The aim of this study was to evaluate the psychometric properties of the attachment scale added in the newly developed self-rating questionnaire Trauma Symptom Inventory-2 (TSI-2). Participants were recruited from the Swedish parent-infant unit Hagadal (N=58). Reliability analyses concluded Cronbach´s α .92 for attachment total scale, .88 for avoidance subscale, and .91 for rejection sensitivity subscale. Convergent validity analyses concluded moderate to strong correlations between TSI-2 attachment scale and subscales, and Experiences in Close Relationships (ECR) total scale and subscales (r= .34 - .68, p ≤ .01). Criterion validity analyses concluded that adverse childhood circumstances measured by Linköping Youth Life Experiences Scale (LYLES) signficantly estimated 17 % of variance in TSI-2 attachment scale scores. Preliminary support for reliability and validity of the TSI-2 attachment scale was obtained. No previous trauma symptom rating instrument has included information about adult attachment styles. The present findings point to the benefits of such inclusion.

Non-suicidal self-injury (NSSI), such as intentionally cutting, burning or hitting oneself, is a behavior with potentially detrimental consequences and empirical studies are necessary to gain knowledge of how to prevent NSSI in adolescents. The aims of this thesis were to investigate the prevalence, methods, characteristics and functions of NSSI in a large community sample of Swedish adolescents, and to examine the relationship between NSSI and adverse life events and trauma symptoms. All empirical studies had a cross-sectional design and were based on 3,097 adolescents in the county of Östergötland, aged 15-17 years, in their first year of high school. Participating school classes were selected through a randomization process and administered self-report questionnaires. In study I (n = 3,060) a single item NSSI question resulted in a prevalence rate of 17.2%, while 35.6% of adolescents reported having engaged in NSSI at least once during the past year when given a checklist. The most commonly reported type of NSSI in this sample was “bit yourself”, followed by “hit yourself on purpose”, “erased your skin” and “cut or carved on your skin”. Applying the proposed DSM-5 diagnostic criteria of NSSI resulted in a prevalence rate of 6.7%. Results in study II (n = 2,964) showed that after controlling for gender, parental occupation and living conditions, adolescents with no self-injurious behavior reported the lowest level of adversities and trauma symptoms, while adolescents with both NSSI and suicide attempts (5.7%) reported the highest levels compared to those with only NSSI or a suicide attempt. Adolescents reporting frequent NSSI reported more adversities and trauma symptoms than those with less frequent NSSI. Automatic functions, such as affect regulation, self-punishment and feeling-generation, were the most commonly reported functions of NSSI. Attempts in study I to confirm Nock and Prinstein’s (2004) four-factor model of underlying factors of NSSI functions resulted in a close to acceptable fit. An attempt to refine the factor analysis on this community sample of Swedish adolescents, using Mplus with cross-validation, was made in study III (n = 836). An exploratory factor analysis resulted in a three-factor model (social influence, automatic functions and non-conformist peer identification), which was validated in confirmatory analysis. In order to adhere more closely to learning theory and the concept of negative and positive reinforcement, the third factor was then split into two factors, resulting in a four-factor model (social influence, automatic functions, peer identification and avoiding demands), which showed excellent fit to the data in the confirmatory factor analysis. Study IV (n = 816) showed that NSSI frequency, gender (female), self-reported experience of emotional and physical abuse, having made a suicide attempt, prolonged illness or handicap and symptoms of depression and dissociation were significant predictors in the final model of the automatic functions, indicating that these variables are important in understanding the mechanisms underlying the need to engage in NSSI to regulate emotions, generate feelings, gain control or to self-punish. Symptoms of depression and dissociation mediated the relationship between sexual, physical and emotional abuse and the automatic  functions. Furthermore, frequency of NSSI, gender, emotional abuse, prolonged illness or handicap and symptoms of depression uniquely predicted automatic functions but not social functions. Self-reported experience of physical abuse, having made a suicide attempt, symptoms of anxiety and dissociation were significant in the final model of social functions, i.e., performing NSSI to influence or  communicate with others, to avoid demands or to identify with peers. Of these, symptoms of anxiety were uniquely associated with social functions. Symptoms of anxiety and dissociation mediated the relationship between physical abuse and social functions of NSSI. Taken together, this thesis has shown that NSSI is prevalent in Swedish adolescents and findings contribute to the discussion of a potential NSSI diagnosis. It is important to consider the effect of different types of negative life events and trauma symptoms in relation to NSSI in adolescents. Assessing the specific reinforcing functions of NSSI and the underlying factor structure can be helpful in developing functionally relevant individualized treatment. / Självskadebeteende, t ex att avsiktligt skära, bränna eller slå sig själv är potentiellt skadliga beteenden. Empiriska studier är viktiga för att kunna förebygga självskadebeteende hos ungdomar. Föreliggande avhandling syftar till att undersöka självskadebeteendets förekomst, funktion, karaktäristik och metoder hos svenska ungdomar, samt att undersöka relationen till negativa livshändelser och traumasymptom. Samtliga fyra empiriska studier hade en tvärsnittsdesign och baserades på 3,097 ungdomar i Östergötland, 15-17 år, i gymnasieskolans årskurs 1, vars skolklasser valts ut slumpmässigt och som besvarat självskattningsformulär. I studie I (n = 3,060) angav 17.2%, som svar på en allmän självskadefråga, att de avsiktligt skadat sig under sin livstid. När ungdomarna däremot svarade på en checklista med olika självskadebeteenden, angav 35.6% att de hade ägnat sig åt någon typ av självskadebeteende under det senaste året. De vanligaste metoderna var att avsiktligt bita eller slå sig själv, sudda på huden och att skära sig. De föreslagna diagnoskriterierna för icke-suicidal självskada i DSM-5 resulterade i en förekomst av 6.7%. Studie II (n = 2,964) visade att ungdomar utan självskadebeteende rapporterade de lägsta antalet negativa livshändelser och traumasymptom, medan de med erfarenhet av både självskadebeteende och självmordsförsök (5.7%) rapporterade de högsta antalen jämfört med de med endast självskadebeteende eller självmordsförsök. Ungdomar med fler självskadetillfällen rapporterade fler negativa livshändelser och traumasymptom än de med färre tillfällen. Automatiska/intrapersonella funktioner, såsom att generera och reglera känslor samt att straffa sig själv var de vanligaste funktionerna som rapporterades. Försök att konfirmera Nock och Prinsteins (2004) fyrfaktormodell av underliggande funktionsfaktorer i studie I resulterade i en modell med nära acceptabel passform. Ett försök att förbättra faktoranalysen på den aktuella urvalsgruppen gjordes med Mplus i studie III (n = 836). En exploratorisk analys resulterade i en trefaktormodell (interpersonell påverkan, automatisk/intrapersonell funktion samt ”icke-konformistisk” kamratidentifikation), vilken även validerades i den konfirmatoriska analysen. Med utgångspunkt i inlärningsteori och begreppen negativ och positiv förstärkning delades därefter den tredje faktorn upp i två faktorer. Det resulterade i en fyrfaktormodell (interpersonell påverkan, automatisk/intrapersonell funktion, kamratidentifikation samt undvikande av krav). Fyrfaktormodellen visade utmärkt passform i den konfirmatoriska analysen. Studie IV (n = 816) visade att självskadebeteendets frekvens, kön (flicka), självrapporterade erfarenheter av psykisk och fysisk misshandel, självmordsförsök, kronisk sjukdom eller handikapp under uppväxten, liksom symptom på depression och dissociation predicerade automatiska självskadefunktioner. De variablerna är potentiellt viktiga för förståelsen av de mekanismer som är involverade när ungdomar skadar sig själva för att generera och reglera känslor, få kontroll, liksom att straffa sig själva. Relationen mellan psykisk och fysisk misshandel och de automatiska funktionerna medierades av symptom på depression och dissociation. Självskadefrekvens, kön, psykisk misshandel, sjukdom/handikapp och symptom på depression predicerade enbart automatiska men inte sociala funktioner. Självrapporterad fysisk misshandel, självmordsförsök, symptom på ångest och dissociation var signifikanta prediktorer för de sociala funktionerna (att påverka/kommunicera med andra, undvika krav eller identifiera sig med kamrater). Ångestsymptom var unikt associerade med sociala funktioner. Symptom på ångest och dissociation medierade vidare relationen mellan fysisk misshandel och sociala självskadefunktioner. Sammanfattningsvis visade resultaten att självskadebeteende är vanligt förekommande hos ungdomar. Avhandlingen bidrar med empiri till diskussionen gällande icke suicidal självskada i DSM-5. Det är viktigt att beakta olika negativa livserfarenheter och traumasymptom i relation till självskadebeteende hos ungdomar. Att undersöka självskadebeteendets funktioner kan vara kliniskt hjälpsamt för att utveckla och utvärdera individuellt anpassade behandlingsstrategier.

