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Psychological Trauma: Theory, Research, Practice, and Policy - Vol 9, Iss 6

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Psychological Trauma: Theory, Research, Practice, and Policy Official Journal of APA Division 56. Psychological Trauma: Theory, Research, Practice, and Policy publishes empirical research on the psychological effects of trauma. The journal is intended to be a forum for an interdisciplinary discussion on trauma, blending science, theory, practice, and policy.
Copyright 2017 American Psychological Association
  • Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events.
    Objective: We investigated whether potentially morally injurious events (PMIEs) during a combat deployment may lead to PTSD through distinct pathways from danger-based events. We also examined the prevalence of perpetration-based PMIEs, during which service members behaved in ways that violated their own moral values, and betrayal-based PMIEs, during which personal moral expectations were violated by trusted others. Method: Using a sample of 867 active duty Marines from a single infantry battalion that engaged in heavy ground combat while deployed to Afghanistan, a structural equation model was built to examine the relationships between perpetration- and betrayal-based PMIEs, combat experiences, and peritraumatic dissociation reported at 1 month postdeployment, and guilt/shame, anger, and PTSD symptoms reported at 8 months postdeployment. Results: The relationship between betrayal-based PMIEs and PTSD was mediated by anger (β = .14). There was marginal evidence of mediation of the relationship between perpetration-based PMIEs and PTSD by shame and guilt (β = .09), and of the relationship between danger-based combat events and PTSD by peritraumatic dissociation (β = .08). No significant direct relationships were found between any of these 3 types of events and subsequent PTSD. Perceived perpetration and betrayal accounted for PTSD symptoms above and beyond combat exposure. Over a third of the sample reported experiencing perpetration- or betrayal-based PMIEs. Conclusions: The associations of perpetration and betrayal with PTSD, controlling for danger-based combat events, highlight the limitations of conceptualizations and treatments of PTSD based on fear or helplessness as sole etiologic factors. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Trauma-informed juvenile justice systems: A systematic review of definitions and core components.
    Objective: The U.S. Department of Justice has called for the creation of trauma-informed juvenile justice systems in order to combat the negative impact of trauma on youth offenders and frontline staff. Definitions of trauma-informed care have been proposed for various service systems, yet there is not currently a widely accepted definition for juvenile justice. The current systematic review examined published definitions of a trauma-informed juvenile justice system in an effort to identify the most commonly named core elements and specific interventions or policies. Method: A systematic literature search was conducted in 10 databases to identify publications that defined trauma-informed care or recommended specific practices or policies for the juvenile justice system. Results: We reviewed 950 unique records, of which 10 met criteria for inclusion. The 10 publications included 71 different recommended interventions or policies that reflected 10 core domains of trauma-informed practice. We found 8 specific practice or policy recommendations with relative consensus, including staff training on trauma and trauma-specific treatment, while most recommendations were included in 2 or less definitions. Conclusion: The extant literature offers relative consensus around the core domains of a trauma-informed juvenile justice system, but much less agreement on the specific practices and policies. A logical next step is a review of the empirical research to determine which practices or policies produce positive impacts on outcomes for youth, staff, and the broader agency environment, which will help refine the core definitional elements that comprise a unified theory of trauma-informed practice for juvenile justice. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • The impact of service-connected disability and therapist experience on outcomes from prolonged exposure therapy with veterans.
    Objective: Although prolonged exposure therapy (PE) has been shown to be effective in treating posttraumatic stress disorder (PTSD), a sizable minority do not benefit. Examining patient and therapist characteristics that impact treatment outcome may improve treatment delivery and identify individuals who are less likely to respond to treatment or are at risk to prematurely discontinue treatment. The current study uses a sample from a large urban Veterans’ Affairs (VA) hospital to build on a previous report that identified correlates of treatment outcome for Veterans who received PE. Method: Two hundred eighty-seven veterans completed measures of PTSD, depression, and quality of life at the beginning and end of treatment. Veterans’ service-connected disability rating, therapist experience, benzodiazepine prescription, and traumatic brain injury diagnosis were investigated as predictors of treatment outcome in linear regression analyses. Results: Results showed that Veterans with a service-connected disability for a mental health condition had smaller treatment gains than those without service connection (p <.01). Additionally, results showed that patients treated by certified PE therapists had larger treatment gains than those treated by noncertified PE therapists (p <.01). Finally, younger age and therapist certification were associated with dropout from treatment (p <.05). Conclusion: Veterans treated by PE-certified therapists and Veterans who were not service-connected for a mental health condition fared better in treatment. Results suggest that additional study of both the national effort to train VA clinicians in PE and the impact of service connection on PTSD treatment outcome may be helpful for future research. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Posttraumatic stress symptoms and marital adjustment among Israeli combat veterans: The role of loneliness and attachment.
