The relationship between trauma centrality, self-efficacy, posttraumatic stress and psychiatric co-morbidity among Syrian refugees: Is gender a moderator?

Abstract

This study examined the inter-relationship between trauma centrality, self-efficacy, posttraumatic stress disorder (PTSD) and psychiatric co-morbidity among a group of Syrian refugees living in Turkey, and whether gender would moderate the mediational effect of self-efficacy on the impact of trauma centrality on distress. Seven hundred and ninety-two Syrian refugees completed the Harvard Trauma Questionnaire, General Health Questionnaire-28, Centrality of Event Scale and Generalized Self-Efficacy Scale. The results showed that 52% met the cutoff for PTSD. Trauma centrality was positively correlated with PTSD, psychiatric co-morbidity and self-efficacy. Self-efficacy was negatively correlated with PTSD only. Gender did not moderate the mediational effect of self-efficacy on the path between trauma centrality and distress outcomes. To conclude, following exposure to traumatic events, more than half reported PTSD. Perception of the future and identity construction was affected. Signs of psychological distress were evident, alongside resilience, regardless of gender.

Introduction

This study examined the psychological effects of the Syrian war, a global crisis which has created over 4 million refugees and left 8 million internally displaced (Jefee-Bahloul et al., 2015, Khalil, 2013, Nassan et al., 2015, Refugees, 2015). A prevalence rate of 33.5% has been estimated for posttraumatic stress disorder (PTSD) (Alpak et al., 2015), but risk factors associated with PTSD and psychiatric co-morbidity have been neglected in research despite being an important key for medical professionals and policy makers from international humanitarian organizations when providing psychological intervention.

Trauma centrality and self-efficacy are potential risk factors affecting PTSD. According to the trauma centrality hypothesis (Berntsen and Rubin, 2006a), vivid personal memories validate thoughts and behaviour and act as personal reference points from which meaning is attributed to existing beliefs, feelings, experiences and future expectations. Memories of traumatic events are particularly accessible, forming personal reference points (Berntsen, 2001, Porter and Birt, 2001, Reviere and Bakeman, 2001, Rubin et al., 2004). The continual media coverage of the ongoing war and their refugee status were constant reminders for these refugees of their war experience, keeping traumatic memories vivid and stimulating reference points. Highly accessible trauma memories lead to overestimation of the frequency of traumatic events, a likelihood of re-traumatization and thereby unnecessary hypervigilance and avoidance behaviour. The link between memories and traumatization echoes further the dual representation model arguing that psychological and physiological states can be affected through accessing trauma material in different memory systems (Brewin et al., 1996).

Traumatic memories consist of highly stressful episodes which can shatter world assumptions (Janoff-Bulman, 1992) leading to oversimplification of life situation, i.e. different aspects of life explained in terms of traumatic experiences and contradictory experiences dismissed (Berntsen and Rubin, 2006a, Linde, 1993, Robinson, 1996). Consequently, outlook on life changes, life course is redirected and turning points become a causal agent in one's life story (Pillemer, 1998, Pillemer, 2003).

Life stories define who we are and how we understand ourselves (Fitzgerald, 1988). When traumatic memories become turning points, they affect self-definition and become central components of personal identity and an integral feature of their sense of self, leading to a traumatized self across situations (Berntsen and Rubin, 2006a). This traumatized self is characterized by profound changes and reconfigurations of the inner world (psychological processes, sense of well-being, beliefs and values) (Wilson, 2006). Trauma centrality is interwoven with a traumatized self and, hardly surprisingly, associated with elevated PTSD and psychiatric co-morbidity (Bernard et al., 2015, Berntsen and Rubin, 2006b, Boals and Schuettler, 2011, Brown et al., 2010, Lancaster et al., 2011, Ogle et al., 2014, Ogle et al., 2016, Schuettler and Boals, 2011).

Trauma centrality affects self-efficacy. The theory of posttraumatic self suggests that trauma changes the self-structure by reducing the self-regulatory, goal-directing capacity (Wilson, 2006) leading to a feeling of powerlessness (Brewin, 2003) and to social cognitive theory's diminished “agentic” model of adaptation (Bandura, 1997, Benight and Bandura, 2004b). The capacity to adapt to distressing events is reduced, influencing PTSD severity and recovery. In short, trauma reduces self-efficacy (Bandura, 1997, Benight and Bandura, 2004a, Brown et al., 2015, Brown et al., 2016, Brown and Ryan, 2004, Wehmeyer et al., 2009), elevating PTSD and psychiatric co-morbidity. This inverse relationship between trauma and self-efficacy has been demonstrated in literature among victims of different kinds e.g. (Benight et al., 2008, Benight and Harper, 2002, Flatten et al., 2008, Hirschel and Schulenberg, 2009, Hoelterhoff and Chung, 2013, Hyre et al., 2008, Weisenberg et al., 1991).

Self-efficacy, then, acts as a mediator. To social cognitive theorists, this mediational effect is expected since people do not react merely to the effect of the trauma but to continuing adaptational strains caused by the trauma (Benight and Bandura, 2004a). This mediational effect has been supported in literature e.g. (Benight and Bandura, 2004a, Bosmans et al., 2013, Cieslak et al., 2008, Lambert et al., 2013, Luszczynska et al., 2009a, Samuelson et al., 2016, Smith et al., 2015).

This mediating effect of self-efficacy is linked to gender. Women are more likely to construct a negative event as central to their identity with ensuing mental health issues (Boals, 2010). Women coping with trauma reported lower levels of self-efficacy (Solomon et al., 2005). The same finding was established among Chinese adolescents in dealing with stressful life events (MA and Xu, 2006). Women have been found to exhibit reduced resilience, a facet of self-efficacy, as trauma centrality increases (Wolfe and Ray, 2015). In other words, gender can moderate mediational effects.

The theoretical framework amounts to the hypothesized model depicted in Fig. 1 for the current investigation. We hypothesized that 1) a higher level of trauma centrality would be associated with higher levels of PTSD and psychiatric co-morbidity, and 2) a higher level of self-efficacy would be associated with lower levels of distress outcomes, and 3) gender would moderate the mediational effects of self-efficacy on the path between trauma centrality and distress outcomes. To the best of our knowledge, no studies have investigated this model among Syrian refugees.