Susan Roth

Approach, Avoidance, and Coping With Stress

The study of stress and coping points to two concepts central to an understanding of the response to trauma: approach and avoidance. This pair of concepts refers to two basic modes of coping with stress. Approach and avoidance are simply metaphors for cognitive and emotional activity that is oriented either toward or away from threat. An approach-avoidance model of coping is presented in the context of contemporary theoretical ap- proaches to coping. The research literature on coping ef- fectiveness, including evidence from our laboratory, is dis- cussed, and speculations are made about the implications for future research. The study of stress and coping has become quite popular in recent years, particularly in regard to traumatic life events. Although the area is broad and the coping process is complex, there is a striking coherence in much of the literature. This coherence is based on two concepts central to an understanding of coping with trauma: approach and avoidance. In its simplest form, this pair of concepts refers to two basic orientations toward stressful infor- mation, or two basic modes of coping with stress. Ap- proach and avoidance are shorthand terms for the cog- nitive and emotional activity that is oriented either toward or away from threat. In this article we will present the case for utilizing the concepts of approach and avoidance to provide a co- herent theoretical structure to our understanding of cop- ing with stress. Several different formulations of the ap- proach-avoidance dimension will be reviewed, followed by a brief review of the coping effectiveness literature. Several studies from our laboratory will be used to illus- trate the relationship between coping and outcome. Fi- nally, a general approach-avoidance model of coping will be presented, with suggestions for further research to cor- roborate or extend the theory. The study of coping with stress has been split into two areas: anticipation of future stressful events and re- covery from trauma. These areas have been kept re- markably distinct in both theory and research on coping. Although there are clearly important differences between the two cases, we have chosen not to emphasize this dis- tinction. For any given stress, anticipation and recovery are not always clearly separable; dealing with a trauma involves coming to terms with the event itself and with the threat of recurrence in the future. More important, Correspondence concerning this article should be sent to Susan

Assessment of a new self-rating scale for post-traumatic stress disorder

BACKGROUND In post-traumatic stress disorder (PTSD) there is a need for self-rating scales that are sensitive to treatment effects and have been tested in a broad range of trauma survivors. Separate measures of frequency and severity may also provide an advantage. METHODS Three hundred and fifty-three men and women completed the Davidson Trauma Scale (DTS), a 17-item scale measuring each DSM-IV symptom of PTSD on 5-point frequency and severity scales. These subjects comprised war veterans, survivors of rape or hurricane and a mixed trauma group participating in a clinical trial. Other scales were included as validity checks as follows: Global ratings, SCL-90-R, Eysenck Scale, Impact of Event Scale and Structured Clinical Interview for DSM-III-R. RESULTS The scale demonstrated good test-retest reliability (r = 0.86), internal consistency (r = 0.99). One main factor emerged for severity and a smaller one for intrusion. In PTSD diagnosed subjects, and the factor structure more closely resembled the traditional grouping of symptoms. Concurrent validity was obtained against the SCID, with a diagnostic accuracy of 83% at a DTS score of 40. Good convergent and divergent validity was obtained. The DTS showed predictive validity against response to treatment, as well as being sensitive to treatment effects. CONCLUSIONS The DTS showed good reliability and validity, and offers promised as a scale which is particularly suited to assessing symptom severity, treatment outcome and in screening for the likely diagnosis of PTSD.

Complex PTSD in Victims Exposed to Sexual and Physical Abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder

Two hundred thirty four participants in the DSM-IV Posttraumatic Stress Disorder (PTSD) Field Trial who reported sexual and/or physical abuse were evaluated. Participants were categorized according to type of abuse (physical, sexual, both), duration of abuse (acute versus chronic), and onset of abuse (early versus late). Separate logistic regression analyses examined the relationship between age of onset, duration, abuse type, and the complex PTSD (CP) lifetime diagnosis for women and men. Sexually abused women, especially those who also experienced physical abuse, had a higher risk of developing CP, although CP symptoms occurred at a high base rate among physically abused women. The theoretical implications and incremental clinical usefulness of targeting CP symptoms with abused populations are discussed.

Development of a criteria set and a structured interview for disorders of extreme stress (SIDES)

Data regarding the development of a structured interview measuring alterations that may accompany extreme stress are presented. A list of 27 criteria often seen in response to extreme trauma and not addressed by DSM-IV criteria for posttraumatic stress disorder (PTSD) were generated based on a systematic review of the literature and a survey of 50 experts. A structured interview for disorders of extreme stress (SIDES) measuring the presence of these criteria was administered to 520 subjects as part of the DSM-IV PTSD field trials. Inter-rater reliability as measured by Kappa coefficients for lifetime Disorders of Extreme Stress was .81. Internal consistency using coefficient alpha ranged from .53 to .96. Results indicate that the SIDES is a useful tool for investigation of response to extremes stress.

