The longitudinal effect of social recognition on PTSD symptomatology and vice versa: Evidence from a population-based study
Introduction
The lack or loss of social relationships and support that meet people's needs may put their (mental) health and wellbeing at risk (Greenberg et al., 2014, Hobfoll, 1989, Hobfoll, 2002, Holt-Lunstad et al., 2010, Holt-Lunstad, 2018, Kawachi and Berkman, 2001, Kelly et al., 2017, Maercker and Müller, 2004, Shor and Roelfs, 2015). When people experience potentially traumatic events and/or crime, such as burglaries, accidents, serious threat, physical or sexual violence and disasters, a lack of social relationships and support may negatively affect their recovery. How people are treated by their social environment, especially when they are suffering from serious mental health problems following these events and/or are suffering from related stressors may therefore affect how they emotionally and cognitively process their traumatic experiences. A specific type of social support after potentially traumatic events is called “social recognition”. It is the acknowledgement or validation of event‐related thoughts, behavior, and feelings by the individual or others, and consists of positive individual or societal reactions that recognize and acknowledge victims’ traumatic experiences and difficulties (Ahrens et al., 2007, French, 2003, Southwick et al., 2000, Maercker and Müller, 2004, Mueller et al., 2009). It differs from social support in that it includes the complete perceived societal context and not only the support from a person´s close environment (Maercker and Müller, 2004).
To date, several empirical studies assessed the associations between social recognition and mental health problems, especially PTSD symptomatology, which vary in, for instance, study designs and type of potentially traumatic events. Below, we briefly discuss these studies and we start with the cross-sectional studies. Most studies used the Social Acknowledgement Questionnaire (SAQ; Maercker and Müller, 2004), that consist of three sub scales (social recognition, general disapproval, and family disapproval) and a total score scale (social acknowledgement).
Among a sample of Chechen refugees living in camps in Ingushetia, Maercker et al. (2009) found that, on a bivariate level, social recognition was not significantly correlated with PTSD symptomatology while PTSD symptomatology was significantly related to the total SAQ total score. A study among former World War II child soldiers showed that social recognition was significantly associated with intrusion, but not with avoidance, arousal, anxiety, depression, or somatization sixty years post-war (Forstmeier et al., 2009). Schumm et al. (2014) assessed the associations between family disapproval, social recognition, and PTSD among a mixed sample of US veterans seeking treatment. Social recognition was, according to the cross-sectional SEM analyses, associated with depression but not with PTSD symptom levels. General disapproval was associated with both mental health problems (they used a modified SAQ). Kuwert et al. (2014) conducted a comparative study among females that experienced conflict-related sexual violence at the end of WWII and matched females with non-sexual WWII trauma. Results showed that compared to victims of non-sexual trauma, victims of sexual violence had more mental health problems such as anxiety and hyperarousal, and lower scores on social recognition and family disapproval. The cross-sectional study by Lis-Turlejska et al. (2018) focused on a group of Polish WWII survivors and found that social recognition was correlated with depression symptoms but not with PTSD symptoms. General disapproval was moderately correlated with PTSD symptom clusters and depression.
Three studies focused on service providers. Among deployed German aid workers and workers who had completed their duty, levels of social recognition were not significantly associated with PTSD symptoms, in contrast to general disapproval, which was significantly associated with intrusion and arousal levels (Jones et al., 2006). Köhler et al. (2018) assessed the associations between PTSD symptom severity and social recognition, and the mediating role of disclosure among emergency service workers. Results suggest that PTSD symptoms indirectly influenced social recognition via reluctance to talk.
Other studies included victims of (non-war) crime and other potentially traumatic events. The study by Kern et al. (2019) among students confronted with assaultive and non-assaultive PTEs showed that social disapproval was modestly to strongly correlated with PTSD symptomatology. In a study among German and Chinese victims of crime, Mueller et al. (2009) found that social recognition and disapproval were not independent predictors of PTSD symptoms over and above other factors such as gender and trauma severity among the separate samples, while general disapproval was an independently associated with PTSD symptomatology in the total sample. Wagner et al. (2012) assessed the association between social recognition and disapproval among family members who were present at an assisted suicide. Fourteen to twenty-four months post-event, social recognition and family disapproval subscales showed significant correlations with hyperarousal, but not with intrusion or avoidance. In the study by Krammer et al. (2016), social acknowledgement (total SAQ scores) was significantly associated with PTSD symptomatology, depression, and dissociation.
In the longitudinal study by Maercker and Müller (2004) among former political prisoners in Eastern Germany, social recognition at baseline was moderately correlated with intrusions, avoidance, hyperarousal, and total PTSD symptomatology scores at follow-up. In addition, the SAQ total score (including general disapproval, family disapproval and social recognition) was a strong independent predictor of PTSD symptoms over and above social support at baseline. Mueller et al. (2008) study among victims of crime with baseline assessments 1.5 years post-event, found that general disapproval and family disapproval explained 4% of the variance of PTSD symptoms 6 months later over and above PTSD symptoms at baseline and other predictors, but not social recognition. The study by Thormar et al. (2016), which was conducted following a disaster, reported that volunteers who worked in the core of the disaster and were resilient, had higher social recognition scores than their colleagues with chronic PTSD symptomatology. The large three-wave study by Ullman and Relyea (2016) with one-year intervals among female assault victims using structural equation modeling (SEM), found that PTSD symptomatology at wave 1 predicted unsupportive acknowledgment at wave 2 and that unsupportive acknowledgment at wave 2 predicted maladaptive coping at wave 3, but not PTSD symptomatology at wave 3 (although they were significantly associated on a bi-variate level). The mean time between event and the first wave was 14 years. In the study among 80-year old former Swiss indentured child laborers, Maercker et al. (2016) found that social acknowledgment as a victim of childhood trauma was associated with an increase in depressive symptoms 20 months after the baseline assessment.
