Psychiatry 76(3) Fall 2013

241

PTSD and Negative Cognitions

Dekel et al.

The Relationship of PTSD to Negative Cognitions:

A 17-Year Longitudinal Study
Sharon Dekel, Tamar Peleg, and Zahava Solomon

With the growing interest in the role of cognitions in PTSD, this prospective study
examined the course and bi-directional relationship between post-trauma cognitions and symptoms of PTSD. A sample of Israeli combat veterans, including
former prisoners of war, was assessed in 1991, and later followed up in 2003 and
2008. PTSD symptoms were measured at three time points. Cognitions concerning the self and the world were measured twice. Applying Autoregressive CrossLagged (ARCL) modeling strategy, initial PTSD symptoms predicted subsequent
negative cognitions but not vice versa. In addition, repeated measures design revealed that individuals with chronic PTSD symptoms had relatively negative cognitions that further amplified with time. More specifically, increasingly negative
cognitions were documented among ex-prisoners of war. The main findings suggest that negative cognitions are fueled by PTSD and that in chronic PTSD there
is an amplification of pathogenic outcomes over time. Discussion of the findings
is in the context of current cognitive models of PTSD.

Posttraumatic stress disorder (PTSD)

is the most prevailing psychiatric outcome
following trauma (Breslau, 2009). It impairs
daily functioning and overall well-being
(Corry, Klick, & Fauerbach, 2010). While a
sizeable portion of survivors experience distress that fades within weeks, a significant
sub-group fails to recover and suffers from
enduring symptoms (e.g., Milliken, Auchterlonie, & Hoge 2007; Shalev, 2009). Individ-

uals exposed to a trauma of prolonged and

extreme nature have a heightened vulnerability for PTSD (Kessler, 2000).
In recent years, the role of cognitions
in PTSD has gained increasing attention.
Among the cognitions receiving empirical
scrutiny are core cognitions concerning the
self and the world held by survivors in the
wake of trauma (e.g., Ehlers & Clark, 2000).
While maladaptive (excessively negative)

Sharon Dekel, Ph.D., is affiliated with the PTSD Research Laboratory, Massachusetts General Hospital-East,
Charlestown, Massachusetts. Zahava Solomon, Ph.D., is affiliated with the Bob Shapell School of Social Work, Tel
Aviv University, Tel-Aviv, Israel. Tamar Peleg, Ph.D., is with the Department of Social Work, Ben Gurion University
of the Negev, Israel.
This study was supported by the Young Investigator Grant of the Brain and Behavior Research Foundation sponsored by Dr. Dylan Tauber, which was awarded to Sharon Dekel.
Address correspondence to Sharon Dekel, PTSD Research Laboratory, Massachusetts General Hospital-East, 120
Second Ave., Charlestown, MA 02129. E-mail: dekel.sharon@gmail.com

2013 Washington School of Psychiatry

242

post-trauma cognitions are deemed to result

in PTSD and impair recovery (see Brewin &
Holmes, 2003, for a review), the reverse relation, PTSD triggering negative cognitions
and their maintenance, has been overlooked
(Power & Dalgleish, 1999). Also, with the
growing evidence that modification of maladaptive post-trauma cognitions is effective
for treating PTSD (Lancaster, Rodriguez, &
Weston, 2011), examining changes in cognitions outside the context of therapy is warranted. This study, therefore, intends to address these gaps.
Normally, most individuals hold relatively positive core cognitions of themselves
and the world (Taylor & Brown, 1988)
and these cognitions are considered to remain rather stable over the life span (Power
& Dalgleish, 1999). A traumatic event, by
its unpredictable, uncontrollable, and extremely negative nature, may nevertheless
challenge enduring cognitions. Given the
intensity of the event, survivors may be unable to interpret their traumatic experiences
as unique and unusual. Rather than assimilating trauma-related information into their
existing cognitions, accommodation may occur: core cognitions are therefore modified
to incorporate a critical mass of inconsistent
information (e.g., Dalgleish & Power, 2004;
Foa & Jaycox, 1999).
Janoff-Bulman (1992) was the first
to coin the term shattered world assumptions to signify the potent impact of trauma
on core cognitions. According to her theory,
three higher-order cognitions concerning the
survivors and their world are challenged.
First, rather than believing in the benevolence of the world, survivors may view the
world as a place in which bad things happen
and its people as uncaring. Second, rather
than believing in the meaningfulness of the
world, survivors may view the world as an
unjust and uncontrollable place in which
events happen by chancethat is, bad things
may happen to good people. Finally, trauma
can pose a threat to survivors belief in selfworth. They may develop a negative self-

