• unlimited access with print and download
    $ 37 00
  • read full document, no print or download, expires after 72 hours
    $ 4 99
More info
Unlimited access including download and printing, plus availability for reading and annotating in your in your Udini library.
  • Access to this article in your Udini library for 72 hours from purchase.
  • The article will not be available for download or print.
  • Upgrade to the full version of this document at a reduced price.
  • Your trial access payment is credited when purchasing the full version.
Buy
Continue searching

Peritraumatic appraisal and self-efficacy: Examination of an expanded Lazarus and Folkman stress appraisal model following traumatic physical injury

Dissertation
Author: Lorie R. Salinas Farmer
Abstract:
Objectives. Lazarus and Folkman's (1984) stress appraisal model, widely applied in the depression literature, was uniquely applied in an expanded peritraumatic model to predict post traumatic stress disorder (PTSD) symptoms. The presented Transactional Vulnerability Model of Psychological Distress utilizes two of the most proximal determinants of PTSD symptoms identified in the stress and coping literature, peritraumatic appraisal and self-efficacy, as variables implicitly and explicitly identified in Lazarus and Folkman's (1984) primary and secondary appraisal processes. Study design. Correlational. Participants. Participants were multiple trauma, burn and orthopedic hand injured English-speaking adults who participated in Victorson's (2003) original psychometric validation study of the Traumatic Physical Injury and Psychosocial Stress Inventory (TIPSI; N = 169). Setting. Level 1 trauma center. Measures. Selected TIPSI subscales; General Perceived Self-Efficacy Scale; Abbreviated Injury Scale; Stressful Life Experiences Screening -- Short. Results. The following variables were each significantly positively related to PTSD symptoms: prior trauma (r = .272); abuse-related prior trauma (r = .187); injury severity (r = .220); and each peritraumatic primary appraisal variable: threat potential (r = .431), controllability (r = .360), predictability (r = .238), meaningfulness (r = .397), stability of impact (r = .522) and globality of impact (r = .443). Each peritraumatic secondary appraisal variable was significantly inversely related to PTSD symptoms: general self-efficacy (r = -.501) and specific self-efficacy (r = -.272). Peritraumatic primary appraisal variables together explained 40.1% of variance in PTSD symptoms (F (2, 164) = 56.503, p < .001). The Transactional Vulnerability Model of Psychological Distress examined each aforementioned construct using mostly Victorson's (2003) measures in linear regression procedures in Model A (N = 161), explaining 45.1% variance in PTSD symptoms (F (11, 149) = 12.965, p < .001); Model B (N = 66) utilized two alternate measures and explained 52.9% variance ( F (10, 55) = 8.289, p < .001). These results support prior trauma and threat potential as predictors of PTSD symptoms and bespeak the importance of attributions of stability of impact and self-efficacy as proximal predictors of PTSD symptoms within an expanded Lazarus and Folkman stress appraisal model. Implications for early intervention among targeted individuals are discussed.

TABLE OF CONTENTS Page LIST OF FIGURES AND TABLES x Chapter 1 INTRODUCTION 1 General overview 1 Theoretical background 3 Summary 8 Research questions, rationale and hypotheses 9 2 REVIEW OF THE LITERATURE 18 Scope of literature review 18 Organization of literature review 18 Literature review 19 PTSD Background and Research: Introduction 20 Challenges to understanding PTSD 21 PTSD and Traumatic Physical Injury 25 Summary 26 PTSD Background and Research: Impact of the Event 27 Personal risk factors for PTSD 28 Prior trauma exposure and traumatic stress sequelae 29 Injury Severity 32 Neurobiological PTSD research 33 Background in psychology 34 More recent research findings 36 Applications to the current research 38 Social support in the traumatic milieu 40 Social support and stress 41 Social support and trauma-specific characteristics 42 Person—environment transactional variables 44 Cognitive attributional styles 45 Cognitive appraisal variables 47 Event severity 49 Peritraumatic processes 52 Peritraumatic dissociation 52 v

