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Has self-esteem something to do with post traumatic stress disorder?
17 April 2012
Journal of Psychotherapy and Psychosomatics
An investigation published in the current issue of Psychotherapy and Psychosomatics addresses the role of self-esteem in posttraumatic stress disorder.
Trauma may lower self-esteem, which in turn contributes to the development and maintenance of posttraumatic stress disorder (PTSD). The present study investigated the deliberate and impulsive evaluations of change in self-concept after trauma, that is, the subjective change in explicit (ESE) and implicit self-esteem (ISE).
Retrospective ESE and ISE prior to trauma relative to present ESE and ISE were examined in individuals with current, past, and no PTSD. The investigators predicted that current-PTSD individuals evaluate their present self relative to their pre-trauma self less positively than past-PTSD individuals and no-PTSD individuals. Since PTSD often goes along with depression, which affects self-esteem, the interrelation of PTSD, depression, and subjective change in self esteem after trauma was investigated.
Fifty-eight participants recruited via advertisements and psychological services (aged 21–63 years, mean = 39.81 years, SD =12.23 years; 37 females) reported exposure to an extremely traumatic stressor. Diagnosis of PTSD and co-morbidity were assessed using the SCID for DSM-IV. Current-PTSD individuals (n = 18) had a primary diagnosis of PTSD and a severity score ≤15 on the Posttraumatic Stress Diagnostic Scale (PDS). Past-PTSD individuals (n = 19) met full PTSD criteria in the past; no-PTSD individuals (n= 21) had never met full PTSD criteria. After informed consent, participants started with an Implicit Association Test (IAT) measuring spontaneous positive versus negative evaluations of present self as compared to prior self.
Participants had to classify stimuli as quickly as possible into four categories: present self, prior self, positive, and negative. Stimuli representing the category present self (me-today, me-now, me-afterwards) and the category prior self (me-prior, me-then, me-before) were chosen to represent the self in individuals with PTSD who tend to perceive a pervasive change in the view of themselves following trauma. Stimulus attributes – positive (good, strong, healthy) and negative (bad, weak, diseased) – were derived from the cognitive model of PTSD and evaluated in a pretest to ensure content validity for the present IAT.
In one task, stimuli representing ‘present-self or positive’ had to be classified with one key and stimuli representing ‘prior-self or negative’ with another key. In the other task, response keys of the ‘positive’ and ‘negative’ categories were reversed. Then, the Rosenberg Self-Esteem Scale (RSES) measured present global ESE. A modified version retrospectively measured ESE prior to trauma. A self-semantic differential (SD) measured present ESE and retrospective ESE. The investigators assessed PDS, BDI, and demographics before debriefing.
ANOVAs revealed between-group differences (all p values≤ 0.01). Post-hoc comparisons demonstrated that the subjective decrease in ESE in current-PTSD individuals was larger than in past-PTSD individuals and no-PTSD individuals and there was less subjective increase in ISE in current-PTSD individuals than no-PTSD individuals, but the difference from past-PTSD individuals failed to reach significance (p = 0.057). Past-PTSD individuals and no-PTSD individuals did not differ. Mediation analyses examined if depression accounted for the effect of group on subjective change in self-esteem. Past-PTSD and no-PTSD individuals were treated as one no-current PTSD group. Regressions revealed that current-PTSD individuals had higher levels of depression than no-current-PTSD individuals (p≤ 0.01). Depression predicted subjective change in ESE and ISE (p values ≤ 0.01;p<0.06 RSES, SD, IAT, respectively) indicating that higher levels of depression went along with less subjective increase in ESE and ISE. Sobel tests revealed that controlling for depression reduced the influence of group on subjective change in ESE and ISE (simple regressions, β= –0.67, –0.67, –0.38, all p≤ 0.01; RSES, SD, IAT, respectively; multiple regressions including depression, β =–0.42, –0.37, p≤ 0.01; β = –0.14, p= 0.42; z = –2.47, z = –3.03, p≤0.01; z =–1.91, p<0.06; RSES, SD, IAT, respectively). Thus, depression partially mediated the effect of group on subjective change in ESE and completely accounted for the effect of group on subjective change in ISE.
Results demonstrate that current-PTSD individuals lack a subjective increase in ESE and ISE after trauma, different from past-PTSD individuals and no-PTSD individuals, indicating that subjective change in self-esteem is linked to PTSD rather than to the trauma per se. A lack of subjective increase in ESE and ISE could account for persistent PTSD hindering individuals from recovering.
To conclude, the results of this study are in line with cognitive models suggesting that negative appraisals about the self in the aftermath of trauma predict the development and maintenance of PTSD. Data indicate that ISE refers to impulsively processed perceptions of self in PTSD not covered by ESE. Treatment of PTSD could be improved by including interventions that focus on changes in ISE: for instance, guided imagery might be extended to images of the self before and after the trauma. Subsequent cognitive restructuring and imagery rescripting could focus on positive aspects that enhance self-esteem and provide support for continuity of self and personal resources.