Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2018 Feb 24.
Published in final edited form as: Depress Anxiety. 2016 Aug 24;33(11):1039–1047. doi: 10.1002/da.22548

Catastrophizing, rumination, and reappraisal prospectively predict adolescent PTSD symptom onset following a terrorist attack

Jessica L Jenness 1, Shari Jager-Hyman 2, Charlotte Heleniak 3, Aaron T Beck 2, Margaret A Sheridan 4, Katie A McLaughlin 3
PMCID: PMC5325818  NIHMSID: NIHMS821122  PMID: 27557454

Abstract

Background

Disruptions in emotion regulation are a transdiagnostic risk factor for psychopathology. However, scant research has examined whether emotion regulation strategies are related to the onset of posttraumatic stress disorder (PTSD) symptoms among youths exposed to trauma. We investigated whether pretrauma emotion regulation strategies prospectively predicted PTSD symptom onset after the 2013 Boston Marathon terrorist attack among adolescents and whether these associations were moderated by the degree of exposure to media coverage of the attack.

Methods

A sample of 78 Boston-area adolescents (mean age =16.72 years, 65% female) who previously participated in studies assessing emotion regulation and psychopathology were recruited following the terrorist attack. Within 4 weeks of the attack, we assessed self-reported PTSD symptoms and attack-related media exposure via an online survey. We examined the association of pretrauma emotion regulation strategies with PTSD symptom onset after adjustment for pretrauma internalizing symptoms and violence exposure.

Results

Greater pretrauma engagement in rumination predicted onset of PTSD symptoms following the attack. Adolescents who engaged in catastrophizing also had greater PTSD symptoms postattack, but only when exposed to high levels of media coverage of the attacks; the same pattern was observed for adolescents who engaged in low levels of cognitive reappraisal.

Conclusions

Engagement in specific emotion regulation strategies prior to a traumatic event predicts the onset of PTSD symptoms among youths exposed to trauma, extending transdiagnostic models of emotion regulation to encompass trauma-related psychopathology in children and adolescents.

Keywords: adolescent, cognition, emotion, posttraumatic, stress disorders, terrorism

1 | Introduction

Trauma exposure is common. A majority of individuals experience a traumatic event at some point in their lifetime, with most exposed to their first event as a child or adolescent (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; McLaughlin et al., 2013). Despite pervasive exposure to trauma, the probability of developing posttraumatic stress disorder (PTSD) following a traumatic event is low (Breslau et al., 1998; Kessler et al., 1995; McLaughlin et al., 2013). Most individuals do not develop PTSD, even after exposure to traumatic events associated with the highest conditional risk of PTSD (Dohrenwend et al., 2006; McLaughlin et al., 2013; Widom, 1999). Identifying vulnerability factors that increase the risk of PTSD following trauma exposure is critical to inform models of PTSD etiology and develop effective preventive interventions. Habitual engagement in specific types of maladaptive emotion regulation strategies (i.e., trait emotion regulation) has been identified as a transdiagnostic risk factor for psychopathology (Aldao & Nolen-Hoeksema, 2010; Aldao, Nolen-Hoeksema, & Schweizer, 2010). However, little is known about whether pretrauma variation in the use of specific emotion regulation strategies prospectively predicts PTSD onset in trauma-exposed youths.

Disruptions in emotion regulation represent a transdiagnostic risk factor for psychopathology, particularly internalizing disorders (Aldao & Nolen-Hoeksema, 2010; Aldao et al., 2010), and have been targeted in PTSD interventions (Cloitre, Koenen, Cohen, & Han, 2002; Cloitre, Stovall-McClough, & Nooner, 2010). In longitudinal studies of adults, cognitive emotion regulation strategies involving conscious efforts to modulate the intensity or duration of responses to emotionally salient cues (Beck, Emery, & Greenberg, 2005; Garnefski & Kraaij, 2007; Garnefski, Kraaij, & van Etten, 2005; Thompson, 1991), have been examined as a predictor of PTSD. Specifically, greater engagement in catastrophizing—overestimating the negative consequences of an event (Bryant & Guthrie, 2005; Gellatly & Beck, 2016) and rumination—the passive and repetitive focus on the causes and consequences of one's distress (Ali, Dunmore, Clark, & Ehlers, 2002; Nolen-Hoeksema & Morrow, 1991; Spinhoven, Penninx, Krempeniou, van Hemert, & Elzinga, 2015) have each been associated with heightened risk for developing PTSD symptoms following a traumatic event. Alternatively, habitual use of adaptive strategies pretrauma such as positive reappraisal—the tendency to positively reframe the consequences of an event (Ali et al., 2002) and engagement in problem-solving (Dirkzwager, Bramsen, & van der Ploeg, 2003)—may reduce vulnerability for PTSD.

Most studies examining the association between emotion regulation and PTSD among youth have been cross-sectional. In one such study of adolescents exposed to war-related trauma, greater engagement in rumination and blaming others were concurrently associated with higher levels of PTSD symptoms, whereas putting experiences into perspective and problem-solving were associated with lower levels of PTSD symptoms (Amone-P'Olak, Garnefski, & Kraaij, 2007). Greater engagement in rumination after a traumatic event predicted prospective increases in PTSD symptoms in a sample of children and adolescents (Ehlers, Mayou, & Bryant, 2003); however we are unaware of studies among youth examining rumination prior to the traumatic event. One prospective study in children with indirect exposure to the 9/11 terrorist attack observed pretrauma negative appraisal and avoidant coping strategies to be associated with the development of PTSD symptoms posttrauma (Lengua, Long, & Meltzoff, 2006). Overall, findings among youth suggest that emotion regulation strategies prior to a traumatic event might predict PTSD symptoms post-trauma. However, prospective investigations including pretrauma assessment of emotion regulation strategies are needed to clarify these relationships.

