ORIGINAL ARTICLE

Posttraumatic Growth After Earthquake Trauma is Predicted by Executive Functions A Pilot Study Emine Eren-Koçak, MD, PhD*† and Cengiz Kılıç, MD, PhD† Abstract: Although positive personal change after adverse events (posttraumatic growth [PTG]) is repeatedly shown to occur after a range of traumatic or distressing events, there is still a debate on the validity of the concept. Using the objective measurement of cognitive functions, we attempted to show that PTG is a scientifically valid construct in a group of earthquake survivors. This is the first study to associate PTG with cognitive functioning. We found that growth was predicted by executive functions and not by memory or processing speed, showing that the correlation between cognitive functions and growth is a specific one. In addition, a specific form of PTG, namely personal growth, was related to cognitive functions, whereas relational growth was not. Our findings provide support for the validity of the PTG concept. Key Words: Posttraumatic growth, executive functions, memory, earthquake (J Nerv Ment Dis 2014;202: 859–863)

T

he negative impact of trauma on psychological health has been extensively studied. The probability of developing posttraumatic stress disorder (PTSD) after exposure to a traumatic event has been reported to be as high as 21% to 65% depending on the type of the traumatic event (Kessler et al., 1995). Clearly, not all develop PTSD after adverse events, and some may even report positive changes after trauma. This subjective experience of positive psychological change experienced because of the struggle with a major life crisis is named posttraumatic growth (PTG), and it involves the development of personal functioning and well-being that exceeds pretrauma levels (Tedeschi and Calhoun, 1996). The changes brought about by PTG are manifested in a variety of ways, including increased sense of personal strength, increased appreciation of life, recognition of new possibilities for one's life, closer relationships with other people, and a richer spiritual life (Tedeschi and Calhoun, 2004; Tedeschi et al., 1998). Several authors have questioned the validity of PTG, stressing the subjective nature of the concept. They argue that it does not reflect positive change and is at best an illusion or a coping strategy (Frazier et al., 2009; McFarland and Alvaro, 2000; McMillen and Cook, 2003). Coyne and Tennen (2010), in their critical review of positive psychology, attack the validity of the concept, arguing that measurement of PTG relies too much on memory (retrospective recall), which is well known to be subject to bias. Some researchers have included “more objective” measurements to counteract those claims. For example, Shakespeare-Finch and Enders (2008) and Park et al. (1996) showed that significant others' assessments of growth in the survivor parallel the trauma survivor's self-assessments. Another aspect of scrutiny relates to PTG's relationship with psychological distress. Given that PTG refers to positive psychological changes after the traumatic experience, it is *Institute of Neurological Sciences and Psychiatry and †Faculty of Medicine, Department of Psychiatry, Hacettepe University, Ankara, Turkey. Send reprint requests to Emine Eren-Koçak, MD, PhD, Faculty of Medicine, Department of Psychiatry, Hacettepe University, Sihhiye, 06100 Ankara, Turkey. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20212–0859 DOI: 10.1097/NMD.0000000000000211