    Objective: War trauma may foster ramifications for marital relationships. Veterans may feel that no one can understand them and thus impact their relationships. The current study aims to shed light on the role that posttraumatic stress symptoms (PTSS), loneliness, and attachment orientations may play in marital adjustment among combat veterans. Method: Participants were 504 veterans who served in the Lebanon War in 1982. Results: Analysis revealed that higher PTSS levels were related to lower marital adjustment and that the indirect path of this relation through loneliness was significant. Furthermore, attachment orientations moderated the direct link between PTSS and marital adjustment, but failed to moderate the indirect effect through loneliness. Conclusions: A sense of isolation should be addressed in therapy, as well as the interpersonal expectations of the veteran. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Predicting domestic and community violence by soldiers living in a conflict region.
    Objective: Past research revealed war trauma and posttraumatic stress disorder (PTSD) symptoms as potential predictors for domestic and community violence in crisis regions and among soldiers in different armed conflicts. The impact of family violence and other adversities experienced in childhood as well as of a combat-enhanced appeal for aggressive behavior (appetitive aggression) remains to be specified. Method: In the present study, the authors separately predicted violence against children, intimate partner violence and community violence in 381 Burundian soldiers returning from foreign deployment and living in a post- conflict region. Using path analysis, they aimed to disentangle the independent contributions and pathways of the following variables: Exposure to war trauma and childhood familial violence, PTSD and depression symptom severity, and appetitive aggression. Results: Childhood familial violence had an independent effect on all contexts of violence and was the only significant predictor for violence against the soldiers’ own children. Intimate partner violence was additionally predicted by depression symptom severity, while community violence was additionally predicted by PTSD symptom severity and appetitive aggression. Conclusions: Besides war-related mental ill-health and appetitive aggression, violent experiences during childhood development must not be overlooked as a factor fueling the cycle of violence in conflict regions. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Does combat exposure affect well-being in later life? The VA Normative Aging Study.
    Objective: Combat exposure can have long-term negative effects in later life; although aspects of service may be appraised positively, the long-term positive effects of combat on well-being in later life is largely unknown. Method: The sample included 1,006 male veterans from the VA Normative Aging Study, surveyed by mail in 1986, 1990, and 1991 (Mage = 65.5 years, SD = 7.3). They reported on their combat exposure, desirable appraisals of military service, unit cohesion, dispositional optimism, self-rated health, and psychological well-being (PWB), as well as age, military rank, and education. Perceived positive aspects (PPA) of military service was postulated to mediate the effects of combat exposure on PWB. Structural equation modeling was used to examine both mediating and moderating effects. Results: Age, combat exposure, and optimism had independent effects on PPA, but optimism did not moderate the effect of combat exposure on PPA. Combat exposure had only indirect effects on PWB through PPA, controlling for the direct effects of optimism. Education had no direct effects on the positive outcomes but did have indirect effects through optimism. Conclusion: Combat exposure contributes to positive well-being in later life, indirectly through positive appraisals, and this effect was independent of optimism. Thus, these results support the idea that combat veterans should be encouraged to focus on positive aspects of military service, which may serve as resilience resources to facilitate optimal aging. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Using the research domain criteria framework to track domains of change in comorbid PTSD and SUD.
    Objectives: Comorbidity in diagnosis raises critical challenges for psychological assessment and treatment. The Research Domain Criteria (RDoC) Project, launched by the National Institutes of Mental Health, proposes domains of functioning as a way to conceptualize the overlap between comorbid conditions and inform treatment selection. However, further research is needed to understand common comorbidities (e.g., posttraumatic stress disorder [PTSD] and substance use disorder [SUD]) from an RDoC framework and how existing evidence-based treatments would be expected to promote change in the RDoC domains of functioning. To address these gaps, the current study examined change in 3 RDoC domains (Negative Valence Systems, Arousal/Regulatory Systems, and Cognitive Systems) during concurrent prolonged exposure (PE) and substance use treatment. Method: Participants were 85 individuals with co-occurring PTSD and SUD who received PE in a residential substance use treatment facility. They completed an experimental task to assess physiological reactivity to trauma and alcohol cues at pre- and posttreatment. Results: Results showed decreased severity in all 3 RDoC domains of interest across the study period. Pairwise comparisons between domains revealed that Arousal/Regulatory Systems had the lowest severity at posttreatment. Subsequent hierarchical linear regression analyses showed that posttreatment domain scores were associated with posttreatment cue reactivity for trauma and alcohol cues. Conclusions: The findings provide preliminary evidence of how the RDoC domains of functioning may change with evidence-based treatments and are discussed in terms of the assessment and treatment of mental health problems using the RDoC framework. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Construct validity of the Race-Based Traumatic Stress Symptom Scale and tests of measurement equivalence.