The use of prospective designs to examine pretrauma risk factors for PTSD onset is of particular importance because individual characteristics, such as preexisting psychopathology and previous exposure to trauma and adversity, are associated with increased risk for both experiencing a traumatic event and PTSD onset (Breslau, 2002; Breslau, Davis, & Andreski, 1995; Breslau et al., 1998; Kessler et al., 1995; Smid et al., 2012). The strong relationship between pretrauma factors and trauma exposure makes it difficult to separate vulnerability factors for PTSD from vulnerability factors that select individuals into environments that increase risk for trauma exposure, such as sociodemographic characteristics and preexisting psychopathology. However, certain events, such as acts of terrorism, are less related to individual characteristics that may confound risk for trauma exposure with risk for PTSD onset than most traumatic events (i.e. car accidents, interpersonal violence) (Comer et al., 2014; Hoven et al., 2005; Otto et al., 2007; Pfefferbaum et al., 1999). Studying terrorism and other traumatic events that are unassociated with individual characteristics permits identification of vulnerability factors for PTSD that are unrelated to the risk of being exposed to trauma. Accordingly, the present study examined the prospective relationship between pretrauma emotion regulation strategies and the onset of PTSD symptoms among Boston-area adolescents following the 2013 Boston Marathon terrorist attack.

Although direct exposure to terrorism is often limited, exposure to media coverage following acts of terrorism, such as the 9/11 and Oklahoma City terrorist attacks, is pervasive among youth (Otto et al., 2007; Pfefferbaum et al., 2001, 2003). Youth may be especially vulnerable to the impact of media coverage due to perception of increased probability of harm following disasters and terrorism (Comer, Furr, Beidas, Weiner, & Kendall, 2008; Kiser et al., 1993). Indeed, terrorism-related media coverage has been associated with development of PTSD among youth (Comer et al., 2014; Otto et al., 2007; Pfefferbaum et al., 2001), even among those living a substantial distance from the attack origin (Pfefferbaum et al., 2003). However, little is known about how such media exposure moderates the influence of preexisting variation in emotion regulation strategies on PTSD symptom onset.

The terrorist attack at the 2013 Boston Marathon directly affected hundreds of participants and spectators, but had a much broader indirect impact on residents of Boston due to the unprecedented shelter-in-place warning issued by police during the search for the perpetrator (Comer et al., 2014). Schools and workplaces were closed in response to the city lockdown, and many Boston residents observed the televised manhunt and widespread media speculation regarding the presence of other explosive devices throughout the city. We assessed trait emotion regulation strategies among Boston-area adolescents preattack and had the unique opportunity to examine prospective associations with PTSD symptom onset postattack and whether these associations varied as a function of attack-related media exposure.

We hypothesized that greater trait engagement in maladaptive emotion regulation strategies pretrauma, specifically catastrophizing and rumination, would predict higher levels PTSD symptoms. In contrast, we expected that pretrauma adaptive emotion regulation strategies, specifically positive reappraisal and problem-solving, would be negatively associated with PTSD symptoms following the attack. Given the strong associations of both pretrauma internalizing psychopathology and prior trauma exposure with risk for PTSD (Koenen et al., 2008; McLaughlin et al., 2013),weexamined whether associations persisted after controlling for pretrauma internalizing symptoms and violence exposure. Finally, we examined whether attack-related media exposure moderated the associations of pretrauma emotion regulation strategies with PTSD symptoms.

2 | Materials and Methods

2.1 | Participants and procedures

Within two to four weeks following the 2013 Boston Marathon terrorist attack, we requested parental consent to recontact all adolescents who had participated in one of two studies conducted in the laboratory of the senior author within two years prior to the attack. These prior studies examined stress, emotion regulation, and stress reactivity in adolescence; recruitment for the original two studies utilized community-based advertising within metropolitan Boston (details about these studies are reported elsewhere (McLaughlin, Alves, & Sheridan, 2014; McLaughlin, Sheridan, Alves, & Mendes, 2014)). In these prior studies, adolescents provided information on emotion regulation strategies, violence exposure, and internalizing symptoms during in-person visits to the laboratory. A total of 219 adolescents and parents were recontacted. Of those, 78 adolescents age 14–19 (65% female) agreed to participate in the study within the 2-week window of recruitment following the recontact request. Nonresponse to our request was almost exclusively related to the inability to reach families within this brief 2-week timeframe. The present sample included relatively more females and White participants and had higher preattack rumination and depression symptoms (Ps < .05), but did not differ on age, other preattack emotion regulation strategies, preattack violence exposure, or anxiety symptoms (Ps > .08) compared to nonresponders. The present sample was diverse with respect to race/ethnicity: 45.5% White, 18.2% Asian, 11.7% Black, 5.2% Latino, 18.2% multi-racial, and 1.3% from other racial/ethnic groups. Once adolescents were consented by their parents to participate in the study, information on attack-related media exposure and current PTSD symptoms was gathered in an online survey. All participants reported exposure to media coverage of the bombings on the day of the marathon, and all but two participants (who declined to respond) reported exposure to media coverage of the shelter-in-place order. No participants reported being injured during the attack and few directly witnessed attack related events (i.e., medical personnel attending injured individuals; n=3). This research was approved by the Institutional Review Board at Harvard University and complied with the Code of Ethics of the World Medical Association (Declaration of Helsinki).

