overall
satisfaction with
support received

 

 

 

 

 

 

 

 

 

 

165

Listed below are a number of events which sometimes bring about change in the lives of

LES

those who experience them. Please check those events which you have experienced it;
the last year. If you have not experienced a speciﬁc event in the last year, check N/A.
Be sure that all check marks are directly across from the items they correspond to.

Also, for each item checked below, please indicate whether you viewed the event as
having a positive or negative impact on your life at the time it occurred. A rating of -3
would indicate an extremer negative impact. A rating of 0 suggests no impact either
positive or negative. A rating of +3 would indicate an extremely positive impact.

 

\

Even

Occ
urre

Extre

mely
negati
ve

Moder

ately
negati

ve nega

No
impa
ct

Sligh
tly
posit
ive

Moder

ately
positiv

Extre

mely
positiv

 

l .
Marriage

+1

+2

+3

 

2.
Detention
in jail or
comparab
le
institution

+1

+2

+3

 

3. Death
of a
romantic
partner

+1

+2

+3

 

4. Maj or
change in
sleeping
habits
(much
more or
much less
sleep)

+1

+2

+3

 

5. Death
of close
family
member

 

 

 

 

 

 

 

 

+1

 

+2

 

+3

 

166

 

 

\

Even

Occ
urre

Extre

mely
negati
ve

Moder
ately
negati
ve

Som
ewh
at
nega
tive

No
impa
ct

Sﬁgh
tly
posit
ive

Moder
ately

positiv

Extre
mely
positiv

 

6. Maj or
change in
eating
habits
(eating
much
more or
much less

food)

+1

+2

+3

 

7. Death
of close
friend

+1

+2

+3

 

8.
Outstandi
118
personal
achievem
ent

+1

+2

+3

 

9. Minor
law
violations
(traffic
tickets,
disturbing
the peace,
etc.)

+1

+2

+3

 

 

1 0.
Pregnanc

Y

 

 

 

 

 

 

 

+1

 

+2

 

+3

 

167

 

 

 

 

\

Even

Occ
urre

Extre
mely

negati
ve

Moder
ately

negati
ve

Som
ewh
at
nega
tive

No
impa
ct

Sﬁgh
ﬂy
posit
ive

Moder
ately
positiv

Extre
mely
positiv

 

l 1.
Changed
work
situation
(different
work
responsibi
lity, major
change in
working
conditions
, working
hours,
etc.)

+1

+2

+3

 

12. New
job

+1

+2

+3

 

1 3.
Serious
illness or
injury of
close
family
member

+1

+2

+3

 

 

14.
Sexual
difﬁcultie
s

 

 

 

 

 

 

 

+1

 

+2

 

+3

 

168

 

 

\

Even

Occ
urre

Extre
mely

negati
ve

Moder

ately
negati
ve

Som
ewh
at
nega
tive

No
impa
ct

Sligh
ﬂy
posit
ive

Moder
ately

positiv

Extre

mely

positiv

 

15.
Trouble
with
employer
(for
example,
in danger
of losing
job, being
suspended
, demoted,
etc.)

+1

+2

+3

 

l 6.
Trouble at
school
(for
example,
failing a
class)

+1

+2

+3

 

17. Major
change in
ﬁnancial
status (a
lot better
off or a
lot worse

oﬁ)

+1

+2

+3

 

 

l 8. Maj or
change in
closeness
of family
members
(a lot
more
close or a
lot less
close)

 

 

 

 

 

 

 

+1

 

+2

 

+3

 

169

 

 

\

Even

Occ
urre

Extre

mely
negati
ve

Moder

ately
negati
ve

Som
ewh
at
nega
tive

No
impa
ct

Sligh
tly
posit
ive

Moder
ately
positiv
e

Extre
mely

positiv

 

1 9.
Gaining a
new
family
member
(through
birth,
adoption,
family
member
moving
in, etc.)