Introduction: This thesis had two primary aims. The first aim was to systematically review the literature investigating trauma symptoms in children and adolescents aged five to eighteen years who had been exposed to domestic abuse. The second aim was to complete an empirical study investigating predictors of trauma symptoms and the relational nature of trauma in women and children aged five to eighteen years who had been exposed to domestic abuse. Method: For the first aim, a systematic literature search identified eligible studies that met predefined inclusion criteria. Following data extraction, the studies were rated against methodological quality criteria. For the second aim, using a quantitative, cross-sectional design, 84 women self-reported on experiences of domestic abuse, symptoms of depression, anxiety, stress and trauma and their child’s trauma symptoms. Analyses investigated the relationship between exposure to domestic abuse and trauma symptoms, predictors of trauma symptoms and whether maternal trauma symptoms moderated the relationship between exposure to domestic abuse and child trauma symptoms. Results: The systematic review identified 14 studies that were eligible for inclusion. Two studies were rated as high quality, ten as acceptable quality and two as low quality. A consistent relationship between exposure to DA and trauma symptoms in children and adolescents was reported, regardless of study quality. The empirical study found a significant relationship between exposure to physical and psychological abuse and trauma symptoms in children aged five to eighteen years. Maternal trauma symptoms were both significantly correlated with and a significant predictor of child trauma symptoms supporting the relational nature of trauma in this population. The interaction was not significant, indicating that maternal trauma symptoms was not a moderator, and the relationship between domestic abuse and child trauma symptoms was present at low, medium and high levels of maternal trauma symptom severity. Conclusion: Across included studies the systematic review found a consistent but variable prevalence of PTSD and trauma symptoms in children and adolescents exposed to domestic abuse, highlighting the importance of assessment and evidence based intervention in this population. Results should be interpreted whilst taking into account the strengths and limitations of individual studies and the overall review. The majority of children in the research study were experiencing trauma symptom severity within the range of clinical concern. The relational nature of trauma was supported in mothers and children exposed to domestic abuse highlighting that treatment should be family based and delivered concurrently to mothers and their children. Results are discussed and should be interpreted whilst considering the limitations discussed.