2.2 | Measures

2.2.1 | Pretrauma emotion regulation strategies

Pretrauma emotion regulation strategies were assessed using the Cognitive Emotion Regulation Questionnaire (CERQ) (Garnefski & Kraaij, 2007). The CERQ is a 36-item measure that asks participants to indicate the degree of engagement in specific cognitive strategies when experiencing negative or unpleasant events on a 5-point Likert scale from 1 (almost never) to 5 (almost always). Responses were summed to create subscales for each of the four cognitive strategies hypothesized to relate to PTSD symptoms posttrauma: rumination, catas-trophizing, positive reappraisal, and refocus on planning (hereafter called problem-solving). The CERQ measures an additional five emotion regulation strategies that were not relevant to study hypotheses (self-blame, other-blame, putting things into perspective, and positive refocusing/distraction; see Supplement 1). Higher scores indicate greater frequency of engagement in each cognitive strategy. The CERQ has good reliability and validity (Garnefski & Kraaij, 2007) and all subscales demonstrated adequate reliability in this sample (α = .66–.84).

2.2.2 | Media exposure to the terrorist attack

Media exposure to the terrorist attack was assessed using two online survey questions administered as part of a larger survey within 2 to 4 weeks of the Boston Marathon terrorist attack. The two survey questions evaluated media exposure on the day of the attack (Monday, April 15th) and the day of the shelter-in-place warning (Friday, April 19th). Survey questions asked “approximately how much of the day on (Monday 15th/Friday 19th) did you spend watching news coverage of the event on a TV, computer, iPad, or other electronic device?” Participants indicated responses on a Likert scale ranging from 1 (none) to 5 (all day). These items were summed to create an overall media exposure composite, with higher scores reflecting greater exposure.

2.2.3 | Pretrauma violence exposure

Pretrauma violence exposure was assessed using the 32-item Screen for Adolescent Violence Exposure (SAVE) (Hastings & Kelley, 1997). The SAVE measures direct and indirect violence in school, home, and neighborhood contexts using a 5-point Likert scale to indicate frequency. The SAVE has good reliability and validity in samples of inner-city youth (Hastings & Kelley, 1997) and good reliability in our sample (α = .88).

2.2.4 | Pretrauma internalizing symptoms

Pretrauma internalizing symptoms were assessed using the 26-item Children's Depression Inventory (CDI; suicidal ideation item removed) (Kovacs, 1992) and the 39-item Multidimensional Anxiety Scale for Children (MASC) (March, Parker, Sullivan, Stallings, & Conners, 1997). Both are widely used, well-validated measures of child psychopathology (Craighead, Smucker, Craighead, & Ilardi, 1998; Muris, Merckelbach, Ollendick, King, & Bogie, 2002) and demonstrated excellent internal consistency in our sample (αs ≥ .96).

An overall composite of pretrauma internalizing symptoms was created for each participant by first standardizing their CDI and MASC total scores, then summing the two standardized totals to create an internalizing score, with higher scores indicating greater levels of internalizing problems.

2.2.5 | PTSD symptoms

Posttrauma PTSD symptoms specifically related to the attack were assessed with a brief 6-item version of the Impact of Events Scale-6 (IES-6) (Thoresen et al., 2007). Respondents rated the frequency of hyperarousal, intrusive thoughts, and avoidance experienced since the bombings on a 5-point Likert scale ranging from 0 (almost never) to 4 (almost always). The IES-6 is an abbreviated version of the Impact of Events Scale-Revised (IES-R) (Weiss, 1999). Previous studies have shown that the IES-6 explains most of the variance of the IES-R (Thoresen et al., 2009), and the measure demonstrated good internal consistency in our sample (α =.89). The present study's sample demonstrated good symptom variability. Approximately 37% of the adolescents met clinical criteria for PTSD based on a cut-off score of ≥7, which has good PTSD diagnostic sensitivity and specificity (Thoresen et al., 2009).

2.3 | Data analysis

First, we examined the main effects of each emotion regulation strategy, media exposure, and pretrauma internalizing symptoms on PTSD symptoms. Next, to test our hypothesis that media exposure would moderate the association between emotion regulation strategies and PTSD symptoms, we generated two-way interaction terms between each emotion regulation strategy and media exposure. All predictor variables were standardized prior to performing interaction analyses (Hayes, 2013). For all significant interactions, simple slopes were evaluated in accordance with procedures outlined by Aiken and West (1991). Age and sex were included as covariates in all regression models. We conducted sensitivity analyses controlling for pretrauma violence exposure and internalizing symptoms using the internalizing composite. These analyses were repeated for the five additional emotion regulation strategies measured by the CERQ that were not the focus of study hypotheses (see Supplement 1).

3 | Results

3.1 | Descriptive statistics

Table 1 presents descriptive statistics on all study variables. Zero-order correlations between these variables are presented in Table 2. Notably, PTSD symptoms after the attack were significantly correlated with pretrauma internalizing symptoms, violence exposure, rumination, catastrophizing, and attack-related media exposure.

Table 1. Descriptive statistics for pretrauma psychopathology, trait emotion regulation strategies, media exposure and demographic variables (n = 78).

Mean Standard deviation Range
Age 16.72 1.33 14–19
CDI 11.36 6.67 0–25
MASC 48.42 19.12 2–85
Media exposure 6.63 2.13 2–10
SAVE 46.22 11.04 2–85
IES-6 5.75 5.31 0–22
CERQ subscales
 Catastrophizing 7.83 3.36 4–17
 Rumination 10.96 3.60 4–20
 Problem solving 11.76 3.98 5–20
 Positive reappraisal 11.71 4.10 4–20
Open in a new tab

CDI, Children's Depression Inventory; MASC, Multidimensional Anxiety Scale for Children; SAVE, Screen for Adolescent Violence Exposure; IES-6, Impact of Events Scale-6 Item; CERQ, Cognitive Emotion Regulation Questionnaire.

Table 2. Correlations between trait emotion regulation strategies, psychopathology, media exposure, violence exposure, and demographic variables.

