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PTSD symptoms and self-injury behaviors among Iranian soldiers; the mediator roles of ruminations and social support
In the last decade, a large volume of research has highlighted the importance of identifying risk and protecting factors of self-injury behaviors in military environments. The purpose of this study was to investigate the fitness of the functional PTSD based model of self-injury behaviors among soldiers residing in Iran military places. 400 man soldiers residing in Tehran military places that committed self- injury behaviors, completed Self-Harm Inventory (SHI), Multidimensional Scale of Perceived Social Support (MSPSS), PTSD Checklist (PCL) and Ruminative Response Scale (RRS). Correlation analyses showed positive associations between PTSD symptoms, rumination, and self-injury. A negative correlation was found between social support and self-injury (p < 0. 0005). Path analysis revealed that PTSD symptoms were significantly associated with increased self-injury, both directly and indirectly, mediated by increased rumination and decreased social support (p < 0. 05). The results of this study revealed that rumination and social support in the relationship between PTSD symptoms and self-injury have a mediating role, so in order to prevent and treat self-harm behaviors, interventions that decrease ruminations and increase perceived social support of soldiers are recommended.
Keywords: self-injury, PTSD, rumination, social support, soldier.
It is believed that all living beings have an innate instinct to protect themselves. This intrinsic effort or momentum for survival and adaptation has, for thousands of years, been an organizing principle that scholars and philosophers have described human and animal behavior based on it and has provided the root of an evolutionary perspective to human growth. However, there are still confusing riddles in human behavior. There are times when people act in an incompatible and opposite manner to the aforementioned organizing principle and their behavior is not such as to maintain their lives. One of these life confounding phenomena which appear to be conflicting with the desire to maintain self and life is self-injury behavior that refers to the direct and deliberate destruction of the body without suicide intention (1). For a long time, self-injury has been considered as a special sign that occurs mainly in suicidal behaviors and any injuries that a person enters into his or her body was linked into the intention to end his or her life (2). This stereotypical view led to the fact that psychologists and psychiatrists usually classify self-injury as a symptom of various mental disorders, such as emotional disturbances of depression or borderline personality disorder (3) (4). However, recent research on non-clinical population has shown that, especially under stressful conditions, self-injury can be widespread and reveals as an independent phenomenon with its own social, personality and biological etiology (5).
Scientific, clinical, and social interest in the phenomenon of self-injury has grown dramatically over the last few years. Probably one of the reasons for the increased attention to the phenomenon of self-injury is the growing prevalence of this issue in the past few years (6). Epidemiology surveys estimate the prevalence rates of self-injury between 4 to 13 percent of the general population (7). Self-injury is most prevalent in young adults and adolescents so that people between the ages of 18 and 25 are considered as the most at risk groups in this area (8) (9). Estimates of the prevalence of self-injury among adolescents and young people were between 13 to 45 percent and 7 to 29 percent, respectively (10) and among the adolescent and young clinical samples, the prevalence of self-injury is between 40 and 60 percent (11). In summary, epidemiology research showed that self-injury is an inclusive problem among people of all ages.
In recent decades, with regard to the growth of the phenomenon of self-injury in military environments, the study of the factors affecting the self-injury in military environments has been noteworthy for a group of psychologists and psychiatrists. The prevalence of self-injury among adults in military environments is estimated at 4 to 28 percent, which is higher than the general population (12). Some researchers believe that a network of intertwined personality, environmental, psychosocial and social factors affects the person living in military environments and the elements, relationships, and function of this complex network determine the likelihood of attempting self-injury behaviors (13). The undesirable outcomes of self-injury behaviors in military environments have made clear the need to determine effective factors on this phenomenon, as well as intervene to prevent it and increase the psychosocial adjustment of high-risk individuals (14).
From the point of view of researchers who work in the field of self-injury, the first variable that causes the occurrence of this behavior in people living in military environments is stressful and disturbing environmental experiences. These experiences, which are the result of hostile and annoying behaviors of the others, shape one’s vision of the military environment and create a clear psychological change in him (15). The result of these changes can be seen in the presence of widespread psychopathological symptoms in soldiers who do harm to themselves. According to research and surveys, at least one psychiatric illness is common in those who commit self-injury behaviors in military environments, with 65% of them having a mental illness (12).
