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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: J Anxiety Disord. 2021 Dec 24;86:102517. doi: 10.1016/j.janxdis.2021.102517

Mental Contamination, PTSD Symptoms, and Coping Following Sexual Trauma: Results from a Daily Monitoring Study

Jordyn M Tipsword 1, C Alex Brake 2, Jesse McCann 1, Matthew W Southward 1, Christal L Badour 1
PMCID: PMC8885963  NIHMSID: NIHMS1767873  PMID: 34973537

Abstract

Mental contamination (MC) – dirtiness experienced in the absence of contact with a physical contaminant – has been linked to PTSD symptoms following sexual trauma. However, there is limited understanding regarding the temporal nature of this association. The present study utilized experience sampling to examine associations between baseline and daily experiences of MC and PTSD symptoms and the mediating role of avoidance and approach coping among a sample of 41 adult women with a history of sexual trauma and current MC. Participants completed baseline measures and 14 days of twice-daily assessments. Results indicated that daily MC and PTSD symptoms were bidirectionally related. The tendency to engage in avoidance coping positively mediated relations between 1) baseline MC and daily PTSD symptoms and 2) baseline PTSD symptoms and daily MC. Further, daily avoidance coping (T-1) positively mediated associations between daily MC (T-2) and subsequent daily PTSD symptoms (T). Approach coping was not a mediator (between- or within-) in any models. Findings lend support to a mutual maintenance model of PTSD symptoms and trauma-related MC mediated by avoidance coping. Future research over a more extended period is warranted to clarify whether PTSD symptoms and MC indeed mutually maintain or exacerbate one another over time.

Keywords: mental contamination, coping, PTSD symptoms, approach, avoidance

1. Introduction

Mental contamination (MC), or the experience of dirtiness in the absence of contact with a pollutant (Rachman, 1994), is often triggered by thoughts, memories, or images (Rachman, 2004). In an early study on MC, Fairbrother and Rachman (2004) found that approximately 70% of women in a community sample reported urges to wash immediately following sexual victimization. Approximately a quarter of those reporting urges to wash continued washing excessively for months to over a year post-trauma, suggesting that MC is prevalent and persistent after sexual trauma.

Subsequent work documented robust correlations between trauma-related MC and PTSD symptoms (Badour, Feldner, Babson, et al., 2013); however, this research has been limited to cross-sectional survey or laboratory-based experimental/quasi-experimental studies. As such, the temporal nature of the MC-PTSD link is unknown. While some have proposed that MC may precede PTSD symptom development (e.g., Badour, Feldner, Blumenthal et al., 2013; Olatunji et al., 2008), others have theorized that PTSD symptoms may lead to increased MC due to internalization of trauma-related disgust and/or negative cognitions involving inflated responsibility and self-blame (Ojserkis et al., 2018). It is also possible that MC and PTSD symptoms mutually influence—and maintain—one another.

Given discrepancies in the proposed direction of associations between MC and PTSD symptoms and the theoretical rationale for a bidirectional association among them, further research evaluating the temporal nature of the MC-PTSD relationship is warranted. The use of an experience sampling design may prove especially useful as this approach assesses MC and PTSD symptoms frequently over brief intervals, allowing for more proximal assessment of process compared to traditional longitudinal designs. A daily monitoring approach limits the influence of recall bias on reporting (Naragon-Gainey et al., 2012) and provides a clearer understanding of how associations between constructs unfold in the short-term (assessment-to-assessment) and over longer periods (e.g., across a multiweek period).

1.1. Approach and Avoidance Coping

Strategies used to cope with trauma-related distress may also contribute to associations between PTSD symptoms and MC. Coping encompasses behavioral and cognitive methods used to manage thoughts and feelings elicited by stressful situations (Folkman & Lazarus, 1988). Although various conceptions of coping exist, one clinically relevant distinction divides coping into two categories: approach and avoidance (Roth & Cohen, 1986; Tiet et al., 2006). In short, approach coping involves actively responding to a stressor (e.g., seeking support; Folkman & Lazarus, 1988), whereas avoidance coping involves cognitively, emotionally, and/or physically distancing oneself from the stressor and related cues (e.g., distraction; Tiet et al., 2006).

1.1.1. Coping and PTSD Symptoms

It has been suggested that individuals engage in avoidance coping to reduce distress associated with traumatic experiences. Avoidance coping leads to immediate reductions in distress, and is thus negatively reinforced (Ullman et al., 2007). However, avoidance prevents processing of negative emotions and unhelpful or inaccurate beliefs surrounding traumatic experiences. Thus, avoidance may perpetuate negative trauma-related outcomes – including PTSD symptoms – in the long term. In line with this idea, trauma-related avoidance coping has been linked to more severe PTSD symptoms among those with a history of sexual trauma (Ullman et al., 2007). Additional work among veterans suggests that greater cognitive avoidance coping (e.g., distracting oneself from trauma-related thoughts) prospectively predicts more severe PTSD symptoms, while greater PTSD symptoms subsequently predict greater behavioral avoidance coping (e.g., social withdrawal; Tiet at al., 2006). Together, these findings suggest that specific domains of avoidance coping may influence – and be influenced by – PTSD symptoms over time. Further work has also documented positive associations between PTSD symptoms and behaviors that serve an avoidant function, including substance use (Kaysen et al., 2014; Ullman et al., 2013) and impulsive behaviors (e.g., risky sexual behavior; Weiss et al., 2019).