+1

+2

+3

 

20.
Change of
residence

+1

+2

+3

 

21 . Maj or
change in
religious
organizati
on
activities
(increased
or
decreased
attendanc

8)

+1

+2

+3

 

 

22. Major
change in
number of
arguments
with
romantic
partner (a
lot more
or a lot
less

arguments
)

 

 

 

 

 

 

 

+1

 

+2

 

+3

 

170

 

 

>\

Extre
mely
negati
ve

Moder
ately
negati
ve

Som
ewh
at

nega

tive

No
impa
ct

Sligh
tly
posit
ive

Moder
ately
positiv

Extre
mely
positiv

 

23. Major
change in
usual type
and/or
amount of
recreation

-2

+1

+2

+3

 

24.
Personall
y
borrowing
more than
$ 1 0,000
(buying
home,
business,
etc)

+1

+2

+3

 

25.
Personal]
Y
borrowing
less than
$10,000
(buying
car, TV,
getting
school
loan, etc.)

+1

+2

+3

 

26. Being
ﬁred from
job

-3

+1

+2

+3

 

27.
Having
abortion

-3

+1

+2

+3

 

 

28. Major
personal
illness or

injury

 

 

 

-3

 

 

 

 

+1

 

+2

 

+3

 

171

 

 

\

Even

Occ
urre

Extre

mely
negati
ve

Moder

ately
negati

ve nega

No
impa
ct

Sligh
ﬂy
posit
ive

Moder
ately
positiv
e

Extre

mely
positiv

 

29. Major
change in
social
activities,
e. g.,
parties,
movies,
visiting
(increased
or
decreased
participati
on)

+1

+2

+3

 

30. Maj or
change in
living
conditions
of family
(building
new
home,
remodelin
8,
deteriorati
on of
home,
neighborh
ood, etc.)

+1

+2

+3

 

3 1.
Serious
injury or
illness of
close
friend

+1

+2

+3

 

 

32.
Ending of
formal
schooling

 

 

 

 

 

 

 

+1

 

+2

 

+3

 

172

 

 

Even

Occ
urre

Extre

mely
negati
ve

Moder
ately

negati
ve

Som
ewh
at
nega
tive

No
impa
ct

Sligh
ﬂy
posit
ive

Moder
ately

positiv

Extre
mely
positiv

 

33.
Separatio
n from
spouse/pa
rtner (due
to work,
travel,
etc.)

+1

+2

+3

 

34.
Engagem
ent

+1

+2

+3

 

35.
Breaking
up with
boyfriend/
girlﬁ'iend

+1

+2

+3

 

36.
Leaving
home for
the ﬁrst
time

+1

+2

+3

 

 

37.
Reconcili
ation with
boyﬁiend/
girlfriend

 

 

 

 

 

 

 

+1

 

+2

 

+3

 

173

 

Family History Questionnaire

Have any of the following illnesses occurred in your immediate family (i.e., parents,
siblings) and extended family (i.e., aunts, uncles, cousins, grandparents, etc.)? This
does not include step-relatives or those related by marriage: just blood relatives. Please
include yourself. If so, please indicate his/her relationship to you, his/her sex, the side
of the family he/she is on, whether he/she has been hospitalized for the illness, and
whether he/she has received other treatment (i.e., psychotherapy or medication) besides
hospitalization for the condition. Please list multiple relatives with the same illness
separately. Do n_ot provide names. Write N/A if no one has had this illness.

 

His/her relationship Hospitalized or
to m (i.e., mother, Sex of other
Illness brother, aunt) Relative treatments?
' (Y, N, or

don’t know

      
   

M F Y N Dk
Paternal 3. M F Y N Dk
Ex‘ended‘ 4. M F Y N Dk

# of Immwiate: 2.

 

 

Maternal

 

 

 

 

 

 

. M Y N
Paternal 3. M F Y N Dk
Extended: 4. M F Y N Dk
Maternal

 
   

Extended:

 

 

 

 

 

 

    

-.-' r rum”
# of Immediate: 2. M F Y N Dk
Paternal 3. M F Y N Dk
Extended: 4. M F Y N Dk
Maternal
Extended:

    
 
   
    
 
   

 

  

 

# of Immediate: . M Y N Dk
Paternal 3. M F Y N Dk
Extended: 4. M F Y N Dk
Maternal

 

 

 

 
  
   

.. Extended:
13 renal

# of Immediate:

 

174

 

 

 

 

 

His/her relationship Hospitalized or

to 11120-0» mother, Sex of other
Illness brother, aunt) Relative treatments?