PTSD and Negative Cognitions

image: viewing themselves as bad, immoral,

and subject to and deserving of ill-fortune.
Early cross-sectional investigation
showed that various traumatized groups
have relatively more negative post-trauma
cognitions than non-traumatized groups
(e.g., Magwaza, 1999; Solomon, Iancu, &
Tyano, 1997), underscoring the impact of
exposure to trauma on cognitions. More recently, a series of studies assessing survivors
of diverse traumatic events suggests that the
emotional response to the trauma entailing
the development of PTSD is linked with endorsement of negative post-trauma cognitions rather than exposure to trauma in itself. For example, patients with myocardial
infractions classified with clinical PTSD had
relatively negative beliefs in comparison to
patients without PTSD and matched controls
(Ginzburg, 2004). In a study of individuals
with a history of physical or sexual assault
and controlling for assault severity, PTSD
symptom severity was positively associated
with negative cognitions (Dunmore, Clark,
& Ehlers, 2001).
In light of this association, an important issue concerning the directional relationship should be raised: negative post-trauma
cognitions may lead to PTSD, yet at the same
time PTSD may fuel negative cognitions.
THE BI-DIRECTIONAL RELATION
BETWEEN POST-TRAUMA
COGNITIONS AND PTSD

The popular view advocates that maladaptive post-trauma (and pre-trauma) cognitions are an imperative catalyst of PTSD.
With their rigid nature, they impede the
processing of corrective information, rendering the individual vulnerable to developing and maintaining PTSD. In accord with
emotional processing theory (EPT) (e.g.,
Foa & Rothbaum, 1998), survivors who
come to view the world as extremely dangerous and the self as inept may be reluctant
to engage in daily behaviors that disconfirm

Dekel et al. 243

these views, systematically avoiding traumarelated thoughts and activities. This way, a
pathological memory fear structure entailing
numerous danger stimulus-responses is
maintained and chronic PTSD develops.
In accord with the cognitive processing theory (Resick, & Schnicke, 1992),
drawn on information-processing models,
survivors who eventually develop PTSD experience a conflict between their pre-trauma
beliefs about the self and world (e.g., the belief that nothing bad will happen to me) and
post-trauma information (e.g., the trauma as
evidence that the world is not a safe place).
These conflicts, so-called stuck points, interfere with the emotional processing of the
event and the recovery.
At the same time, others have postulated that PTSD may trigger negative posttrauma cognitions. As Power and Dalgleish
(Dagleish & Power, 2004; Power & Dagleish, 1999) originally postulated, the relation
of cognitive schemas to emotional disorders,
including PTSD, is bi-directional. In their
multi-level model, post-trauma negative automatic thoughts related to the trauma may
result in shattered schematic representation
(higher order ideation of extreme belief in
vulnerability), which then generate symptoms and accompanied emotions. Once these
elements are active, a top-down process begins, suggesting that symptoms of PTSD may
fire back and amplify negative cognitions.
More specifically, PTSD is coined a
pervasive disorder and its debilitating symptoms may therefore penetrate the traumatized inner psychological world. In fact,
symptoms of PTSD were previously found
to have a pathogenic effect on survivors attachment orientation (Solomon, Dekel, &
Mikulincer, 2008), which is underlined by a
relational cognitive schema. It follows that
PTSD symptoms and accompanied behaviors may lead to impairments in the traumatized core cognitions. For example, maladaptive social functioning entailing outbursts of
uncontrolled anger and violence along with
an enduring sense of loneliness, often seen in
PTSD (Solomon & Dekel, 2008), may give

rise to negative post-trauma cognitions of

the self and the world.
A possible way to address the bi-directional relation between negative cognitions and PTSD is by employing prospective
designs. Interestingly, a growing number of
recent studies utilizing this approach seem
to confirm that negative cognitions lead to
PTSD (e.g., Dunmore, Clark, Ehlers, 2001;
Kleim, Ehlers, & Glucksman, 2007; Michael, Ehlers, Halligan, & Clark, 2005). For
example, Dunmore and colleagues (2001)
found that negative core beliefs assessed less
than 4 months after an assault predicted
subsequent PTSD severity 6 and 9 months
post assault. A shortcoming of the studies,
however, is that assessments pertained to the
relatively short term following exposure. To
the best of our knowledge, no study to date
has examined the predictive value of negative post-trauma cognitions for PTSD in the
very long term, and more important, the theorized bi-directional relation between PTSD
and cognitions has not been assessed over
time. It may be that the interplay between
negative cognitions and PTSD varies with
time following the trauma or even that it is
short-lived and fades away.
THE RELATION BETWEEN
CHANGES IN POST-TRAUMA
COGNITIONS OVER TIME AND
PTSD