Links between PTSD symptoms and approach coping are less clear. Higher PTSD symptoms may be associated with less approach coping as PTSD-related distress may impede active processing of traumatic experience(s). Such a relationship may be particularly likely to emerge as engaging in approach coping may increase emotional or symptom distress in the short term (Ullman et al., 2007). Individuals who engage in approach coping – despite any distress it may elicit – may experience fewer subsequent PTSD symptoms as approach coping involves processing traumatic experience(s) underlying PTSD symptoms. However, there are mixed findings regarding associations between PTSD symptoms and approach coping. Cross-sectional studies in community and non-treatment-seeking samples have documented negative (Hassija et al., 2012) or nonsignificant (Tiet et al., 2006) associations between approach coping and PTSD symptoms. Similarly, some longitudinal research has linked increased approach coping to decreased subsequent PTSD symptoms in the context of treatment (Boden et al., 2012), while other prospective work suggests no association between approach coping and subsequent PTSD symptoms (Tiet et al., 2006).

It is possible that approach coping is less strongly associated with PTSD symptoms than avoidance coping. Although individuals often cope with stressful experiences via both approach and avoidance strategies (Folkman & Lazarus, 1988; Ullman et al., 2007), avoidance behaviors may be more central in maintaining PTSD symptoms than approach behaviors as avoidance coping prevents actions that might facilitate improvements in PTSD symptoms (e.g., engaging with friends/family; Ullman et al., 2007). Thus, approach and avoidance coping may be best conceptualized as related but orthogonal processes. Previous work varies in the extent to which approach and avoidance coping have been evaluated together, and in the breadth of strategies that have been evaluated. Both of these methodological differences may contribute to inconsistent findings and the failure to reflect that many individuals employ mixtures of avoidance and approach coping strategies (Doron et al., 2015; Southward & Cheavens, 2020; Stanisławski, 2019). It is critical to evaluate avoidance and approach coping in the same model to allow for comparisons of relative effects. It is further important to clarify the nature of proximal (i.e., same-day) associations between approach coping and PTSD symptoms, as well as associations that emerge over a more extended period of time (i.e., weeks) given limited prospective work evaluating associations between approach coping and PTSD symptoms.

1.1.2. Coping and Mental Contamination

Perhaps the most well-established form of coping linked to MC is washing behavior, which is thought to serve an avoidant function (Badour, Feldner, Babson et al., 2013; Fairbrother & Rachman, 2004). Additionally, Brake and colleagues (2018) observed that individuals experiencing trauma-related MC are more likely to engage in risk behaviors that may serve an avoidant function (e.g., substance use). While such findings provide preliminary support for links between MC and avoidant trauma-related coping, research examining a broader range of behaviors is warranted. Though no existing work has examined associations between MC and approach coping, individuals experiencing more severe MC may be less likely to engage in approach coping as the distress associated with MC may be perceived as aversive and may hinder willingness to engage with associated experiences.

Though preliminary links between MC and coping have been reported, little is presently known about the specific role of trauma-related coping (defined here as coping with stress related to an unwanted sexual experience) in the ongoing association between PTSD symptoms and MC. As such, the present study involves a prospective examination of MC, PTSD symptoms, and coping among a sample of women with a history of sexual trauma and current MC using an experience sampling approach. We anticipated a bidirectional relationship between MC and PTSD symptoms (i.e., baseline MC would predict daily PTSD symptoms and vice versa). Additionally, we expected that avoidance coping would positively mediate the associations between baseline MC and daily PTSD symptoms (and vice versa), as well as between daily MC and subsequent daily PTSD symptoms (and vice versa). We further anticipated that approach coping would negatively mediate these same associations.

2. Method

2.1. Participants

Participants included 41 women (Mage = 32.95, SD = 12.59, range = 18–57) recruited as part of a larger study focused on PTSD and MC (Brake, Tipsword, & Badour, 2021). Participants were 73.2% Caucasian, 19.5% African American, and 4.9% Multiracial; 2.4% of women self-identified as belonging to another group. Additionally, 9.8% of our sample identified as Hispanic. Participants reported the following non-exclusive forms of sexual trauma: unwanted sexual contact during childhood (56.1%); unwanted sexual contact involving force or threatened force (90.2%); and unwanted sexual contact while under the influence of substances (and therefore unable to provide consent; 58.5%).