(Y, N, or
don’t know)

Paternal 3. M F Y N Dk
Extended: 4. M F Y N Dk
Maternal

Extended:

    

# of Immediate: 2. V

 

 

Dk

 

 

M F Y N
Paternal 3. M F Y N Dk
Extended: 4. M F Y N Dk
Maternal

 

# of Immediate: 2.

Dk

 

 

M F Y N
Paternal 3. M F Y N Dk
Extended: 4. M F Y N Dk
Maternal

 

_Et dd'

   

 

 

 

 

# of Immediate: 2. M F Y N Dk
Paternal 3. M F Y N Dk
Extended: 4. M F Y N Dk
Maternal

Extended:

 

 

 

 

 

175

PDS

Part 1:

Many people have lived though or witnessed a very stressful and traumatic event at some
point in their lives. Indicate whether or not you have experienced or witnessed each
traumatic event listed below by marking Yes or No on the answer sheet, the age at the
time of the event, your relationship to perpetrator, and your reaction to the traumatic
event at the time it occurred as well as now.

1. Serious accident, fire, or explosion (for example, an industrial, farm, car,
plane, or boating accident)

Age at time of event

How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
b. A little bit
0. Moderately
d. A lot

How many times did this event occur?

2. Natural disaster (for example tornado, hurricane, ﬂood, or major
earthquake)

Age at time of event

How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
b. A little bit
c. Moderately
d. A lot

How many times did this event occur?

3. Non-sexual assault by a family member or someone you know (for example,
being mugged, physically attacked, witnessing domestic violence between
parents, shot, stabbed, or held at gunpoint)

Age at time of event

How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
h. A little bit
c. Moderately
d. A lot

176

Who was the person committing these actions? (Circle all that apply)
a. Family member (e. g. father, brother, step-father). # of times
b. Family Friend, neighbor, or an acquaintance. # of times

 

 

4. Non-sexual assault by a stranger (for example, being mugged, physically
attacked, shot, stabbed, or held at gunpoint)

Age at time of event

How upsetting was the event at the time it occurred? (Pick one)

a. Not at all

h. A little bit
c. Moderately
d. A lot

How many times did this event occur?

5. Sexual assault by a family member or someone you know (for example, rape
or attempted rape).

Age at time of event

How upsetting was the event at the time it occurred? (Pick one)
Not at all

A little bit

Moderately

A lot

999‘.”

Who was the person committing these actions? (Circle all that apply)
a. Family member (e. g. father, brother, step-father). # of times
b. Family Friend, neighbor, or an acquaintance. # of times

 

 

6. Sexual assault by a stranger (for example rape or attempted rape)
Age at time of event

How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
b. A little bit
c. Moderately
d. A lot

Who was the person committing these actions? (Circle all that apply)
a. Family member (e. g. father, brother, step-father). # of times
b. Family Friend, neighbor, or an acquaintance. # of times

 

 

177

7. Military combat or a war zone
Age at time of event

How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
b. A little bit
c. Moderately
d. A lot

How many times did this event occur?

8. Sexual contact when you were younger than 18 with someone who was 5 or
ore years older than you (for example, contact with genitals or breasts)

Age at time of event

How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
b. A little bit
c. Moderately
d. A lot

Who was the person committing these actions? (Circle all that apply)
a. Family member (e. g. father, brother, step-father). # of times
b. Family Friend, neighbor, or an acquaintance. # of times
c. Stranger. # of times

 

 

 

9. Imprisonment (for example, prison inmate, prisoner of war, hostage)
Age at time of event
How upsetting was the event at the time it occurred? (Pick one)

a. Not at all

b. A little bit

c. Moderately

d. A lot

How many times did this event occur?