1 2 3 4 7 9 10 12
1. Internalizing symptoms —
2. Media exposure .25* —
3. SAVE .47** .23 —
4. IES-6 .40** .26* .34** —
5. CERQ rumination .32** –.02 .17 .34* —
6. CERQ problem solving –.05 .10 .06 .18 .39** —
7. CERQ reappraisal .00 .26* .30* .03 .12 .44** —
8. CERQ catastrophizing .38** .17 .13 .33** .41** .04 –.19 —
Open in a new tab

CERQ, Cognitive Emotion Regulation Questionnaire;SAVE, Screen for Adolescent Violence Exposure; IES-6, Impact of Events Scale-6 item.

*

P < .05.

**

P < .001.

3.2 | Emotion regulation strategies and PTSD symptoms

Pretrauma catastrophizing (β = .51, P = .01) and rumination (β = .47, P = .01) were each associated with PTSD symptoms following the terrorist attack, controlling for age and sex (Table 3).?? In contrast, no significant associations were observed between pretrauma positive reappraisal and problem-solving with PTSD symptoms.

Table 3. Results for regression models predicting PTSD symptoms.

β SE 95% CI P-value
Main effects
 Catastrophizing 0.51 .18 [0.15, 0.86] .01*
 Rumination 0.47 .17 [0.14, 0.80] .01*
 Problem solving 0.23 .15 [−0.08, 0.53] .14
 Positive reappraisal –0.02 .16 [−0.33, 0.30] .92
 Media exposure 0.64 .31 [0.03, 1.25] .04
 Internalizing symptoms 1.12 .34 [0.45, 1.78] .001
 Violence exposure 2.01 .74 [0.54, 3.49] .008
Interaction effects
 Catastrophizing × media exposure 1.43 .63 [0.18, 2.67] .03*
 Rumination × media exposure 0.62 .58 [−0.54, 1.78] .29
 Problem solving × media exposure 0.05 .67 [−1.29, 1.39] .94
 Positive reappraisal × media exposure –1.55 .65 [−2.84, −0.26] .02†
Open in a new tab

All models control for age and sex. Separate models were run for each CERQ subscale and for main effects of pretrauma internalizing symptoms and violence exposure. They are presented in one table for ease of interpretation.

*

Remained significant when controlling for internalizing psychopathology and violence exposure.

†

Reduced to a trend when controlling for internalizing psychopathology and violence exposure.

We next examined whether emotion regulation strategies and media exposure continued to predict PTSD symptoms after controlling for pretrauma internalizing symptoms and violence exposure (each of which was independently associated with PTSD symptoms). Using this more conservative approach, the association of rumination with PTSD symptoms persisted (β = .35, P = .04), and catastrophizing maintained trend-level significance (β = .35, P = .05). See Supplement 1 for associations of emotion regulation strategies that were not the focus of our hypotheses with PTSD symptoms.

3.3 | Interactions of emotion regulation strategies with media exposure

To determine whether media exposure moderated the associations of pretrauma emotion regulation strategies with PTSD symptoms, we examined two-way interactions between each emotion regulation strategy and media exposure in predicting PTSD symptoms (Table 3).1 Catastrophizing (β = 1.43, P = .03) and positive reappraisal (β = −1.55, P = .02) each interacted with media exposure to predict PTSD symptoms, controlling for age and sex. The interaction with catastrophizing (β = 1.62, P = .01) remained significant when controlling for pretrauma internalizing symptoms and violence exposure, whereas the interaction with positive reappraisal became marginally significant (β = −1.20, P = .06). No significant interactions were found between media exposure and rumination or problem solving.

Next, we evaluated the simple slopes of each significant interaction and plotted the association between catastrophizing and positive reappraisal and PTSD symptoms at high (+1 SD) and low (−1 SD) levels of media exposure, controlling for age and sex (Fig. 1). At high media exposure, catastrophic thinking significantly predicted PTSD symptoms (β = 2.86, P = <.001), whereas it did not predict PTSD symptoms at low media exposure (β = .01, P = .99). Positive reappraisal was significantly negatively associated with PTSD symptoms for those with high media exposure (β = −.22, P = .02), but not low exposure (β = .15, P = .33). Results remained unchanged when controlling for internalizing symptoms and violence exposure.

Figure 1.

Figure 1

Open in a new tab

Interaction between catastrophizing (a) and positive reappraisal (b) strategies and attack related media exposure. High levels of catastrophizing and low levels of positive reappraisal predicted greater post-trauma PTSD symptom development among adolescents exposed to greater attack related media coverage. All variables depicted at 1 SD above and below the mean.

4 | Discussion

Disruptions in emotion regulation are a proposed risk factor for PTSD onset (Aldao & Nolen-Hoeksema, 2010; Aldao et al., 2010), yet there is limited prospective research demonstrating a relationship between these constructs among youth. The present study provided novel evidence that pretrauma emotion regulation strategies prospectively predicted development of PTSD symptoms among adolescents following the Boston Marathon terrorist attack. Specifically, greater rumination predicted onset of PTSD symptoms regardless of the degree of attack-related media exposure. Engagement in high levels of catastrophizing and low levels of positive reappraisal were also related to the onset of posttraumatic symptoms, but only among adolescents with high levels of attack-related media exposure. These findings persisted after accounting for pretrauma internalizing symptomatology and violence exposure, indicating that emotion regulation strategies are an important pretrauma riskfactor in the development of PTSD among youth.