One of the most suitable indicators for knowing the extent to which people are affected by a stressful military environment is the symptoms of post-traumatic stress (PTSD). Posttraumatic stress disorder includes a set of symptoms developed after confronting life traumatic incidents. The persons respond to this experience by fear and helplessness, continually imagines the incidents in his mind, and yet wants to avoid reminding it (16). Recently, researches have shown that difficult military trainings and helplessness feeling during the training period due to difficult assignments and punishments can raise PTSD symptoms in soldiers (17). Entry into the military environment during early youth is accompanied by cognitive, behavioral, organizational, cultural, ethnic and tribal changes; therefore it can start a profound mental pressure and anxiety in soldiers which will affect his psychological status and provides the background for developing PTSD symptoms in them (18). Sometimes, the major stresses during the military service period and living in military environment can be a major threat for one’s life, because soldiers consider living under military environment pressures so difficult and overwhelming that they prefer to harm themselves as a better alternative (19). Therefore, the stresses of the military environment and the PTSD symptoms experienced by the individual, create a unique status that is one of the underlying causes of their self-injury behaviors (20).
From a functional point of view, self-injury behaviors are created and maintained because they provide a temporary solution to intrapersonal and interpersonal problems (1). In fact, intrapersonal and interpersonal problems can be considered as mediators between the primary factors (PTSD symptoms) and self-injury behaviors. According to the functional approach, people who are in an unfavorable environment when experience intrapersonal or interpersonal problems resort to self-injury as a temporary and available solution to relieve the stress caused by these problems. This temporary solution will be strengthened and continued with decreasing tension (21).
An intrapersonal factor that affects the formation and continuity of self-injury behaviors, is cognitive tensions and in particular, rumination (22). Ruminating is defined as a resistant and recurring thought that circles a subject. These thoughts automatically enter into consciousness and distract attention from the topics and current goals (23). Voon, Hasking, and Martin report rumination in people who commit self-injury as self-blame and self-criticism thoughts and refer to them as self-decreasing rumination (24). Also, Selby, Connell, and Joiner refer to rumination as one of the important cognitive components of disturbances that cause self-injury (25).
According to the functional approach, self-injury behaviors that occur during rumination can be sustained and strengthened by reducing or stopping these annoying thoughts. On the other hand, if rumination has self-blaming content, self-injury also brings a sense of satisfaction to the person and increases the process of reinforcement. Therefore, rumination with the creation of cognitive disturbance leads the person to use self-injury as an ineffective, but quick and available coping strategy (26).
In addition to the intrapersonal factors, there are interpersonal factors that also are considered in the functional model as a mediator between the primary factors (PTSD symptoms) and self-injury behaviors. Bryan, Bryan, May and Klonsky by studying psychological situation of people living in military environments concluded that some military personnel became involved with interpersonal problems due to the feeling of loneliness and lack of social support. The lack of social support, which may show itself as emotional disturbances, increased irritability, mood swings and interpersonal distress accompanied by anger and hostility, can lead to self-injury behaviors in residents of military environments (12). Therefore, one of the interpersonal factors that has a significant impact on self-injury behaviors, especially for those experiencing persistent stress, is social support. Claes et al. defined social support as having the affection, assistance and attention of family members and others. It is assumed that social support acts as a striker or mediator between the pressures of life and the psychological state. Due to the lack of satisfaction of the soldiers’ emotional needs in the military environment as well as particular stresses of soldiership era, social support plays an important role in reducing the soldiers’ tension and anxiety (27). Self-injury behaviors in the absence of social support are activated through a social rewards process, in such a way that the individual wounds himself to gain social support (28). So interpersonal variable that is considered as a mediator between the primary factors (PTSD symptoms) and self-injury behaviors, is social support.
In summary, as mentioned above, risk factors or predictors of self-injury behaviors can be classified into three groups: primary factors (PTSD symptoms), intrapersonal factors (rumination) and interpersonal factors (social support). Considering the characteristics of each of the above mentioned factors and how these factors are related to the formation of self-injury behaviors, it can be predicted that simultaneous examination of these factors that has not been taken into account could be useful in clarifying the ambiguities of the issue of self-injury in Iranian soldiers and preventing this lurid event. Therefore, the purpose of this study was to investigate the fitness of the functional PTSD based model of self-injury behaviors among soldiers residing in Iran military places.
