Polyvictimization and Psychological Distress in Early Adolescence: A Mediation Model of Defense Mechanisms and Coping Styles

Abstract

In the current study, we aim to examine the link between exposure to multiple traumatic events (polyvictimization), posttraumatic stress disorder (PTSD) symptoms (PTSS), and psychiatric symptomatology in early adolescence. Furthermore, we aim to explore the mediating roles of defense styles and coping styles in the associations between polyvictimization, PTSS, and psychiatric symptomatology. Data from a Danish national representative sample of 390 eighth-grade students with a mean age of 13.95 (SD = 0.37) years were used. Participants responded to validated self-report questionnaires in 2001. The dimensions of immature defense styles and emotional and avoidance coping mediated the positive associations between polyvictimization, PTSS, and psychiatric symptomatology. Serial multiple mediation indicated that the sum of exposure to traumatic events was significantly associated with more immature defense styles, associated with both high levels emotional and avoidance coping, which, in turn, were associated with high levels of PTSS and psychiatric symptomatology. Polyvictimization is related to adverse outcomes in early adolescence. Both immature defense styles and emotional and avoidance coping styles should be considered as risk factors for the development of psychological distress following exposure to multiple traumas.

Keywords

adolescents coping defense styles PTSD life events

Introduction

Adolescents are known to be susceptible to experiencing potentially traumatic events (PTEs) during this developmental phase (e.g., Breslau, Wilcox, Storr, Lucia, & Anthony, 2004). Those who are exposed to one PTE type are at elevated risk for experiencing multiple PTEs over their lifetime (Finkelhor, Ormrod, & Turner, 2007). Moreover, exposure to multiple traumatic events (polyvictimization) during the life phase is known to be associated with heightened posttraumatic stress disorder (PTSD) symptoms (PTSS) and diagnosis (Nooner et al., 2012). However, the high variability in PTSD rates indicates that the number and nature of PTEs are not sufficient for an adolescent to develop PTSD. Rather, developing a better understanding of the variables that mediate the link between multiple exposures to PTEs and psychological distress is needed. The current study aims to examine the contribution of two possible psychological mechanisms—that is, defense styles and coping styles—to the understanding of the association between polyvicitimation, PTSS, and psychiatric symptomatology in early adolescence.

Polyvictimization and PTSD

Early adolescence (approximately 12-14 years of age) is a developmental period that is characterized by a physiological growth spurt and a rapid brain development soon to be followed by psychological, cognitive, and social changes. Due to these changes, adolescents face a number of new developmental challenges including adaption to their sexual transformations, development of coherent identities, establishing relations with peers, practicing adult roles, and developing independence from parents (e.g., Spear, 2009). However, during this period, adolescents are also more prone to risky behaviors such as bullying victimization (e.g., Vieno, Gini, & Santinello, 2011), sexual violence, and exploitation (Steinberg, 2007). Thus, it is not surprising that longitudinal research has identified adolescence as a developmental period where youth are particularly susceptible to experiencing traumas and, in turn, developing psychological distress (Breslau et al., 2004; Reardon, Leen-Feldner, & Hayward, 2009).

Indeed, a recent review found that the rates of traumatic exposure peak in adolescence compared with adulthood, with about 70% to 80% of adolescents meeting diagnostic criteria for exposure to a serious traumatic event. The most common types of trauma documented were witnessed violence, natural disaster, and physical abuse (Nooner et al., 2012). It is a known fact that exposure to a single PTE, especially severe events such as childhood physical or sexual abuse, is sufficient for developing PTSD. However, youth exposed to one PTE type are also at elevated risk for experiencing multiple PTE types over their lifetime (Finkelhor et al., 2007), with a significant proportion of them experiencing five or more traumatic events during adolescence (Finkelhor, Turner, Shattuck, & Hamby, 2013).

It is quite surprising that compared with adult samples, there are relatively few epidemiological studies on the prevalence of PTSD among adolescents. The latest review (Nooner et al., 2012) and meta-analysis (Alisic et al., 2014) concluded that the average prevalence were 13.6% and 15.9%, respectively. Both studies indicated that the highest risk was for interpersonal trauma (e.g., sexual assault) and female gender. However, beyond the exposure to a single PTE, repeated exposures to traumatic events and polyvictimation are associated with heightened risk for a range of mental health problems (Briere, Kaltman, & Green, 2008) and especially with PTSD (Ford, Wasser, & Connor, 2011), both in clinical (Dixon, Howie, & Starling, 2005) and nonclinical settings (Elklit, 2002). Moreover, recent meta-analysis results indicated that exposure to posttrauma negative life events in itself constitutes a risk factor for future PTSD (Trickey, Siddaway, Meiser-Stedman, Serpell, & Field, 2012). Nevertheless, the high variability of the rates of PTSD and the fact that only a small but significant segment of the adolescent population develops psychopathology and PTSD following exposure to polyvicitimization highlight the need to better understand the ways adolescents perceive, process, and cope with PTEs.

Defense Mechanisms

The concept of defense mechanisms, rooted in the psychoanalytic perspective (Freud, 1894/1962), is central for the understanding of human behavior. Although it has been removed from Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), its clinical utility (e.g., Bornstein, 2006) and predictive value for positive adaptation (e.g., Vaillant, 2011) is profound. Defense mechanisms are patterns of involuntary thoughts, feelings, and behaviors that function to hide or alleviate internal or external anxiety-causing stressors (APA, 2000). Some defenses (e.g., denial) can be maladaptive because their use involves high distortion of reality. Other defenses (e.g., humor) are considered to be adaptive in that they represent a form of involuntary coping with stressful life events that provides a means for adjustment.