Greater engagement in rumination predicted PSTD symptom onset and attack-related media exposure did not moderate this relationship. Rumination is a transdiagnostic risk factor for psychopathology, particularly internalizing disorders (Aldao & Nolen-Hoeksema, 2010; Aldao et al., 2010). Given the strong relationship between preexisting internalizing symptoms and the development of PTSD (McLaughlin et al., 2013), it is possible that rumination may function as a mediator of this relationship. Indeed, prior research has shown that pretrauma depression and rumination are associated with acute increases in PTSD symptoms post-trauma in adults (Nolen-Hoeksema & Morrow, 1991), and rumination mediates the association of stressful life events with the onset of anxiety and depression (Michl, McLaughlin, Shepherd, & Nolen-Hoeksema, 2013). However, no prior study has tested the relationship among internalizing psychopathology, rumination, and PTSD within a true multiple time-point mediation framework. Future work utilizing multi-wave measurements of these constructs is necessary to demonstrate whether rumination accounts for the strong relationship between preexisting internalizing psychopathology and PTSD onset following trauma.

The tendency to catastrophize prior to a traumatic event predicts PTSD symptoms and disorder onset among adults exposed to occupational traumas (e.g., firefighters (Bryant & Guthrie, 2005)). We had the unique opportunity to examine whether there was a similar association of pretrauma catastrophizing with PTSD symptoms among trauma-exposed adolescents. We found catastrophizing predicted PTSD symptoms among adolescents with high levels of attack-related media exposure. Catastrophizing is characterized by exaggerated perceptions of harm and risk for future threat. Therefore, it is likely that greater exposure to posttrauma media exacerbated the impact of catastrophic cognitions on PTSD symptoms, particularly as media coverage included speculation about additional possible attacks and ongoing threats to the city. Our findings highlight the importance of evaluating and addressing catastrophic cognitions in the context of terrorism and mass trauma, especially when the event garners high profile media coverage.

We expected greater trait use of adaptive emotion regulation strategies, including positive reappraisal and problem-solving, would predict reduced risk for PTSD symptoms posttrauma. This hypothesis was supported for positive reappraisal, but not problem solving. Pretrauma use of positive reappraisal was negatively associated with PTSD symptoms, but only among adolescents who viewed greater amounts of attack-related media coverage. This suggests that greater use of positive reappraisal strategies is a protective factor that buffered adolescents from the deleterious effects of media exposure. Positive reappraisal is a cognitive strategy frequently utilized in evidenced-based cognitive-behavioral oriented therapies targeting PTSD (Beck et al., 2005; Robertson, Humphreys, & Ray, 2004) and our findings suggest that training in positive reappraisal might be useful in preventive interventions aimed at reducing risk for PTSD. Although problem-solving has been negatively associated with PTSD in previous studies, only posttrauma cognitive aspects of problem solving (Amone-P'Olak et al., 2007), or pretrauma behavioral aspects of problem solving (i.e., putting problem-solving into action) (Dirkzwager et al., 2003), have been measured. Given our small sample size, future prospective studies are needed to better understand the relationship between pretrauma use of cognitive and behavioral components of problem solving and PTSD symptom development.

Exploratory analyses examined a range of other emotion regulation strategies that were not part of our focal hypotheses. Most of these strategies, including acceptance, distraction, putting things into perspective, and self-blame, were not associated with PTSD symptoms and did not interact with media exposure to predict PTSD symptom development (see Supplement 1). However, adolescents who both viewed greater amounts of media coverage and engaged in the habitual tendency to blame others were at higher risk for PTSD symptoms posttrauma, even after controlling for pretrauma internalizing symptoms and violence exposure. Self-blame has been associated with PTSD following other types of trauma (Ullman, Townsend, Filipas, & Starzynski, 2007; Weaver & Clum, 1995), suggesting a need for greater research on both self- and other-blame with respect to trauma-related psychopathology.

This is the first study, to our knowledge, that utilizes pretrauma measurement of a broad range of emotion regulation strategies to prospectively predict PTSD symptoms among youth. Identifying preexisting risk factors that are independent of trauma exposure allows firmer conclusions to be drawn regarding the predictive relationship between emotion regulation strategies and PTSD symptoms. The prospective design also permitted adequate control for preexisting internalizing symptoms and violence exposure. Furthermore, study of PTSD symptoms in relation to the Boston Marathon terrorist attack provided a trauma exposure that is independent of individual characteristics shown to increase risk for experiencing a traumatic event (Breslau et al., 1998; Koenen et al., 2008). However, in the revised PTSD diagnosis in DSM-5, media exposure no longer qualifies as a traumatic event (American Psychiatric Association, 2013). Changes in the DMS-5 PTSD diagnosis have received criticism from PTSD experts (Hoge et al., 2016), and substantial evidence—including the present study's findings—indicates that indirect exposure to traumatic events, particularly terrorist attacks, can trigger PTSD symptoms and clinical diagnosis (Ahern, Galea, Resnick, & Vlahov, 2004; Comer et al., 2014, 2008; Galea et al., 2002; Hoge et al., 2016). Use of mobile devices and technology is ubiquitous among adolescents of diverse economic and demographic backgrounds (Madden, Lenhart, Duggan, Cortesi, & Gasser, 2013), so media exposure to local, national, and international terrorism will likely remain common or even increase over time. Therefore, future studies are needed to empirically evaluate the exclusion of indirect trauma exposure as a traumatic event.