A related issue of clinical relevance

concerns the temporal change in negative
cognitions underlying PTSD. Modification
of negative post-trauma cognitions is conceived as associated with the change in the
severity of PTSD. This is consistent with
cognitive theories (e.g., Brewin & Holmes,
2003) and is supported by a body of clinical studies, documenting reduction in negative cognitions accompanied with good outcome shortly after treatment, mostly among
abuse survivors (e.g., Foa & Rauch, 2004;
Livanou et al., 2002; Owens, Chard, & Cox,

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PTSD and Negative Cognitions

2008). These promising findings call for a

long-term investigation of changes in cognitions in PTSD among non-treatment-seeking
individuals, including those exposed to extreme eventsparticularly, as relatively little
is known about changes in cognitions with
respect to the long-term persistence of PTSD
over decades and its delayed occurrence.
To address these issues, as well as the
bi-directional relation of negative cognitions
to PTSD, in this prospective, longitudinal
study we examined post-trauma cognitions
of the self and the world in a sample of veterans of the Yom Kippur War, among them
former prisoners of war, at three points in
time: 18, 30, and 35 years after the war. The
two main research questions were: (1) Do
negative post-trauma cognitions lead to subsequent PTSD and/or vice versa? and (2) Are
changes in post-trauma cognitions over time
moderated by PTSD symptom trajectory?
METHODS

Participants and Procedure

This study uses data from a longitudinal study on the psychological effects of
war. A cohort of Israeli male veterans who
participated in the 1973 Yom Kippur War
were followed over 17 years with assessment
at three time points: 1991 (T1), 2003 (T2),
and 2008 (T3). Following approval from
both the Israel Defense Forces (IDF) and Tel
Aviv University review boards, lists of potential participants from the IDF computerized
data bank were composed. We then phoned
those participants and, after explaining the
purpose of the study, asked them to take part
in the assessments. The questionnaire packet
was administered in their homes or in another location of their choice. Informed consent
was obtained from all participants.
Two groups of combat veterans were
comprised based on IDF records: first, individuals who were captured during the war
(47%) and consequently subjected to torture,

harassment, and humiliations as indicated

in their self-report (see Solomon & Dekel,
2008, for detailed information); and second,
veterans who participated in the same war,
were not taken captive (53%), but who were
exposed to battlefield stressors entailing active fighting and encounters with death. Inclusion criteria in this group included matching to the captivity group on the following
personal and military variables: (1) military
assignment, a soldier from the same unit and
the same duty; and (2) scores on military performance prediction tests that were administered when the soldiers were first drafted
and consisted of personality features and
measures of intelligence. While the sample
was self-selected, respondents did not differ
from non-respondents in sociodemographic
and military variables. Further examination
indicated no differences between the study
groups in age, education, ethnic background,
marital status, and pre- and post-war report
of potentially traumatic events (i.e., previous
military experience perceived as life threatening in any of the wars and military operations in which Israel was involved before the
Yom Kippur War and post-war life events
tapping four domains: family, work, health,
and personal events) (see Neria, Solomon, &
Dekel, 1998, for further details).
In the original study, 349 veterans
participated in T1, 287 participated in T2
(51 could not be located/refused, 5 had died,
and 6 could not participate due to mental
deterioration), and 301 took part in T3 (22
could not be located/refused, 20 had died,
and 6 could not participate due to mental
deterioration). In this study, there were 314,
227, and 221 participants, respectively, in
each time point, and among them 145 participants took part in all three assessments. The
mean age of the sample was 53.4 (SD = 4.4);
years of schooling was 14.02 (SD = 3.41);
the majority were secular (67%) with an average income (62%) (i.e., with respect to the
Israeli population) in T2. No significant differences were found between those who participated in the follow-up assessments with