Contemporary psychoanalytical theories (e.g., Cramer, 2000) suggested a possible hierarchical model of defenses. The most influential and empirically tested model is Vaillant’s (1977) classification of defense according to their maturity. Within a developmental hierarchy, defenses range from the “immature” (e.g., projection) that are cognitively simple and have emerged early in life, to intermediate or “neurotic” defenses (e.g., displacement), and to more complex, “mature” defenses (e.g., sublimation). “Mature” defenses are adaptive because they promote positive mental health by amplifying gratification and reinstating psychological homeostasis, while allowing for the conscious recognition of psychosocial stressors. Neurotic and immature defenses distort reality in ways that require relatively low levels of cognitive complexity. Consistent with this supposition, immature defense use has been found to decline with age (e.g., Andrews, Singh, & Bond, 1993).

Defense mechanisms are considered an enduring aspect of personality that remains stable following the maturation process (Vaillant, 2011). However, stressful and traumatic experiences are known to affect mental processes, events altering basic personality constructs such as attachment orientations (e.g., Solomon, Dekel, & Mikulincer, 2008) and, specifically, impacting defensive functioning (Perry, Metzger, & Sigal, 2015). Indeed, the empirical literature indicates that individuals might react with defense mechanisms lower on the hierarchy of defensive adaptation to a single trauma (e.g., child-birth related trauma; Fenech & Thomson, 2015) or repeated trauma (e.g., captivity; Punamäki, Kanninen, Qouta, & El-Sarraj, 2002). Thus, it is plausible that the effect of polyvictimization on defense mechanisms during the early adolescence period would be more profound due to its unstable characteristics.

Although defenses themselves are not psychopathological, it has been suggested that specific psychiatric disorders involve frequent use of maladaptive defense mechanisms. A number of studies have reported that immature or maladaptive defense styles (i.e., characterized by distinct patterns of defense mechanisms) were associated with various types of psychiatric symptomatology (e.g., Jun et al., 2015), such as personality disorders (Perry, Presniak, & Olson, 2013) or depression and anxiety (Spinhoven & Kooiman, 1997). Specifically, immature defenses (e.g., acting out, projection) have been found in combat veterans with PTSD, as well as North Korean refugees (Jun et al., 2015). Another study found that neurotic and immature defense styles mediate the link between polyvicitimization and PTSS (Shevlin & Elklit, 2008). Unfortunately, this study did not integrate the related and complementary variable of coping styles. We aim to fill this gap with an advanced statistical approach and more comprehensive outcome variables of both PTSS and psychiatric symptomatology.

Coping Styles

Coping is conceptualized as a conscious, volitional, cognitive, and behavioral process individuals use to manage external (e.g., environmental) and/or internal (e.g., emotional) challenging events or circumstances (e.g., Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001). As the theoretical and empirical literature is abundantly populated with various, and somewhat overlapping, definitions and classifications for coping styles, a distinction can be made with reference to two main complementary coping styles: emotion and problem-focused coping styles. The emotional coping style refers to the process of emotional regulation in the face of demanding circumstance. Thus, individuals use emotional coping when they believe that nothing can be done to modify the challenging environmental conditions and they attempt to escape feelings of distress. The problem-focused coping refers to a more rational process in which one tries to do things to change the situation and the relations between the two. Thus, individuals use problem-focused coping perceived as helpful when conditions are considered to be amenable to change. Another related classification of coping styles is engagement versus disengagement coping. With engagement coping, the individual confronts the stressor or related emotions (e.g., planning ahead), whereas in disengagement coping, the individual aims to escape the threat or related emotions (e.g., detachment, avoidance; Carver & Connor-Smith, 2010).

Exposure to polytraumatization that might be characterized by uncontrollability might impact adolescent coping styles, leading to more incompetence and disengagement (Skinner & Zimmer-Gembeck, 2011). Many studies among adolescents exposed to single trauma or/and repeated trauma revealed the effects of exposure to stress on the use of maladaptive coping styles (e.g., Pfefferbaum, Noffsinger, & Wind, 2012). For example, both Israeli and Palestinian adolescents who were exposed to ongoing violence frequently reported used tactics such as accepting the reality and distraction (Pat-Horenczyk et al., 2009). In another recent study among adolescents, polyvictimization was positively related to maladaptive coping strategies (avoidance and emotional coping; Guerra, Pereda, Guilera, & Abad, 2016).

Certain coping styles have been linked with the development and maintenance of PTSD (e.g., Meiser-Stedman, 2002). Taken together, coping styles which are characterized by emotional coping or disengagement/avoidance coping, such as cognitive avoidance (Dempsey, Overstreet, & Moely, 2000), distraction, thought suppression, and rumination (e.g., Aaron, Zaglul, & Emery, 1999), were associated with PTSD and PTSS among various samples and age ranges. A recent meta-analysis among children and adolescents indicated that thought suppression, blaming others, and distraction are predictors of PTSD with medium to large effect sizes (Trickey et al., 2012). Importantly, a systematic review of prospective studies concludes that emotional-avoidance coping styles such as rumination were predisposing risk factors for PTSD symptoms (DiGangi et al., 2013). Moreover, coping styles may be mediators between polyvictimization and a wide variety of psychopathology. For example, among adolescents, maladaptive coping acted as a mediator in the relationship between polyvictimization and internalizing symptoms (Guerra et al., 2016).

Defense Mechanisms and Coping Styles

The interrelations between defense mechanisms and coping styles have been debated, especially regarding similarities and differences in their intentionality, functionality, and adaptiveness (e.g., Cramer, 1998). Scholars have characterized defense mechanisms as being unconsciously mediated and non-intentional, whereas coping styles were characterized as operating on a conscious level and involve pre-judgment and agency (Cramer, 2000). Recent integrative models have argued, however, that coping includes both conscious and unconscious efforts, coping and defense have very similar functions, defense adaptiveness is considered as more qualitative and coping as more quantitative, and that both stabilities over time are still unclear (Kramer, 2010).