Limitations of the current study provide avenues for future research. First, our sample size was relatively small. Therefore, it is possible that certain non significant findings reflect lack of statistical power, and future studies utilizing larger samples of adolescents to examine a broad range of emotion regulation strategies are needed. Second, findings are based on self-report measures, which could bias results due to shared-method variance. Use of objective measures, such as coded observations of cognitive strategies, might decrease such bias. Third, self-report of PTSD symptoms within 4 weeks postattack may limit conclusions about clinical PTSD onset. However, approximately one-third of our sample met clinical criteria for PTSD (Thoresen et al., 2009), which is consistent with empirical and epidemiological research utilizing diagnostic interviewing techniques posttrauma (McLaughlin et al., 2013, 2012; Shaw, 2003). Fourth, although the media exposure assessment was completed within a relatively short time-frame 2–4 weeks postattack, retrospective report may have influenced the accuracy of responses. Fifth, we found survey responders had higher pretrauma depression symptoms compared to survey nonresponders, so the present sample may reflect more exposed or symptomatic adolescents. Finally, the majority of our sample experienced indirect exposure to the terrorist attack; therefore, findings may not generalize to adolescents who have experienced direct trauma exposure (i.e., adolescents injured during a terrorist attack).

5 | Conclusion

Emotion regulation strategies prospectively predict development of PTSD symptoms among adolescents following a terrorist attack. Greater engagement in rumination prior to the attack predicted PTSD symptom onset, whereas catastrophizing, blaming others, and low-positive reappraisal were associated with PTSD symptoms only among adolescents with high levels of attack-related media exposure. These findings highlight the importance of emotion regulation strategies as a risk factor in the development of PTSD among youth.

Supplementary Material

S1
S2

Acknowledgments

Grant sponsor: National Institute of Child Health and Human Development; Grant number: T32-HD057822; Grant sponsor: National Institute of Mental Health; Grant numbers: K01-MH092526,R01-MH103291, R01-MH106482, F31-MH108245,R01-MH 086572,and R21-MH 109878; Grant sponsor: Doris Duke Fellowship for the Promotion of Child Well-Being.

Abbreviations

CDI

Children's Depression Inventory

CERQ

Cognitive Emotion Regulation Questionnaire

IES-6

Impact of Events Scale-6

IES-R

Impact of Events Scale-Revised

MASC

Multidimensional Anxiety Scale for Children

PTSD

posttraumatic stress disorder

SAVE

Screen for Adolescent Violence Exposure

Footnotes

1

Results were unchanged when the three participants who directly witnessed attack related events were removed from analyses.

Conflict of Intrest: All author declare that they have no conflicts of interest.

Supporting Information: Additional Supporting Information may be found online in the supporting information tab for this article.