Peritraumatic behaviors and emotions 54 Peritraumatic evaluative processes 54 PTSD Background and Research: Summary 57 Review of Stress and Coping Theories: Lazarus and Folkman Stress Appraisal Model of Coping 58 Primary Appraisal 59 Non-stressful appraisals 60 Stressful appraisals 61 Secondary Appraisal 63 Personal controllability and environmental clarity 64 Coping strategies 66 Coping during trauma and recovery 67 Summary 71 Review of Stress and Coping Theories: Bandura's Self-Efficacy Theory 72 Key concepts in Bandura's Self-Efficacy Theory 73 Personal agency as proximal determinants of stress 74 Motivation 75 Incentives and performance 77 Outcome expectancies and performance 78 Forethought 80 Appraisal and self-efficacy 81 Social comparison 82 Clinical and health applications 83 Adverse clinical symptoms 83 Health consequences 85 Traumatic physical injury 88 Summary 89 Review of Stress and Coping Theories: PTSD Appraisal Theories 90 Horowitz 91 Janoff-Bulman 93 Emotional Processing Theory 95 Dual Representation Theory 98 Ehlers and Clark 100 SPAARS 104 Conservation of Resources Theory 108 Summary 109 Review of Stress and Coping Theories: Summary 115 VI

The Transactional Vulnerability Model of Psychological Distress: An expanded Lazarus and Folkman model of stress appraisal 116 Primary appraisal and trauma 119 Perceived initial threat appraisals 121 Perceived chronic threat attributions 126 Secondary appraisal and trauma 128 General self-efficacy 130 Specific self-efficacy 131 Summary 133 Summary and Conclusions 134 Statement of Purpose 139 Figure 1. Transactional Vulnerability Model of Psychological Distress 140 METHODOLOGY 141 Participants 141 Inclusion criteria 141 Exclusion criteria 141 Recruitment 142 Sample characteristics 142 Procedures and Measures 142 Screening instruments 143 Assessment battery 145 Data collection 153 Analyses 153 RESULTS 155 Demographics 155 Analysis of the results 157 Data Plan 157 Missing Data 158 Assumptions of Hierarchicai Multiple Regression 158 Table 1. Psychometric Properties of Variables in the Model 161 Table 2. Correlation Matrix for Variables in the Model 162 Reliability 163 VII

Research Question 1 164 Correlational analyses 164 Mediational analyses 165 Perceived initial threat as a mediator 166 Perceived chronic threat as a mediator 167 Conclusions 169 Research Questions 2-5 169 Model A 169 Model B 171 Table 3. Summary of Model A and Unique Contributions of Predictor Variables 173 Table 4. Summary of Model B and Unique Contributions of Predictor Variables 174 DISCUSSION 175 Review of research questions 175 Review of research findings 176 Prior trauma and injury severity 176 Primary appraisal in the expanded Lazarus and Folkman model 177 Perceived initial threat appraisal 177 Perceived chronic threat attributions 179 Secondary appraisal in the expanded Lazarus and Folkman model 180 Self-efficacy and perceived coping resources 180 The full expanded Lazarus and Folkman model 181 Implications of findings 182 Prior trauma and injury severity 183 Primary appraisal in the expanded Lazarus and Folkman model 185 Perceived initial threat appraisal 186 Perceived chronic threat attributions 189 Secondary appraisal in the expanded Lazarus and Folkman model 192 Self-efficacy and perceived coping resources 192 The full expanded Lazarus and Folkman model 196 Methodological issues 200 VIII

Summary 202 Recommendations for future research 210 REFERENCES 217 APPENDICES Appendix A: Definition of key terms 237 Appendix B: Informed consent form 244 IX

LIST OF FIGURES AND TABLES Page Figure 1. Transactional Vulnerability Model of Psychological Distress 140 Table 1. Psychometric Properties of Variables in the Model 161 Table 2. Correlation Matrix for Variables in the Model 162 Table 3. Summary of Model A and Unique Contributions of Predictor Variables 173 Table 4. Summary of Model B and Unique Contributions of Predictor Variables 174 x

CHAPTER I Introduction General overview The majority of Americans (60%) experience at least one traumatic event in their lifetimes (Friedman, 2007), and an estimated 20-30% of these individuals develop Post Traumatic Stress Disorder (PTSD) (Foa, Hembree, & Rothbaum, 2007; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Ozer& Weiss, 2004). Post-traumatic stress disorder is a psychophysiological response to a traumatic event in which an individual witnesses or personally experiences a violation of personal integrity and responds with an extremely helpless or fearful reaction (Criterion A); demonstrates at least one re-experiencing symptom (Criterion B); at least three symptoms of avoidance or numbing of general responsiveness (Criterion C); and at least two symptoms of increased arousal (Criterion D), with slightly unique presentations among children and for which individuals experience marked discomfort or distress in everyday functioning (Criterion F), lasting at least one month after the event (Criterion E; American Psychiatric Association (APA), 2000). PTSD pathology may be acute (less than 3 months duration), chronic (at least 3 months duration) or with delayed onset (symptoms initially present at least 6 months following the traumatic event; APA, 2000). Some 50% of those diagnosed with PTSD may go on to develop chronic posttraumatic pathology (Green, 1994; Power & Dalgleish, 1997). The acute response to a traumatic event occurs in the first month following exposure to trauma, during which an Acute Stress Disorder (ASD) diagnosis may be given. 1