Background: Little is known about the relationship between women's birthing experiences and the development of trauma symptoms. This study aimed to determine the incidence of acute trauma symptoms and posttraumatic stress disorder (PTSD) in women as a result of their labor and delivery experiences, and identify factors that contributed to the women's psychological distress. Method: Using a prospective, longitudinal design, women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics. Four to six weeks postpartum, telephone interviews were conducted with participants (n = 499) and explored the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms. Results: One in three women (33%) identified a traumatic birthing event and reported the presence of at least three trauma symptoms. Twenty-eight women (5.6%) met DSM-IV criteria for acute posttraumatic stress disorder. Antenatal variables were not found to contribute to the development of acute or chronic trauma symptoms. The level of obstetric intervention experienced during childbirth (beta = .351, p <.0001) and the perception of inadequate intrapartum care (beta = .319, p <.0001) during labor were consistently associated with the development of acute trauma symptoms. Conclusions: Posttraumatic stress disorder following childbirth is an under-recognized phenomenon. Women who experienced both a high level of obstetric intervention and were dissatisfied with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate. Such findings should prompt a serious review of intrusive obstetric intervention during labor and delivery, and the psychological care provided to birthing women.

Recent increases in opioid overdose rates have changed the role of first responders on the front lines of this national crisis. The present study used a semi-structured qualitative interview to investigate how the increase in opioids, opioid-related harm, and opioid-related death within Tennessee has affected the first responder population. Law enforcement officers, firefighters, and paramedics (N = 30) from rural-serving counties in Tennessee completed a semi-structured interview. Eight themes emerged from the interviews: (1) mental health symptoms, including posttraumatic stress disorder and secondary traumatic stress symptoms; (2) coping behaviors; (3) available resources; (4) barriers to accessing resources; (5) recommendations for what is needed; (6) hardest circumstances; (7) discrepant thoughts and feelings; (8) perception of role in reducing the impact of the epidemic. This study provides novel insights into the impact of the opioid epidemic on Tennessee first responders, and can inform future efforts to reduce adverse outcomes in these care providers.

The current study used a sample of service members and veterans to explore the association of combat exposure and perceptions of the family system using a moderated mediation model. Combat veterans over the age of 18 with a family of creation (N = 154) completed an online survey through which they were administered a background information questionnaire, the Combat Experiences subscale of the Deployment Risk and Resilience Inventory – 2, the Moral Injury Events Scale, the PTSD Checklist for DSM-5, the Patient Health Questionnaire, the Beck Anxiety Inventory, the McMaster Family Assessment Device, and the Dyadic Adjustment Scale – Revised. Results of six moderated mediation analyses revealed that exposure to potentially morally injurious events (pMIEs) moderated the relationship between (1) combat exposure and couple relationship satisfaction and (2) combat exposure and family functioning, both via PTSS, anxious symptoms, and depressive symptoms. To our knowledge, the empirical models presented in this paper are the first to model the role of pMIEs in SMV literature, and provide a foundation for other models to emerge moving forward. Implications and limitations are discussed.

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This study explores the possible use of digital media as an effective psychotherapeutic aid in art psychotherapy, specifically in addressing the effects of trauma experienced by adolescents. A literature review provides evidence on what exactly can be understood under the concepts 'art psychotherapy' and 'digital media'. The literature study further investigates trauma, its treatment and how art psychotherapy can be used as a psychotherapeutic tool with adolescents who have been exposed to trauma. An empirical study including six participants, chosen through a specific sampling process, and whose background information regulates the appropriate methods of intervention demonstrates the practicality of digital media in art psychotherapy. Data gathered from pre-assessment activities, art psychotherapy sessions and post-assessment activities are analysed, interpreted, and reduced through a systematic process. The empirical findings are then presented in a detailed, concise manner From the empirical investigation, it is determined that digital media can be used as a successful tool in art psychotherapy, specifically with adolescents who have experienced trauma. The researcher gained experience in the implementation of digital media in art psychotherapy and was able to provide valuable information about this practice, specifically for professionals interested in the field of art psychotherapy. The researcher was also able to identify limitations and further areas for research in this field. / Psychology of Education / M. A. (Guidance and Counselling)--University of South Africa --2013