intuitive to assume that such growth would be associated with decreased psychological distress. The literature on the relationship between PTG and psychological distress, however, is inconsistent. PTG has been reported to decrease (Frazier et al., 2001; Hall et al., 2008; McMillen et al., 1997), to increase (Hobfoll et al., 2006; Tomich and Helgeson, 2004), or to have no effect on psychological distress experienced after adverse effects (Cordova et al., 2001; Joseph et al., 1993; Powell et al., 2003). That the relationship of PTG to psychopathology is not consistent across studies adds to the debate on the questionability of the concept. Yet, another unresolved issue about PTG is how to measure it. Posttraumatic Growth Inventory (PTGI; Tedeschi and Calhoun, 1996), the most commonly used measure of PTG, has been translated into several languages and used in different cultures. There is still no consensus on whether total scores or subscale scores should be used. Research conducted in different samples resulted in differing numbers of underlying (two to five) factors. Generally speaking, studies done using non-Western populations failed to replicate the original fivefactor structure (Dirik and Karanci, 2008; Ho et al., 2004; Kılıç, 2010; Kira et al., 2012; Levine et al., 2008; Powell et al., 2003; Taku et al., 2007; Weiss and Berger, 2006). Three studies with Middle Eastern (Kira et al., 2012; Levine et al., 2008) and Asian (Ho et al., 2004) samples suggest that a two-factor solution may be best in explaining their data sets. The content of factors in those studies were not identical, but all had personal growth items separated from relations with others items. The two-dimensional conceptualization of PTG is also in line with the so-called Janus face model (Maercker and Zoellner, 2004) and JanoffBulman's (2004) “personal strength” versus “existential reevaluation.” A fundamental prerequisite for PTG development is hypothesized to be cognitive processing. The traumatic experience that leads to growth should be severe enough to shatter the person's assumptions about the world, thus requiring rebuilding of an alternative world scheme, which may help to give a meaning to the trauma (Calhoun and Tedeschi, 2006). In accordance with this assumption, it has been reported that persons, whose posttraumatic cognitive processing includes significant voluntary thinking about the event and its potential meaning, are more likely to experience PTG (Calhoun et al., 2000; Tedeschi et al., 1998). An electroencephalography study, which showed a positive correlation between PTG total scores and left frontal brain activity, provides encouraging findings in this respect (Rabe et al., 2006). Interestingly, left frontal activity showed a significant positive correlation with all PTG factors except for spiritual change. A brain imaging study on healthy volunteers also suggested, albeit indirectly, the involvement of prefrontal cortex in PTG. In this study, subjects were asked to increase, maintain, or decrease their emotional response to the aversive photographs shown (Ochsner et al., 2002). Cognitive reappraisal of aversive photographs resulted in decreased negative affect, decreased activation of the amygdala and medial orbitofrontal cortex, and increased activation of the lateral and medial prefrontal cortices. Because cognitive reappraisal is the major mechanism through which PTG develops (i.e., building a new world scheme), this study can be seen to be supportive of the role of the prefrontal cortex in PTG. Although most studies on the relationship between cognitive factors and PTSD show a general impairment in attention, memory, and

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executive functions (for detailed reviews, see Qureshi et al., 2011, and Brewin, 2011), there are no studies to date that investigated the relationship of cognitive functions with PTG. Given the skepticism about the validity of PTG based on its “subjectivity,” evaluation of cognitive functions may provide more solid evidence to base our judgments on PTG. We assessed a sample of earthquake survivors, using standardized psychopathology and cognitive measures to investigate whether and how memory and executive functions relate to PTG. We chose to investigate these cognitive functions because they were most consistently reported to be affected in PTSD subjects. Moreover, the significant involvement of the prefrontal cortex, the anatomical region related to executive functioning, in the management of stress is not new; prefrontal cortex functioning is known to relate to better handling and reappraisal of stressful experiences (Ochsner et al., 2002; Southwick et al., 2005). Our hypothesis was that PTG would not be uniformly correlated with different cognitive functions of earthquake survivors. Specifically, better executive functions and memory were hypothesized to differentially moderate the development of different PTG domains.

METHODS Participants and the Procedure Fifty-three survivors of the Marmara Earthquakes of 1999 were enrolled in a comprehensive assessment of memory and executive functions 4 years after the earthquake (Eren-Koçak et al., 2009). They were a subset of an epidemiological sample (n = 526) assessed 1 year previously (Kılıç et al., 2006). Inclusion criteria were age of 18 to 65 years; having at least primary school education; and having no history of head injury, psychotic disorder, bipolar disorder, dementia, or neurological disease. The study protocol was approved by the ethical committee of Başkent University in Ankara.