Other evidence stems from intervention studies. In the web-based intervention study by Xu et al. (2016) among a relatively small group confronted with PTEs, changes in social recognition and changes in PTSD symptoms were strongly negatively correlated, and an improvement of social recognition mediated the reduction of PTSD symptoms during and after the intervention. In addition, Sommer and colleagues (2017) assessed changes in PTSD symptomatology following treatment and found that a decrease of PTSD symptoms was significantly associated with disapproval but not with social recognition.
In summary, current research findings suggest that social recognition may protect victims against the development of PTSD symptomatology, but the number of longitudinal studies is limited and mostly started a long time after the event. Furthermore, results are mixed, with both positive and negative findings.
In addition, the results of longitudinal studies assessing the longitudinal interplay between, for instance, social support (Kaniasty and Norris, 2008) or coping self-efficacy (Bosmans and van der Velden, 2017) and PTSD symptomatology, have shown that reciprocal longitudinal associations may change over time. In these studies, while support and event-related coping efficacy did protect against the development of PTSD symptomatology in the short term, in the intermediate term PTSD symptomatology eroded support and coping self-efficacy. It is therefore important to consider and assess possible reciprocal longitudinal associations between social recognition and PTSD symptomatology (Cf. Ullman and Relyea, 2016) in the short and intermediate term. Next, studies based on a representative sample of the general population are absent. And finally, to the best of our knowledge, to date no study assessed the longitudinal interplay between PTSD symptom severity (PTSS) and social recognition in the short and intermediate term while also taking pre-event loneliness and pre-event mental health problems into account, which may impact both PTSS and social recognition levels (cf. van der Velden et al., 2018b).
For this reason, we conducted a population-based study to assess the longitudinal interplay between PTSD symptomatology and social recognition (hereinafter also abbreviated as Recognition) in the short and intermediate term, while taking pre-event loneliness and mental health problems into account. The research questions were:
- 1.
What are the longitudinal cross-lagged associations between PTSS and Recognition (PTSS → Recognition and Recognition → PTSS) in the short term (0–2 months after the PTE), taking into account pre-event loneliness and mental health problems?
- 2.
The second research question is similar to the first research question but is aimed at the same associations in the intermediate term, i.e. a longer period after the PTE (5–12 months).
- 3.
To what extent do the cross-lagged and autoregressive associations between PTSS and Recognition in the short term differ from the associations in the intermediate term, taking into account pre-event loneliness and mental health problems?
In our study, the time between baseline and follow-up PTSS and Recognition assessments was six months. We focused on adults victimized by 1.) burglary, theft or fraud, 2.) traffic or other accidents, and 3.) serious threat or physical (sexual) violence in the 12 months prior to the first survey on PTEs.
Section snippets
Procedures and participants
This study is part of the longitudinal Victims in Modern Society (VICTIMS) study of potentially traumatic events and/or crime, and support in the Netherlands. Data were collected in the Longitudinal Internet studies for the Social Sciences (LISS) panel, administered by CentERdata (Tilburg, The Netherlands; Scherpenzeel and Das 2011) and granted by the Netherlands Organization for Scientific Research (NWO). The LISS panel is based on a large representative random sample drawn from the Dutch
Participants
Table 1 provides an overview of the demographics, the three types of potentially traumatic events, pre-event loneliness and mental health problems, and posttraumatic stress symptoms and Recognition of both subgroups. Results showed that both subgroups, after we randomly selected victims to obtain equal distributions of type of events, did not differ significantly and were highly comparable. The intercorrelations of study variables are presented in Table 2. In both subsamples, study variables
Discussion
To the best of our knowledge, this is the first population-based study examining the longitudinal interplay between PTSD symptomatology and social recognition among adults who were affected by potentially traumatic events recently (short term; in the past 0–2 months) and longer ago (intermediate term; in the past 5–12 months). In this study we focused on victims of 1.) burglary, theft and fraud, 2.) (traffic) accidents, and 3.) serious threat and physical (sexual) violence.
The results of the
Conclusions
According to the results of the present study, social recognition during the first months after potentially traumatic events enhances the psychological recovery of victims, i.e. is related to lower PTSD symptom levels at later stages. However, the positive effects of social recognition on PTSD symptom levels 6 months later disappear in the intermediate term, suggesting that it is critical to offer social recognition during the first months (at least). The relevance of early social recognition
Declaration of Competing Interest
None.
Acknowledgment
This study is part of the longitudinal Victims in Modern Society (VICTIMS) study, granted by the VictimSupport Foundation (Fonds Slachtofferhulp), The Netherlands.
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2020, Journal of Anxiety DisordersCitation Excerpt :If the provided social support matches the victim’s needs, it may help him/her to cope with the event, with event-related sources of stress, or with a loss of resources, which in turns helps reduce the risk for post-event mental health problems (cf. Hobfoll, Freedy, Lane, & Geller, 1990). As such, perceived social support may moderate, mediate, or provide a buffer against the potential negative effects of serious threat and physical, sexual, and partner violence on victims’ mental health (Adams et al., 2006; Cohen & Wills, 1985; Birkeland et al., 2017; Kaniasty & Norris, 2004; van der Velden et al., 2019; Yap & Devilly, 2004). Post-event social support may furthermore enhance the efficacy of the treatment of PTSD (Palardy et al., 2018).