Dekel et al. 245

regard to initial PTSD level, military rank,

age, and education.
Measures
Posttraumatic Stress. Posttraumatic stress
was measured using the PTSD Inventory
(Solomon et al., 1993) in all assessments.
This self-report questionnaire consists of
17 statements, anchored on the Yom Kippur War experiences, corresponding to the
17 PTSD symptoms listed in the DSM-IIIR (American Psychiatric Association, 1987),
which was the standard of practice when the
study commenced. For each statement, participants are asked to indicate the frequency
with which they experienced symptoms in
the past month, on a 4-point scale ranging
from 1 (not at all) to 4 (I usually did), with
3 indicating cutoff for symptom endorsement, in accord with Brewin and colleagues
(2002). We then calculated PTSD symptom
count and classified participants as meeting
PTSD criteria in accord with DSM-IV (APA,
1994). The DSM-IV moved the physiological reactivity to resembling events symptom
of the DSM-III-R from the hyperarousal
cluster (Criterion D) to the intrusion cluster (Criterion B). In order to conform to the
DSM-IV symptom clusters, we analyzed the
data in accordance with this classification.
The PTSD Inventory has previously
been used in clinical and non-clinical samples.
For example, 20 years after the 1982 Lebanon war, Israeli veterans who fought during
that war and developed a combat stress reaction (CSR) had mean scores of 2.03, 1.83,
and 2.28, respectively, for intrusion, avoidance, and hyperarousal symptoms, while veterans without CSR had scores of 1.31, 1.31,
and 1.50, respectively (Solomon, Shklar, &
Mikulincer, 2005).
Reliability values for the PTSD symptoms were high in all assessments (Cronbachs was .87, .95, and .96, respectively, in
T1, T2, and T3). Values for the three symptom clusters were also good (Cronbachs
for intrusion, avoidance, and hyperarousal

symptoms was .78, .79, and .86, respectively,

in T1; .91, .88, and .91, respectively, in T2;
.92, .78, .87, respectively, in T3). Concurrent validity of the scale was also high when
it was compared with both widely accepted
self-report measures, such as the Impact of
Event Scale, and clinical diagnosis of PTSD
(Solomon et al., 1993).
Cognitions. Cognitions were assessed by
the World Assumptions Scale (WAS; JanoffBulman, 1989a) in T1 and T3. This 32-item
questionnaire entails eight assumptions that
tap into three core cognitions concerning
the benevolence of the world (i.e., assumptions of benevolence of world and of people), the meaningfulness of the world (i.e.,
assumptions of randomness, control, and
justice), and self-worth (i.e., assumptions of
self-control, luck, and self-controllability).
Participants are asked to indicate the extent
with which they agree with each statement
on a 6-point Likert scale, ranging from 1
(strongly disagree) to 6 (strongly agree), with
lower scores indicating lower beliefs in that
assumption. As previously done, we assessed
the three core cognitions by summing the
scores of the individual assumptions associated with each cognition. In a clinical sample
of individuals with a history of sexual and
physical assault, mean scores were 32.88
for benevolence of the world and 46.97 for
self-worth at the entry of cognitive behavioral therapy (CBT) (Owens, Pike, & Chard,
2001); and in a sample of firefighters, some
with posttraumatic symptoms, scores were
55.72, 44.46, respectively, for these two cognitions and 37.48 for meaningfulness (Wagner, McFee, & Martin, 2009). Estimates of
reliability of each of the three core cognitions
have tended to be reasonable. Janoff-Bulman
(1989b) reported Cronbachs alphas of .87,
.76, .80, respectively, for benevolence of the
world, meaningfulness, and self-worth. In
this study, values ranged between .68.72, in
T1 and T3. Previous studies of trauma survivors with PTSD reported similar values ranging between .60.85 (e.g., Livanou et al.,
2002) and between .60.75 (e.g., Ginzburg,

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PTSD and Negative Cognitions

2004); and in a non-clinical sample of undergraduate students, values were between

.64.83 (e.g., Jeavons & Greenwood, 2007).
More importantly, a recent validation study
suggests that the scale has adequate psychometric properties and is correlated significantly with trauma severity (Elkit, Shevlin,
Solomon, & Dekel, 2007).
Statistical Analysis
Basic statistical analysis included Pearson correlations using SPSS version 15.00
to examine cross-sectional relationships between world assumptions and PTSD. Next,
we applied structural equation modeling
(SEM), namely, an autoregressive crosslagged modeling strategy (ARCL; Anderson,
1960) with latent variable using AS 7.0 SEM
software (e.g., SAS CALIS) to examine the
longitudinal, bi-directional relationship between world assumptions and PTSD. Finally,
GLM Repeated Measure analysis of variance (ANOVA) was applied using the same
SPSS version, first, to examine the trajectory
of PTSD (chronic, delay, no-PTSD) in relation to the change in world assumptions over
time and second, to examine the severity of
the trauma (captivity vs. combat) in relation
to changes in world assumptions over time.
RESULTS

Descriptive Statistics
Initially, we conducted a series of Pearson correlations assessing the magnitude of
associations between post-trauma cognitions
and PTSD (Table 1). Significant cross-sectional and longitudinal relations were found
between cognition and PTSD symptom levels. Individuals with more PTSD symptoms
had relatively negative cognitions in both T1
and T3. Likewise, individuals who tended to
have more PTSD symptoms in T2 their cognitions were relatively negative in T1 and T3.