The present study adopts Chabrol and Callahan’s (2004) perspective in which sequential relations exist whereby defense mechanisms precede coping processes. Thus, defense mechanisms are conceptualized as developmentally early, internal, and dynamic personality structures, whereas coping styles are behaviorally activated once the individual’s basic unconscious defensive stance has been established. In the context of the stress-diathesis model (e.g., Pynoos, Steinberg, & Piacentini, 1999), the development of PTSS and psychiatric symptomatology may also be mediated by the defense styles habitually used by an individual, which may reduce or exacerbate the PTSS and psychiatric symptoms. Maladaptive defense styles can also lead to increased use of maladaptive coping styles later resulting in more PTSS and psychiatric symptomatology.

Based on the literature review, we hypothesize the following:

Hypothesis 1: The sum of direct exposure to traumatic events; neurotic and immature defense styles; emotional, detachment, and avoidance coping styles will be positively associated with both PTSS and psychiatric symptomatology.

Hypothesis 2: Multiple mediation models are predicted such that reports of immature defense style and emotional coping will mediate the relation between exposure to traumatic events and both PTSS and psychiatric symptomatology.

Hypothesis 3: Serial multiple mediation models are predicted such that reports of immature defense style will relate to emotional and avoidant coping and, finally, to both PTSS and psychiatric symptomatology.

Method

Participants

This is a secondary analysis of data collected in 2001 from a questionnaire survey with a Danish national representative probability sample of 390 adolescents aged 13 to 15 years (M = 13.95, SD = 0.37). The sample was geographically stratified by 10 regions, with sample allocation proportionate to the Danish population distribution. Thirty schools that taught eighth-grade students were approached. Twenty-two schools accepted and participated (73.3% coverage). Each class consisted of 12 to 25 pupils (M = 17.7), and an average of 0.9 pupils (95% response rate) were missing on the day of the study. All pupils present completed the questionnaires. The gender distribution was 50% (n = 195) females and 50% (n = 192) males. Seventy-four percent (n = 287) of the pupils lived with both parents, 25% (n = 99) lived with one parent, and 1% (n = 4) had other arrangements. The differences between the parents’ education and participation from the various regions of the country were not significant.

Procedure

The study was introduced through (a) a letter to the headmasters explaining the selection procedure—the primacy of the initials of the head teachers decided which class was chosen, in case there was more than one eighth-grade class in the school; (b) a letter to the head teacher describing introduction, monitoring, support, and confidentiality procedures (i.e., the sealing of the return envelope in front of the pupils); and (c) a letter to each pupil explaining the purpose, confidentiality, option of not participating, and collection procedures. In all five Nordic countries, psychologists follow a common set of Nordic ethical guidelines. Only studies within the hospital sector have to be approved by a regional Helsinki committee; ethical questions in studies in all other areas are the sole responsibility of the psychologist in charge of the research.

Measures

The first part of the questionnaire contained questions about gender, age, parent education, and living arrangements (living with one parent, two parents, or others such as grandparents or within an institution). Parent education was chosen as a crude measure for the socioeconomic situation.

Traumatic Life Events questionnaire (Elklit, 2002) was composed in the absence of a valid Danish-translated self-report questionnaire at the time of the study. Participants were asked about 20 potentially traumatic and negative life events they had experienced over their life that can lead to PTSD or psychological distress. The events were selected from empirical and clinical literature, covering possible traumatic life-threatening experiences (e.g., rape, traffic accident) and distressing family conditions (e.g., neglect, abuse). Each question offered the possibility for students to answer according to direct exposure or indirect exposure (i.e., witnessing an event or having a person close to them experience an event). The sum of negative life events that participants were directly exposed to was used for analysis. The actual range of the direct exposure index was 0 to 16 and for the indirect exposure index was 17 to 0. This measure has been widely used cross-culturally (e.g., Bödvarsdóttir & Elklit, 2007). As no psychometric data are available on this measure, a support for the external validity of the items might come from its high resemblances to the well-validated measure of Life-Event checklist (Gray, Litz, Hsu, & Lombardo, 2004). The inventory reliability in the current study for direct exposure items was Cronbach’s α = .67 and for indirect exposure Cronbach’s α = .82.

The Harvard Trauma Questionnaire–Part IV (HTQ; Mollica et al., 1992) yields both a PTSD diagnosis according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994) criteria and a measure of PTSD symptom severity. The scale consists of 30 items, of which 16 directly correspond to the PTSD symptoms in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000). The other items reflect PTSD-like states such as negative changes in mood and cognitions (e.g., “I blame myself for what happened”). The HTQ asks the respondents how much each symptom has bothered them at the time when the event that was most distressing to them happened. Items are scored on a 4-point Likert-type scale (1 = not present, 4 = very often present). The criteria for PTSD were met if a person scores (3) “often” or (4) “very often” on one symptom of re-experiencing, three symptoms of avoidance, and two symptoms of arousal. In addition, a subclinical level of PTSD is noted when the Intrusion subscale is fully met, although one of the other subscales misses just one symptom. The total sum of HTQ was used as a Symptom Severity Index. The HTQ-Part IV has been used extensively in Denmark (e.g., Shevlin & Elklit, 2008). Mollica et al. (1992) found good reliability and validity for the scale. A previous study indicates good construct validity and unique predictive utility with other trauma-related variables (Elklit & Shevlin, 2007). In the present study, the Cronbach’s α for the HTQ scale was .94.

The Trauma Symptom Checklist (TSC-33: Briere & Runtz, 1989) was originally developed to assess the long-term impact of a variety of traumatic experiences (e.g., rape, child sexual abuse) on various psychological states. The scale is highly overlapping with the Symptom Checklist (SCL-90; Derogatis, 1977) and the Hopkins Symptom Checklist (HSCL; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974), and is comprised of subscales such as Depression, Anxiety, Somatic Problems, Interpersonal Sensitivity, and Dissociation. It contains 33 items which are rated in relation to the previous month (“How often have you experienced each of the following in the last month?”). The items are answered on a 4-point Likert-type scale from “never” (1) to “very often” (4). In the current study, the total sum of HTQ was used as an index of general psychological distress. The TSC-33 has previously been found to be internally consistent, in both subscales and total scores, and has good discriminant validity (Briere & Runtz, 1989; Elklit & Shevlin, 2007). In the present study, the Cronbach’s α for the TSC scale was .76.