2.2. Procedure

Participants were recruited from the community via flyers and online advertisements. Interested individuals completed: 1) a phone screen to determine eligibility; 2) an online questionnaire battery; 3) a laboratory visit including interviews and additional questionnaires; and 4) 14 days of twice-daily assessments completed via LifeData, a smartphone app. Participants received notifications to complete twice-daily assessments (9:00 AM EST and 5:00 PM EST). Reminders were sent every 30 minutes until the survey was completed. A daily assessment was “skipped” if it was not completed within four hours of the assessment window opening. Participants completed 974 of 1148 possible daily surveys, resulting in an 84.8% response rate. The mean number of responses per participant was 23.76 (SD = 5.24, range 7–28), with over 90% completing 15 or more assessments. Participants received $30 following the opening. Participants completed 974 of 1148 possible daily surveys, resulting in an 84.8% response rate. The mean number of responses per participant was 23.76 (SD = 5.24, range 7–28), with over 90% completing 15 or more assessments. Participants received $30 following the laboratory visit and received $1 for every completed assessment during the 14-day diary period (up to $28). A $5 bonus payment was awarded each time four consecutive assessments were completed. All procedures were approved by the university’s Institutional Review Board (IRB) and informed consent was obtained prior to any study procedures.

2.3. Measures

2.3.1. Baseline Measures

2.3.1.1. Sexual Trauma History.

Sexual trauma history was assessed using four items from the National Stressful Events Survey (NSES; Kilpatrick et al., 2011) that evaluated a) sexual contact by an adult during childhood, b) unwanted sexual experiences involving force, c) unwanted sexual experiences occurring while under the influence of substances, and d) whether any unwanted sexual experiences involved penetration (including oral, anal, and vaginal penetration). Eligibility was based on responses to the first three items.

2.3.1.2. Trauma-Related Mental Contamination.

Current sexual trauma-related MC was assessed via the Posttraumatic Experience of Mental Contamination scale (PEMC; Brake et al., 2019). The PEMC is a 20-item self-report measure modeled after the Vancouver Obsessional Compulsive Inventory – Mental Contamination scale (VOCI-MC; Radomsky et al., 2014). PEMC items were administered in reference to the index trauma reported by participants during the screening phase and participants indicated the extent to which they experienced the described sensation using a five-point Likert-type scale (0 to 4). Scores were summed to create an overall severity index, with greater scores indicating more severe MC. Participants were considered to be experiencing current MC – and were thus eligible for the study – if they reported a severity score of 10 or greater based on cut scores indicating moderate levels of MC on the VOCI-MC (Coughtrey et al., 2014). Scores on the PEMC have demonstrated evidence of strong reliability (α = .92 in the current study) and convergent validity with the VOCI-MC (Brake et al., 2019). Current experiences of trauma-related MC were also confirmed during an in-person interview using a two-item excerpt from Fairbrother and Rachman’s (2004) sexual assault-related MC interview schedule (“What, if anything brings back that feeling of dirtiness now?”; “What about memories of the unwanted sexual experience, do they bring back that feeling of dirtiness?”).

2.3.1.3. PTSD Symptoms.

Past-month PTSD symptoms were assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013a). The CAPS-5 is a semi-structured interview assessing the frequency and intensity of DSM-5 PTSD symptoms. The CAPS-5 displays excellent psychometric properties (Weathers et al., 2018). Total severity scores were calculated by summing the CAPS-5 frequency/intensity score. Scores were also used to determine PTSD diagnostic status (Weathers et al., 2018). The CAPS-5 exhibited satisfactory internal consistency in the current study (α = .84). Random selection of 20% of interviews indicated excellent interrater reliability for diagnostic agreement (κ = 1.0) and agreement on PTSD symptom severity (average r = .98).

2.3.2. Daily Questionnaires

2.3.2.1. Trauma-Related Mental Contamination.

Mental contamination was assessed twice daily using the State Mental Contamination Scale (SMCS; Lorona et al., 2018). The SMCS is a 15-item self-report inventory assessing state experiences of MC by modifying original VOCI-MC items. Participants rated agreement with each item since the previous daily assessment (i.e., since the morning assessment for evening assessments and vice versa for morning assessments) using a Likert-type scale (0 to 4). Daily assessment instructions for the SMCS were adjusted to reference the index traumatic event identified during the CAPS-5 interview. Total scores were calculated at each assessment by summing item responses. The SMCS has demonstrated strong reliability (between-person differences [Rkf = .99] and within-person change [RC = .95] in the current study) and convergent validity (Lorona et al., 2018).

2.3.2.2. PTSD Symptoms.

Daily PTSD symptoms were evaluated using a modified version of the 20-item PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013b) that assessed severity of daily symptoms, consistent with other studies using daily diary assessments (Dworkin et al., 2017). Participants reported PTSD symptoms (e.g., sleep difficulties, negative emotions) related to their index experience of sexual trauma since the previous daily assessment on a Likert-type scale (0 to 4). Total symptom severity scores were calculated at each assessment timepoint by summing item responses. Reliability estimates for evaluating between-person differences (Rkf = .99) and within-person change (RC = .92) via the PCL-5 were excellent.