Exploring the Bidirectional

Associations Between Post-Trauma
Cognitions and PTSD
We then examined the bi-directional
association between post-trauma cognitions
and PTSD across two time points, T1 and
T3 (Figure 1). To this end, we employed autoregressive cross-lagged modeling strategy
(ARCL; Anderson, 1960) which allows for
simultaneous assessment of whether earlier
measures of PTSD predict later measures of
cognitions and vice versa. Since PTSD consists of three clusters (intrusion, avoidance,
and hyperarousal), and in this study posttrauma cognitions consisted of three factors
(benevolence of the world, meaningfulness
of the world, and self-worth), we used latent variables in a structural equation model
(SEM) environment to represent the PTSD
and cognition underlying phenomena. Latent variables were estimated in the model by
loading the measured PTSD symptom clusters, composed of individuals symptoms in
accordance with DSM-IV, and the measured
factors of the WAS as detailed in the methods
section.
In order to assess the appropriateness
of the ARCL, we used the SAS 7.0 SEM software (e.g., SAS CALIS). To estimate the models fit, the comparative fit index (CFI), the
Bentler-Bonett non-normed fit index (NNFI),
the root mean square residual (RMR), and
the root-mean-square error of approximation (RMSEA) were applied. Missing data
were handled with the case-wise maximum
likelihood estimation for possible non-normality. The number of observations entered
in the model was 240.
The fit indices of the model were:
(82) = 318.3, p < .01, CFI = .85, NNFI = .93,
RMR = 0.06, and RMSEA = 0.11. In accordance with Hu and Bentler (1995), interpretation of the data should favor relative (i.e.,
NNFI) and noncentrality-based indices (i.e.,
RMSEA) over absolute ones (i.e., , RMR),
which are affected by sample size and vari-

-. 13

41.25(7.33)

.43***

.01

.26**

-. 15**

-. 15*

-. 14

33.24(6.19)

WA-1, T3

WA-2, T3

WA-3, T3

PTSD, T1

PTSD, T2

PTSD, T3

Mean (SD)

.36***

WA-3, T1

51.17(6.88)

-.04

-.08

-.11*

.26**

.08

.08

31.07(6.94)

-.41***

-.33***

-.03

-.52***

-.24***

40.86(7.91)

-.16*

-.20*

-.04

.27***

50.53(8.84)

-.40***

-.31***

-.05

1.76(3.36)

.24***

.37***

6.37(5.74)

.80***

6.63(5.79)

Note. WA-1 = benevolence of the world, WA-2 = meaningfulness of the world, WA-3 = self-worth. PTSD refers to PTSD symptom count, T1, T2, and T3 = measurement in 1991, 2003, and
2008. N = 240. *p < .05.**p < .01. ***p < .001.

-. 06

.11*

.14

.37*

.27*

.13*

.21***

WA-2, T1

WA-1, T1

TABLE 1. Means, Standard Deviations, and Intercorrelations Between Main Study Measures

Dekel et al. 247

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PTSD and Negative Cognitions

FIGURE 1. ARCL Model for Assessing the Bidirectional Association Between PTSD and Cognitions
Across Three Time Points, 1991, 2003, and 2008.

able distribution. Recommended NNFI cutoffs vary between .80 (Hooper, Coughlan,
& Mullen, 2008) and .95 (Bollen & Curran,
2006). While RMSEA values .05 are considered a good fit, values between .08 and
.10 are still acceptable, representing a mediocre fit (Browne & Cudeck, 1993).
The stability of cognitions and PTSD
over time ranged from moderate to high.
Participants with high cognition or PTSD
symptom levels in T1 had high cognition
and PTSD symptom levels, respectively, in
T3. More importantly, higher PTSD symptom levels in T2 predicted subsequent more
negative cognitions levels in T3, above and
beyond cognition stability. However, initial
cognition levels in T1 did not predict later
PTSD symptom levels in T2 and T3.