The Defense Style Questionnaire–40 (DSQ-40; Andrews et al., 1993) measures 20 defense mechanisms (two items per mechanism), which are categorized into three groups: mature (e.g., humor, sublimation), neurotic (e.g., reaction formation, undoing), and immature defense styles (e.g., splitting, denial). The items are scored on a 9-point Likert-type scale ranging from (1) strongly disagree to (9) strongly agree. The DSQ has good construct validity, and the three factors correlate highly with the same factors of the original 72-item DSQ (Andrews et al., 1993). Alpha values for the three factors have shown to be acceptable and the three scales provide good test–retest reliability (Andrews et al., 1993). Elklit and Shevlin (2007) demonstrated that the DSQ is in good accordance with clinical assessment of subjects. The Cronbach’s alpha values for the three subscales in the current study were low to moderate (Mature α = .53, Neurotic α = .53, and Immature α = .76).

The Coping Style Questionnaire (CSQ; Roger, Jarvis, & Najarian, 1993) originally consisted of 60 items rated on a 4-point Likert-type scale (1 = never to 4 = always) and relates to how respondents generally deal with stressors. It is comprised of four coping styles: rational coping, emotion-focused coping, avoidance coping, and detached coping. Elklit (1996) made a validation study on Danish respondents and proposed a shorter 37-item version that significantly loads the four primary coping components: rational coping (11 items), emotional coping (10 items), detached coping (six items), and avoidant coping (10 items). Concordance between the four subscales in the original and revised version is high (67%-84%). The internal consistencies of the subscales in this study were acceptable (Rational Coping α = .76; Emotion-Focused Coping α = .78; Detached Coping α = .64; and Avoidance Coping α = .65).

Analytic Strategy

Data analysis was divided into four stages. First, prior to the data analyses, the data were screened for errors. The percentage of missing values in the studied variables ranged between 0% to 28.2%. Thus, due to the high percentage of missingness in some variables, we chose to impute missing data. To decide whether the data were missing at random, we conducted a Little’s Missing Completely at Random (MCAR) test. The analysis revealed that the data were missing completely at random, χ²(1446) = 1,445.08, p = .50. Missing data were handled with maximum likelihood (ML) module in AMOS 23 software. Compared with conventional methods such as arithmetic mean, listwise, or pairwise deletion, the ML method was recommended as an optimal method for computing missing data to avoid biased data (e.g., Schafer & Graham, 2002). The mediation analyses were therefore conducted on 390 participants. Second, the relationships between the study variables were examined with a series of Pearson correlation analyses. Third, to address our multiple mediation hypotheses, we employed Hayes’s (2013) PROCESS script in IBM SPSS software (Version 21; 2012). In the multiple mediation analysis (Model 4), 10,000 bootstrapped samples were drawn to estimate indirect effects of each of the mediators. Bias corrected and accelerated (BCa) 95% confidence intervals (CIs) were computed to determine statistical significance of the ab paths of each mediator. A CI that does not include zero provides evidence of a significant indirect effect, or significant mediation (Preacher & Hayes, 2008). Last, to assess our serial mediation integrated model, we have used structural equation modeling (SEM; Hoyle & Smith, 1994), a strategy using AMOS software (Version 21; Arbuckle, 2012), and the ML method. We used a number of criteria to examine the fit of the SEM model: (a) a chi-square test, (b) the root mean square error of approximation (RMSEA), (c) the comparative fit index (CFI), and (d) the normed fit index (NFI), a model for which the chi-square value was nonsignificant, CFI and NFI were greater than 0.95, and the RMSEA index was between 0.00 and 0.06. All analyses were conducted with statistical control over the gender variable.

Results

Prevalence of Exposure to Traumatic Events and PTSD

As a preliminary analysis, we examined the number of traumatic and distressing events. As can be seen in Table 1, the average number of direct exposure to events per pupil was 2.5 (percentage who experienced one event = 17%, two events = 23%, three events = 20%, four events = 14%, and five events or more = 14%). Of the 289 students who reported one traumatic event and who gave full information on the HTQ, 11 (5.6%) males and 24 females (12.3%) fulfilled the various criteria for PTSD at the time of the event, corresponding to 9% of the total group. Twenty-two males (11.2%) and 34 females (17.4%) constituted a subclinical group missing the PTSD diagnosis by one symptom or one subcriterion (of the C and D group, according to the DSM-IV). The gender difference in PTSD rates was significant, χ²(3) = 23.6; p < .0005. A comprehensive presentation of traumatic event distribution and probability of PTSD according to specific event is presented in Elklit (2002).

Table 1.

Pearson Correlation Coefficients of Study Variables.

	1	2	3	4	5	6	7	8	9	10
1. Exposure to traumatic events	—
2. Mature defense style	.10*	—
3. Neurotic defense style	.11*	.23**	—
4. Immature defense style	.23**	.19**	.14*	—
5. Rational coping	.18**	.43***	.30***	.10*	—
6. Emotional coping	.24**	.02	.20**	.29***	.09	—
7. Detachment coping	.04	.29***	.08	.03	.43***	−.14*	—
8. Avoidance coping	.20**	.14*	.24***	.28***	.20**	.39***	.09	—
9. PTSD symptoms	.27***	.04	.12*	.22***	.07	.34***	−.07	.28***	—
10. Psychiatric symptomatology	.26***	−.06	.16**	.23***	.01	.46***	−.11*	.20**	.28***	—
M	2.46	41.85	38.83	94.79	24.74	17.50	12.83	21.25	51.62	47.34
SD	2.27	8.72	9.51	20.08	4.93	4.14	2.97	4.12	17.99	10.34

Note. PTSD = posttraumatic stress disorder.

†

p < .07. *p < .05. **p < .01. ***p < .001.