    Objectives: The study was designed to examine the construct, measurement equivalence, and predictive validity of the Race-Based Traumatic Stress Symptom Scale (RBTSSS). Method: Confirmatory factor analysis (CFA) and structural equation modeling (SEM) were used with adults from various racial backgrounds throughout the Northeast. Results: The CFA revealed a good model fit and a second-order SEM supported the concept of race-based traumatic stress. Measurement equivalence was found for gender and race. Convergent validity was tested using canonical correlation analysis, whereby RBTSSS reactions were related to psychological outcomes. Conclusions: The findings of the CFA and SEM provide support for the measurement and theoretical models of the RBTSSS. Study findings offer scholarly and practical contributions to trauma assessment and treatment. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Measuring psychological change after trauma: Psychometric properties of a new bi-directional scale.
    Objective: The current scientific measures of posttraumatic changes in the wake of major stressors have mostly been unidirectional. This study is an attempt to develop a scale that will capture the continuum of positive to negative psychological changes after trauma. Method: Forty-five statements were presented to a veteran sample (N = 4,053) with the request to report for each item their experiences of negative, positive, or no posttraumatic changes as a result of their deployment to Afghanistan. Results: Principal component analysis brought out 4 dimensions; 26 nonoverlapping items that had correlations above .40 were selected for the final version of the scale. The 4 dimensions were given the following designations: Self-Confidence, Interpersonal Involvement, Awareness, and Social Adaptability. Most veterans reported positive changes (36.8–80.8%) whereas a minority reported negative changes (4.5–22.0%). The total scale score correlated negatively with measures of depression, anxiety, sleep disorders, and posttraumatic stress symptoms. Conclusion: The posttraumatic change scale (PTCS) demonstrated acceptable psychometric properties and captured the range from negative to positive posttraumatic changes after major stress. Contrary to several previous studies, positive posttraumatic change, as measured by the PTCS, was not associated with increased symptoms of psychopathology. This underscores the heterogeneity of psychological responses to traumatic events. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Predictive accuracy and factor structure of the Child Report of Posttraumatic Symptoms (CROPS) among adjudicated youth.
    Objective: Trauma exposure and trauma symptom manifest have been associated with issues unique to the adjudicated youth population (Perkins, Calhoun, Glaser, & Kunemund, 2016), which necessitates accurate screening tools to facilitate appropriate allocation of resources (Briggs et al., 2013; Kerig, Moeddel, & Becker, 2011). The Child Report of Posttraumatic Symptoms (CROPS; Greenwald & Rubin, 1999) is a short and effective trauma assessment tool; however, predictive accuracy of the CROPS in classifying previous trauma exposure(s) as well as the factor structure of the CROPS has not been examined with this population. Method: Retrospective data of 215 adjudicated youth (50.2% boys) were used to investigate the predictive accuracy of the CROPS in detecting previous trauma exposures. Further, researchers examined the factor structure of the CROPS to identify principle components that most strongly contributed to accurate classification. Results: Logistic regression analyses indicated moderate predictive accuracy (64.2%) in identifying reported trauma histories for the total sample and among both adjudicated males (61.1%) and females (66.4%). Principle components analyses revealed a stable 3-factor solution (accounting for 47% of total variance) and yielded a 14-item CROPS factor accounting for 32.3% of total variance. The 14-item factor demonstrated improved predictive accuracy over the full 26-item CROPS for the total sample (65.1%) and among adjudicated males (66.7%). Conclusion: Overall findings provide moderate support for the utility of the CROPS in accurately identifying previous trauma exposure(s) among adjudicated youth and provide preliminary support for a 14-item version of the CROPS for screening for trauma symptoms in adjudicated youth. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Development of the Healthcare Triggering Questionnaire in adult sexual abuse survivors.