Materials and Method
Participants were 400 man soldiers residing in Tehran military places that committed self- injury behaviors. The committing of self-injury was determined through the report of the commanders. Soldiers were aged between 19 and 30 years (M = 22.76 years, SD = 2.40 years). 91% of participants were single and 9% were married. Education level of 2.3% of participants was primary, 21.5% Junior, 40.3% Diploma, 12.8% associate, 20.3% bachelor and 3% master. Participation was voluntary and a consent form was signed by all participants. Each subject had 20 to 30 minutes to answer all four questionnaires. The questionnaires were performed individually, and the subjects were explained to answer the questions by taking into account the knowledge of their personality and psychological state. After completing the questionnaires, participants were debriefed with respect to the specific purposes of the study. Soldiers did not receive compensation for completing the questionnaires.
Self-Harm Inventory (SHI)
The Self-Harm Inventory (SHI; 1998) was developed by Sansone et al. (1998) (29). It is a one-page, 22-item, yes/no, self-report questionnaire that explores respondents’ histories of self-harm. Each item in the inventory is preceded by the phrase, “Have you ever intentionally, or on purpose…” Individual items include, “cut yourself, burned yourself, hit yourself, scratched yourself,” and, “prevented wounds from healing.” There are three eating-disorder items (i.e., “exercised an injury on purpose, starved yourself to hurt yourself, abused laxatives to hurt yourself”), two high-lethal items (i.e., “overdosed, attempted suicide”), and three items relating to medical issues (i.e., “prevented wounds from healing, made medical situations worse, abused prescription medication”). All endorsements are pathological, and the SHI total score is simply the sum of “yes” responses, with a maximum possible score of 22. Although according to Sansone et al. (1998) alpha coefficients were not applicable to this scale (29), in this study the scale was found to have good reliability. The Cronbach’s alpha for this study was 0.84.
Multidimensional Scale of Perceived Social Support (MSPSS)
The MSPSS, is a 12-item scale that measures perceived support from Family, Friends, and a Significant Other (30). Respondents answer items on a 7-point Likert-type scale (very strongly disagree to very strongly agree). The reliability and validity of the MSPSS have been demonstrated across several populations (31) (32).Terms used to describe sources of social support in the MSPSS were specifically designed to allow respondents to interpret items in ways most relevant to themselves. For example, the items measuring support from a significant other refer to a ‘‘special person,’’ which may be interpreted variously to mean a boyfriend / girlfriend, teacher, counselor, etc. The use of more specific terms could have weakened the scale (e.g., asking about a boyfriend/girlfriend presumes the existence of a romantic relationship).
PTSD Checklist (PCL)
The PCL was developed by Weathers, Litz, Huska, & Keane (1991). This checklist provides point-to-point correspondence between individual items and the DSM-IV diagnostic symptom criteria for PTSD (33). The PCL has been shown to have very good internal consistency (alpha = 0.94) and temporal stability (retest r = 0.88, 1-week interval), and it correlates strongly (i.e., r > 0.75) with other measures of PTSD symptomatology (34). The diagnostic efficiency in two clinical samples (motor vehicle accident victims and sexual assault victims), using the CAPS as the criterion, has also been found to be quite good (i.e., 0.90;) (35).
Ruminative Response Scale (RRS)
The ruminative response scale was developed by Nolen-Hoeksema & Morrow (1991)(36). This scale includes 22 items describing responses to depressed mood that are self-focused, symptom-focused, and focused on the possible causes and consequences of dysphoric mood. Each item is rated on a Likert scale ranging from 1 (almost never) to 4 (almost always). Total scores can thus range from 22 to 88. The RRS has demonstrated good reliability and validity as a measure of rumination (36) (37).
Pearson correlation coefficients were calculated to explore the correlations between the study variables. Data analyses were conducted using SPSS (v. 21; IBM Corporation, Armonk, NY, USA). A path analysis was conducted to explore the indirect effect of PTSD symptoms on self-injury through social support and rumination, using the software LISREL 8.80. The path analysis aimed to determine whether social support and rumination (mediators), would contribute for the association between PTSD symptoms (exogenous variable) and self-injury (dependent, endogenous variable). Path analyses are a subset of Structural Equation Modelling (SEM), used to assess theoretically expected causal relations between previously defined variables, testing for direct and indirect effects between exogenous and endogenous variables, while controlling for error (38). The covariance matrix served as database for the path analysis and the method of estimation was maximum likelihood.
Descriptive Statistics and Correlations
Descriptive statistics and Cronbach’s alphas for the study variables are presented in table 1.