Exploring the Relationship Between

Changes in Post-Trauma Cognitions
and PTSD
To examine changes in post-trauma
cognitions between T1 and T3 in relation to
PTSD, we conducted a series of 3X2 mixed
repeated measures designs and we ran in
each an ANOVA. PTSD symptom trajectory (chronic PTSD, delayed PTSD, and no
PTSD) was entered as the between-subjects
variable, time of measurement (T1 vs. T3)
as the within-subjects variable, and the cognitions (benevolence, meaningfulness, and
self-worth) as the dependent variable in each
design. A total of 17.9% (n = 26) of the sample were classified as chronic PTSD (i.e.,
met PTSD symptoms criteria in all measure-

Dekel et al. 249

ments); 42.1% (n = 61) as delayed PTSD

(i.e., met symptoms criteria at T2 and/or T3
but not at T1); and 37.2% (n = 54) as no
PTSD. Since 2.8% (n = 4) were recovered
(met PTSD symptoms criteria in T1 and/or
T2 but not in T3), their data were not included in the analyses.
For benevolence of the world, all effects in the ANOVA were significant. The
time effect indicated that cognitions were
more negative between T1 (M = 32.36, SE =
.61) and T3 (M = 30.87, SE = .66), F(1, 116)
= 5.14, p = .03, p2 = .04. More importantly,
the group X time effect indicated that individuals with chronic (T1: M = 29.62, SD =
8.32; T3: M = 29.10, SD = 7.16) or delayed
PTSD symptoms (T1: M = 34.21, SD = 5.29;
T3: M = 29.10, SD = 7.16) had less belief
in benevolence of the world between T1 and
T3 but not those classified as no PTSD (T1:
M = 33.26, SD = 5.92; T3: M = 33.59, SD
= 5.47), F(2, 116) = 6.40, p = .01, 2 = .10.
Finally, the group effect, F(2, 116) = 4.03, p
= .02, p2 = .07, followed by post-hoc analyses, indicated that the chronic PTSD group
(M = 29.36, SE = 1.20) endorsed relatively
negative cognitions compared to the no
PTSD group (M = 33.42, SE = .80), p = .016.
For self-worth, the only significant effect was the group effect, F(2, 107) = 3.01,
p = .05, p2 = .05. Once again, post-hoc
analysis showed that individuals with chronic PTSD symptoms (M = 47.58, SE = 1.41)
had relatively negative cognitions compared
to those classified as no PTSD (M = 51.69,
SE = 0.94), p = .05. Finally, for meaningfulness of the world, the analysis revealed no
significant effects.
Examining the Relationship Between
Severity of Trauma and Post-Trauma
Cognitions
As previously mentioned, the sample
consisted of combat veterans and among
them ex-POWs. Consequently, this group

of veterans was exposed to extreme trauma.

For ex-POWs, Pearson cross-sectional correlations between post-trauma cognition and
PTSD symptom levels were significant at T1
and T2 (T1: benevolence: r = -.20, p = .02;
self-worth: r = .17, p = .04; meaningfulness:
r = .17, p = .04; T3: benevolence: r = .34, p
= .001, self-worth: r = -.30, p = .001). For
combatants, the correlations were significant
only at T3 (benevolence: r = -.28, p = .01;
self-worth: r = - .33, p = .01). More importantly, the correlations between PTSD at T2
and the cognitions at T3 were significant
among ex-POWs (benevolence: r = -.22, p =
.04; self-worth: r = - .25, p = .03) but marginally significant among combatants (benevolence: r = -.26, p = .05).
To examine the relationship between
post-trauma cognitions and severity of trauma, a 2X2 repeated-measures ANOVA was
performed with severity of trauma (captivity, n = 76 vs. combat, n = 55) entered as
the between-subjects variable. Once again we
used time (T1 vs. T3) as the within-subjects
variable and the cognition as the dependent
variable in each analysis. Because the groups
differed in initial (T1) PTSD symptom count
such that individuals in captivity (POW: M
= 2.05, SD = 3.86) reported more symptoms
than combatants (non-POW: M = 1.31, SD
= 2.44), t(492) = 2.48, p = .01, PTSD at T1
was entered as a covariate.
For benevolence of the world, the time
and time X group effects were significant,
F(1, 128) = 8.52, p = .01, p2 = .06 and
F(1, 128) = 7.40, p = .01, p2 = .06, respectively. The results indicated that cognitions
were more negative between T1 and T3 (T1:
M = 33.27, SE = .54, T3: M = 31.78, SE =
.55). More importantly, ex-POWs (T1: M =
33.20, SD = 6.33; T3: M = 30.2, SD = 7.11)
cognitions were more negative between T1
and T3 but not among combatants (T1: M =
33.44, SD = 5.96; T3: M = 33.4, SD = 5.91).
For self-worth, the time X group effect was significant, F(1, 118) = 5.37, p = .03,
p2 = .05. Once again the results indicated