References

  1. Ahern J, Galea S, Resnick H, Vlahov D. Television images and probable posttraumatic stress disorder after September 11: The role of background characteristics, event exposures, and perievent panic. Journal of Nervous and Mental Disease. 2004;192(3):217–226. doi: 10.1097/01.nmd.0000116465.99830.ca. [DOI] [PubMed] [Google Scholar]
  2. Aiken LS, West SG. Multiple regression: Testing and interpreting interactions. Thousand Oaks, CA, US: Sage Publications, Inc; 1991. [Google Scholar]
  3. Aldao A, Nolen-Hoeksema S. Specificity of cognitive emotion regulation strategies: A transdiagnostic examination. Behaviour Research and Therapy. 2010;48(10):974–983. doi: 10.1016/j.brat.2010.06.002. [DOI] [PubMed] [Google Scholar]
  4. Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review. 2010;30(2):217–237. doi: 10.1016/j.cpr.2009.11.004. [DOI] [PubMed] [Google Scholar]
  5. Ali T, Dunmore E, Clark D, Ehlers A. The role of negative beliefs in posttraumatic stress disorder: A comparison of assault victims and non victims. Behaviour Cognitive Psychotherapy. 2002;30(3):249–257. [Google Scholar]
  6. Amone-P'Olak K, Garnefski N, Kraaij V. Adolescents caught between fires: Cognitive emotion regulation in response to war experiences in Northern Uganda. Journal of Adolescence. 2007;30(4):655–669. doi: 10.1016/j.adolescence.2006.05.004. [DOI] [PubMed] [Google Scholar]
  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 5th. Arlington, VA: American Psychiatric Publishing; 2013. [Google Scholar]
  8. Beck AT, Emery G, Greenberg RL. Anxiety disorders and phobias: A cognitive perspective. Basic Books; New York, NY, US: 2005. [Google Scholar]
  9. Breslau N, Davis GC, Andreski P. Risk factors for PTSD-related traumatic events: A prospective analysis. American Journal of Psychiatry. 1995;152(4):529–535. doi: 10.1176/ajp.152.4.529. [DOI] [PubMed] [Google Scholar]
  10. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry. 1998;55(7):626–632. doi: 10.1001/archpsyc.55.7.626. [DOI] [PubMed] [Google Scholar]
  11. Breslau N. Epidemiologic studies of trauma, posttraumatic stress disorder, and other psychiatric disorders. Canadian Journal of Psychiatry. 2002;47(10):923–929. doi: 10.1177/070674370204701003. [DOI] [PubMed] [Google Scholar]
  12. Bryant RA, Guthrie RM. Maladaptive appraisals as a risk factor for posttraumatic stress: A study of trainee firefighters. Psychological Science. 2005;16(10):749–752. doi: 10.1111/j.1467-9280.2005.01608.x. [DOI] [PubMed] [Google Scholar]
  13. Cloitre M, Koenen KC, Cohen LR, Han H. Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology. 2002;70(5):1067–1074. doi: 10.1037//0022-006x.70.5.1067. [DOI] [PubMed] [Google Scholar]
  14. Cloitre M, Stovall-McClough KC, Nooner K, Zorbas P, Cherry S, Jackson CL, et al. Petkova E. Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry. 2010;167(8):915–924. doi: 10.1176/appi.ajp.2010.09081247. [DOI] [PubMed] [Google Scholar]
  15. Comer JS, Dantowitz A, Chou T, Edson AL, Elkins RM, Kerns C, et al. Green JG. Adjustment among area youth after the Boston marathon bombing and subsequent manhunt. Pediatrics. 2014;134(1):7–14. doi: 10.1542/peds.2013-4115. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Comer JS, Furr JM, Beidas RS, Weiner CL, Kendall PC. Children and terrorism-related news: Training parents in coping and media literacy. Journal of Consulting and Clinical Psychology. 2008;76(4):568–578. doi: 10.1037/0022-006X.76.4.568. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Craighead WE, Smucker MR, Craighead LW, Ilardi SS. Factor analysis of the Children's Depression Inventory in a community sample. Psychological Assessment. 1998;10(2):156–165. [Google Scholar]
  18. Dirkzwager AJE, Bramsen I, van der Ploeg HM. Social support, coping, life events, and posttraumatic stress symptoms among former peacekeepers:Aprospective study. Personality and Individual Differences. 2003;34(8):1545–1559. doi: 10.1016/S0191-8869(02)00198-8. [DOI] [Google Scholar]
  19. Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koenen KC, Marshall R. The psychological risks of Vietnam for US veterans: A revisit with new data and methods. Science. 2006;313(5789):979–982. doi: 10.1126/science.1128944. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Ehlers A, Mayou RA, Bryant RA. Cognitive predictors of post-traumatic stress disorder in children: Results of a prospective longitudinal study. Behaviour Research and Therapy. 2003;41(1):1–10. doi: 10.1016/s0005-7967(01)00126-7. [DOI] [PubMed] [Google Scholar]
  21. Galea S, Ahern J, Resnick H, Kilpatrick D, Bucuvalas M, Gold J, Vla-hov D. Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine. 2002;346(13):982–987. doi: 10.1056/NEJMsa013404. [DOI] [PubMed] [Google Scholar]
  22. Garnefski N, Kraaij V. The cognitive emotion regulation questionnaire. European Journal of Psychological Assessment. 2007;23(3):141–149. doi: 10.1027/1015-5759.23.3.141. [DOI] [Google Scholar]
  23. Garnefski N, Kraaij V, van Etten M. Specificity of relations between adolescents' cognitive emotion regulation strategies and internalizing and externalizing psychopathology. Journal of Adolescence. 2005;28(5):619–631. doi: 10.1016/j.adolescence.2004.12.009. [DOI] [PubMed] [Google Scholar]
  24. Gellatly R, Beck AT. Catastrophic thinking: A transdiagnostic process across psychiatric disorders. Cognitive Therapy and Research. 2016:1–12. [Google Scholar]
  25. Hastings TL, Kelley ML. Development and validation of the Screen for Adolescent Violence Exposure (SAVE) Journal of Abnormal Child Psychology. 1997;25(6):511–520. doi: 10.1023/a:1022641916705. [DOI] [PubMed] [Google Scholar]
  26. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY, US: Guilford Press; 2013. [Google Scholar]
  27. Hoge CW, Yehuda R, Castro CA, McFarlane AC, Vermetten E, Jetly R, et al. Rothbaum BO. Unintended consequences of changing the definition of posttraumatic stress disorder in DSM-5: Critique and call for action. JAMA Psychiatry. 2016;73(7):750–752. doi: 10.1001/jamapsychiatry.2016.0647. [DOI] [PubMed] [Google Scholar]
  28. Hoven CW, Duarte CS, Lucas CP, Wu P, Mandell DJ, Goodwin RD, et al. Susser E. Psychopathology among New York City public school children 6 months after September 11. Archives of General Psychiatry. 2005;62(5):545–551. doi: 10.1001/archpsyc.62.5.545. [DOI] [PubMed] [Google Scholar]
  29. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry. 1995;52(12):1048–1060. doi: 10.1001/archpsyc.1995.03950240066012. [DOI] [PubMed] [Google Scholar]
  30. Kiser L, Heston J, Hickerson S, Millsap P, Nunn W, Pruitt D. Anticipatory stress in children and adolescents. American Journal of Psychiatry. 1993;150:87–87. doi: 10.1176/ajp.150.1.87. [DOI] [PubMed] [Google Scholar]