2 Other common posttraumatic sequelae include adjustment disorders, depression, anxiety, pain, dissociative disorders, somatoform responses, substance abuse, psychosis, or more complicated changes to one's personality or physical health (Briere & Scott, 2006; Dalgleish, 2004; DeGood & Kiernan, 1996; Geisser, Roth, Backman, & Eckert, 1996; Kilpatrick, Ruggiero, Acierno, Saunders, Resnick, & Best, 2003). A number of traumatic events may lead to PTSD. Some of these events include domestic violence; domestic fires; assault; sexual assault and rape; mass interpersonal violence; mass transportation accidents; combat exposure; emergency worker exposure; natural disasters; political imprisonment; torture; or traumatic physical injury (Briere & Scott, 2006). Traumatic physical injury contributes to more cases of PTSD than many other types of events in the general community (Foa & Meadows, 1997; O'Donnell, Creamer, Elliott, & Atkin, 2005; Taylor & Koch, 1995). Traumatic physical injury is physical injury resulting from an accident, assault, or acts of nature and is distinguished from organic disease processes (Victorson, 2003). Those who develop PTSD symptoms following trauma have more prevalent health problems, a greater utilization of healthcare, and greater healthcare service costs than those without PTSD (Foa, Hembree, & Rothbaum, 2007; O'Donnell, et al., 2005; Schnurr & Green, 2004), which makes the identification of risk factors for early detection and treatment of PTSD an important research area. Several variables have been identified as risk factors increasing one's likelihood of developing PTSD symptoms following trauma. In a recent meta-

analytic study, Brewin, Andrews and Valentine (2000) identified individual or family psychiatric history, childhood abuse and social support as most consistently predictive of PTSD symptoms across research studies. Other risk factors previously identified include prior traumatic exposure; perceived lack of control or blame for the cause of the event; trauma or injury severity; level of initial threat; current life stress; education or intelligence; lack of social support, and maladaptive coping styles; among others (Brewin, et al., 2000; Ozer, Best, Lipsey, & Weiss, 2003; Victorson, Farmer, Burnett, Ouellette, & Barocas, 2005). Although previous research has shown many variables are important in predicting PTSD symptoms, many researchers are finding that the current understanding of post traumatic stress is limited in its research focus and clinical utility (Dalgleish, 2004; Power & Dalgleish, 1997; van der Kolk, Roth, Pelcovitz, Sunday & Spinazzola, 2005). By further investigation of the relationships of post traumatic stress and concurrent sequelae (e.g. peritraumatic cognitive appraisal processes), the treatment of traumatized individuals potentially can be made more efficient and effective (Dalgleish, 2004; van der Kolk, et al., 2005). Theoretical background Cognitive appraisal theorists propose that certain belief systems place individuals at risk for developing and/or maintaining PTSD symptoms. Some of the most prototypal and useful theories of PTSD (e.g., Horowitz, 1976; Janoff- Bulman, 1985, 1989; Foa & Kozak, 1985, 1986; Dual Representation Theory, Brewin, Dalgleish & Joseph, 1996; the SPAARS model, Powers & Dalgleish, 1997; and Ehlers & Clark, 2000) are cognitive appraisal models that describe