Relationships Between the Study Variables

As can be seen in Table 1, according to our first hypothesis, the sum of exposure to traumatic events was positively related to both PTSS and general psychiatric symptomatology with medium effect sizes. As hypothesized, both neurotic and immature defense styles, but not mature defense style, were positively related to PTSS and general psychiatric symptomatology with small to medium effect sizes. Moreover, participants’ emotional and avoidance coping were positively related to both PTSS and general psychiatric symptomatology with medium to large effect sizes. In addition, while rational coping was not related to outcome measures, detachment coping was negatively related to PTSS and general psychiatric symptomatology with a small effect size (Cohen, 1988).

Multiple Mediation Analyses

Defense styles and coping styles mediate the relationship between the exposure to traumatic events and PTSS

The second hypothesis stated that defense styles and coping styles would mediate the relationship between the sum of exposure to traumatic events and PTSS. Specifically, we examined (a) whether the sum of exposure to traumatic events is directly related to PTSS and psychiatric symptomatology and (b) whether the sum of exposure to traumatic events is indirectly related to PTSS and psychiatric symptomatology via the three defense styles (mature, neurotic, and immature) and the four coping styles (rational, emotional, detachment, and avoidance). The analysis was conducted with statistical control for gender. The results of the multiple mediation model for PTSS are presented in Figure 1. The point estimates, SEs and 95% BCa CI are reported in Table 2.

Figure 1.

A multiple mediational model for PTSD symptoms (HTQ) by defense styles and coping styles.

Table 2.

Bootstrapped Point Estimate for Direct and Indirect Effects and 95% CI for Predicting PTSD Symptoms (HTQ) and Psychiatric Symptomatology (TSC) by Sum of Exposure to Traumatic Events Through Defense Styles and Coping Styles Dimensions.

	Point Estimate	SE	BCa 95% CI [Lower, Upper]
PTSD symptoms (HTQ)
Direct effect of exposure	1.30	.38	[0.54, 2.06]***
Total indirect effect	0.71	.17	[0.40, 1.11]**
Mature defense style	0.01	.05	[−0.08, 0.13]
Neurotic defense style	−0.01	.04	[−0.13, 0.07]
Immature defense style	0.19	.11	[0.01, 0.46]^†
Rational coping	0.02	.08	[−0.13, 0.21]
Emotional coping	0.30	.12	[0.11, 0.61]***
Detachment coping	−0.02	.03	[−0.16, 0.01]
Avoidance coping	0.21	.10	[0.05, 0.48]*
Psychiatric symptomatology (TSC)
Direct effect of exposure	0.69	.21	[0.27, 1.10]***
Total indirect effect	0.43	.12	[0.20, 0.71]**
Mature defense style	−0.04	.03	[−0.16, 0.01]
Neurotic defense style	0.03	.03	[−0.01, 0.12]
Immature defense style	0.12	.07	[0.01, 0.28]*
Rational coping	−0.02	.04	[−0.14, 0.05]
Emotional coping	0.36	.10	[0.20, 0.60]***
Detachment coping	−0.01	.01	[−0.06, 0.01]
Avoidance coping	−0.01	.04	[−0.10, 0.09]

Note. CIs that do not include 0 (null association) are significant. CI = confidence intervals; PTSD = posttraumatic stress disorder; HTQ = Harvard Trauma Questionnaire; TSC = Trauma Symptom Checklist; BCa = bias corrected and accelerated.

†

p < .07. *p < .05. **p < .01. ***p < .001.

The total set of variables explained 19.44% of the variance of the participants’ PTSS, F(9, 380) = 10.19, p = .000. As can be seen in Table 2, results show both significant direct and total indirect effects. Thus, after controlling for gender, the set of mediators of defense styles and coping styles explain the relation between the sum of exposure to traumatic events and PTSS. However, the significance of the direct effect indicates that the direct exposure to traumatic events also predicts participants’ PTSS thus suggesting partial mediation.

The specific indirect effects for defense styles (mature, neurotic, and immature) and coping styles (rational, emotional, detachment, and avoidance) were also estimated to determine whether one variable contributed significantly to the total indirect effect while also considering all other indirect effects and the covariate. As can be seen in Figure 1 and Table 2, the specific indirect effects of emotional coping (z = 2.58, p = .000) and avoidance coping (z = 2.11, p = .03) accounted for a significant proportion of the total indirect effect. The specific indirect effect of immature defense mechanism approached significance (z = 1.82, p = .064). The unstandardized parameter estimates showed that exposure to high number of traumatic events was related to higher usage of immature defense mechanism, emotional coping, and avoidance coping styles, which, in turn, were related to a higher number of PTSS.

Defense styles and coping styles mediate the relationship between exposure to traumatic events and psychiatric symptomatology

The total set of variables explained 27.23% of the variance of the participants’ psychiatric symptomatology, F(9, 380) = 15.80, p = .000. As can be seen in Table 2, results show both significant direct and total indirect effects. Thus, after controlling for gender effect, the set of mediators of defense styles and coping styles explain the relation between the sum of exposure to traumatic events and PTSS. However, the significance of the direct effect indicates that the direct exposure to traumatic events also predicts participants’ psychiatric symptomatology thus suggesting partial mediation.

The specific indirect effects for defense styles (mature, neurotic, and immature) and coping styles (rational, emotional, detachment, and avoidance) were also estimated to determine whether one variable contributed significantly to the total indirect effect while also considering all other indirect effects and the covariate. As can be seen in Figure 2 and Table 2, the specific indirect effects of immature defense mechanism (z = 2.08, p = .036) and emotional coping (z = 3.89, p = .000) accounted for a significant proportion of the total indirect effect. The unstandardized parameter estimates showed that exposure to a high number of traumatic events was related to higher usage of an immature defense mechanism and emotional coping style, which, in turn, were related to a higher number of psychiatric symptomatology.

Figure 2.

A multiple mediational model for psychiatric symptomatology (TSC) by defense styles and coping styles.