Clinical Measures

dimensions of PTG (translated and adapted into Turkish by Kılıç, 2004, unpublished PhD thesis, University of London). The PTGI was originally developed by Tedeschi and Calhoun (1996). The original version had 21 items on five factors: new possibilities, relating to others, personal strength, spiritual change, and appreciation of life. Item 1, “my priorities about life have changed,” in the original version was omitted in the Turkish version because the translation of “new interests” and “establish a new path” items partly cover the concept tapped in item 1, resulting in 20 items. Item 1 was similarly dropped in a culturally comparable sample (Powell et al., 2003). A 4-point scale (0, no change; 3, much change) was preferred rather than the 6-point scale in the original inventory, for ease of administration. Exploratory factor analyses were conducted on the original (n = 421) sample, with varimax rotation. The forced two-factor solution explained 48.8% of the total variance. The first factor was mainly composed of two of the Tedeschi and Calhoun's original five factors—“personal strength” (e.g., I can handle difficulties, feeling of self-reliance, more likely to try to change things, etc.) and “new possibilities” (e.g., I developed new interests, established new path, able to do better things with my life, etc.)—and was named “personal growth.” The second factor, on the other hand, was a condensed version of the remaining three factors—“closer relationships with other people,” “a richer spiritual life,” and “increased appreciation of life” (e.g., I accept needing others, can count on others in times of trouble, stronger religious faith, etc.)—and named “relational growth” (Table 1). Two subscale scores were computed to be used in the analyses.

Cognitive Measures These included Auditory Verbal Learning Test (AVLT), ReyOsterreith Complex Figure Test (ROCFT), Color Trail Making Test, Short Category Test, Stroop test, and Verbal Fluency Test.

Sociodemographic Evaluation Form This form included information about participants' age, sex, education, and medical history. Information regarding severity and details of trauma (participation in rescue efforts, seeing dead people, seeing bodies under the rubble, seeing mutilated bodies, entrapment under the rubble, injury or disability due to the earthquake, family members injured, family members died, relatives died, friends or neighbors died, degree of fear during the earthquake, degree of damage to the building) was also collected by this form. A trauma severity measure was computed by summing up five variables (seeing dead bodies under rubble, family member injured, relative died, friend died, and loss of house).

Traumatic Stress Symptom Checklist This 23-item self-rated questionnaire taps traumatic stress (17 items) and depression symptoms (six items) in the last month. Each item is coded between 0 and 3 (0, no problem; 1, a little; 2, marked; and 3, a lot). Both 17- and 23-item versions of the Traumatic Stress Symptom Checklist (TSSC) were shown to reliably detect PTSD in a sample of 130 earthquake survivors in Turkey (Basoglu et al., 2001). We used the total score of the 17 TSSC items derived from the original sample (n = 421).

Beck Depression Inventory This widely used, 21-item self-report questionnaire measures depressive symptoms. Each item is rated on a 4-point scale for the last week. The validity and reliability study in Turkish was established by Hisli (1989). Total score of the Beck Depression Inventory (BDI) was used in analyses.

Posttraumatic Growth Inventory PTG was assessed by the Turkish version of the PTGI, which is composed of 20 items with a 4-point scale assessing different 860

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TABLE 1. Factorial Structure of PTGIa (n = 421) Component 1 Able to do better things Established new path Knowing I can handle difficulties Feeling of self-reliance I developed new interests New opportunities emerged Discovered I was stronger than I thought Sense of closeness to others Willing to express emotions More likely to try to change things Accept the ways things work out I accept needing others How wonderful other people are Compassion for others Can count on others in times of trouble Putting effort into relationships Stronger religious faith Better understanding of spiritual matters Appreciation for value of life Appreciating each day

0.77 0.77 0.72 0.67 0.65 0.64 0.61 0.58 0.58 0.54 0.49

0.41

0.44

2

0.40 0.80 0.75 0.67 0.63 0.62 0.57 0.55 0.50 0.47

a

Varimax rotation.

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Because of our relatively small sample size, we grouped cognitive tasks into three different domains—memory, executive function, and processing speed—as described in the literature (Sheline et al., 2006). Processing speed was included to control for changes in memory performance or executive functions due to a general cognitive slowing. We created z-scores for each variable and summed all z-scores to compute new variables of three cognitive domains. Cronbach's alpha was also computed for each domain as a measure of internal consistency.

