73 Impact of Trauma Exposure and Post-Traumatic Stress Symptoms on Baseline Self-Reported Safety Behaviors Versus Observer-Rated Safety Behaviors During the Trauma Film Paradigm

Faculty Mentor: Anu Asnaani (Psychology, University of Utah)

Abstract

Background: Post-traumatic stress disorder (PTSD) is a high burden disorder marked by safety behaviors (SB), which are covert or overt actions used to escape distressing feelings or places. However, literature suggests scores on observer-rated and self-reported SBs can be discrepant, creating a need to examine if this discrepancy exists in those who have had a traumatic exposure or in those with both trauma exposure and significant PTSD symptoms, to examine how SBs may present in PTSD and trauma. We expect that the presence of significant PTSD symptoms will be correlated with greater SBs and will result in a greater discrepancy between these two types of SB reporting standards. Methods: We used an analysis of variance (ANOVA) to examine difference scores between an observer-rated measure of SBs performed by participants exposed to trauma-related videos and a self-reported measure of SBs at baseline. This was done across three groups: individuals with no trauma exposure (n= 77), those with trauma exposure but minimal symptoms (n= 49) and those with trauma exposure and likely PTSD (n=24). Results: PTSD symptoms were correlated with self-reported SBs (r = .44, p<.001), but not observer-rated SBs (r = -.15, p=.30). The ANOVA revealed a significant difference between self-reported and observer-rated SBs for those with probable PTSD compared to the other groups, who did not show this discrepancy between types of SBs (F(2,101) =3.53, p= .03), such that those with likely PTSD had greater self-reported SBs than observer-rated SBs. Conclusions: We found that individuals with probable PTSD showed significant discrepancy in types of SBs, which suggests SBs may be more covert for individuals with PTSD and harder for observers to spot in clinical or research settings, highlighting that SBs may differ in those with PTSD and emphasizing the need to provide education on how individuals with PTSD may mask their avoidance.

Keywords: Posttraumatic stress disorder, safety behaviors, trauma, trauma avoidance, exposure therapy

Impact of trauma exposure and posttraumatic stress symptoms on baseline self-reported safety behaviors versus observer-rated safety behaviors during the trauma film paradigm

Posttraumatic stress disorder (PTSD) is a multi-layered and complex disorder. It is a pervasive and potentially debilitating mental illness defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) as the presence of each the following points: A) a direct or indirect exposure to a traumatic event, B) presence of intrusion symptoms associated with the traumatic event beginning after the traumatic event occurred, including disassociation episodes or reoccurring distressing memories and/or nightmares, C) avoidance of stimuli associated with the traumatic event, D) negative alterations in cognitions and mood associated with the traumatic event, beginning or worsening after the traumatic event, E) marked alterations in arousal and reactivity associated with the traumatic event, including hypervigilance, and F) symptoms lasting over one month and not being due to effects of substances or medications (APA, 2013). One major factor that complicates the diagnostic process is that despite around 70% of the adult population experiencing a traumatic event at some point in their lives, such as military combat, sexual assault, or serious life- threatening illness or injury (National Institute of Mental Health, 2017), research has further shown that only around 8-15% of the general population will end up meeting diagnostic criteria for PTSD (Bryant-Genevier et al., 2021). This peculiar aspect of PTSD invokes a question as to what possibly differentiates patients who develop a PTSD diagnosis from those who do not following an exposure to trauma, a question that warrants scientific and empirical investigation.

Several current theoretical models of PTSD that exist to explain how PTSD occurs delineate the role that avoidance behaviors (i.e., the tendency to avoid thoughts, feelings or situations that remind one about the trauma) may play in maintaining symptom longevity of PTSD (LoSavio et al., 2017; Brewin & Holmes, 2003). Exposure-based treatments for PTSD target such behaviors, and involve guided, systematic, and repeated confrontation with feared stimuli, with significant evidence of their efficacy for PTSD (Brown et al., 2019). One particular target in exposure therapy is eliminating a type of avoidance known as safety behaviors (SBs, i.e., overt or covert actions performed to prevent, escape, or minimize a feared catastrophe and/or associated distress; VandenBos, 2015). Essentially, individuals utilize SBs to cope with the anxiety and distress of unpleasant feelings or the risk of feared outcomes associated with traumatic feelings, places, or events (Helbig-Lang & Petermann, 2010).

