Research paperA psychometric evaluation of the Posttraumatic Cognitions Inventory with Veterans seeking treatment following military trauma exposure
Introduction
Theory and extant research have identified clinically meaningful connections between negative posttraumatic cognitions and PTSD symptoms. Cognitive models of PTSD suggest that preexisting negative beliefs about the self and others facilitate the development of PTSD by both expediting fear conditioning and maintaining the perceptions of continuing threat and inability to cope (Ehlers and Clark, 2000, Foa and Rothbaum, 1998). Additional cognitive vulnerability models postulate that the distress experienced by individuals with PTSD yields a sense of vulnerability which fosters development of negative beliefs (Shahar et al., 2013). Empirical research has supported a connection between posttraumatic cognitions and the persistence and severity of PTSD symptom. More specifically, studies find that reductions in negative beliefs are associated with decreased PTSD symptoms (Zalta et al., 2014), and that chronic PTSD symptoms are associated with worsening negative cognitions (Dekel et al., 2013). Further, Shahar et al. (2013) identified a cyclical pattern between PTSD symptoms and negative cognitions. Clinical research also suggests that the best validated interventions for PTSD (e.g., Prolonged Exposure, Cognitive Processing Therapy) result in decreased PTSD symptoms and negative cognitions (Foa and Rauch, 2004, Iverson et al., 2015) and change in thoughts appears to drive symptom change (Kumpula et al., 2016, Schumm et al., 2015). The significance of negative trauma-specific cognitions as mediators of posttraumatic functioning seems clear. As such, it is critical that assessment instruments designed to gauge such cognitions are psychometrically robust.
To this end, Foa and colleagues designed the Posttraumatic Cognitions Inventory (PTCI), a 36-item self-report questionnaire, to assess for and characterize the nature of posttraumatic cognitions (Foa et al., 1999). This widely used measure has the potential to be a standard assessment of this critical construct. Utilizing negative beliefs derived from clinical and theoretical foundations, the authors rigorously evaluated the psychometric properties of the scale with individuals without trauma histories, those with histories of trauma but not experiencing PTSD, and those with moderate or greater severity of PTSD. Their initial analyses yielded a three factor solution with 33 items comprised of three subscales: Negative Cognitions about Self (SELF), Negative Cognitions about the World (WORLD), and Self-Blame (BLAME) subscales. Three original items were included in the initial version of the scale with a recommendation for further evaluation, and not used in scoring. Their initial investigation found excellent internal consistency reliability, high convergent validity with PTSD symptom severity, and good discriminative validity to distinguish between those with and without PTSD following trauma.
Since its introduction, research examining the PTCI has included participants with a wide variety of trauma histories (e.g. Daie-Gabai et al., 2011), including physical and sexual assault (Foa et al., 1999; Van Emmerik et al., 2006) and motor vehicle accidents (e.g. Beck et al., 2004), for which the interpersonal nature of the events may vary. To date, PTCI validation studies have supported three-factor structures and identified acceptable model fit for samples who have experienced assault. However, the BLAME subscale has proven less consistently associated with PTSD symptom severity following non-interpersonal traumas, suggesting that the validity of the PTCI may vary depending on trauma type (Su and Chen, 2008). In addition, results have varied widely with respect to support for using all items of the PTCI and the dependability of items to load on anticipated factors. This evidence, coupled with the frequent use of convenience populations in PTCI validation studies, may limit our conclusions regarding the psychometric constancy of the PTCI with trauma-exposed individuals.