2.3.2.3. Avoidance Coping.

Trauma-related avoidance coping was assessed using five items from the emotional avoidance subscale of the Brief COPE (Carver, 1997; Schnider et al., 2007) and two items assessing washing and thought suppression (given research suggesting that both domains are relevant to MC; Coughtrey et al., 2012). Selected items from the Brief COPE were chosen based on pilot data suggesting a significant correlation with VOCI-MC mental contamination. The item addressing washing behavior was developed by modifying one item from the Vancouver Obsessive Compulsive Inventory (VOCI; Thordarson et al., 2004), while the item evaluating thought suppression was adapted from the Thought Suppression Inventory (TSI; Rassin, 2003). Participants rated the extent to which they utilized a given strategy since the previous daily assessment in relation to sexual trauma using a Likert-style scale (1 to 4). Total scores were calculated at each timepoint by summing item responses. Though reliability estimates examining within-person change in avoidance coping were low (Rc = .65), estimates evaluating between-person differences in avoidance coping were excellent (Rkf = .99).

2.3.2.4. Approach Coping.

Approach coping was evaluated using six items: four items from the emotional support and acceptance subscales of the Brief COPE (Carver, 1997) and two items measuring emotional expression and processing from the Emotional Approach Coping measure (EAC; Stanton et al., 2000). Participants indicated how frequently they engaged in each behavior since the previous daily assessment using a Likert-type scale (1 to 4). Total scores were calculated at each timepoint by summing item responses. This six-item index of approach coping has demonstrated strong reliability across daily assessments in previous studies (Park et al., 2004). Reliability estimates in this study evaluating between-person differences (Rkf = .99) and within-person change a (Rc = .78) were excellent and acceptable, respectively.

2.4. Data Analytic Approach

Zero-order correlations were examined for level-2 variables. Paired-samples t-tests were used to compare the frequency of avoidance versus approach coping over the daily diary period. Timepoints for each daily assessment were coded by assessment number centered at the midpoint (−13.50 to 13.50) and time of day (0 = morning, 1 = evening). All continuous level-2 predictors were grand mean-centered to aid in interpretation of intercepts.

Primary analyses included 2-1-1 (level-2 independent, level-1 mediator, level-1 dependent) and 1-1-1 (level-1 independent, level-1 mediator, level-1 dependent) multilevel mediation models with random intercepts and slopes (for the predictor and both mediators in 1-1-1 models and both mediators in 2-1-1 models) using restricted maximum likelihood (REML) estimation in Version 2.0 of the MLmed macro for SPSS (Rockwood & Hayes, 2017). The MLmed macro disaggregates within- and between- components of level-1 predictors. Random effects were determined based on best fitting models via −2LL comparisons. Lagged (T-1) daily avoidance and approach coping scores were calculated to allow for temporal precedence in predicting daily (T) outcomes and lagged (T-2) daily MC and PTSD symptom scores were computed to allow for temporal precedence in 1-1-1 models.

Analyses included two 2-1-1 [baseline predictor ⇒ daily mediators (T-1) ⇒daily outcome (T)] models and two 1-1-1 [daily predictor (T-2) ⇒daily mediators (T-1) ⇒ daily outcome (T)] lagged models. Within-person components of previous assessment MC or PTSD symptom scores (T-1) were included as covariates in relevant models. Additional covariates in 2-1-1 models included scores for the outcome variable (MC or PTSD symptoms) at baseline, age at first sexual violation, and assessment number and time of day. Covariates were entered simultaneously. Both 1-1-1 models controlled for the same covariates, as well as relevant between-level effects at each path.

Upper-level mediation (at the level of the individual) and lower-level mediation (at the level of the observation) are orthogonal paths in multilevel mediation. Additionally, level-2 variables are limited to predicting only between-level variance in mediators in multilevel modeling (Preacher et al., 2016). As predictors in our 2-1-1 models (baseline MC and PTSD symptoms) were level-2 predictors, the mediating pathway between baseline PTSD symptoms (or MC) and daily MC (or daily PTSD symptoms) was through between-person coping (i.e., to what degree did participants tend to engage in avoidance or approach coping over the 14-day period?) versus through lagged within-person coping (i.e., to what degree did participants engage in avoidance or approach coping at the previous assessment [T-1]?). Mediation tests in 1-1-1 models were examined via within-person avoidance and approach coping (controlling for between-person avoidance/approach coping).

3. Results

3.1. Descriptive Statistics and Zero-Order Correlations

Notably, 68.3% (n = 28) of participants met criteria for current PTSD. Participants reported more frequent approach versus avoidance coping, t(40) = 2.54, p = .02. Descriptive statistics and zero-order correlations for level-2 variables are presented in Table 1. Baseline MC was positively associated with average daily avoidance and approach coping and baseline and average daily PTSD symptoms. Baseline PTSD symptoms were also positively correlated with average daily avoidance coping and average daily MC. Baseline PTSD symptoms were not correlated with average daily approach coping. Between-person scores on the PCL-5 and SMCS across the two-week daily diary period were very highly correlated (r = .92), prompting closer examination to determine whether those scores reflect separate constructs when considered at the daily level versus in aggregate over the two-week period. Detrended measures of short-term instability (or within-person variability) in scores on the PCL-5 and SMCS were moderately to strongly correlated (.52 - .74) when examined via mean square successive difference (MSSD)—a measure of symptom instability that accounts for overall variability and statistical non-independence of scores over time (Jahng et al., 2008). These correlations support the discriminant validity of state MC and PTSD symptoms when considering within-person (assessment-to-assessment) variability rather than aggregated scores over the two-week period.