4 how traumatic events disrupt pre-traumatic belief systems and may create strong associative memories (Dalgleish, 2004; Ehlers & Clark, 2000; Powers & Dalgleish, 1997). For example, Horowitz' (1976) "completion tendency" refers to the individual's psychological need to integrate their traumatic experiences into existing belief representations (Powers & Dalgleish, 1997; Resick, 2001). Other theories of PTSD suggest that symptoms are maintained by continued threat appraisal long after the initial traumatic event has gone (e.g., Ehlers & Clark, 2000; Foa & Kozak, 1986). For example, Ehlers and Clark (2000) present a model in which individuals continue to perceive "current threat" following traumatic events, and as a result maintain post traumatic stress symptoms. Each of these theories of PTSD addresses how pre-traumatic belief systems are strained, overwhelmed, or even "shattered" (e.g., Janoff-Bulman, 1985, 1989) by traumatic events. As such, each of these theories addresses pre-traumatic and/or post-traumatic beliefs that hold temporal distance relative to the beliefs occurring during the peritraumatic period. While most of the variables in prior research (e.g., person and social variables) help explain distal associations with PTSD, recent meta-analytic studies recommend the investigation of more proximal links, "such as the association between pretrauma risk factors and immediate trauma responses" (Brewin et al., 2000, p. 756; See also Dalgleish, 2004; and Ozer et al., 2003) in predicting individual post traumatic stress reactions. Two mechanisms of proximal links to this investigation are: 1.) peritraumatic evaluative processes; and 2) self-efficacy. Peritraumatic evaluative processes refer to the appraisals that

5 occur during the immediate response to a traumatic event (Dalgleish, 2004). Ozer et al. (2003) in their meta-analytic review state that "peritraumatic psychological processes, not prior characteristics, are the strongest predictors of PTSD" (p. 52). Self-efficacy refers to one's perceived ability to meet life's challenges successfully and is arguably the most "central and pervasive" of personal agency mechanisms (Bandura, 1993, p. 118). Bandura (1993) states that self processes "give meaning and valence to external events ... [and thereby] operate as important proximal determinants at the very heart of causal processes" (p. 118). Beliefs about self-efficacy (i.e., self-enhancement or self- debilitating statements) are associated with coping (e.g., motivation and perseverance) and post traumatic stress symptomatology in previous research (e.g., Benight, Ironson, Klebe, Carver, Wynings, Burnett, Greenwood, Baum & Schneiderman, 1999; Benight & Bandura, 2004; Malluche, Burnett, Victorson, Farmer, Burns, Del Pilar, Haynes, & Ouellette, 2006). Both peritraumatic evaluative processes and self-efficacy can be investigated in an expanded application of variables implicitly and explicitly described in Lazarus and Folkman's (1984) stress appraisal model of coping. Lazarus and Folkman's (1984) stress appraisal model of coping, widely applied in the depression literature and underrepresented in traumatic stress studies (Lazarus, 1999) provides a framework in which to investigate two of the most proximal links to traumatic stress reactions identified in the trauma literature: peritraumatic evaluation of threat and secondary appraisal of coping self-efficacy, in the proposed Transactional Vulnerability Model of Psychological

6 Distress. Lazarus (1999) states, "My writings are not well represented in the PTSD literature, perhaps because the earlier book (Lazarus & Folkman, 1984) made no mention of the syndrome" (p. 161). While research has investigated secondary appraisal coping strategies employed following traumatic events, no research has tested Lazarus and Folkman's (1984) full stress appraisal model of coping to include the evaluation of threat in primary appraisal despite its obvious association with trauma. Peritraumatic evaluation of threat implicitly assesses both current and anticipated impact of the threatening event (Farmer et al., 2005). Evaluation of one's capacity to cope involves self-efficacy mechanisms (Lazarus and Folkman, 1984); however, the influence of general- and specific self-efficacy beliefs regarding one's abilities to cope with traumatic stressors has not been studied as a secondary appraisal process within the Lazarus and Folkman model. The investigation of peritraumatic threat appraisal and acute coping ability would move the traumatic stress field in recommended directions and improve the identification and treatment of individuals within the acute post traumatic period (Dalgliesh, 2004; Farmer, Victorson, Burnett, Ouellette, Barocas, Enders, & Fals, 2005; Ozer et al., 2003). The proposed Transactional Vulnerability Model of Psychological Distress represents an expanded application of Lazarus and Folkman's (1984) stress appraisal model of coping. The proposed research is transactional because it is based on the Lazarus and Folkman (1984) stress appraisal model of coping which is a transactional model, and it expands upon their theory by investigating more complex and complete stress appraisal processes with constructs explicitly

