Mechanisms of Psychological Distress following War in the Former Yugoslavia: The Role of Interpersonal Sensitivity

Morina N (2014) Mechanisms of Psychological Distress following War in the Former Yugoslavia: The Role of Interpersonal Sensitivity. PLoS ONE 9(3): e90503. doi:10.1371/journal.pone.0090503 Mechanisms of Psychological Distress following War in the Former Yugoslavia: The Role of Interpersonal Sensitivity Angela Nickerson 0 Stefan Priebe 0 Richard A. Bryant 0 Nexhmedin Morina 0 Sharon Dekel, Harvard Medical School, United States of America 0 1 School of Psychology, University of New South Wales , NSW, Sydney , Australia , 2 Unit for Social and Community Psychiatry, Barts' and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom, 3 Department of Clinical Psychology, University of Amsterdam , The Netherlands While high prevalence rates of psychological symptoms have been documented in civilian survivors of war, little is known about the mechanisms by which trauma exposure might lead to poor psychological outcomes in these populations. One potential mechanism that may underpin the association between war-related traumatic experiences and psychopathology is interpersonal sensitivity. In the current study, we applied structural equation modeling to investigate the impact of interpersonal sensitivity on posttraumatic stress disorder (PTSD) symptoms, depression symptoms, and anger responses following exposure to war trauma. 3313 survivors of the war in the former Yugoslavia were identified and selected using a multistage, probabilistic sampling frame and random walk technique. Participants were interviewed regarding trauma exposure, interpersonal sensitivity, and PTSD symptoms, depression symptoms, and anger responses. Structural equation modeling analyses revealed that the relationship between trauma and PTSD symptoms and depression symptoms was partly statistically mediated by interpersonal sensitivity. Further, findings indicated that the relationship between trauma and anger responses was fully statistically mediated by interpersonal sensitivity. These results suggest that interpersonal sensitivity may function as a key mechanism that contributes to psychopathology following trauma. - Funding: This study was funded by a grant from the European Commission, contract number INCO-CT-2004-509176. AN was supported by a Clinical Early Career Research Fellowship (113295) and a Project Grant (1042882) from the National Health and Medical Research Council (NH&MRC) of Australia. The views expressed are those of the authors and not necessarily those of the European Commission or the NH&MRC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Research has consistently documented elevated rates of psychological disorders in civilian survivors of war trauma [13]. A meta-analysis of 181 studies conducted across the globe estimated that approximately 30% of conflict-affected civilians and refugees meet criteria for posttraumatic stress disorder (PTSD) and/or depression [2]. While exposure to war trauma is associated with elevated rates of psychopathology, individuals meeting criteria for disorder in conflict-affected groups are usually in the minority. This highlights the considerable variation in how well people adapt psychologically following exposure to war-related trauma. Research has identified contextual factors, such as type and/or dosage of trauma exposure and post-trauma stressors, which impact on the variable psychological outcomes in conflictaffected groups [46]. In contrast, relatively little research attention has been paid to the psychological mechanisms that contribute to the development and maintenance of psychological symptoms following trauma exposure in war-affected populations. Traumatic events that occur in the context of war and persecution are often repeated and human-instigated, such as witnessing the violent death of loved ones, being beaten or seriously injured by another person, or being tortured. In addition to poor mental health outcomes, exposure to interpersonal trauma has been linked to negative social consequences including impaired capacity to relate to others and decreased interpersonal trust [7,8]. One specific mechanism by which human-instigated trauma has been demonstrated to influence mental health and social functioning is interpersonal sensitivity, defined as undue and excessive awareness of, and sensitivity to, the behaviour and feelings of others [9]. Studies suggest that interpersonal sensitivity is associated with exposure to various types of trauma, including childhood abuse [10], dating violence [11], and war trauma [4]. Individuals who have experienced multiple traumatic events evidence higher levels of interpersonal sensitivity than those who have experienced a single traumatic event [12]. Further, interpersonal sensitivity has been linked to negative mental health outcomes including PTSD, depression, and anxiety [4,1316]. Researchers and clinicians have noted that difficulty trusting others and increased perceptions of hostility are common phenomena in refugee and post-conflict populations [1720]. Indeed, these responses may be adaptive in the context of war and persecution, where heightened awareness of the intentions of others is likely to facilitate the identification (and adaptive avoidance) of interpersonal threat. In conflict-affected settings, where misplaced trust may have catastrophic consequences, sensitivity to potential interpersonal threat may remain high, even when there is no longer imminent danger. This heightened sensitivity may be unnecessary or even contribute to psychological distress, as evidenced by research findings linking interpersonal sensitivity and psychological symptoms [4,15,16]. Further, interpersonal sensitivity is likely to impact on interpersonal behaviors and social functioning. One plausible consequence of interpersonal sensitivity is heightened anger reactions, as rumination on trauma and injustice may precipitate anger reactions in response to perceived threat. This may be especially salient in conflict-affected settings where preoccupation with past injustices and the desire for revenge is common [21,22]. Accordingly, emerging research suggests that anger reactions are highly prevalent amongst war survivors and refugees [2325], and are associated with exposure to human rights violations and socio-economic factors [24,25]. The enormous social and healthcare cost of anger and violence, and the recognized relationship between anger, trauma and PTSD [2628] necessitates further research on anger responses and their underlying mechanisms. Based on research documenting the deleterious impact of war trauma on mental health [13] and that linking interpersonal sensitivity with both trauma exposure and psychological symptoms [4,15,16], the aim of the current study was to investigate the association between tr (...truncated)