The impact of social support, unit cohesion, and trait resilience on PTSD in treatment-seeking military personnel with PTSD: The role of posttraumatic cognitions

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Abstract

Background

The personal resources of social support, unit cohesion, and trait resilience have been found to be associated with posttraumatic stress disorder (PTSD) severity among military personnel. However, the underlying mechanisms of these relationships are unclear. We hypothesized that negative posttraumatic cognitions, which are associated with PTSD, mediate the relationships between these personal resources and PTSD.

Methods

The relationship between PTSD symptom severity and a latent factor comprised of social support, unit cohesion, and trait resilience was evaluated using cross-sectional data from 366 treatment-seeking active duty military personnel with PTSD following deployments to or near Iraq or Afghanistan. Structural equation modeling (SEM) was used to test whether posttraumatic cognitions mediated this relationship.

Results

The SEM model indicated that (1) a robust latent variable named personal resources (indicated by social support, unit cohesion, and trait resilience) was negatively associated with PTSD severity; (2) personal resources were negatively associated with negative posttraumatic cognitions; (3) negative posttraumatic cognitions fully mediated the association between personal resources and PTSD severity. The final SEM mediation model showed a highly satisfactory fit [χ2 (22) = 16.344, p = 0.798; χ2/df = 0.743; CFI = 1; RMSEA = 0.000].

Conclusions

These findings suggest that among active duty military personnel seeking treatment for PTSD, personal resources (social support, unit cohesion, and trait resilience) may mitigate PTSD severity by reducing negative posttraumatic cognitions.

Introduction

The prevalence of posttraumatic stress disorder (PTSD) in active duty military personnel who have deployed in support of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), is estimated to be between 5% and 17% (Gates et al., 2012, Hoge et al., 2004, Milliken et al., 2007, Richardson et al., 2010). Prior research examining predictors of PTSD have identified several psychosocial factors that are thought to mitigate PTSD severity in military personnel, including social support, unit cohesion, and resilience.

The protective effect of social support on PTSD has long been recognized (Charuvastra and Cloitre, 2008). Meta-analyses have found that greater perceived social support is strongly related to lower PTSD symptom severity among military personnel (Brewin et al., 2000, Ozer et al., 2003). A similar but distinct construct is unit cohesion, which is the sense of unity a service members feel in terms of interpersonal relationships and task orientation with other members in their unit (Oliver et al., 2000). Unit cohesion has been associated with lower PTSD severity among Marines returning from Iraq (Armistead-Jehle et al., 2011) and among Air Force medical personnel, even when controlling for trauma exposure (Dickstein et al., 2010). Similarly, trait resilience has also been associated with lower PTSD severity among soldiers returning from OEF/OIF (Pietrzak et al., 2009, Pietrzak et al., 2010). Trait resilience is a multidimensional construct which is conceptually distinct from “no-psychopathology”. It encompasses behaviors, ways of thinking, and emotional reactions that support positive adaptions to challenging and stressful situations (Agaibi and Wilson, 2005). In the context of war-related trauma, military personnel with greater trait resilience would be those who are more able to maximize internal resources (e.g., hardiness and self-esteem) and external resources (e.g., social support and unit cohesion) to mitigate the negative impact of adversities (Duan et al., 2015).

How these factors might mitigate PTSD severity is not well understood, as few prior studies have tested hypothesized mediators between single psychosocial factors and PTSD severity. One possible mediator is negative posttraumatic cognitions. Posttraumatic cognitions (e.g., Foa et al., 1999), which include negative cognitions about the self (e.g., I'm incompetent), negative cognitions about the world (e.g., the world is a dangerous place, no one can be trusted), and self-blame (e.g., the event [trauma] happened because of the sort of person I am) have been consistently related to PTSD severity (e.g. Ehlers et al., 2012, Mueser et al., 2008, Zalta et al., 2014, Zoellner et al., 2011), and reductions in posttraumatic cognitions have been associated with reductions in PTSD symptoms (Foa and Rauch, 2004, Moser et al., 2007). Moreover, there is reason to hypothesize that psychosocial factors such as social support, unit cohesion, and trait resilience would be related to lower negative posttraumatic cognitions. Specifically, several theorists have posited that high social support may reduce the risk for the development and persistence of negative posttraumatic cognitions by influencing victims' attributions about traumatic events (Ehlers and Clark, 2000, Guay et al., 2006). Indeed, two studies have tested posttraumatic cognitions as a mediator of the relationship between social support and PTSD with cross-sectional data. One study with victims of intimate partner violence and motor vehicle accidents found that support from family and friends was negatively correlated with posttraumatic cognitions, which in turn were positively associated with PTSD (Woodward et al., 2015). Similarly, research among mixed trauma survivors found that the relationship between PTSD and social constrains (negative/unsupportive social interaction) was partially mediated by posttraumatic cognitions (Belsher et al., 2012). In a longitudinal study among civilian survivors of serious motor vehicle accidents, it is found that when controlling for posttraumatic cognitions, the longitudinal relationship between social support and PTSD severity became nonsignificant (Robinaugh et al., 2011). Psychological resilience has also been theorized to decrease negative cognitions by enhancing self-efficacy and control (Bonanno, 2004). In a nonclinical sample of undergraduate students, higher trait resilience was significantly related to more positive global cognitions about the self, the world, and the future (Mak et al., 2011). Although, to our knowledge, no prior study has investigated the relationship between unit cohesion and posttraumatic cognitions, we hypothesize that unit cohesion may also be related to posttraumatic cognitions, as high-level unit cohesion may enhance confidence in unit members and thus reduce negative cognitions (e.g. self-blame).