7 and implicitly identified in their model. Evaluative processes, and not independent event or person-specific characteristics, determine the reasons and extent to which transactions between the person and environment are perceived as stressful (See also, Lazarus, 1998, p. 395; Lazarus and Folkman, 1984; 1987, p. 142). The current research is a transactional vulnerability model because it qualifies the level of engagement individuals have with traumatic environments and the subjective impact of the event on their coping abilities and success. Lazarus and Folkman (1984) state that the depth and strength of individuals' relevant commitments, beliefs, ideals or goals influence their psychological vulnerability to events (p. 51); the greater the depth and strength of relevant goals, for example, the more vulnerable they are to the encounter. Bandura (1986a) states that self-inefficacy is one's "perceived vulnerability to total loss of personal control", one's perceived incapacity to engage in self-efficacious behavior and cope effectively (p. 1390). In addition, Resick (2001) describes how traumatic events invalidate individuals' beliefs in personal invulnerability (See also, Janoff-Bulman, 1985, 1992). Thus, self-efficacy motivational processes within secondary appraisal are interrupted when person—environment encounters threaten their perceived capabilities. The Transactional Vulnerability Model of Psychological Distress will examine primary threat appraisal and secondary evaluation of coping resources by investigating whether and how primary appraisal of the degree of stress from one's injury (i.e., perceived initial and perceived chronic threat) and the secondary appraisal of perceived coping self-efficacy (e.g., general self-efficacy, specific self-efficacy) are related to PTSD

8 symptomatology in a sample of adults during the acute recovery period following traumatic physical injury. Summary Many people experience at least one traumatic event in their lifetimes (Friedman, 2007). The identification of risk factors for PTSD has been an important research area due to the incidence and severity of the disorder and its associations with other debilitating clinical conditions, great economic and healthcare costs (Brewin, et al., 2000; Briere & Scott, 2006; Dalgleish, 2004; DeGood & Kiernan, 1996; Foa & Meadows, 1997; Foa, Hembree & Rothbaum, 2007; Friedman, 2007; Geisser, et al., 1996; Green, 1994; Kessler, et al., 1995; Kilpatrick, et al., 2003; O'Donnell, et al., 2005; Ozer & Weiss, 2004; Schnurr & Green, 2004; Taylor & Koch, 1995). Recent meta-analytic studies state that proximal links such as peritraumatic psychological processes are the strongest predictors of PTSD yet have been understudied in previous trauma research (Brewin et al., 2000; Dalgleish, 2004; Ozer et al., 2003). Lazarus and Folkman's (1984) stress appraisal model of coping, widely studied in the depression literature, will be uniquely applied as a framework in which to examine a more complex and complete role of primary appraisal of threat and the evaluation of coping resources following trauma. The proposed Transactional Vulnerability Model of Psychological Distress will investigate how peritraumatic appraisal processes and coping self-efficacy may be related to PTSD symptomatology during the acute recovery period following traumatic physical injury.

9 Research questions, rationale and hypotheses Background While many types of traumatic events are associated with PTSD symptom development, traumatic physical injury contributes to more cases of PTSD in the general community (Foa & Meadows, 1997; Taylor & Koch, 1995; O'Donnell, et al., 2005). As those who develop PTSD symptoms following trauma have more prevalent health problems, a greater utilization of healthcare, and greater health service costs than those without PTSD (Foa, et al., 2007; Green, Epstein, Krupnick, & Rowland, 1997; O'Donnell, et al., 2005; Schnurr & Green, 2004), the identification of risk factors for early detection and treatment of PTSD is an important research area. In recent meta-analytic studies, Dalgleish (2004) recommends that future research should investigate more proximal elements to the initial encoding of the trauma, such as peritraumatic attributions about the event. Lazarus and Folkman's (1984) stress appraisal model of coping involves two key cognitive appraisal processes: a) primary appraisal of stressful events as harmful, threatening or challenging; and b) secondary appraisal of one's resources to cope with a stressful encounter. Therefore, stress results when events are appraised as characterizing harm/ loss, threat or challenge, and when individuals appraise that they will unsuccessfully cope given their resources. The Lazarus and Folkman (1984) stress appraisal model, traditionally used as a modei for coping with stress in the depression literature and underrepresented in traumatic stress studies (Lazarus, 1999), implicitly and explicitly identifies