Serial Mediation Analysis

To test our serial mediation hypotheses, we used the Hayes, Preacher, and Myers’s (2011) multiple step mediation methodology which uses a bootstrapped CI for the indirect effects (Model 6; Hayes, 2013). As we integrate in the final model two variables as second step mediators (emotional and avoidance coping styles) and two outcome variables (PTSS and psychiatric symptomatology), we chose to examine this model via SEM. Specifically, we examined (a) whether the sum of exposure to traumatic events is directly related to PTSS and psychiatric symptomatology; (b) whether the sum of exposure to traumatic events is indirectly related to PTSS and psychiatric symptomatology via immature defense styles; and (c) whether the sum of exposure to traumatic events is indirectly related to PTSS and psychiatric symptomatology via a two-step mediation process: (1) immature defense style and emotional coping and (2) immature defense style and avoidance coping.

The mediational model showed good fit to the observed data, χ²(5) = 13.79, p = .02, NFI = .97, CFI = .98, RMSEA = .06, and significantly explained 18% of the variance in PTSS and 24% of the variance in psychiatric symptomatology. As illustrated in Figure 3 and Table 3, the direct paths from sum of exposure to traumatic events to PTSS (b = 1.42, z = 3.77, p < .00) and psychiatric symptomatology (b = 0.71, z = 3.47, p < .00) remained significant when all the mediators were included in the model. The total indirect effect to PTSS and psychiatric symptomatology were significant. Specifically, the sum of exposure to traumatic events was significantly associated with a more immature defense style (b = 2.09, z = 4.82, p < .00), associated with high levels of emotional coping (b = 0.05, z = 5.22, p < .00), which, in turn, was associated with high levels of PTSS (b = 0.95, z = 4.37, p < .00) and psychiatric symptomatology (b = 0.91, z = 7.69, p < .00). This specific two-step indirect effect to PTSS and psychiatric symptomatology was found to be significant. Furthermore, the sum of exposure to traumatic events was significantly associated with a more immature defense style (b = 2.09, z = 4.82, p < .00), associated with high levels of avoidance coping (b = 0.04, z = 4.30, p < .00), which, in turn, was associated with high levels of PTSS (b = 0.76, z = 3.61, p < .00), but was not associated with psychiatric symptomatology (b = 0.20, z = 1.67, p = .09). This specific two-step indirect effect to PTSS and psychiatric symptomatology was found to be significant.

Figure 3.

A serial mediational integrated model for posttraumatic symptoms (HTQ) and psychiatric symptomatology (TSC) by defense styles and coping styles.

Table 3.

	Point Estimate	SE	BCa 95% CI [Lower, Upper]
PTSD symptoms (HTQ)
Direct effect of exposure	1.42	.41	[0.64, 2.26]***
Total indirect effect	0.60	.15	[0.32, 0.93]***
Indirect via immature defense style	0.35	.13	[0.16, 0.57]***
Indirect via immature defense style and emotional coping	0.33	.13	[0.15, 0.57]***
Indirect via immature defense style and avoidance coping	0.32	.13	[0.15, 0.57]***
Psychiatric symptomatology (TSC)
Direct effect of exposure	0.72	.30	[0.15, 1.34]***
Total indirect effect	0.41	.11	[0.22, 0.63]***
Indirect via immature defense style	0.22	.07	[0.11, 0.36]***
Indirect via immature defense style and emotional coping	0.20	.08	[0.09, 0.34]***
Indirect via immature defense style and avoidance coping	0.21	.08	[0.11, 0.36]***

†

p < .07. *p < .05. **p < .01. ***p < .001.

Discussion

The current study examined the mediating roles of defense styles and coping styles in the associations between polyvictimization, PTSS, and psychiatric symptomatology during early adolescence. Our main results indicated that the dimensions found to significantly mediate these associations were immature defense styles and emotional and avoidance coping. Finally, the results of the integrative model indicated that the sum of exposure to traumatic events was significantly associated with a more immature defense style associated with both high levels of emotional and avoidance coping, which, in turn, were associated with high levels of PTSS and psychiatric symptomatology. To our knowledge, the current study is the first to examine the interrelations between defense and coping styles and their important role in the adaptation to stressful and traumatic events in early adolescence. As this study is based on a national representative sample, the external validity of our findings is strengthened.

It should be noted that as this study is cross-sectional, our ability to infer causality from results of the multiple and serial mediation analyses is very limited. This is especially important in this field as a recent systematic review of prospective studies (DiGangi et al., 2013) found that the uses of various coping styles (e.g., rumination, avoidance) that were assessed before the traumatic exposure are actually predisposing risk factors for PTSS and not only the consequences of traumatic exposure or the results of the interaction with it. Thus, the pattern of associations that has been found in this study should be further validated in future prospective studies among adolescents.

The results indicated that exposure to multiple traumatic events is associated with heightened use of the three defensive styles. However, only the lower ordered defenses of immature and neurotic styles were positively associated with PTSS and psychiatric symptomatology, and only the immature defense style mediated the link between polyvictimization and distress. Two explanations for these results are suggested. First, as Vaillant (2011) proposed, the immature defense style is common in adolescents, and involuntary reliance on those mechanisms (e.g., projection) has been found to decline with age (e.g., Andrews et al., 1993). Second, consistent with other empirical studies among adult trauma survivors, individuals who are exposed to repeated traumatic experiences might react with defense mechanisms lower on the hierarchy (e.g., Perry et al., 2015), and, in turn, might develop psychiatric symptomatology (e.g., Jun et al., 2015) and PTSS (Lee, Vaillant, Torrey, & Elder, 1995). Therefore, the effects of polyvictimization on defense mechanisms during the early adolescence period might be more profound due to the unique characteristics of this age-related developmental phase such as proneness to risky behaviors (Steinberg, 2007) and the practice of independence from parents that might hinder the request for support (Pat-Horenczyk et al., 2009).