Executive Function This domain included all three categories of Verbal Fluency, Color Trail Making Part 2, the color-word interference condition of the Stroop test (number completed), number of errors made in the Short Category test, and proactive interference score of AVLT (the difference between number of words remembered from the interference list and number of words remembered from the test list in the first trial divided by 15, i.e., the total number of words in a list) (α = 0.68).

Memory This domain included AVLT immediate recall, AVLT late recall, and ROCFT recall (α = 0.82).

Processing Speed This domain included the color naming condition of the Stroop test (number completed) and Color Trail Making Part 1 (α = 0.67).

Data Analysis SPSS 17 was used for statistical analyses. Regression analyses were performed to determine how executive functions and memory related to PTG domains. For this purpose, we performed a hierarchical linear regression analysis, which enabled us to examine the relationship of executive functions and memory with PTG domains after controlling for the effects of other independent variables. The variables included in the analyses were age (18–65 years), sex (0, female; 1, male), education (years in school), traumatic stress (TSSC-17 total score), depression (BDI total score), executive functions (composite z-score), memory (composite z-score), processing speed (composite z-score), and trauma severity (composite, sum of five traumatic earthquake-related events).

PTG Predicted by Executive Function

Two separate regression analyses were conducted, using personal growth score and relational growth score as the dependent variables at each turn.

RESULTS The mean age of the subjects (n = 53) was 36.7 (SD, 13.4; range, 18–62) years. Women constituted 69.8% (n = 37) of the sample. Participants had a mean educational level of 11.9 years (SD, 3.0 years), and 83% of all the participants had an educational level of at least high school. Total PTGI score was 26.1 (12.7) and did not relate to sex, age, or either of the psychopathology measures (TSSC or BDI). The mean TSSC and BDI scores were 18.2 (SD, 12.6) and 12.4 (SD, 8.2), respectively. The mean (SD) subscale scores of PTGI, namely personal or relational growth, were 12.4 (7.5) and 13.7 (6.8), respectively. They did not relate to either TSSC or BDI. Although there was no gender difference for PTGI subscales, younger age significantly correlated with personal growth. The cognitive test scores and their correlations with PTGI are presented in Table 2. Higher performance in visual recall, fewer errors in short category test, and better verbal fluency performance in human names correlated positively with personal growth. Relational growth and total PTGI scores did not show significant correlations with cognitive measures. Hierarchical linear regression analysis was performed to determine the relationship of cognitive factors with personal and relational growth separately (Table 3). In the final solution, personal growth was predicted by better executive functions (β = 0.52, p = 0.025), but not by memory or processing speed. Total PTGI score or relational growth was not predicted by any of the cognitive functions studied. None of the sociodemographic variables were predictive of growth.

DISCUSSION This is the first study to examine the relationship of cognitive functions with PTG. We showed that, among earthquake survivors, better executive functions related to more PTG, whereas better memory did not. In addition, the relationship between executive functions and growth was a specific one: those with better executive functions reported they grew more in the personal domain than in the relational

TABLE 2. Cognitive Test Performances and Their Correlation With PTGI Factor Scores Pearson Correlation, r Cognitive Domains Memory AVLT immediate recall AVLT late recall ROCFT recall Processing speed Stroop number of colors named Color trail making part 1 Executive functions Stroop interference Color trail making part 2 Verbal fluency: animal names Verbal fluency: human names Verbal fluency: animal/human pairs Short category number of errors

Mean (SD)

Personal Growth

Relational Growth

PTGI Total Score

10.0 (2.8) 9.98 (3.0) 17.5 (5.86)

0.19 0.07 0.29*

−0.18 −0.20 0.07

0.01 −0.07 0.20

67.76 (12.63) 48.03 (18.75)

0.22 −0.1

−0.003 0.03

0.10 −0.02

49.72 (7.65) 89.9 (27.5) 22.5 (5.30) 28.9 (6.18) 8.85 (2.26) 36.6 (15.2)

0.02 −0.17 0.21 0.37* 0.25 −0.28**

−0.24 0.06 −0.03 −0.06 −0.02 −0.05

−0.12 −0.05 0.14 0.24 0.14 −0.19

*p < 0.05, **p = 0.050.