10 variables associated with traumatic stress reactions: peritraumatic evaluative processes and coping self-efficacy. Bandura's (1977a) self-efficacy construct is explicitly identified by Lazarus and Folkman (1984) as an instrumental component of individuals' evaluations of their perceived abilities to cope. Peritraumatic processes and self-efficacy represent two of the most proximal links to the investigation of traumatic stress reactions; investigation of these variables follow the recommendations of Brewin et al. (2000), Dalgleish (2004) and Ozer et al. (2003) to examine more proximal links to traumatic stress reactions and make the early identification and treatment of traumatized individuals more efficient and effective. The Lazarus and Folkman (1984) stress appraisal model will be used as a framework in which to examine a more complex and complete process of coping with stress following trauma. Primary appraisal of perceived initial and perceived chronic threat and secondary appraisal of genera! and specific coping self-efficacy will be examined as constructs within the proposed Transactional Vulnerability Model of Psychological Distress to predict PTSD symptoms during the acute recovery period following traumatic physical injury. Research question 1 What is the relationship between PTSD symptoms and each of the variables explicitly and implicitly described in Lazarus and Folkman's stress appraisal model? Rationale. Research has supported the significant relationships of PTSD symptoms with prior trauma history (Briere & Scott, 2006; Fillingim, Wilkinson, &

11 Powell, 1999; Joseph, Yule, Williams & Hodgkinson, 1994; McCann, Sakheim & Abrahamson, 1988; van der Kolk, et al., 2005; Ozer, et al., 2003) and injury severity (Baker, O'Neill, Haddon & Long, 1974; Blanchard, Hickling, Mitnick, Taylor, Loos, & Buckley, 1995; Briere & Elliott, 2000; Briere & Scott, 2006; Copes, Sacco, Champion & Bain, 1990; Foy, Resnick, Sipprelle, & Caroll, 1987; Ulmer, 1997; Vaiva, Brunet, Lebigot, Boss, Ducrocq, Devos, Laffargue, & Goudemand, 2003). Perceived threat potential of an event has predicted PTSD symptoms (e.g., Fairbank, Hansen, & Fitterling, 1991) and should be examined for relative to other peritraumatic perceptions of initial threat evaluation (e.g., predictability, controllability, meaningfulness) and perceived chronic threat (i.e., globality and stability). While specific coping self-efficacy may be more predictive of one's outcomes than general self-efficacy in a given scenario, effective coping requires accurate appraisal of stressful events. As traumatic events may overwhelm one's appraisal of the event (i.e., during primary appraisal processes), individuals may determine they have less resources to internalize realistic objectives and goals necessary for coping effectively during trauma recovery (i.e., specific coping self-efficacy during secondary appraisal). Thus, while both general and specific self-efficacy may be related to PTSD symptoms, specific self-efficacy should be more predictive of coping during trauma recovery. Hypotheses: a. Each construct specified in the Transactional Vulnerability Model of Psychological Distress will be significantly associated with PTSD symptoms.

12 i. Prior trauma and injury severity will be significantly positively related to PTSD symptoms, ii. Perceived initial threat will be significantly positively related to PTSD symptoms. 1. Peritraumatic threat potential (i.e., a dimension of initial threat) will be significantly positively related to PTSD symptoms. 2. Peritraumatic predictability (i.e., a dimension of initial threat) will be significantly inversely related to PTSD symptoms. 3. Peritraumatic controllability (i.e., a dimension of initial threat) will be significantly inversely related to PTSD symptoms. 4. Peritraumatic meaningfulness (i.e., a dimension of initial threat) will be significantly positively related to PTSD symptoms. iii. Perceived chronic threat will be significantly positively related to PTSD symptoms. 1. Perceived stability of primary anticipatory stress appraisal (i.e., a dimension of perceived chronic threat) will be significantly positively related to PTSD symptoms.

13 2. Perceived globality of anticipatory stress appraisal (i.e., a dimension of perceived chronic threat) will be significantly positively related to PTSD symptoms. Perceived initial threat appraisal and perceived chronic threat attribution together predict PTSD symptoms. Perceived initial threat will mediate the relationship between perceived chronic threat and PTSD symptoms after controlling for prior trauma and injury severity, a. No predictions will be made for the relative contributions of peritraumatic threat potential, predictability, controllability or meaningfulness dimensions. Perceived chronic threat will mediate the relationship between perceived initial threat and PTSD symptoms after controlling for prior trauma and injury severity, a. No predictions will be made for the relative contributions of stability or globality dimensions. Perceived self-efficacy will be significantly inversely correlated with PTSD symptoms. 1. General coping self efficacy will be significantly inversely correlated with PTSD symptoms.