    Objective: One in 4 women and 1 in 10 men in the United States are survivors of sexual abuse (SA). For these survivors, healthcare experiences may trigger memories, thoughts, feelings or sensations related to this past abuse. Such triggering can be associated with negative responses to healthcare (e.g., anxiety, avoidance). However, to date, no healthcare triggering assessment tool exists. Therefore, the study goal was to describe the prevalence of healthcare triggering, to develop a brief Healthcare Triggering Questionnaire (HTQ), and to examine its initial validity. Method: An initial pool of 117 items was developed based on previous research. Two-parameter logistic item response theory models were used to develop the scales. SA survivors [male (n = 233), female (n = 222)] and a comparison group of non-SA individuals [male (n = 114), female (n = 106)] were recruited through Amazon Mechanical Turk and completed the study anonymously online. Results: Three 10-item scales were developed: (a) the HTQ-M for males; (b) the HTQ-F for females; and (c) the HTQ-U (unisex) for all respondents. The results supported the utility and initial validity of the gender-specific and unisex scales. Conclusions: The HTQ scales are a psychometrically sound approach to evaluating healthcare triggering experienced by adult sexual abuse survivors. The HTQ may be considered for use by researchers interested in studying healthcare triggering, healthcare retraumatization, and healthcare adherence. The HTQ may also be of use to clinicians interested in identifying trauma survivors who are more likely to experience triggering in healthcare settings. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Examining the incremental contribution of metacognitive beliefs beyond content-specific beliefs in relation to posttraumatic stress in a community sample.
    Objective: Cognitive-behavioral models of posttraumatic stress disorder (PTSD) propose that the content of one’s thoughts, including negative beliefs about the self, others, and world, play a fundamental role in our understanding and treatment of PTSD. Metacognitive theory suggests that metacognitive beliefs (i.e., beliefs about thinking), rather than content-specific beliefs, underlie PTSD. The present study provided the first known examination of the incremental contribution of metacognitive beliefs and trauma-related cognitions in relation to posttraumatic stress. Method: Community adults recruited through an online crowdsourcing website who reported experiencing a criterion A traumatic event (N = 299) completed self-report measures of the study variables. Results: Results from multiple linear regression analyses indicated that metacognitive beliefs of the uncontrollability and danger of thinking shared associations with each posttraumatic stress symptom cluster after accounting for the effects of content-specific beliefs and other covariates. The individual content-specific beliefs did not consistently share associations with posttraumatic stress symptoms in the regression analyses. The contribution of the individual content-specific beliefs to posttraumatic stress symptoms was consistently attenuated or rendered nonsignificant after accounting for metacognitive beliefs. Conclusions: These results are consistent with metacognitive theory in suggesting that metacognitive beliefs may be more important than trauma-related thought content in relation to posttraumatic stress. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Mental strategies as mediators of the link between attachment and PTSD.
    The authors analyzed the relationship between attachment dimensions (avoidance and anxiety) and posttraumatic stress disorder (PTSD) symptoms through the mediation of the mental strategies organization, that is, behavioral and intrapsychic strategies used to cope with traumatic events and symptoms, among a sample of war veterans. Sample was composed of Portuguese war veterans (N = 60): 30 veterans suffered from chronic PTSD (nonrecovered) and 30 veterans had remission from PTSD (recovered). Assessment of mental strategies was retrieved from 1 interview assessed by 3 judges, and attachment patterns and PTSD symptoms were assessed through self-report measures. Path coefficients of direct and total effects were estimated. Results showed lower mental strategies organization and higher attachment anxiety among nonrecovered participants. Indirect effect of attachment anxiety on PTSD symptoms through mental strategies was significant when no variable was entered as covariate. Indirect effect of attachment avoidance on PTSD symptoms through mental strategies organization was not significant. The authors discussed that the development of more mature mental strategies play a central role in working with veterans to cope with posttraumatic symptoms. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Ethnoracial differences in PTSD symptoms and trauma-related cognitions in treatment-seeking active duty military personnel for PTSD.
    Objective: It is uncertain whether ethnoracial factors should be considered by clinicians assessing and treating posttraumatic stress disorder (PTSD) among service members. The purpose of this study was to shed light on ethnoracial variation in the presentation of PTSD symptoms, trauma-related cognitions, and emotions among treatment-seeking active duty military personnel. Method: Participants were 303 male active duty military members with PTSD participating in a clinical trial (60% were self-identified as White, 19% as African American, and 21% as Hispanic/Latino). In the parent study, participants completed a baseline assessment that included clinician-administered and self-report measures of PTSD, trauma-related cognitions, and emotions. Results: Multivariate hierarchical regression models were used to examine ethnoracial differences in these variables, covarying age, education, military grade, combat exposure, and exposure to other potentially traumatic events. Hispanic/Latino and African American participants reported more reexperiencing symptoms, more fear, and more guilt and numbing than White participants. All effect sizes were in the small to medium range. Conclusions: These findings suggest ethnoracial variation in PTSD symptom burden and posttraumatic cognitions among treatment-seeking service members with PTSD. Attending to cultural factors related to differences in PTSD presentation and cognitive coping strategies during the assessment and treatment process could increase rapport and lead to more comprehensive trauma processing. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Spiritual struggles and suicide in veterans seeking PTSD treatment.