Veterans with exposure to military combat and sexual traumas experience PTSD at higher rates than non-military samples (Kang et al., 2005, Tolin and Foa, 2006), and evidence suggests that negative posttraumatic cognitions are highly prevalent among Veterans presenting for trauma-focused care (Rauch et al., 2009). While military combat traumas (MCT) often share some of the interpersonal aspects of civilian assault trauma, the PTCI has not been empirically evaluated for use in the context of combat trauma. Relatedly, though some psychometric studies are based on physical and sexual assault survivors, it is unknown whether the PTCI will retain its utility following experiences of military sexual trauma (MST). The possibility that Veterans’ experiences of sexual trauma within the context of military culture differ from those experienced by their civilian counterparts in unique ways that influence cognitions and beliefs concerning self and others warrants consideration. For example, the military prizes unit cohesiveness and bodily strength. As such, survivors of MST may be more likely to believe military peers would be unsupportive of efforts to report assaultive behaviors (Burns et al., 2014; Suris and Lind, 2008). Similarly, those who have experienced MST may be more prone to believing they are to blame for not being able to physically deter an attack. Nonetheless, researchers have been using the PTCI with combat Veterans and identified that the PTCI has clinical utility in mediating associations between PTSD and anger or pain, for example (Germain et al., 2015, Porter et al., 2013). Yet, without establishing the psychometric characteristics of the PTCI for Veterans with military-specific traumas, the generalizability and interpretability of these findings is limited. The current study aimed to address this gap in the literature by evaluating the validity and reliability of the PTCI in a sample of treatment-seeking Veterans and directly contrasted the pervasiveness of negative cognitions between those seeking care for combat and military sexual traumas while taking gender into consideration.
While no currently published studies have examined gender differences in the PTCI among American military Veterans, studies of other populations suggest that significant gender differences exist, particularly for SELF. In a sample of Israeli adults with exposure to heterogeneous trauma types, for example, women reported higher scores on SELF, whereas no differences were found on the PTCI total score or the WORLD or BLAME scales (Daie-Gabai et al., 2011). Similarly, Moser et al. (2007) examined the PTCI among trauma-exposed college students and found that the associations between the WORLD and BLAME scales with PTSD symptoms were no longer significant once gender and other relevant variables were included in the model. Unfortunately, in Veteran populations, gender and trauma type are often conflated as women Veterans are more likely to present for treatment secondary to sexual trauma while men are more likely to seek care for combat events. To address this concern, we also investigated gender differences on PTCI total and subscale scores with and without controlling for trauma type.
To further assess the psychometric performance of the PTCI with Veterans, we aimed to explore its factor structure in treatment-seeking Veterans and contrasted the performance of our empirically-derived factor model with that originally proposed by Foa et al. (1998). PTCI responses were also compared to self-reported symptom and coping scales to establish convergent validity, and internal reliability was investigated using both models. We hypothesized negative cognitions would be positively correlated with PTSD and depression symptom scales and negatively correlated with a scale of resilient coping.
Section snippets
Participants and procedure
Participants were 949 Veterans presenting for trauma-focused treatment at a Midwestern Veterans Healthcare Administration PTSD specialty clinic between 2006 and 2013. At their initial visit, Veterans completed self-report questionnaires, (including the PTCI), as part of the intake and treatment planning process. In order to investigate the psychometric performance of the PTCI following military-specific traumas, only Veterans with complete PTCIs who endorsed primary combat or military sexual
Descriptive and service characteristics
Characteristics of the total sample and the subgroups used for the factor analyses are described in Table 1. The two samples were similar on demographic and service characteristics with the exception of a significantly higher representation of Vietnam service era Veterans in the EFA group compared to the CFA subgroup. Of the 92 Veterans comprising the MST group, 50 were female. Among the 857 Veterans presenting for treatment associated with MCT exposure, 822 were male.
Exploratory factor analysis
All 36 PTCI items were
Discussion
The current study supports the psychometric integrity of the PTCI for a Veteran population through replication and extension of the original PTCI in a large Veteran sample. Specifically, the PTCI demonstrated convergent and discriminative validity and internal reliability using the scoring and factor validity of the BLAME and COPE subscales. As such, the current study supports the PTCI total score for use in the Veteran population. The normative means provided from this large sample represent
Role of funding source
The research presented was supported by the Mental Health Service at VA Ann Arbor Healthcare System and the University of Michigan Department of Psychiatry. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
The authors would like to thank Margaret Venners, Caitlyn Authier, and Lauren McSweeney for their contributions to this research.
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