Table 1.

Descriptive Data and Zero-Order Correlations for 2-1-1 Model Variables

Variable 1 2 3 4 5 6 M (SD) Range
1. Baseline mental contamination (PEMC) - .45** .57** .43** .51** .51** 50.32 (14.67) 0 – 80
2. Baseline PTSD symptom severity (CAPS-5) - - .60** .28 .62** .59** 32.17 (10.57) 0 – 80
3. Daily avoidance coping (Brief COPE+) - - - .47** .87** .75** 1.94 (0.60) 1 – 4
4. Daily approach coping (Brief COPE+) - - - - .44** .42** 2.22 (0.74) 1 – 4
5. Daily PTSD symptom severity (PCL-5) - - - - - .92** 24.10 (16.97) 0 – 80
6. Daily mental contamination (SMCS) - - - - - - 14.33 (15.54) 0 – 60
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Note.

**

p < .01.

Means and standard deviations for daily approach coping, daily avoidance coping, daily PTSD symptoms, and daily MC reflect average person-mean scores. CAPS-5 = Clinician-Administered PTSD Scale for DSM-5, PCL-5 = PTSD Checklist for DSM-5, PEMC = Posttraumatic Experience of Mental Contamination Scale, SMCS = State Mental Contamination Scale.

3.2. Does Trauma-Related Mental Contamination Predict Daily PTSD Symptoms Via Approach or Avoidance Coping?

As depicted in Figure 1a, there was a significant total effect of baseline MC on daily PTSD symptoms (Path C). Baseline MC positively predicted daily avoidance coping (Path A1) and daily approach coping (Path A2). Both between-level (Path B1Between) and prior-assessment (PathB1Within) avoidance coping positively predicted daily PTSD symptoms (T) after accounting for model covariates and variance associated with baseline MC. However, neither between-level (Path B2Between) nor prior-assessment (PathB2Within) approach coping predicted daily PTSD symptoms. As expected, between-level daily avoidance coping positively mediated the relationship between baseline MC and daily PTSD symptoms (Path AB1Between), whereas the indirect effect via approach coping was non-significant (Path AB2Between). The indirect effect via avoidance coping was significantly larger than the indirect effect via approach coping, 95% CI [−0.58, −0.003]. The direct effect of baseline MC on daily PTSD symptoms was no longer significant after accounting for the mediating pathways (Path C’).

Figure 1a.

Figure 1a.

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2-1-1 multilevel mediation model predicting daily PTSD symptoms from baseline MC via lagged daily avoidance and approach coping.

As depicted in Figure 2a, there was a significant total effect of daily MC (T-2) on subsequent daily PTSD symptoms (T; Path C). Consistent with hypotheses, daily MC positively predicted next-assessment avoidance coping (Path A1); however, daily MC did not predict next-assessment approach coping (Path A2). Prior-assessment avoidance coping (Path B1) positively predicted daily PTSD symptoms after accounting for variance associated with daily MC and model covariates. However, prior-assessment approach coping (Path B2) did not predict daily PTSD symptoms. As anticipated, avoidance coping (Path AB1Within) positively mediated the association between daily MC and subsequent daily PTSD symptoms; conversely, the indirect pathway of daily MC on subsequent daily PTSD symptoms via approach coping (Path AB2Within) was nonsignificant. The direct effect of daily MC (T-2) on daily PTSD symptoms (T) remained significant after accounting for indirect effects (Path C’).1

Figure 2a.

Figure 2a.

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1-1-1 multilevel mediation model predicting daily PTSD symptoms from lagged (T-2) daily MC via lagged (T-1) daily avoidance and approach coping.

3.3. Do PTSD Symptoms Predict Daily Trauma-Related Mental Contamination Via Approach and Avoidance Coping?

As depicted in Figure 1b, there was a significant total effect of baseline PTSD symptoms on daily MC (Path C). As expected, baseline PTSD symptoms positively predicted between-level daily avoidance coping (Path A1). However, the association with daily approach coping failed to reach significance (Path A2). Between-level avoidance coping positively predicted daily MC after accounting for covariates and variance associated with baseline PTSD symptoms (Path B1Between). However, prior-assessment avoidance coping did not predict daily MC after accounting for model covariates and variance associated with baseline PTSD symptoms (Path B1Within). Additionally, neither between-level (Path B2Between) nor prior-assessment (Path B2Within) approach coping predicted daily MC. As anticipated, between-level daily avoidance coping positively mediated the relationship between baseline PTSD symptoms and daily MC (Path AB1Between), whereas the indirect effect via approach coping was non-significant (Path AB2Between). The indirect effect via avoidance coping was significantly larger than the indirect effect via approach coping, 95% CI [−0.68, −0.03]. The direct effect of baseline PTSD symptoms on daily MC was no longer significant after accounting for indirect effects (Path C’).

