علائم استرس پس از سانحه، فراشناخت، طرح عاطفی و تنظیم احساسات: یک مدل معادله ساختاری

Abstract Objective The present study aimed to assess the direct and indirect impacts of the metacognition, emotional schema and emotion regulation in prediction of post-traumatic stress (PTS) symptom. Method Participants consisted of 678 high school students from earthquake-stricken areas of eastern Azerbaijan selected from Varzaghan, Ahar and Heris by multistage cluster sampling. PTSD Symptom Scale—Self Report (PSS-SR), Metacognition Questionnaire—Adolescent Version (MCQ-A), Leahy Emotional Schema Scale (LESS) and Difficulties in Emotion Regulation Scale (DERS) were utilized for data collection. SPSS software and LISREL software were used for data analysis. Results The results of SEM and path analysis indicated the direct and indirect (through emotion regulation) impacts of metacognition and also indirect (through emotion regulation) impact of emotional schema on PTS symptom. Model examination presented the good fitness of the proposed theoretical model. Conclusions Consistent with metacognitive model and also emotional schema model, results of this study indicated the impact of metacognition and emotional schema on post-traumatic stress symptom through emotion regulation. This finding emphasizes that both metacognitive and emotional factors are important in explanation of PTS symptom.

Introduction Human life has never been free from the traumatic events and also trauma has never been free from the economic, somatic, social and especially psychological consequences such as PTSD that is a prevalent outcome of traumatic events and includes reexperiencing, avoidance, negative cognitions and mood, and arousal (Association, 2013). There are many models for the explanations of the mechanism of the formation and persistence of the post-traumatic stress disorder (PTSD). On the one hand there are third wave approaches such as metacognitive model (Wells, 2000) and emotional schema model (Leahy, 2002). These approaches are particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tend to emphasize contextual and experiential change strategies in addition to more direct and didactic ones (Hayes, Follette, & Linehan, 2004). On the other hand, there exist a vast amount of studies that focus on the role of emotion regulation in psychopathology (Aldao et al., 2010, Cloitre et al., 2005 and Tull et al., 2007). According to the metacognitive model, metacognition refers to cognition applied to cognition and maybe defined as any knowledge or cognitive processes involved in the appraisal, control, and monitoring of thinking (Wells, 2000). The activation of the Cognitive-Attentional Syndrome (CAS) is the main factor in formation of the PTSD. This syndrome contains the worry, rumination and threat monitoring (Wells, 2009). In line with the appraisal of the metacognitive model of PTSD, path analysis and structural equation model have reported the acceptable fitness of model with data (P. Roussis, 2007). These studies indicated that both worry (P. Roussis & Wells, 2006) and rumination (Bennett & Wells, 2010) which are two components of the CAS, play a mediating role between metacognitive beliefs and post-traumatic stress (PTS) symptom. Another model that explains the emotional disorders, is the emotional schema model (Leahy, 2002). The emotional schema model is a model based on the metacognitive theory (Wells, 2000) that integrates emotional-focused model with a metacognitive model and argues that the metacognitive model stresses disorders of the theory of mind, and the emotional schema model stresses disorders of the theory of emotion and mind. Specific styles of self-reflective thinking and evaluations of one's own thoughts and feelings can lead to problematic appraisals and strategies of emotional regulation. These ideas serve as foundational theory for “emotional schema therapy” (Herbert & Forman, 2011). This is notable that both metacognitive and emotional schema models agree that interpretations and strategies that people use for the manipulation of unpleasant cognitive or emotional phenomenon have an effect on the anxiety disorders (Leahy, 2007). Furthermore, the studies support the relationship between problematic emotional schema and the variety of psychopathology such as PTSD (Herbert & Forman, 2011). The third variable in this study is emotion regulation which is related to metacognition and also to emotional schema but hasn't been considered enough. Although emotion regulation deficits have been implicated in a range of clinical disorders (Cloitre, Cohen, & Koenen, 2006), it has been identified as a central feature of PTSD. Deficits in emotion regulation would likely lead to greater appraisals of threat, diminished coping resources, and more intense emotional responding upon exposure to a traumatic stressor, and thus, these deficits may function in the etiology of PTSD (Bardeen, Kumpula, & Orcutt, 2013). Deficits in emotion regulation likely contribute to the maintenance of PTSD in multiple ways. Individuals may perceive their emotions as uncontrollable (Frewen & Lanius, 2006) and subsequently learn to fear internal and external cues that elicit emotional reactions. A lack of access to adaptive emotion regulation strategies may then lead to avoidance of trauma-related experiences, thus preventing exposure to trauma relevant reminders that would otherwise facilitate habituation (Foa & Kozak, 1986). In metacognitive model, emotion regulation is one of the CAS components that metacognitive beliefs lead to disorder through it. Also emotional schema therapy tries to change the dysfunctional strategies of emotion regulation through identification and modification of emotional schema (Leahy, Tirch, & Napolitano, 2011). Totally metacognitive model of PTSD is accepted as a model with good fitness, however studies have restricted to worry and rumination and emotion regulation (as a component of CAS) is neglected. Also, despite a growing body of literature indicating a link between emotion regulation deficits and PTSD symptomatology (Ehring and Quack, 2010 and Tull et al., 2007) the precise nature of the relationships among emotion dysregulation and PTSD is unclear (Bardeen et al., 2013). As noted by Manser, Cooper, and Trefusis (2012), the role of emotion in metacognitive theory has been relatively neglected as an area for research and discussion in both the academic and clinical literature. According to the above, we considered the metacognitive model of PTSD as a base model and entered two variables (emotional schema and emotion regulation) into this model to clarify the role of emotion in metacognitive model of PTSD. We hypothesized that a) metacognition has direct and indirect impacts (through emotion regulation) on the PTS symptom, b) emotional schema has direct and indirect impacts (through emotion regulation) on the PTS symptom, and c) emotion regulation has a direct impact on the PTS symptom. The primary aim of the current study was to examine this theoretical model and clear the role of emotion regulation in metacognitive model of PTSD.

