Research paperThe relationship between rumination, posttraumatic stress disorder, and posttraumatic growth among Chinese adolescents after earthquake: A longitudinal study
Introduction
It has been suggested that posttraumatic stress disorder (PTSD) is the most common negative outcome after traumatic events (Bal, 2008, Campbell et al., 2007, Wang et al., 2012). Nevertheless, some positive outcomes, such as posttraumatic growth (PTG), have also been reported (Jin et al., 2014, Ying et al., 2014). PTG refers to positive changes, such as the feeling of strength and wisdom, placing increased value on friends and family, and finding a fresh appreciation for each new day, which results from experiencing a traumatic event (Tedeschi and Calhoun, 1995, Tedeschi and Calhoun, 1996). More importantly, PTG and PTSD can coexist in individuals following traumatic experiences (Tedeschi and Calhoun, 1996, Zhou et al., 2015a), and thus, an important issue is to examine whether PTSD and PTG share influencing factors. Previous studies suggested that rumination may play an important role in the developmental process of PTSD and PTG (Calhoun and Tedeschi, 2006, Janoff-Bulman, 2006), and found different ruminations may have different effects on PTSD and PTG (Wu et al., 2015, Zhou et al., 2015b), but these studies are cross-sectional design and have a critical limitations on making the conclusion about casual relation. Therefore, the aim of this study was to extend previous study from a longitudinal perspective, and further examine the effects of different ruminations on PTSD and PTG in a long-time frame after Ya'an earthquake which occurred in Sichuan province of China on April 20th 2013.
Traumatic event can challenge people's stable cognitive system involving understanding the world by according to the model of PTG from Calhoun and Tedeschi (2006). They suggested that, in this model, to reconstruct the understanding on the world after trauma, people may reexamine their personal belief systems and think repetitively on the traumatic event. The repetitive thoughts on causes and consequences of negative events or mood are called “rumination”, which may include two forms as intrusive and deliberate rumination. The former involves a negative focus on trauma-related clues or negative mood, whereas the latter involves a deliberate reexamination of and contemplation about the trauma.
Furthermore, there is a positive relationship between intrusive rumination and deliberate rumination. Calhoun and Tedeschi (2006) PTG model suggested that intrusive rumination can provide traumatic survivors with traumatic clues and opportunities for further deliberate rumination. In addition, intrusive rumination may also elicit psychological stress (Nolen-Hoeksema et al., 2008), which in turn creates enough cognitive dissonance for positive recurrent thought on traumatic clues. Therefore, intrusive rumination is supposed to be an impetus for deliberate rumination.
While there is a positive relationship between intrusive rumination and deliberate rumination, it is worthwhile to note that intrusive and deliberate rumination are two different functional forms, which may play different roles in posttraumatic psychological reactions (Zhou et al., 2015b). From the shattered world assumption (Janoff-Bulman, 2010), before traumatic event, people have stable basic perceptions of personal worth, trust in others, and justice or predictability in the world. Nevertheless, traumatic event will severely challenge these stable perceptions and lead to a cognitive discrepancy of survivors before and after the trauma, which can further elicit their intrusive rumination on traumatic events. Engaging in intrusive rumination, people always focuses on the negative effects of the traumatic event and negative emotion (Janoff-Bulman, 2010), which is more likely to be related to various types of posttraumatic distress (Affleck and Tennen, 1996, Dunn et al., 2011). In addition, by engaging in intrusive rumination, people are also exposed to traumatic cues, thereby encouraging further cognitive processing of traumatic events, which results in PTG (Park and Fenster, 2004, Taku et al., 2009, Yanez et al., 2011). Thus, it is likely that intrusive rumination can be considered to play a “two-sided” role in posttraumatic psychological reactions, and may be a predictor of PTSD and PTG.
Engaging in deliberate rumination, based on Calhoun and Tedeschi (2006) PTG model, people may pay attention to the positive aspects of the world, the self and others after highly stressful events, which is more likely to be related to eventual PTG (Affleck and Tennen, 1996, Cann et al., 2010, Dunn et al., 2011, Taku et al., 2008). Likewise, deliberate rumination on traumatic events also can change pathological thinking styles and reduce trauma-related fear, which in turn ameliorates PTSD symptoms (Ehlers and Steil, 1995, Paunovic and Öst, 2001). Thus, deliberate rumination has been proposed as a protective factor against PTSD and a predictive factor for PTG.
For most people, intrusive ruminations tends to occur soon after the traumatic event (Lindstrom et al., 2013), may persist for a long time (Taku et al., 2008). Wu et al. (2015) also found that intrusive rumination soon after Wenchuan earthquake have a positive effect on continued intrusive rumination, and it also results in deliberate rumination. It is likely that baseline intrusive rumination can predict latter intrusive and deliberate rumination, and in turn results in posttraumatic psychological reactions. However, because of the limitations of cross-sectional design, previous studies do not indicate causality or a temporal sequence. Furthermore, previous studies found that the predictors for PTSD and PTG are different, then it can be concluded that the pathways to PTSD and PTG are different (Wu et al., 2015, Zhou et al., 2015b). Although this conclusion may be helpful for us to understand the difference on predictors for PTSD and PTG, it is difficultly to find the difference on the developmental process of PTSD and PTG because there lack of longitudinal and developmental perspective.
Given this background, the present study examines the role of intrusive and deliberate rumination in the developmental process of PTSD and PTG from a longitudinal perspective. And, based on the shattered world assumption (Janoff-Bulman, 2006) and the PTG model (Calhoun and Tedeschi, 2006), we will address the following hypotheses: deliberate rumination would mediate the relationships of intrusive rumination to both PTSD and PTG; and this mediating effect of deliberate rumination would be stable with time change.
Section snippets
Participants and procedures
According to our study aim, after the Ya'an earthquake, we firstly focused on Lushan county in Sichuan province, which was most affected by the Ya'an earthquake. Then we informed some schools of our study aims and ways of investigation, and that we could provide some psychological services if they needed. With the approval of several primary and secondary schools, we randomly selected several classes, in which all the students attended school at the date of measurement were recruited to the
Descriptive statistics and correlations between measures
For illustrative purposes, we report the prevalence rate for PTSD in the present sample. Participants with CPSS scores above 11 were identified as having PTSD (Foa et al., 2001). According to this criterion, the prevalence rate of PTSD in this study was 60.7%. In addition, in order to describe the study sample, the means and standard deviations with full-information maximum likelihood estimates for all measures are presented Table 1. We found that age had no significant relationship to other
Discussion
To our knowledge, this is the first study to date to examine the effect of intrusive and deliberate rumination on PTSD and PTG from a longitudinal perspective, and the results showed that intrusive rumination at T1 had a significant positive effect on PTSD, which is consistent with the shattered world assumption (Janoff-Bulman, 2006) and findings in previous studies (Egan et al., 2014, Ehlers et al., 1998). Ehlers et al. (1998) suggested that intrusive rumination may impede changes in negative
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