Coping with Cancer

This study examined coping strategies in head and neck cancer patients. The relationships between the use of approach and avoidant coping strategies and the physical and emotional distress of 35 newly diagnosed head and neck cancer patients during the early stages of cancer treatment were evaluated. Patients were categorized on the basis of coping strategy at the time of diagnosis and then evaluated twice during the course of their treatment at four- to six-week intervals. Cancer patients who predominantly employed either approach or avoidant strategies had lower initial levels of emotional distress than patients who did not use either of these strategies. Although symptoms of distress decreased in patients using approach or avoidance, symptoms increased for those patients who did not use these strategies. The level of stress for this cancer population is highest at the point of confirmed diagnosis and recedes during the course of treatment. The theoretical and clinical implications of these findings are discussed.

“I felt like a slut”: The cultural context and women's response to being raped

This paper examines how cultural beliefs (cultural constructions) about women influence how women survivors of rape make sense of their traumatic experience. A thematic content analysis of interviews with female survivors of rape was undertaken to provide a systematic description of the phenomenology of the experience. This paper reports on one major finding which highlighted the ways in which cultural beliefs about women, sexuality, and rape become salient to women, and are accessed by them as they struggle to bring meaning to the experience of being raped. The nature of these beliefs and their implications for response and recovery are discussed.

Thematic resolution, PTSD, and complex PTSD: the relationship between meaning and trauma-related diagnoses.

The role of modifying schemas in trauma-focused psychotherapy has received theoretical and clinical attention. However, the relationship of schematic processing to posttraumatic stress disorder (PTSD) diagnosis has not been examined empirically. The current study-compared measures of thematic disruption among individuals with PTSD alone, PTSD with concurrent complex PTSD, and no PTSD. Eighty two participants were interviewed to assess PTSD status, complex PTSD status, traumatic life events, and trauma-related thematic processing. Results indicated that variables quantifying thematic disruption and thematic resolution significantly distinguished those individuals with concurrent PTSD plus complex PTSD from the other two groups. Exploratory analyses indicated that PTSD symptom severity and the interpersonal nature of the trauma were related to thematic disruption.

Victimization history and victim-assailant relationship as factors in recovery from sexual assault

The present study investigated the psychological aftermath of sexual assault in a probability sample of university women, with an emphasis on how various aspects of a victims lifetime sexual assault history and their relationship with their assailant(s) mediate posttraumatic recovery. Victims were almost twice as likely as nonvictims to meet given criteria for a psychiatric case. Surprisingly, date rape victims were as distressed as victims of chronic childhood assault, possibly because of the ambiguous nature of the assault circumstance. Also, repeated victimization was related to denial, a symptom of posttraumatic stress. Denial was discussed in regard to the likelihood of its increasing the risk of revictimization.

The Process of Coping with Incest for Adult Survivors Measurement and Implications for Treatment and Research

The process of coping with sexual trauma is defined in terms of trauma themes—affect and schema categories—and a dimension along which trauma resolution can be measured in regard to these themes. The recovery process is a dynamic one that involves integration of traumatic material into ones personality. Thematic issues define the abusive dynamics that drive current behavior and become the focus of psychotherapeutic interventions. Integration of traumatic experiences proceeds by the processing of these thematic issues. Reliably and validly measuring the coping or recovery process that is facilitated by therapeutic interventions is a first step in understanding the treatment process and in creating effective and efficient interventions.

Relationship between Cognitive Activity and Adjustment in Four Spinal-Cord-Injured Individuals: A Longitudinal Investigation

Although most of the stress one faces in life occurs in anticipation of a stressful period, very little research has been done on what anticipatory cognitive activities are related to subsequent adjustment. The present study investigated the relationship between measures of anticipatory cognitive activity and subsequent adjustment in four spinal-cord-injured individuals. Measures of anticipatory cognitive activity, which were assessed before subjects left the rehabilitation center, were related to measures of adjustment, which were assessed when subjects returned to the rehabilitation center for a medical checkup anywhere from 7 to 13 1/2 weeks following discharge. Seven-month follow-ups were conducted with two of the subjects. Although the small sample size precluded any statistical analysis of the data, the rank orderings of subjects across the variables of interest revealed a number of interesting trends. The most striking trend was that the best adjusted subject predominantly employed rationalization and denial in anticipating going home. A theory to explain why these strategies may be effective for spinal-cord-injured individuals is proposed. Other trends revealed that individuals who avoid catastrophizing and worrying about what their life will be like, who think more about the various goals they may have once they leave the rehabilitation center, and who employ internal forms of mental rehearsal in anticipating going home tend to be better adjusted. Although any conclusions that can be drawn from this study are only suggestive, given the small sample size, the fruitfulness of conducting this type of research is demonstrated.