178

 

 

10. Torture
Age at time of event

How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
b. A little bit
c. Moderately
d. A lot

How many times did this event occur?
11. Life threatening illness (e.g. cancer, AIDS)
Age at time of event
How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
b. A little bit
c. Moderately
d. A lot
How many times did this event occur?
12. Other traumatic event (Specify
Age at time of event
How upsetting was the event at the time it occurred? (Pick one)
a. Not at all
b. A little bit

c. Moderately
d. A lot

Who was the person committing these actions? (Circle all that apply)
a. Family member (e. g. father, brother, step-father). # of times

b. Family Friend, neighbor, or an acquaintance. # of times
0. Stranger. # of times

 

 

 

IF YOU MARKED YES TO ANY OF THE ITEMS ABOVE, CONTINUE. IF

NOT, PLEASE STOP HERE.

179

Part 2:

13. If you marked Yes for more than one traumatic event in Part 1, indicate which one
bothers you the most. If you marked Yes for only one traumatic event in Part 1,
mark the same one on the answer sheet

Accident

Disaster

Non-sexual assault by a family member or someone you know
Non-sexual assault by a stranger

Sexual assault by a family member or someone you know
Sexual assault by a stranger

Military combat or a war zone

Sexual contact under 18 with someone who was 5 or more years older than you
Imprisonment

Torture

Life threatening illness

Other traumatic event

Prrr'n‘qa ran an .c‘a

During this traumatic event:
14. Were you physically injured?
15. Was someone else physically injured?
16. Did you think that your life was in danger?
17. Did you think that someone else’s life was in danger?
18. Did you feel helpless?
19. Did you feel terriﬁed?

180

Part3:

Below is a list of problems that people sometimes have after experiencing a traumatic
event. Read each one carefully and choose the answer that best describes how often that
problem has bothered you in the past month. Rate each problem with respect to the
traumatic event you marked in Item 13.

 

Not at all Once in a Half of the Almost

 

(only 1 while (1 time always
time) time a week (2-4 times (5 or more
or less) a week) times a
week)
20. Having upsetting
thoughts or

images about the
traumatic event
that came into
your head when
you didn’t want
them to

 

 

21. Having bad
dreams or
nightmares about
the traumatic
event

22. Reliving the
traumatic event,
acting or feeling
as if it was
happening_again

23. Feeling
emotionally upset
when you were
reminded of the
traumatic event
(for example
feeling scared,
angry, sad, guilty,
etc.)

24. Experiencing
physical reactions
when you were
reminded of the
traumatic event
(for example,

 

 

 

 

 

 

 

 

 

 

181

 

breaking out in a
sweat, heart,
beating fast)

 

25.

Trying not to
think about, talk
about, or have
feelings about the
traumatic event

 

26.

Trying to avoid
activities, people,
or places that
remind you of the
traumatic event

 

27.

Not being able to
remember an
important part of
the traumatic
event

 

28.

Having much less
interest or
participating
much less often in
important
activities

 

29.

Feeling distant or
cut off from
people around
you

 

30.

Feeling
emotionally numb
(for example,
being unable to
cry or unable to
have loving
feelings)

 

31.

Feeling as if your
future plans or
hopes will not
come true (for
example, you will
not have a career,
marriage,
children, or a
lonLlife)

 

 

32.

Havinglrouble

 

 

 

182

 

 

 

 

 

fallinggsleep

 

33. Feeling irritable
or having fits of

anger

 

34. Having trouble
concentrating (for
example, drifting
in and out of
conversations,
losing track of a
story on
television,
forgetting what
you read)

 

35. Being overly alert
(for example,
checking to see
how is around
you, being
uncomfortable
with your back to
a door, etc)

 

 

 

36. Being jumpy or
easily startled (for
example when
someone walks up
behind you)

 

 

 

 

 

 

37. How long have you experienced the problems that you reported above? (Mark
only one)

a. Less than 1 month

b. 1 to 3 months

c. More than 3 months

38. How long after the traumatic event did these problems begin? (Mark only one)

a. Less than 6 months
b. 6 or more months

183

SASRQ

NOTE: These questions refer to the traumatic event you marked as most upsetting
to you on the PDS

DIRECTIONS: Below is a list of experiences people sometimes have during and after a
stressful event. Please read each item careﬁllly and decide how well it describes your
experience during and after immediately after the event that you reported bothered you
the most (during and in the four weeks afterwards). Refer to this event in answering the
items below. Use the 0-5 point scale shown below and circle the number that best
describes your experience.