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that ex-POWs had more negative cognitions

(T1: M = 50.78, SD = 7.2; T2: M = 49.07,
SD = 8.49) between T1 and T3 but not combatants (T1: M = 50.81, SD = 6.22; T2: M =
52.94, SD = 8.80). For meaningfulness of the
world, the analysis revealed no significant effects.
DISCUSSION

This study is original in examining the

bi-directional relation between PTSD and
post-trauma cognitions in the long term following trauma. We found that PTSD symptoms predicted subsequent relatively negative cognitions concerning the self and the
world, endorsed as far as 35 years following the war. This may suggest that PTSD is
implicated in the amplification of negative
cognitions in the long term and, on a broader level, underscores the potent widespread
pathogenic effect that PTSD may have on the
traumatized.
Within the context of previous studies, there is possibly a positive feedback loop
associating negative post-trauma cognitions
with PTSD. While negative cognitions trigger the development of PTSD and its maintenance (e.g., Foa & Feeny, 2006), at the same
time PTSD symptoms may contribute to
the deterioration of negative cognitions and
keep them negatively enduring.
Specifically, impairments in the autobiographical memory of the trauma in PTSD
may account for our findings. A large segment of the memory is not deliberately accessed but rather appears as an intrusive,
vivid, threat-laden recollection, leaving the
sense that the event is ongoing in the present (e.g., Brewin, 2007). A growing body
of studies suggests that trauma memory is
re-consolidated as increasingly more negative over time rather than remaining unchanged (e.g., Dekel, Ein-Dor, & Solomon,
2011; Engelhard, van den Hout, & McNally,
2008). Possibly then, accompanied cogni-

tions are modified negatively to incorporate

the new trauma information.
Maladaptive appraisal of the symptoms of PTSD may also fuel negative posttrauma cognitions. In accord with Ehlers and
Clarks model (2000), individuals may fail to
identify their symptoms as part of normal
processing, but instead appraise them as a
marker of permanent inadequacy. Emotional
numbing, for example, may be appraised as,
Im dead inside. Accompanied negative
appraisals are recurrent and over-generalized
to relatively neutral events. It follows that
these appraisals may subsequently amplify
and maintain the view of the self as totally
inept.
The behavioral characteristics of
PTSD, which are deployed to manage symptoms and distress, can paradoxically also
worsen negative post-trauma cognitions. For
example, an exaggerated startle response
may generate selective attention on threat
cues (e.g., Bryant & Harvey, 1997). In the
same vein, avoiding reminders of the trauma
may impede the emotional processing of the
event, such that the event remains threat-laden (e.g., Brewin, Dalgleish, & Joseph, 1996).
Once again, when the threat is chronically
perceived as ongoing, it may have a pathogenic effect on survivors cognitions. The fact
that this study did not support the contribution of negative post-trauma cognitions in
predicting PTSD, as previously shown, may
have to do with differences in measurements,
sample nature, or the long time gap (12
years) between cognitions and subsequent
PTSD assessments and the long gap between
the war and subsequent assessments. Possibly, there are fluctuations in cognitions over
time, similar to the course of symptoms of
PTSD (Port, Engdahl, & Frazier, 2001). Alternatively, it may be that negative post-trauma cognitions lead to PTSD in the short but
not long term following trauma. In the long
term, processes which slowly kick in, such
as the reconsolidation of the memory of the
trauma over time (e.g., Dekel & Bonanno,
2013), may fuel PTSD rather than the sud-