Those who use SBs intend to use them as a short-term means to relieve anxious feelings and symptoms (Helbig-Lang & Petermann, 2010). However, emerging research has shown that utilization of SBs has been shown to maintain those symptoms, rather than the intended purpose of reducing anxiety and fear (Allen et al., 2020). This leads to persistence of such symptoms, showing that the short-term relief provided by SB usage does not necessarily translate to long- term relief of mental health symptoms (Blakey & Abramowitz, 2016; Forsyth et al., 2016). Since SBs are a hallmark of trauma disorders (Blakey et al., 2021), the study of SBs is highly relevant to understanding the multi-layered relationship between PTSD and trauma exposure. The frequency of patient usage of SB has been shown to be a significant predictor of a PTSD diagnosis as well a correlate of severity of symptoms (Karamustafalioglu et al., 2006; Freeman et al., 2013; Goodson & Haeffel, 2018). Additional research has shown an association between SB engagement and traumatic intrusions in particular (McClure et al., 2019).

Despite these empirical findings, patients with PTSD and/or trauma exposure who utilize SBs are often hesitant to eliminate them. One likely explanation for this is that patients may misattribute positive outcomes in anxiety- and trauma-provoking situations to the use of SBs. For example, an individual who becomes anxious in a public place may exhibit the SBs of bringing anti-anxiety medication in anticipation of feeling anxious in public. If the anxious feelings do not arise, the patient may misattribute this to bringing the medications as opposed to other factors. In essence, the patient is assigning causality to the utilization of the SBs as the reason for maintaining safety rather than an actual cause of the traumatic or anxiety-inducing event not occurring. Furthermore, patients utilizing SBs seldom understand their actual role in maintaining symptoms rather than alleviating symptoms (Helbig-Lang & Petermann, 2010).

Safety behavior measuring methods can be divided into two distinct categories: subjective, or patient self-report methods, and objective observer-rated methods. Self-report methods are usually offered by clinicians and researchers as a questionnaire wherein the participant voluntarily self-reports frequency of SBs, usually during day-to-day activities. Objectively reported methods are those that are coded by an observer – for example, based on SBs performed during a task or video clip designed to elicit an anxious or trauma-like response (Olatunji & Fan, 2015). A more recently developed method of objectively measuring safety and avoidance behaviors is rating behaviors made by participants in a computer simulation game involving avoidance-like decision making in simulated events or situations (Myers et al., 2016). While methods vary, the goal of observation methods is to measure frequency of SBs’ usage and these objective measures are most often used to measure correlations with mental health symptoms.

Despite numerous empirically supported methods of measuring SBs, the process of examining the role trauma exposure and PTSD symptoms have on SBs is significantly complicated by research showing that there exists a significant discrepancy between subjective participant reporting of SBs and observer ratings of such behaviors in fear-based disorders more broadly. Specifically, Rowa et al. (2015) found that self-reported SB scores were greater than observed SBs when rated by a coder during a recorded speech test. Research done by Blakey et al. (2020) in the United States has shown that this discrepancy on reporting SBs can vary by region with cultural attitudes significantly influencing how some self-report SBs present. To our knowledge, however, there has been limited work that experimentally examines whether and how this discrepancy exists specifically in the context of PTSD when compared to those with a no traumatic exposure and/or a traumatic exposure that does not manifest as PTSD.

While SBs were only initially examined in the context of the broader class of anxiety disorders (i.e., generalized anxiety disorder and obsessive-compulsive disorder), there is growing interest in examining the role they may play in maintaining PTSD symptoms and diagnosis. However, there exists a dearth of research examining if this discrepancy also exists in participants with simply a history of an exposure to trauma or what role, if any, PTSD symptoms may play in explaining this reporting discrepancy. A major focus of exposure therapy is targeting and eliminating symptom-maintaining SBs, necessitating further examination into whether trauma exposure and/or PTSD symptoms may be associated with discrepancies between patient- reported as opposed to clinician-rated methods of safety behavior utilization.