    Objective: Research indicates that trauma can precipitate a loss of faith and struggles in the spiritual domain, leading to increased suicide risk. However, little is known about the specific types of spiritual struggles that may confer risk. This brief report examines the utility of a newly developed measure, the Religious and Spiritual Struggles Scale in gauging suicide risk in veterans. Method: As part of their initial assessment, 52 veterans presenting to an outpatient posttraumatic stress disorder and substance use clinic were administered self-report symptom measures. Results: Multiple regression analyses revealed that divine struggles and struggles with the ultimate meaning were significantly and positively associated with increased suicide risk, even after controlling for relevant demographic (e.g., being male and Caucasian) and psychological variables (e.g., posttraumatic stress disorder symptoms as well as alcohol and substance use symptoms). Conclusions: Results provide preliminary support for use of the Religious and Spiritual Struggles Scale with veterans and highlight the potential utility in assessing for spiritual struggles when assessing suicide risk. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Trauma cognitions are related to symptoms up to 10 years after cognitive behavioral treatment for posttraumatic stress disorder.
    Objectives: This study examined (a) relationships between trauma-related cognitions and posttraumatic stress disorder (PTSD) symptoms from pretreatment through a long-term period after cognitive–behavioral therapy (CBT) for PTSD and (b) whether these relationships were impacted by treatment type. Method: Participants were 171 women randomized into treatment for PTSD after rape. Measures of self-reported trauma-related cognitions and interviewer-assessed PTSD symptoms (i.e., Posttraumatic Maladaptive Beliefs Scale, Trauma-Related Guilt Inventory, and Clinician-Administered PTSD Scale) were obtained at pretreatment, posttreatment, and 3-month, 9-month, and 5–10 year follow-ups. Multilevel regression analyses were used to examine relationships between trauma-related cognitions and PTSD symptoms throughout the study period and whether these relationships differed as a function of treatment type (i.e., Cognitive Processing Therapy or Prolonged Exposure). Results: Initial multilevel regression analyses that examined mean within-participant associations suggested that beliefs regarding Reliability and Trustworthiness of Others, Self-Worth and Judgment, Threat of Harm, and Guilt were related to PTSD symptoms throughout follow-up. Growth curve modeling suggested that patterns of belief change throughout follow-up were similar to those previously observed in PTSD symptoms over the same time period. Finally, multilevel mediation analyses that incorporated time further suggested that change in beliefs was related to change in symptoms throughout follow-up. With 1 minor exception, relationships between beliefs and symptoms were not moderated by treatment type. Conclusions: These data suggest that trauma-related cognitions are a potential mechanism for long-term maintenance of treatment gains after CBT for PTSD. Moreover, these cognitions may be a common, rather than specific, treatment maintenance mechanism. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • The four faces of rumination to stressful events: A psychometric analysis.
    Objective: To increase the knowledge of rumination and its associations with stressful events, we explored the relationships between 4 types of rumination (brooding, reflection, intrusive, and deliberate rumination) in a sample of 750 adult participants who experienced a highly stressful event. We also explored the predictive value of the different types of rumination on posttraumatic stress symptoms and posttraumatic growth 6 months after the highly stressful event occurred. Method: Participants completed the Ruminative Response Scale and the Event-Related Rumination Inventory. Brooding and reflection rumination were obtained from the Ruminative Response Scale, whereas deliberate and intrusive rumination were obtained from the Event-Related Rumination Inventory. Confirmatory factorial analyses were conducted using the 4 types of rumination to test 3 different models: (a) 4-factor model (brooding, reflection, intrusive, and deliberate rumination), (b) 2-factor model: adaptive rumination (reflection and deliberate) and maladaptive rumination (brooding and intrusive), and (c) 2-factor model: depressive rumination (brooding and reflection) and posttraumatic rumination (intrusive and deliberate). Results: It was observed that the 4-factor model showed the best fit to the data. Moreover, 6 months later it was observed that the most significant predictor of posttraumatic symptoms was intrusive rumination, whereas deliberate rumination was the most significant predictor of posttraumatic growth. Conclusions: Results indicate that the 4 types of rumination are differentiated constructs. Ruminative thoughts experienced after a stressful event predicted posttraumatic consequences 6 months later. Implications of these findings are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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