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TABLE 3. Predictors of PTGI Total and Factor Scores Total PTGI Scorea

Personal Growthb

Relational Growthc

Explanatory Variables

St Beta

t

St Beta

t

St Beta

t

Age Sex Education Traumatic stress Depression Executive functions Memory Processing speed Trauma severity

−0.28 0.15 −0.17 0.03 0.07 0.45** −0.17 −0.19 0.12

−1.55 0.94 −1.07 0.14 0.30 1.96 −0.84 −0.94 0.79

−0.27 0.08 −0.03 0.003 0.05 0.52* −0.07 −0.23 0.05

−1.55 0.53 −0.20 0.02 0.24 2.32 −0.38 −1.19 0.35

−0.19 0.18 −0.25 0.22 −0.04 0.27 −0.26 −0.02 0.08

−1.04 1.07 −1.56 0.93 −0.18 1.16 −1.30 −0.07 0.56

a

Full regression model (r 2 change = 0.19, F[9, 52] = 1.09, p = 0.39). Full regression model (r 2 change = 0.23, F[9, 52] = 1.46, p = 0.19). c Full regression model (r 2 change = 0.14, F[9, 52] = 0.78, p = 0.64). *p = 0.025, **p = 0.057. b

domain. We have thus demonstrated a specific moderator effect of executive functions on the development of PTG. Our results are in line with the previous literature documenting the involvement of prefrontal cortex functions in handling and reappraisal of stress (Ochsner et al., 2002; Southwick et al., 2005) and with the electroencephalography study that showed a link between PTG and frontal cortex activation (Rabe et al., 2006). The finding that memory did not predict any of the PTG factors is surprising. Although there are no previous study findings to which to compare ours, it is still intuitive to think that better memory should relate to more growth, given the possible protective role of better memory functions against the development of PTSD (Brewin, 2011; Qureshi et al., 2011). This expectation may not be justified, however. During a cognitive reappraisal task, prefrontal cortex (executive function–related area), but not hippocampal structures (memory-related area), was activated (Ochsner et al., 2002), a finding that supports the specificity of executive functions in the development of PTG. One of the limitations of the study is the small sample size, which forced us to group cognitive functions into three domains, therefore precluding analyses to show how each cognitive function relates to growth. Another limitation is the time lag between assessment of PTG and cognitive functions. The first and second assessments were 3 and 4 years after the earthquake, respectively. Although it is possible for PTG scores to change over time, there is evidence for the stability of growth experienced after trauma (Affleck et al., 1987; Frazier et al., 2001). There is reason, therefore, to assume that the level of PTG attained in our subjects after the earthquake would have stayed the same throughout the 1-year interval. Because the data were gathered years after the earthquake, both the cognitive and growth measures may have been affected or modified by interim events that we did not assess. Finally, the design of our study does not allow us to draw definitive conclusions about the direction of causality between cognitive functions and PTG.

ACKNOWLEDGMENTS The authors thank Prof Kathy M. Magruder for her contributions on improving our manuscript.

CONCLUSION

Frazier P, Conlon A, Glaser T (2001) Positive and negative life changes following sexual assault. J Consult Clin Psychol. 69:1048–1055.

We showed that better executive functions are more important in the development of PTG than memory or faster processing speed. The effect seems to be stronger for growth in the personal domain. Our findings provide support for the validity of the PTG concept. Future studies designed to replicate these findings are called for and should ideally be prospective, include repeated measures, and use larger samples. 862

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PTG Predicted by Executive Function

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Posttraumatic growth after earthquake trauma is predicted by executive functions: a pilot study.

Although positive personal change after adverse events (posttraumatic growth [PTG]) is repeatedly shown to occur after a range of traumatic or distres...
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