Figure 1b.

Figure 1b.

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2-1-1 multilevel mediation model predicting daily MC from baseline PTSD symptoms via lagged daily avoidance and approach coping.

Note. T and T-1 represent the lagged nature of within components of coping (mediator) variables relative to the assessment of daily MC (outcome variable). Mediation tests only occur via between-person components of coping variables. Unstandardized regression coefficients are presented, and standard errors are provided in parentheses. *p <.05, **p < .01, ***p <.001

As depicted in Figure 2b, there was a significant total effect of daily PTSD symptoms (T-2) on subsequent daily MC (T; Path C). As expected, daily PTSD symptoms positively predicted next-assessment avoidance coping (Path A1). Daily PTSD symptoms also positively predicted next-assessment approach coping (Path A2). Additionally, prior-assessment avoidance coping did not predict subsequent daily MC (Path B1) after accounting for variance associated with daily PTSD symptoms and model covariates. Similarly, prior-assessment approach coping (Path B2) did not significantly predict daily MC. The direct effect of daily PTSD symptoms (T-2) on daily MC (T) was no longer significant after accounting for indirect effects (Path C’).

Figure 2b.

Figure 2b.

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1-1-1 multilevel mediation model predicting daily MC from lagged (T-2) daily PTSD symptoms via lagged (T-1) daily avoidance and approach coping.

Note. T, T-1, and T-2 represent the lagged nature of within components of daily PTSD symptoms (predictor variable) relative to coping variables (mediators) and coping variables relative to daily MC (outcome variable). Unstandardized regression coefficients are presented and standard errors are provided in parentheses. **p <.01, ***p <.001

4. Discussion

This study was the first to evaluate prospective bidirectional associations between sexual trauma-related MC and PTSD symptoms using an experience sampling design. Previous work has primarily examined these associations using cross-sectional designs, limiting conclusions about temporal relationships between MC and PTSD symptoms. As expected, a bidirectional association emerged, wherein baseline MC positively predicted daily PTSD symptoms and vice versa. Likewise, daily MC (T-2) positively predicted subsequent daily PTSD symptoms (T), and daily PTSD symptoms (T-2) also positively predicted subsequent daily MC (T). These findings are the first to demonstrate that MC and PTSD symptoms predict one another over time.

A second aim of this study was to examine whether daily avoidance and approach coping mediated the bidirectional associations between MC and PTSD symptoms. Results revealed partial support for hypotheses. Individuals reporting higher PTSD symptoms at baseline (between-person) also reported a higher tendency to engage in avoidance (but not approach) coping over the two-week assessment period. This increased tendency to engage in avoidance coping mediated the association between baseline PTSD symptoms and daily MC. At the daily (within-person) level, experiencing higher than average PTSD symptoms at a given assessment predicted greater proximal use of both avoidance and approach coping when measured 8–16 hours later. However, neither of these strategies predicted MC at the subsequent assessment. In contrast with findings for baseline PTSD symptoms, individuals reporting higher MC at baseline (between-person) also reported a higher tendency to use both avoidance and approach coping strategies over the two-week assessment period. At the daily level (within-person), higher than average MC predicted greater proximal use of only avoidance coping when measured 8–16 hours later. Avoidance coping significantly mediated the association between MC and subsequent PTSD symptoms when measured at the daily level (i.e., T-1) and when averaged over the assessment period. Approach coping failed to predict subsequent daily PTSD symptoms in either model.

The finding that PTSD symptoms prospectively predicted a higher tendency to engage in avoidance coping is in line with prior research (Tiet at al., 2006). A notable, and unique, contribution of this study is the demonstration that when an individual was experiencing more intense PTSD symptoms than typical, they also tended to engage in greater avoidance coping over the next 8–16 hours. The distinction between measuring coping tendencies (aggregated behavior over weeks, months, years) and proximal use of coping strategies following acute fluctuations in PTSD symptoms may also explain some of the prior inconsistencies regarding PTSD symptoms and approach coping. Our results suggest that people experiencing more severe PTSD symptoms may not show a particular tendency to engage or not engage in approach coping. However, when someone is experiencing more intense PTSD symptoms than typical, they are likely to engage in increased coping efforts that involve both approach and avoidance over the next 8–16 hours.

The ability of this daily monitoring design to tease apart associations between how one tends to cope (i.e., at the level of the individual) versus how one copes in particularly distressing moments (i.e., at the level of the observation) is a substantial strength of daily monitoring designs. Given the complexity and context-dependence of coping behavior, movement beyond measurement of general approaches toward coping is sorely needed. It will be imperative for future research to consider the timeline on which different coping strategies are implemented, as well as the perceived effectiveness of said strategies. When individuals are experiencing distress associated with an acute increase in symptoms, they may make efforts to employ a range of coping strategies – perhaps diverging from their general coping tendencies. In moments of acute distress, individuals may perceive that some strategies (including certain avoidance coping strategies) are more likely to result in immediate distress reduction, which may increase the likelihood of using those strategies in the future. Relying on self-report measures that index avoidance and approach coping tendencies may miss important nuances that can aid in better understanding associations between PTSD symptoms and coping behavior.