Our results also show that the most prominent dimensions that mediated the link between polyvictimization, PTSS, and psychiatric symptomatology were emotional and avoidance coping styles. Our results are consistent with other studies which reported the effects of polyvictimization on avoidance and emotional coping (e.g., Guerra et al., 2016), as well as the implications of maladaptive coping styles, such as thought suppression and distraction that resemble avoidance coping styles in PTSD (Trickey et al., 2012). Importantly, although other studies reported that maladaptive coping acted as a mediator in the relationship between polyvictimization and psychiatric symptomatology (Ullman, Peter-Hagene, & Relyea, 2014), our study is the first to report on the mediation of emotional and avoidance coping styles, polyvictimization, and PTSS among early adolescents. Two explanations are suggested.

First, it is known that youth exposed to one PTE type are also at elevated risk for experiencing multiple PTE types over their lifetime (Finkelhor et al., 2007). Consistent with other studies (e.g., Nooner et al., 2012), we also found direct associations between polytraumatization and heightened levels of PTSS and psychiatric symptomatology. However, repeated exposure to stressful events might bring with it unpleasant emotions such as fear and anger (e.g., Lavi & Solomon, 2005). It is possible that coping styles relevant for adaptation to these emotions among early adolescents are those which refer to emotional regulation (Carver & Connor-Smith, 2010). Second, exposure to polytraumatization might inevitably create alterations in basic world assumptions such as unexpected destiny and the uncontrollability of one’s actions (Janoff-Bulman & Berger, 2000). It is possible that to adapt to these cognitions, adolescents react with more avoidance coping styles, leading to more incompetence and behavioral disengagement and, in turn, to more psychological distress (Skinner & Zimmer-Gembeck, 2011).

Importantly, the integrative model results indicated that the sum of exposure to traumatic events was significantly associated with a more immature defense style, associated with both high levels of emotional and avoidance coping, which, in turn, were associated with high levels of PTSS and psychiatric symptomatology. A recent theoretical contribution (Kramer, 2010) suggested that defense styles and coping styles serve similar adaptational processes in the face of adversity, namely, affect regulation and mental system homeostasis maintenance. However, defense styles are personality-driven constructs combining both trait and state characteristics while coping styles are more situation-oriented (Cramer, 1998). Therefore, our integrative model’s results support the functional organization and temporal sequencing suggested by Chabrol and Callahan (2004) where defense mechanisms precede and facilitate the cognitive- or behavior-oriented coping processes.

However, in the adaption process to a specific traumatic or negative life event, both defenses and coping styles might work simultaneously to adapt to the anxiety-provoking stressor. Nevertheless, our results suggest that the characteristics of polyvictimization are related to PTSS and psychiatric symptomology through indirect processes in which an underlying immature defense might restrict adaptive coping styles. In other words, the heavy usage of immature defenses due to multiple exposure to stressful events is building the infrastructure in which maladaptive emotional and avoidance coping styles are easily triggered. However, there is a possibility that rational, problem-focused, and engaged coping would be triggered following the use of immature defense styles. Still, in the unstable phase of early adolescence, the aforementioned indirect path can provide stable, albeit psychological risky, adaptation to multiple and repeated traumatic events.

The present study has several limitations. First, the study relies on the use of self-reporting measures entailing the risk of a reporting bias. Second, the traumatic life-event questionnaire has not been validated, although it was widely used in other countries and the endorsement of specific events corresponds to findings from other studies (e.g., Bödvarsdóttir1 & Elklit, 2007). Third, although we assessed exposure to multiple traumas, we did not include a measurement that will allow us to understand whether a certain event had occurred more than once (i.e., repeated trauma). Fourth, the subscale reliabilities of some of the studies were rather moderate. Thus, the magnitudes of associations must be interpreted with caution.

Last, the generalizability of the present study’s findings should be examined with reference to the particular cultural aspects of the Danish population and, specifically, Danish adolescents. For example, it was found that compared with Danish female adolescents, males had more instances of witnessing an injury, coming close to injury themselves, the threat of being beaten, and being the victim of theft. Females more often attempted suicide, lost a family member, and had an absent parent (Elklit, 2002). In another recent study, it was found that the majority of Danish and Icelandic adolescent samples were dismissively attached (positive perception of the self and negative perception of others) compared with the Faroese adolescent sample that was securely attached (Petersen & Elklit, 2013). Taken together, the specific individualistic characterization of Danish Western culture, as well as its specific distribution of exposure to negative life events, should inform readers regarding the interpretation of this study’s findings.

Despite these limitations, the present study suggests a number of important practical implications. Our results emphasize that early adolescence is a risk period for considerable exposure to stressful events, as well as to a wide spectrum of psychopathological outcomes closely related to polyvictimization. Thus, in the assessment phase of interactions with clients, clinicians should not only pay attention to high-magnitude index traumas such as sexual abuse but also to the comprehensive picture of a client’s traumatic history. Thus, clinicians are encouraged to ask clients if they have experienced more traumatic events beyond their acknowledged index trauma. Moreover, our results point to the importance of psychological mechanisms—immature defense style and emotional and avoidance coping styles—in the link between polyvictimization and psychological distress. It is important that mental health professionals learn to identify adolescents at risk by paying close attention to signs of qualitative use of discrete defense mechanisms such as projection and hypochondria, as well as intense quantitative reliance on emotional and avoidance coping tactics. Thus, during therapy, clinicians should closely examine the associations between defense and coping styles. Within this developmental model, coping processes can still be adaptive even when the preceding defenses are not necessarily adaptive, and the same holds inversely (Cramer, 2000). Therefore, there is reason to believe that adolescents can actively change their psychopathological outcomes by development of more rational and adaptive coping styles during this formative developmental period.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Gadi Zerach, PhD, is a certified clinical psychologist and a senior lecturer in the Department of Behavioral Sciences, Ariel University, Ariel, Israel.

Ask Elklit, PhD, is a certified clinical psychologist and the head of the National Center of Psychotraumatology, Institute of Psychology, University of Southern Denmark, Odense, Denmark.