Table 1. Descriptive statistics and Cronbach’ alphas for study variables (N = 400).
Table 2 gives the correlation matrix for the study variables. Results showed positive associations between PTSD symptoms, rumination and self-injury. Negative correlation was found between social support and self-injury. Also there was a positive correlation between PTSD symptoms and rumination and a negative correlation between rumination and social support.
Table 2. pearson correlation coefficients between the study variables (N = 400).
|1. PTSD symptoms||1|
|3. social support||-0.053||-0.128*||1|
Note: p < .05; * p < .0005; **
As shown in Figure 1, the model was composed of one exogenous variable (i.e. PTSD symptoms) and three endogenous variables (i.e. rumination, social support and self-injury). Paths were specified according to the proposed model. Statistical tests were conducted in order to determine the significance of the mediator sequence. In order to test this, the whole model sequence was broken down into two parts in order to assess each part of the chain composed of a predictor, a mediator, and an outcome. In line with recent simulation studies with respect to mediation analyses (39) (40), we focused on the significance of the association between the predictor and the mediator and that of the mediator and the outcome and tested the significance of the whole mediation sequence with Sobel tests. If the Sobel test is significant, the mediation effect is significant. Thus, in order to assess the mediating roles of rumination and social support in the association between PTSD symptoms and self-injury, we used a Sobel test.
Note: p < .05; *. p < .01; **
FIGURE 1. Results of path analysis
Data was screened for uni-and multivariate normality, Skewness (which varied from – 0.08 social support to 0.29 self-injury) and Kurtosis (values ranged from -0.05 social support to -0.51 self-injury). So there was no violation of normal distribution. The model tested for the indirect effect of PTSD symptoms on self-injury, through the mechanism of rumination and social support (Figure 1). The results of the path analysis revealed a satisfactory fit of the model to the data. The chi-square value was not significant, χ2 = 2.28, p = .548, and fit indices were satisfactory, with the Comparative Fit index (CFI) = 0.96, the Goodness of Fit Index (GFI) =0.94, the Normed Fit Index (NFI) = 0.97, the Standardized Root Mean Square Residual (SRMR) = .012, and the Root Mean Square Error of Approximation (RMSEA) = .007 indicating support for the hypothesized model.
As shown in Figure 1, the estimated paths between PTSD symptoms and rumination (β = 0.52) was positive and significant (t-value > 2.58), and the estimated path between rumination and self-injury (β = 0.44) was positive and significant (t-value > 2.58). On the other hand, the estimated path between PTSD symptoms and social support (β = -0.14) was negative and significant (t-value > 1.96) and the estimated path between social support and self-injury (β = -0.33) was negative and significant (t-value > 2.58). Also the estimated paths between PTSD symptoms and self-injury (β = 0.37) was positive and significant (t-value > 2.58).
Sobel tests were used in order to assess the mediating role of rumination and social support (40). The significant value (z = 3.59, p < .001) of the indirect effect indicates that rumination mediate the relationship between PTSD symptoms and self-injury. Also the significant value (z = -1.99, p < .05) of the indirect effect indicates that social support mediates the relationship between PTSD symptoms and self-injury.
The purpose of this study was to investigate the fitness of the functional PTSD based model of self-injury behaviors among soldiers residing in Iran military places. The results showed that rumination and social support in the relationship between PTSD symptoms and self-injury have a mediating role. As predicted, PTSD symptoms affected the formation of cognitive disturbances and in particular rumination, thereby indirectly affecting people’s tendency to self-injury behaviors. Therefore, PTSD symptoms are a positive predictor of rumination and self-injury behaviors. The findings also suggest that PTSD symptoms are associated with lower social support and, by disrupting social support, may lead to self-injury behaviors.
The results of path analysis indicated that the mediator role of rumination and social support in relation between symptoms of PTSD and self-injury behaviors are significant. Rumination under the influence of PTSD symptoms, increase self-injury behaviors and experience less social support that is due to PTSD symptoms, causes the formation of self-injury behaviors. So, rumination positively predicted self-injury behaviors and social support, negatively predicted these behaviors.