 

 

0 1 2 3 4 5-..--..---
not very rarely Rarely Sometimes often very often
experienced experienced experienced experienced experienced experienced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. I had difﬁculty falling or staying asleep. 0 l 2 3 4 5

2. I felt restless O l 2 3 4 5

3. I felt a sense of timelessness. 0 1 2 3 4 5

4. I was slow to respond. 0 l 2 3 4 5

5. I tried to avoid feelings about that event. 0 1 2 3 4 5

6. I had repeated distressing dreams about that event. 0 1 2 3 4 5

7 I felt extremely upset if exposed to events that 0 1 2 3 4 5

' reminded me of an aspect about that event.
8. I would jump in surprise at the least thing. 0 1 2 3 4 5
9 Knowing about the event made it difficult for me to do 0 1 2 3 4 5
' perform work or other things I needed to do.

10. I did not have the usual sense of who I am. 0 1 2 3 4 5

1 1. I tried to avord act1v1t1es that reminded me about the 0 1 2 3 4 5
event.

12. I felt hypervigilant or “on edge”. 0 l 2 3 4 5

13. I experienced myself as though I were a stranger. O l 2 3 4 5

14. I tried to avoid conversations about that event. 0 l 2 3 4 5

15. I had a bodily reaction when exposed to reminders of 0 1 2 3 4 5
that event.

16. I had problems remembering important details about 0 1 2 3 4 5
that event.

 

 

 

184

 

 

17.

I tried to avoid droughts about that event.

 

18.

Things I saw looked different to me from how I know
they really looked.

 

19.

I had repeated and unwanted memories about that
event.

 

20.

I felt distant from my own emotions.

 

21.

I felt irritable or had outbursts of anger.

 

22.

I avoided contact with people who reminded me of that
event.

 

23.

I would suddenly act or feel as if learning about my
that event was happening again.

 

24.

My mind went blank.

 

25.

I had amnesia for large periods of learning about that
event.

 

26.

The experience of that event caused problems in my
relationships with other people.

 

27.

I had difﬁculty concentrating.

 

28.

I felt estranged or detached from other people.

 

29.

I had a vivid sense that the experience of that event
was happening all over again.

 

 

30.

 

I tried to stay away from places that reminded me of
that event.

 

185

 

 

 

 

 

 

 

 

MAPSAIS II

NOTE: These questions refer to the traumatic event you marked as most upsetting
to you on the PDS

 

Have you ever had YES NO If YES, how often in the past year?

 

any of the Not at Seldo Occasi Often
following health all m onal 3
problems in your 0 1 2
life?

 

1 Hospitalized for
injuries due to
traumatic event

 

2 Taken to Emergency
Room

 

3 Injuries requiring
surgery due to
traumatic event

 

4 Injuries requiring
stitches due to
traumatic event

 

5 Broken bones due to
traumatic event

 

6 Arthritis due to
injuries from
traumatic event

 

7 Facial injuries
(black eye, bruises,
bloody nose) due to
traumatic event

 

8 Head injury due to
traumatic event
(concussion)

 

 

 

 

 

 

 

 

 

 

186

CSS- 11

Think back to when the event you reported bothered you the most occurred. Please
report how you felt about the social support at that time. Please refer to support from
friends and/or family at that time.

 

Never
Rarely
Occasro
nally
Half of
the
Tune
Some of
the
Time
Most of
the
Time
Always

 

1. Someone willing to
listen

 

2. Contact with
people in a similar
situation

 

3. Able to talk about
thoughts and
feelings

 

4. Sympathy and
support from
others

 

5. Practical help

 

9‘

Feeling let down

 

 

>3

Overall
satisfaction with
support received

 

 

 

 

 

 

 

 

 

 

187

REFERENCES

 

188

 

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ill/1111’]. il‘illnlll‘ll.‘

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