  31. Koenen KC, Moffitt TE, Caspi A, Gregory A, Harrington H, Poulton R. The developmental mental-disorder histories of adults with posttraumatic stress disorder: A prospective longitudinal birth cohort study. Journal of Abnormal Psychology. 2008;117(2):460–466. doi: 10.1037/0021-843X.117.2.460. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Kovacs M. Children's depression inventory: Manual. North Tonawanda: Multi-Health Systems; 1992. [Google Scholar]
  33. Lengua LJ, Long AC, Meltzoff AN. Pre-attack stress-load, appraisals, and coping in children's responses to the 9/11 terrorist attacks. Journal of Child Psychology and Psychiatry. 2006;47(12):1219–1227. doi: 10.1111/j.1469-7610.2006.01664.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Madden M, Lenhart A, Duggan M, Cortesi S, Gasser U. Teens and Technology 2013. Washington, DC: Pew Internet & American Life Project; 2013. [Google Scholar]
  35. March JS, Parker JDA, Sullivan K, Stallings P, Conners CK. The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36(4):554–565. doi: 10.1097/00004583-199704000-00019. [DOI] [PubMed] [Google Scholar]
  36. McLaughlin KA, Alves S, Sheridan MA. Vagal regulation and internalizing psychopathology among adolescents exposed to childhood adversity. Developmental Psychobiology. 2014;56(5):1036–1051. doi: 10.1002/dev.21187. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC. Childhood adversities and first onset of psychiatric disorders in a national sample of US adolescents. Archives of General Psychiatry. 2012;69(11):1151–1160. doi: 10.1001/archgenpsychiatry.2011.2277. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. McLaughlin KA, Koenen KC, Hill ED, Petukhova M, Sampson NA, Zaslavsky AM, Kessler RC. Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 2013;52(8):815–830. doi: 10.1016/j.jaac.2013.05.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. McLaughlin KA, Sheridan MA, Alves S, Mendes WB. Child maltreatment and autonomic nervous system reactivity: Identifying dysregulated stress reactivity patterns by using the biopsychosocial model of challenge and threat. Psychosomatic Medicine. 2014;76(7):538–546. doi: 10.1097/PSY.0000000000000098. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Michl LC, McLaughlin KA, Shepherd K, Nolen-Hoeksema S. Rumination as a mechanism linking stressful life events to symptoms of depression and anxiety: Longitudinal evidence in early adolescents and adults. Journal of Abnormal Psychology. 2013;122(2):339. doi: 10.1037/a0031994. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Muris P, Merckelbach H, Ollendick T, King N, Bogie N. Three traditional and three new childhood anxiety questionnaires: Their reliability and validity in a normal adolescent sample. Behaviour Research and Therapy. 2002;40(7):753–772. doi: 10.1016/s0005-7967(01)00056-0. [DOI] [PubMed] [Google Scholar]
  42. Nolen-Hoeksema S, Morrow J. A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta Earthquake. Journal of Personality and Social Psychology. 1991;61(1):115–121. doi: 10.1037//0022-3514.61.1.115. [DOI] [PubMed] [Google Scholar]
  43. Otto MW, Henin A, Hirshfeld-Becker DR, Pollack MH, Biederman J, Rosenbaum JF. Posttraumatic stress disorder symptoms following media exposure to tragic events: Impact of 9/11 on children at risk for anxiety disorders. Journal of Anxiety Disorders. 2007;21(7):888–902. doi: 10.1016/j.janxdis.2006.10.008. [DOI] [PubMed] [Google Scholar]
  44. Pfefferbaum B, Nixon SJ, Krug RS, Tivis RD, Moore VL, Brown JM, et al. Gurwitch RH. Clinical needs assessment of middle and high school students following the 1995 Oklahoma City bombing. American Journal of Psychiatry. 1999;156(7):1069–1074. doi: 10.1176/ajp.156.7.1069. [DOI] [PubMed] [Google Scholar]
  45. Pfefferbaum B, Nixon SJ, Tivis RD, Doughty DE, Pynoos RS, Gurwitch RH, Foy DW. Television exposure in children after a terrorist incident. Psychiatry. 2001;64(3):202–211. doi: 10.1521/psyc.64.3.202.18462. [DOI] [PubMed] [Google Scholar]
  46. Pfefferbaum B, Seale TW, Brandt EN, Pfefferbaum RL, Doughty DE, Rainwater SM. Media exposure in children one hundred miles from a terrorist bombing. Annals of Clinical Psychiatry. 2003;15(1):1–8. doi: 10.1023/a:1023293824492. [DOI] [PubMed] [Google Scholar]
  47. Robertson M, Humphreys L, Ray R. Psychological treatments for posttraumatic stress disorder: Recommendations for the clinician based on a review of the literature. Journal of Psychiatric Practice. 2004;10(2):106–118. doi: 10.1097/00131746-200403000-00005. [DOI] [PubMed] [Google Scholar]
  48. Shaw JA. Children exposed to war/terrorism. Clinical Child and Family Psychology Review. 2003;6(4):237–246. doi: 10.1023/b:ccfp.0000006291.10180.bd. [DOI] [PubMed] [Google Scholar]
  49. Smid GE, Van der Velden PG, Lensvelt-Mulders G, Knipscheer JW, Gersons BPR, Kleber RJ. Stress sensitization following a disaster: A prospective study. Psychological Medicine. 2012;42(8):1675–1686. doi: 10.1017/S0033291711002765. [DOI] [PubMed] [Google Scholar]
  50. Spinhoven P, Penninx BW, Krempeniou A, van Hemert AM, Elzinga B. Trait rumination predicts onset of Post-Traumatic Stress Disorder through trauma-related cognitive appraisals: A 4-year longitudinal study. Behaviour Research and Therapy. 2015;71:101–109. doi: 10.1016/j.brat.2015.06.004. [DOI] [PubMed] [Google Scholar]
  51. Thompson RA. Emotional regulation and emotional development. Educational Psychology Review. 1991;3(4):269–307. [Google Scholar]
  52. Thoresen S, Tambs K, Hussain A, Heir T, Johansen VA, Bisson JI. Brief measure of posttraumatic stress reactions: Impact of Event Scale-6. Social Psychiatry and Psychiatric Epidemiology. 2009;45(3):405–412. doi: 10.1007/s00127-009-0073-x. [DOI] [PubMed] [Google Scholar]
  53. Ullman SE, Townsend SM, Filipas HH, Starzynski LL. Structural models of the relations of assault severity, social support, avoidance coping, self-blame, and PTSD among sexual assault survivors. Psychology of Women Quarterly. 2007;31(1):23–37. doi: 10.1111/j.1471-6402.2007.00328.x. [DOI] [Google Scholar]
  54. Weaver TL, Clum GA. Psychological distress associated with interpersonal violence: A meta-analysis. Clinical Psychology Review. 1995;15(2):115–140. doi: 10.1016/0272-7358(95)00004-9. [DOI] [Google Scholar]
  55. Weiss DS. The impact of event scale—Revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. 2nd. New York, NY, US: Guilford Press; 2004. pp. 168–189. [Google Scholar]
  56. Widom CS. Posttraumatic stress disorder in abused and neglected children grown up. American Journal of Psychiatry. 1999;156(8):1223–1229. doi: 10.1176/ajp.156.8.1223. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1
NIHMS821122-supplement-S1.docx (25.9KB, docx)
S2
NIHMS821122-supplement-S2.tif (25.9KB, tif)

RESOURCES