It is possible that approach coping did not predict subsequent PTSD symptoms (or MC) because the relative importance of avoidance coping in predicting short-term relief from distress substantially outweighs the contribution of approach coping. Under this framework, approach coping might predict less severe PTSD symptoms (or MC) if evaluated over an extended period, as the benefits of approach coping (e.g., processing traumatic experiences) may take longer to manifest, appearing once individuals re-engage with aspects of their lives that were previously avoided. Such a model may also explain some of the inconsistent findings observed in the present study and in previous research on PTSD symptoms and approach coping. However, the relative importance of approach and avoidance coping in predicting both short-term and long-term PTSD symptoms and MC would be best evaluated over a more prolonged period.

It should be noted that our findings regarding MC and avoidance coping align with more nascent work documenting positive associations between MC and avoidance-related constructs (e.g., washing/cleansing; Fairbrother & Rachman, 2004). Importantly, similar to PTSD symptoms, individuals experiencing more severe MC at baseline reported a greater tendency to engage in avoidance coping. When symptoms of MC were higher than typical at a given assessment, individuals also reported higher engagement in avoidance coping behaviors 8–16 hours later. Diverging from PTSD symptom results, however, MC only predicted a greater tendency to engage in approach coping (not higher approach coping) at the next assessment.

It is possible that MC may lead to the tendency to engage in a more diverse array of coping strategies to manage trauma-related distress than PTSD symptoms, while fluctuations in acutely experienced MC may only lead to immediate avoidance coping. Compared to MC, it is also possible that PTSD symptoms may contribute to greater short-term (i.e., assessment-to-assessment) trauma-related distress as PTSD symptoms may capture a greater array of highly distressing experiences. Thus, individuals experiencing acutely elevated MC may not always be experiencing the wider band of PTSD symptom distress. Additional research is warranted to more precisely understand the timeline on which different coping strategies are utilized among individuals experiencing elevated MC and/or PTSD symptoms, as well as how patterns of strategy use or effectiveness may differ following elevated MC and/or PTSD symptoms.

Further refinement of the frequency of assessments, examination of specific coping strategies (e.g., washing), and evaluation of perceived short- and longer-term effectiveness of strategies is needed to better understand the nature of the relationships observed in this study. Although we did not observe systematic changes in PTSD symptoms or MC over the two-week daily diary period, it is possible that changes might emerge if symptoms were evaluated over a longer interval. A more traditional longitudinal design would also reveal whether participants are increasing the frequency of avoidance coping – or implementing avoidance behaviors to address additional distressing experiences – and would clarify whether avoidance coping functions to maintain or exacerbate PTSD symptoms and trauma-related MC.

Taken together, these results extend prior cross-sectional work by suggesting that avoidance coping may be one pathway through which PTSD symptoms and trauma-related MC mutually maintain or exacerbate one another over time. When an individual experiences higher MC than is typical, they may be more likely to avoid reminders of their trauma to seek relief from distress. However, when that process happens repeatedly over time, it likely limits engagement with aspects of the traumatic memory that contribute to more general experiences encompassed by PTSD symptoms (e.g., negative thoughts about the self). Similarly, specific PTSD symptoms may contribute to ongoing experiences of trauma-related MC over time by making salient aspects of the trauma that underlie those experiences of contamination. For example, efforts to avoid recurrent unwanted memories of the event may contribute to subsequent MC by prompting more intensive thoughts or imagery linked to contamination-related aspects of the event (e.g., bodily fluids). Additionally, avoidance of distressing self-focused experiences associated with trauma-related distress (e.g., feelings of self-disgust/shame, negative thoughts about the self) may be especially likely to precipitate higher subsequent MC as these self-focused emotions and cognitions are more closely linked to symptoms of MC than other alterations in cognition and affect that may occur within the context of PTSD (e.g., fear/anger, negative beliefs about the world). Under such a framework, the use of avoidance coping may lead to an exacerbation in overall trauma-related distress over time as avoidance can contribute to increased dysfunction in its own right (e.g., social isolation, work dysfunction).