Given this gap in the literature, the present study sought to examine if a discrepancy between self-reported and/or objectively measured, observer-rated SBs exists, and if this may be linked to an exposure to trauma, or the presence of significant PTSD symptoms. There were three aims of this present study: the first aim was to measure if the presence of PTSD symptoms were correlated with self-reported and/or observer-rated SBs. We hypothesized that there would be a significant correlation between the variables of both observer-rated and self-reported safety behavior in individuals reporting greater PTSD symptoms. The second aim of this study was then to examine if there were any significant differences in the self-reported and observer-rated SBs across three groups: those with no trauma exposure, those with a past trauma exposure but few PTSD symptoms, and those with trauma exposure and significant PTSD symptoms. Based on previous literature examining the role SBs play in symptom severity and maintenance, we expected that the groups with trauma exposure and minimal PTSD symptoms and probable PTSD would have a significantly greater number of both kinds of SBs compared to those with no trauma exposure. The third and final aim herein was to test if a discrepancy between the two types of safety behavior reporting methods would be associated with specific group membership. We lastly hypothesized that a difference in reporting discrepancy between types of SBs would be statistically associated with having probable PTSD only, in line with research in other fear-based disorders (Blakey et al., 2020).

Methods

Participants

Institutional Review Board approval was given for all research and procedures performed in this study. Signed informed consent was received from all participants and all data were deidentified. Participants (N=150) for this experiment were recruited as part of a larger study conducted by a research laboratory at a public university in the Mountain West region of the United States. Recruitment for this study was done via SONA, a centralized online recruitment program for recruitment of undergraduate students, for which participation in this study was awarded course credit. The sample included participants identifying ethnically as 62.0% white,19.7% Hispanic or Latino, 8.3% Asian/Pacific Islander, 1% Native American, 2.2% Black, and 7.3% other races. Demographics additionally included 24.2% first-generation college students and 34.6% upper income-class participants.

Materials

Trauma Film Paradigm. This task consisted of one of two different video clips viewed by study participants. The videos were both five-and-a-half minute long videos of potentially fatal car crashes. Specifically, one of the videos was a compilation of various scenes of car crashes with injuries explicitly shown and the other was of unedited footage of one particular car crash shown in a full five-and-a-half-minute long interval. These clips have been shown to elicit anxious feelings and were designed to evoke SBs in participants who utilize them (Olatunji & Fan, 2015). Due to a desire to maintain social distancing in light of the ongoing COVID-19 pandemic, these videos were displayed on the participant’s own computer while on a live video Zoom call with a lab assistant.

Self-Reported Safety Behavior Assessment Form (SBAF). The Safety Behavior Assessment Form (SBAF) was utilized in this study to measure subjective self-reported safety behavior utilization. The SBAF is a self-report questionnaire wherein participants respond to a 41-item battery regarding various SBs they may potentially utilize in day-to-day activities, including questions/statements such as, “Do you over-plan for everyday events?” and “I stay on the outside of crowds and/or monitor for exits or escape routes”. Participants rate each question on a scale of zero, one, two, or three, with each number corresponding to “never”, “sometimes”, “often”, or “always”, respectively (Goodson et al., 2016). Each question is further categorized into one of four subscales, in addition to a total overall score. These subscales are vigilance (7 items), social (7 items), health (8 items), or PTSD (12 items) and seven unaffiliated questions contributing to the final score, and the range of total scores was 0 to 123. Previous research has shown that this measure has high levels of internal consistency and test-retest reliability (r = .76), as well as an excellent level of internal consistency (α = .92) and may be used by clinicians and experimenters to measure patient SBs for treatment/research (Goodson et al., 2016). Internal consistency of the SBAF total measure in the current sample was excellent (α=90).

Objectively-Rated Safety Behavior Coding. The observer-rated SB measure was scored via a behavioral coding measure specifically designed for this study. Specifically, videos of study participants engaging in the trauma film paradigm were recorded and later coded by undergraduate research assistants trained to code for observed SBs by a licensed clinician. Research assistants were specifically trained to record the frequency and type of various observed participant SBs, including items such as how often the participant looked away from the screen or how often they engaged with the lab assistant to feel safer. Training procedures included having coders rate three test subjects with 90% accuracy to the scores obtained by the training clinician, and only being cleared to conduct study coding upon reaching this threshold with three consecutive test participants. There were ten questions rated by the coders on a scale of zero, meaning “not at all”, to four, meaning “very often”, on how often these behaviors were exhibited over the viewing of each distressing film. These included the observer rating behaviors such as delaying starting the films and intentionally engaging the observer to avoid the film. Additionally, some questions included a scale measuring intensity of the behaviors, also measured on a zero, meaning “never” to four, meaning “very intense behavior”. The total score had a range of scores of zero to forty. Data regarding observed SBs were recorded in the survey software program Qualtrics to generate a total score of observable SBs during each distressing film task.