14 2. Specific coping self efficacy will be significantly inversely correlated with PTSD symptoms. 3. Specific coping self efficacy will contribute significantly more to the prediction of PTSD symptomatology than general coping self efficacy. Research question 2 How much unique variance in post traumatic stress symptomatology is explained by perceived initial threat appraisal variables after removing the variance of previously identified historical factors (i.e., prior trauma history, injury severity)? Rationale. Injury severity has been an historical predictor of PTSD symptoms (e.g., Maes, Mylle, Delmeire, & Altramura, 2000). By removing the effects of injury severity from the analysis, the proposed Transactional Vulnerability Model of Psychological Distress distinguishes between injury severity and the subjective impact of injury (i.e., event severity). Prior trauma history has also been associated with PTSD symptoms. For these reasons, injury severity and prior trauma history will be evaluated regarding their explanatory value of PTSD symptoms and controlled for in subsequent analyses of the relative contributions of perceived initial threat appraisal and perceived chronic threat attributions, and of general and specific coping self-efficacy in predicting PTSD symptoms.

15 Hypothesis: In a two-step hierarchical linear regression model, perceived initial threat appraisal (step 2) will add significant unique variance after controlling for prior trauma history and injury severity at step 1. Research question 3 How much unique variance in post traumatic stress symptomatology is explained by perceived chronic threat attribution after removing the variance of previously identified historical factors (i.e., prior trauma history, injury severity) and perceived initial threat appraisal? Rationale. Events can impact individuals' senses of vulnerability to actual or threatened harm or loss, such as physical impairment following traumatic physical injury or adverse clinical symptomatology. Anticipatory stress causes negative clinical symptoms (Folkman and Lazarus, 1985), and chronic stressors affect adjustment and coping. Immediately following a traumatic event, the perception of anticipatory stress (defined as stable and global impact of the event on one's life) may create perceived chronic threat reactions similar to the processes observed in anticipatory coping literature when individuals have not yet experienced a stressor but do expect one (e.g., Folkman & Lazarus, 1985). Prior research supports this rationale, suggesting that the perceived impact of one's injury on one's life predicts PTSD symptoms (Farmer, et al., 2005). Hypothesis: In a three-step hierarchical linear regression model, perceived chronic threat attribution (step 3) will add significant unique variance after controlling for historical factors (i.e., prior trauma history, injury severity) at step 1 and perceived initial threat at step 2.

Full document contains 260 pages
Abstract: Objectives. Lazarus and Folkman's (1984) stress appraisal model, widely applied in the depression literature, was uniquely applied in an expanded peritraumatic model to predict post traumatic stress disorder (PTSD) symptoms. The presented Transactional Vulnerability Model of Psychological Distress utilizes two of the most proximal determinants of PTSD symptoms identified in the stress and coping literature, peritraumatic appraisal and self-efficacy, as variables implicitly and explicitly identified in Lazarus and Folkman's (1984) primary and secondary appraisal processes. Study design. Correlational. Participants. Participants were multiple trauma, burn and orthopedic hand injured English-speaking adults who participated in Victorson's (2003) original psychometric validation study of the Traumatic Physical Injury and Psychosocial Stress Inventory (TIPSI; N = 169). Setting. Level 1 trauma center. Measures. Selected TIPSI subscales; General Perceived Self-Efficacy Scale; Abbreviated Injury Scale; Stressful Life Experiences Screening -- Short. Results. The following variables were each significantly positively related to PTSD symptoms: prior trauma (r = .272); abuse-related prior trauma (r = .187); injury severity (r = .220); and each peritraumatic primary appraisal variable: threat potential (r = .431), controllability (r = .360), predictability (r = .238), meaningfulness (r = .397), stability of impact (r = .522) and globality of impact (r = .443). Each peritraumatic secondary appraisal variable was significantly inversely related to PTSD symptoms: general self-efficacy (r = -.501) and specific self-efficacy (r = -.272). Peritraumatic primary appraisal variables together explained 40.1% of variance in PTSD symptoms (F (2, 164) = 56.503, p < .001). The Transactional Vulnerability Model of Psychological Distress examined each aforementioned construct using mostly Victorson's (2003) measures in linear regression procedures in Model A (N = 161), explaining 45.1% variance in PTSD symptoms (F (11, 149) = 12.965, p < .001); Model B (N = 66) utilized two alternate measures and explained 52.9% variance ( F (10, 55) = 8.289, p < .001). These results support prior trauma and threat potential as predictors of PTSD symptoms and bespeak the importance of attributions of stability of impact and self-efficacy as proximal predictors of PTSD symptoms within an expanded Lazarus and Folkman stress appraisal model. Implications for early intervention among targeted individuals are discussed.