Several limitations warrant consideration. First, although coping was evaluated twice daily, participants did not provide information contextualizing their coping behaviors to evaluate the extent to which coping was linked to either experiences of MC or PTSD symptoms. Thus, it is possible that the observed associations between trauma-related MC, PTSD symptoms, and coping behaviors may be due to participants coping with general trauma-related distress and/or other negative trauma-related outcomes rather than coping with MC and PTSD symptoms specifically. It is also worth noting that individuals may engage in avoidance coping differently in response to MC and/or PTSD symptoms. As such, additional work evaluating coping behaviors specific to MC and PTSD symptoms is necessary. The period of time between daily assessments in the present study also precludes documenting reductions in PTSD symptoms and/or MC scores immediately following coping activities. Though our data provide a clearer understanding of how avoidance and approach coping predict (and may potentially influence) symptoms 8–16 hours later, our design does not allow us to determine whether engagement in avoidance or approach coping behaviors contributes to acute reductions in PTSD symptoms and MC, as theory would suggest. Future studies may benefit from considering an event-triggered design or more frequent assessments to more proximally assess effects of coping efforts on PTSD and MC symptom fluctuation. Furthermore, unmeasured contextual factors (e.g., setting within which coping occurs) may contribute to the adaptiveness (or maladaptiveness) of a given coping style. Thus, approach and avoidance coping strategies may represent adaptive or maladaptive means of coping depending on the circumstances within which an individual is employing them (Aldao, 2013). Individuals may not always implement coping strategies in ways that effectively reduce distress (Kalokerinos et al., 2019), or they might use coping strategies that are effective at reducing some types of distress (e.g., PTSD symptoms) but not others (e.g., MC). Future research would benefit from considering context and perceived effectiveness of coping efforts.

Our findings are also limited by the high correlation between daily measures of PTSD and MC when aggregated across the two weeks. Detrended measures of short-term within-person fluctuations in daily PTSD (PCL-5) and daily MC (SMCS) scores supported the discriminant validity of the two constructs in the present study. However, future work using the PCL-5 and SMCS within daily assessments should refine these measures to maximize discriminant validity upon repeated administration. Though estimates of fixed effects for level-1 variables are relatively robust even under high multicollinearity in multilevel modeling (Shieh & Fouladi, 2003), there was evidence of multicollinearity in the 1-1-1 model predicting daily PTSD symptoms. Removal of predictors led to a similar pattern of findings, increasing confidence in the conclusions. However, interpretation of specific path coefficients from this model should be cautioned as multicollinearity may have inflated standard errors. Furthermore, it is worth noting that the reliability estimate for evaluating within-person change in daily avoidance coping was poor in the present study. Although between-person differences in daily avoidance coping were of primary interest and the reliability estimate for evaluating between-person differences in avoidance coping was excellent, the poor reliability estimate for evaluating systematic change in daily avoidance coping suggests that additional work is needed to validate daily measures of avoidance coping and determine whether avoidance coping represents a unidimensional construct. The relatively small sample size in this study may have led to biased standard errors for variance parameters in 2-1-1 models. However, fixed effects estimates have been shown to be relatively robust to small sample sizes in multilevel models, and our confidence in findings are increased by relatively consistent patterns across 2-1-1 and 1-1-1 models. Nonetheless, replication of these findings in a larger sample is needed. Finally, the present sample was restricted to women with a history of sexual trauma, limiting generalizability to other groups.

4.1. Conclusions

Despite limitations, this study documents a prospective bidirectional association between PTSD symptoms and MC following sexual trauma, wherein trauma-related MC and PTSD symptoms may mutually maintain one another at the daily level and across a two-week period via avoidance coping. These findings reconcile conflicting conceptualizations of the temporal ordering of MC and PTSD symptoms by illuminating the bidirectional nature of their associations. These results provide important insights into the processes by which trauma-related MC and PTSD symptoms may influence one another following sexual trauma. Given evidence of notable comorbidity between symptoms of PTSD and obsessive-compulsive disorder (OCD; Franklin & Raines, 2019) and the relevance of MC and contamination-related concerns to OCD (Coughtrey et al., 2012), our findings likewise underscore the potential importance of considering the role of MC in co-occurring PTSD and OCD. Findings also suggest that more closely examining coping behaviors may aid in clarifying potential mechanisms underlying the associations between sexual trauma-related MC and PTSD symptoms.

Supplementary Material

1

Highlights.

  • Mental contamination (MC) and PTSD symptoms are bidirectionally related over time.

  • Avoidance coping mediates several associations between MC and PTSD symptoms.

  • Approach coping does not mediate associations between MC and PTSD symptoms.

  • Results support the mutual maintenance of MC & PTSD symptoms via avoidance coping.

Acknowledgements

Funding: This work was supported by the Office for Policy Studies on Violence Against Women at the University of Kentucky. This project was also supported by the National Center for Advancing Translational Sciences through Grant no. UL1TR001998 at the National Institute of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Office for Policy Studies on Violence Against Women.

Abbreviations:

MC

Mental Contamination

Footnotes

Declaration of Interest

Declarations of interest: none.

1

Variance inflation factor (VIF) values suggested evidence of multicollinearity of the b1/b2 path and c’ path in the 1-1-1 model predicting daily PTSD symptoms. Removal of predictors yielded models with MC (T-2 within, between) as a predictor of either avoidance (T-1) or approach (T-1) alternating as mediators (controlling for the between component), and daily PTSD score (T) as the outcome, controlling for assessment number and time of day. The pattern of results for these reduced models were consistent with the primary model. Thus, the primary model was retained to allow comparison with the other models. VIF values in all other models < 5.

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