PC-PTSD-5. The PC-PTSD-5 is a five-question clinical assessment self-report questionnaire that assesses for probable PTSD. The questionnaire asks participants questions on a yes or no scale, initially asking if the participant has experienced any one event of a list of traumatic events such as combat, having been in an accident, having a close loved one die through homicide or suicide, among others. If the participant answers “yes”, they are then asked five follow-up questions that ask details about the presence of PTSD symptoms in the past month (yes or no). This portion of the questionnaire includes questions such as “had nightmares about the event(s) or thought about the event(s) when you did not want to?” and “have you been constantly on guard, watchful, or easily startled?”, to which participants answer “yes” or “no”. Scores can range from 0 to 5, with those scoring three or higher categorized as having “probable PTSD”. Previous research with the PC-PTSD-5 has shown good test-retest reliability (r = 0.83) as well as strong internal validity (r=.083; Prins et al., 2016). Internal consistency of this measure in the current sample was found to be good (α=.79).

Procedure

After informed consent was received from participants, individuals were asked to fill out the SBAF and PC-PTSD-5. Participants were then given one of the two distressing films from the trauma film paradigm to view, which they were asked to complete either before or after a separate breath holding task (not examined in this study), in addition to subsequently completing one of three interventions (interoceptive exposure, mindfulness, and a positive self-efficacy induction) occurring after the trauma film paradigm that were aimed at improving participants’ distress tolerance (which were also not the focus of the current paper). They then were given the second trauma video to view either before or after another breath-holding task (with counterbalanced order; this second video was also not examined in the current study). During these tasks, participants’ behaviors were monitored and recorded via the Zoom meeting. After completion of the entire study, all participants were debriefed and provided with support resources if they requested, as this study included exposure to distressing videos and risked being emotionally upsetting to participants. The recorded videos of participants viewing the trauma film videos before and after intervention were then later coded for SBs by the aforementioned coders. As mentioned above, for the current study, only SBs observer-coded for the trauma film viewed before the provided intervention were examined and compared to participant self- reported SBs at baseline.

Data Analysis

All data were analyzed via the statistical software program SPSS Statistics version 27. Initially, we ran the suggested scoring guidelines to organize participant data into three groups of either non-trauma exposed, trauma-exposed with minimal PTSD, and trauma exposed with probable PTSD, based on scores on the PC-PTSD-5 to address aims 2 and 3. Specifically, participants who answered “no” to the first question, i.e., if they had a previous exposure to a traumatic event, were placed in the non-trauma exposed group (n = 77). Those endorsing a trauma exposure but answering ‘yes’ to only one or two of the remaining questions were placed into the trauma-exposed group (n = 49). Participants reporting a trauma exposure and endorsing three or more PTSD symptoms on the PC-PTSD-5 were placed into the probable PTSD group (n= 24), based on previously suggested scoring guidelines for this measure (Williamson et al., 2022).

Data regarding subjective self-reported SBs as measured by the SBAF (including the vigilance, social, health, and PTSD subscales, and the total score) and the observer-coded safety behavior usage data were correlated with the score on the PC-PTSD-5 (Aim 1). Following this, an analysis of variance (ANOVA) was conducted to test if there were significant differences in self-reported or observer-rated SBs across any of the three trauma exposure groups (Aim 2). Finally, to examine whether there was a significant difference between the discrepancies on both types of SBs and whether this was associated with any of the trauma groups (Aim 3), the self- report and observer-rated measures were compared by first z-scoring the SBAF total scores and the video-coded observer scores and calculating the difference between the two sets of z scores. This difference z score was then compared across the three groups of participants via a between- groups ANOVA, followed up with pairwise comparisons to examine any significant differences between groups in the discrepancy between self-reported and observer-rated SBs, at the significance level of p=.05.

Results

For Aim 1, correlations regarding SBs for both the self-report and observer-rated measures with the PC-PTSD-5 score can be found in Table 1. Briefly, observer-rated scores were not found to be statistically associated with PC-PTSD-5 scores (see Table 1). However, each of the subscores on the self-reported SBAF, other than the PTSD subscore and the total score were found to be positively correlated with greater scores on the PC-PTSD-5.

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