These findings are in line with the results of previous research that noted to the mediator role of rumination and social support for self-injury behaviors. Borders et al. (2012) studied the moderator role of rumination in the associations between PTSD and self-injury behaviors and consistent with the findings of this study, concluded that veterans with more PTSD symptoms reported more self-injury behaviors. Moreover, rumination significantly interacted with PTSD symptoms, such that PTSD symptoms only predicted self-injury behaviors for veterans with moderate to high levels of rumination (41). Selbi et al. (2013) examined the role of rumination and emotional disturbance in committing self-harm behaviors and concluded that emotional disturbances lead to annoying rumination, and individuals self-injure to get rid of this annoying cognitive disturbance by diverting their attention from the sad thoughts. They also point out that those who experience emotional excitability (such as those with PTSD symptoms) report poorer emotional processing and higher levels of rumination (22).
In a study that investigated the relationship between post-traumatic stress disorder symptoms and self-harm behaviors, the results showed that PTSD symptoms predict, even after several years, self-injury behaviors. The researchers explained the reasons for the long-term effects of PTSD symptoms on the tendency to self-injury behaviors in relation to the active process of sadness that occurs after a traumatic event. In this period that is characterized by low mood, a person with PTSD symptoms, experiences the traumatic event in a variety of ways (in rumination, dreams, and as quasi-illusory symptoms). These experiences, which include the cognitive, emotional, and behavioral aspects of the individual’s psychological world, are unbearable and predispose to self-injury behaviors, because self-injury behaviors for a short time eliminate cognitive and emotional disturbance (42).
Claes et al. (2015) examined the role of social support and psychopathology symptoms in self-injury behaviors. By differentiating between intrapersonal and interpersonal factors, they concluded that each of these factors, both independently and in interaction with another, was involved in committing self-injury behaviors. Their results also showed that the psychopathology symptoms lead to more intrapersonal problems and less social support, which was also observed in the results of the present study (28). Nock et al. (2013) explored and explained the role of social support in committing self-injury behaviors in military environments. They point out that the lack of social support has a lot of pressure on soldiers who show psychopathology symptoms, such as PTSD symptoms. Because, following the self-injury behaviors, the perpetrator transmits to the medical services for receiving medical services or receives initial support from his relatives, self-injury behavior is strengthened and its re-occurrence probability is increased (13). In this regard, Klonsky and Moyer pointed out that those who committed to self-harm behaviors, compared to the peer control group, had higher scores in the conversion disorder scale that indicate the physicalization of psychic symptoms to attract others’ support (43).
In summary, the results of this study revealed that rumination and social support in the relationship between PTSD symptoms and self-injury have a mediating role. When a post-traumatic stress disorder occurs, the sufferer will have to live in a prolonged period of uncertainty about temporary or permanent damage caused by the trauma. Certainly, the cognitive and emotional disturbances associated with the disorder lead to rumination and interpersonal problems which restricts person’s social support. Subsequently, the decline in social support becomes a major source of stress and underlies inability to adapt to living in military environments. This incompatibility with the circumstance and widespread experience of cognitive-emotional disturbances provides the basis for the formation of self-injury behaviors.
Although these findings are consistent with literature and theory that individuals with psychopathology symptoms, cognitive disturbance and poor social support may be especially likely to respond to negative moods by engaging in self-injury behaviors, future research with soldiers should examine these variables longitudinally in order to establish directional associations. Also, lack of strong literature about rumination and social support in Iranian military personnel are among the limitations of the research. Given the importance of the attention to psychological state of military personnel, it is highly recommended to carry out other studies in this regard for more generalization. The result of this study revealed that rumination and lack of social support may exacerbate vulnerabilities that soldiers are already experiencing, further increasing the likelihood of self-injury behaviors. Future studies with this population could also examine whether specific types of rumination (e.g., depressive, anger) and social suppoort (family, friends, significant others) relate to particular outcomes.
Due to the heavy pressure they bear, patients with self-injury behaviors need to receive adequate support interventions at the time they experience the limitations of military environments. The finding that PTSD symptoms were related to self-injury behaviors through rumination suggests that interventions targeting rumination may help prevent self-injury behaviors. Rumination-focused cognitive behavioral therapy teaches clients alternative coping strategies (e.g., disclosure of emotions, effective coping styles) and effectively decreases symptoms of PTSD (44). Also, considering the mediator role of social support in the relationship between PTSD symptoms and self-injury behaviors, interventions that increase the perceived social support of soldiers are recommended. Research has shown that the promotion of perceived social support is associated with a reduction in the impact of PTSD symptoms on cognitive and emotional disturbances and, subsequently, less self-injury behaviors (45).
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 Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.