3. Results Descriptive statistics (mean, standard deviation) and correlation among variables are presented in Table 1. The mean of the PTS symptom score in the current sample was 16.03. The correlation between PTS symptom and other variables – metacognition (MC), emotional schema (ES) and emotion regulation (ER) – was significant (P < .01). Higher correlation has been shown between metacognition and PTS symptom 0/49. Table 1. Means, standard deviations, and correlations among variables modeled in structural equation modeling. M SD 1 2 3 4 1. PTS 16.03 11.59 1 2. MC 64.95 13.72 .49⁎⁎ 1 3. ES 76.16 13.14 .22⁎⁎ .44⁎⁎ 1 4. ER 92.36 18.87 .36⁎⁎ .37⁎⁎ .15⁎⁎ 1 Note: PTS = post-traumatic stress symptom; MC = metacognition; ES = emotional schema; ER = emotion regulation. ⁎ P < .05. ⁎⁎ P < .01. Table options 3.1. Structural equation modeling Beta coefficients and significance status of direct and indirect impacts of variables are shown in Table 2. According to this information all relationships (exception of the direct impact of emotional schema on PTS symptom) between variables are significant. Table 2. Structural equation model. β SE t P Direct impact Metacognition on PTS symptom .60 0.08 7.48 .001 Metacognition on emotion regulation .22 0.07 3.22 .001 Emotional schema on PTS symptom −.16 0.09 − 1.82 ns Emotional schema on emotion regulation .54 0.07 7.44 .001 Emotion regulation on PTS symptom .17 0.06 2.65 .01 Indirect impact Metacognition via emotion regulation .64 0.02 Emotional schema via emotion regulation .25 0.04 Table options 3.2. Direct impact analysis According to the results of structural equation modeling, metacognition has a direct impact (β = .60; P < .001) on the PTS symptom. But direct impact of emotional schema on PTS symptom was not significant (β = −.16; ns). The results of SEM indicate that emotion regulation has a direct impact on the PTS symptom (β = .17; P < .01). 3.3. Mediation analysis Results of path analysis presented in Table 2 indicated that metacognition has an indirect impact (via emotion regulation) on the PTS symptom (β = .64; se = 0.02). Also the emotional schema has an indirect impact (via emotion regulation) on the PTS symptom (β = .25; se = 0.04). According to the results of SEM, as hypothesized emotion regulation mediates the impact of the independent variables (metacognition and emotional schema) on PTS symptom. The magnitude of the mediation of emotion regulation in the relationship between metacognition and PTS symptom was .04. This amount for the relationship between emotional schema and PTS symptom was .09. Fig. 1 shows the hypothesized theoretical model of PTS symptom. In this figure beta coefficients and the relationships between variable have been presented. Results of structural equation modeling analysis of the direct and indirect ... Fig. 1. Results of structural equation modeling analysis of the direct and indirect impacts of metacognition and emotional schema and the mediating role of emotion regulation on posttraumatic stress symptom. Note: MCQ1: positive beliefs; MCQ2: uncontrollability and danger; MCQ3: cognitive confidence; MCQ4: SPR; MCQ5: cognitive self-consciousness; DERS1: nonacceptance of negative emotional responses; DERS2: difficulties engaging in goal-directed behavior when distressed; DERS3: difficulties controlling impulsive behaviors when distressed; DERS4: lack of emotional awareness; DERS5: limited access to effective ER strategies; DERS6: lack of emotional clarity; LESS1: rumination; LESS2: emotional self-awareness; LESS3: guilt; LESS4: expression of feeling; LESS5: controllability; LESS6: validation by others; LESS7: comprehensibility; LESS8: blame; LESS9: demands for rationality; LESS10: simplistic view of emotions; LESS11: higher values; LESS12: acceptance of feelings; LESS13: consensus. ∗∗ P < .01; ∗∗∗ P < .001. Figure options 3.4. Measurement model The analysis of the structural model of post-traumatic stress symptom resulted in good indexes of fitness. Results of model fitness examination are shown in Table 3. According to this information hypothesized theoretical model in current study confirmed. Table 3. Model fitness examination indexes. χ2/df GFI NFI CFI IFI RFI RMR RMSEA 1.80 .92 .91 .90 .90 .90 .05 .06