Based on the theory (e.g., Ehlers and Clark, 2000) and previous empirical research (e.g., Dickstein et al., 2010, Foa and Rauch, 2004, Pietrzak et al., 2009, Pietrzak et al., 2010) noted above, we hypothesized that posttraumatic cognitions would mediate the relationship of social support, unit cohesion and trait resilience on PTSD. We also hypothesized that social support, unit cohesion, and trait resilience would be interrelated, and that these three factors reflect a single meta-construct, which we termed “personal resources.” This hypothesis was based on research showing that resilience and social support work in concert with one another in the context of trauma. Specifically, previous studies have found that United States Army personnel with greater resilience tend to be more skilled at developing social networks and seeking social support in times of need than those with less resilience (King et al., 1998, Sharkansky et al., 2000). Conversely, developmental research with civilians has shown that individuals living in supportive environments tend to have higher levels of resilience (National Scientific Council on the Developing Child, 2010). The hypothesis that social support, unit cohesion and trait resilience will form a latent construct recognizes that individuals are embedded in social systems (e.g., soldiers embedded in their unit), and that these systems likely support the adaptive psychological capacities of the individual.

Using cross-sectional baseline data from a large randomized clinical trial, we examined the associations between personal resources, posttraumatic cognitions, and PTSD severity among active duty military personnel seeking treatment for PTSD. As shown in Fig. 1, we hypothesized that: (1) social support, unit cohesion, and trait resilience will all be the indicators of a robust latent variable, named personal resources; (2) social support, unit cohesion, and trait resilience will be negatively associated with PTSD severity; (3) personal resources will be negatively associated with posttraumatic cognitions; (4) posttraumatic cognitions will mediate the association between personal resources and PTSD severity.

Section snippets

Procedure

This study utilized baseline data collected as part of a randomized clinical trial evaluating the efficacy of prolonged exposure (Foa et al., 2007) therapy for the treatment of PTSD in active duty military personnel. Following informed consent, eligibility was determined during a baseline evaluation consisting of a clinical interview administered by an independent evaluator and the completion of self-report measures. The institutional review boards of Brooke Army Medical Center, the University

Results

Pearson's correlations among all variables included in the model are reported in Table 2. Means and standard deviations of all variables are also presented.

Discussion

This is the first study, to our knowledge, that examined the relationship between psychosocial resources (interpersonal support, unit cohesion, and resilience) as a meta-construct called personal resources, and PTSD severity, and the first to examine posttraumatic cognitions as a mediator between these personal resources and PTSD. Consistent with our first hypothesis, the latent construct of personal resources was confirmed by the SEM model, supporting the notion that individual-level factors

Contributors

Author Yinyin Zang contributed to the writing and the conceptualization of this manuscript, as well as the statistical analysis. Authors Thea Gallagher, Carmen P. McLean, Hallie S. Tannahill, Jeffrey S. Yarvis, Edna B. Foa, and the STRONG STAR Consortium contributed to the writing and the conceptualization of this manuscript. All authors have approved the final version of this manuscript.

Role of funding source

Funding for this work was made possible by the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program awards W81XWH-08-02-109 (Alan Peterson), W81XWH-08-02-0111 (Edna B. Foa), and W81XWH-08-02-0114 (Brett Litz).

Conflict of interest

The authors do not have any financial interests or conflicts of interests to report.

Acknowledgments

The views expressed in this article are solely those of the authors and do not reflect an endorsement by the official policy of the U.S. Army, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government. The authors express their sincerest appreciation to the study participants who shared their struggles with the research team.

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