Dekel et al. 251

den shattering of world assumptions in the

immediate aftermath of the event.
We also documented that changes in
cognitions over time are linked with the trajectory of PTSD. For individuals with chronic PTSD symptoms, time does not seem to
heal negative cognitions; instead, cognitions
of the traumatized may further amplify negatively over time. Relatively little is known
about the mechanism maintaining PTSD.
Possibly, then, in chronic PTSD there is a
failure to modify maladaptive post-trauma
cognitions in a positive direction as time
passes following the traumatic event (e.g.,
Dekel & Bonanno, 2013).
Individuals endorsing PTSD are vulnerable to the pathogenic effects of aging
(Averill & Beck, 2000). In aging, suppressed
traumatic memories may arise as a consequence of loss and changes experienced (e.g.,
Schnurr, Lunney, Sengupta, & Spiro, 2005).
Participants in the present study were in their
early sixties at the final follow-up; therefore,
it may be that the suppressed traumatic memories of participants endorsing symptoms of
PTSD became increasingly more accessible,
subsequently worsening accompanying cognitions. It is also important to note that at
the time of the first follow-up (T2), participants as well as other Israelis were threatened by repeated terrorist actions. Individuals with chronic PTSD have an increased
responsivity to subsequent traumas, partly
due to dysregulation of the stress response
(e.g., Yehuda & Seckl, 2011) and inadequate
processing of the trauma (e.g., Foa & Jaycox, 1999). This way, increasingly negative
cognitions may ensue.
Since this longitudinal study entailed
long-term follow-up, our findings may also
provide insight into the cognitions of survivors experiencing fluctuations in symptoms
of PTSD. There is accumulating evidence of
substantial portions of delayed-onset PTSD
among war veterans, although the genuine
occurrence of a delayed response remains
debatable (Andrews, Brewin, Philpott, &
Stewart, 2007). In the present study, partici-

pants with delayed PTSD endorsed relatively

positive cognitions before onset of the symptoms, similar to individuals with no PTSD.
Yet, their cognitions became relatively negative with the endorsement of symptoms at
follow-up. Possibly then, individuals classified with delayed PTSD onset experience not
only a delay in the appearance of symptoms
and the accompanying distress but also a
delayed formation of negative post-trauma
cognitions.
Finally, the findings are in accord with
the notion that a particularly extreme and
prolonged trauma may have pervasive, potent effects on survivors (e.g., van der Kolk
& Courtois, 2005). In captivity, captives are
victims of prolonged torture, harassment,
and humiliation entailing personal relationships of coercive control. These experiences
are deemed to undermine identity, the basic
sense of self-integrity, and the fundamental
belief in a just world (Herman, 1992). Not
surprisingly, we found that ex-POWs but
not combatants had relatively negative posttrauma self and world cognitions, which became increasingly more negative with time.
Moreover, our findings point to the direction
that when individuals endorse symptoms of
PTSD related to extreme trauma, then initial
symptoms may affect subsequent core cognitions. Taken as a whole, the outcome of
traumatization under extreme conditions is
disturbance in the systems of meaning (van
der Kolk, Roth, Pelcovitz, Sunday, & Spinzzola, 2005), possibly due in part both to the
nature of the trauma and the nature of the
response itself.
There are several limitations to our
study worth noting. First, it does not allow
inferences regarding causal relationships.
Unfortunately, like most trauma research,
we too were unable to measure participants
cognitions prior to the trauma, which may
have already been negative and complementary with negative cognitions from after the
trauma. We were also unable to measure
level of exposure in the immediate aftermath
of the trauma and its impact on post-trauma

252

PTSD and Negative Cognitions

cognitions before the development of PTSD

symptoms; therefore, interpretation of the
findings should be made with caution. Clearly, severity of the trauma is strongly implicated in PTSD (Brewin et al., 2000). While
our findings suggest that the event and the
response itself possibly affect survivors core
cognitions, any interpretation should be
carefully made; the model we used to represent the bi-directional relationship between
PTSD and post-trauma cognitions cannot be
fully trusted, particularly as it is based on
asymmetry variables. There are also limitations inherent in longitudinal designs. Attention should be given to generalization of
our findings. Not all participants took part
in later assessments, although the initial and
follow-up samples did not differ with respect
to PTSD symptoms and demographic background. Also, since we focused on the longterm phase, we may have overlooked the fine
fluctuations in cognitions given short intervals assessment. While the findings suggest
worsening of negative cognitions over time,
cognitions endorsed in the wake of trauma
may be more negative. Future research may

therefore benefit from obtaining assessments

from the very early post-trauma phase, ideally including pre-trauma cognitions, diagnosis of PTSD, and additional measures of
cognitions, as there are many ways by which
cognitions may be conceptualized and measured.
Within the context of these limitations,
our findings, derived from a sample of veterans with no prior psychopathology before the
war, point to the implications of PTSD in the
maintenance and the amplification of negative basic cognitions in the long term following trauma. Thus, PTSD may have enduring
detrimental effects on the personality of the
traumatized. Our findings clearly encourage
a new line of investigation to unmask the bidirectional relations between clinical conditions and their so-called predicting factors.
Importantly, conceptualizing PTSD within a
cognitive frame may contribute to its future
diagnostic revisions. Not surprisingly, effective treatments for PTSD, such as cognitive
therapy, aim at helping trauma survivors
modify their core cognitions as more benign.

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