References

Aaron

Zaglul

Emery

R. E.

(1999). Posttraumatic stress in children following acute physical injury. Journal of Pediatric Psychology, 24, 335-343.

Alisic

Zalta

A. K.

Wesel

F. V.

Larsen

S. E.

Hafstad

G. S.

Hassanpour

. . . Smid

G. E.

(2014). Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: Meta-analysis. The British Journal of Psychiatry, 204, 335-340. doi:10.1192/bjp.bp.113.131227

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Andrews

Singh

Bond

(1993). The Defense Style Questionnaire. The Journal of Nervous and Mental Disease, 181, 246-256.

Arbuckle

J. L.

(2012). IBM Spss AMOS 20 user’s guide. Chicago, IL: SPSS Inc.

Bödvarsdóttir

Í.

Elklit

. (2007). Victimization and PTSD-like states in an Icelandic youth probability sample. BMC Psychiatry, 7, 51-63.

Bornstein

R. F.

(2006). A Freudian construct lost and reclaimed: The psychodynamics of personality pathology. Psychoanalytic Psychology, 23, 339-353.

10.

Breslau

Wilcox

H. C.

Storr

C. L.

Lucia

V. C.

Anthony

J. C.

(2004). Trauma exposure and posttraumatic stress disorder: A study of youths in urban America. Journal of Urban Health, 81, 530-544.

11.

Briere

Kaltman

Green

B. L.

(2008). Accumulated childhood trauma and symptom complexity. Journal of Traumatic Stress, 21, 223-226.

12.

Briere

Runtz

(1989). The Trauma Symptom Checklist (TSC-33): Early data on a new scale. Journal of Interpersonal Violence, 4, 151-163.

13.

Carver

C. S.

Connor-Smith

(2010). Personality and coping. Annual Review of Psychology, 61, 679-704.

14.

Chabrol

Callahan

(2004). Mécanismes de défense et coping [Defense mechanisms and coping]. Paris, France: Dunod.

15.

Cohen

(1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.

16.

Compas

B. E.

Connor-Smith

J. K.

Saltzman

Thomsen

A. H.

Wadsworth

M. E.

(2001). Coping with stress during childhood and adolescence: Problems, progress, and potential in theory and research. Psychological Bulletin, 127, 87-127.

17.

Cramer

(1998). Coping and defense mechanisms: What’s the difference? Journal of Personality, 66, 919-946.

18.

Cramer

(2000). Defense mechanisms in psychology today. Further processes of adaptation. American Psychologist, 55(6), 637-646.

19.

Dempsey

Overstreet

Moely

(2000). “Approach” and “avoidance” coping and PTSD symptoms in innercity youth. Current Psychology, 19, 28-45.

20.

Derogatis

L. R.

(1977). SCL-90. Administration, scoring & procedures manual-I for the (revised) version and other instruments of the psychopathology rating scale series. Baltimore, MD: John Hopkins University.

21.

Derogatis

L. R.

Lipman

R. S.

Rickels

Uhlenhuth

E. H.

Covi

(1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19, 1-15.

22.

DiGangi

J. A.

Gomez

Mendoza

Jason

L. A.

Keys

C. B.

Koenen

K. C.

(2013). Pretrauma risk factors for posttraumatic stress disorder: A systematic review of the literature. Clinical Psychology Review, 33, 728-744.

23.

Dixon

Howie

Starling

(2005). Trauma exposure, posttraumatic stress, and psychiatric comorbidity in female juvenile offenders. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 798-806.

24.

Elklit

(1996). Coping styles questionnaire: A contribution to the validation of a scale for measuring coping strategies. Personality and Individual Differences, 21(5), 809-812.

25.

Elklit

(2002). Victimization and PTSD in a Danish national youth probability sample. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 174-181.

26.

Elklit

Shevlin

(2007). The structure of PTSD symptoms: A test of alternative models using confirmatory factor analysis. British Journal of Clinical Psychology, 46, 299-313.

27.

Fenech

Thomson

(2015). Defence against trauma: Women’s use of defence mechanisms following childbirth-related trauma. Journal of Reproductive and Infant Psychology, 33, 268-281.

28.

Finkelhor

Ormrod

Turner

(2007). Polyvictimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7-26. doi:10.1016/j.chiabu.2006.06.008

29.

Finkelhor

Turner

H. A.

Shattuck

Hamby

S. L.

(2013). Violence, crime, and abuse exposure in a national sample of children and youth: An update. JAMA Pediatrics, 167, 614-621.

30.

Ford

J. D.

Wasser

Connor

D. F.

(2011). Identifying and determining the symptom severity associated with polyvictimization among psychiatrically impaired children in the outpatient setting. Child Maltreatment, 16, 216-226.

31.

Freud

(1962). The neuro-psychoses of defense. In Strachey

(Ed.), The standard edition of the complete works of Sigmund Freud (Vol. 3, pp. 43-61). London, England: Hogarth Press. (Original work published 1894)

32.

Gray

M. J.

Litz

B. T.

Hsu

J. L.

Lombardo

T. W.

(2004). Psychometric properties of the life events checklist. Assessment, 11, 330-341.

33.

Guerra

Pereda

Guilera

Abad

(2016). Internalizing symptoms and polyvictimization in a clinical sample of adolescents: The roles of social support and non-productive coping strategies. Child Abuse & Neglect, 54, 57-65.

34.

Hayes

A. F.

(2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: The Guilford Press.

35.

Hayes

A. F.

Preacher

K. J.

Myers

T. A.

(2011). Mediation and the estimation of indirect effects in political communication research. Sourcebook for political communication research: Methods, measures, and analytical techniques, 23, 434-465.

36.

Hoyle

R. H.

Smith

G. T.

(1994). Formulating clinical research hypotheses as structural equation models: A conceptual overview. Journal of Consulting and Clinical Psychology, 62, 429-440.

37.

Janoff-Bulman

Berger

A. R.

(2000). The other side of trauma: Towards a psychology of appreciation. In Harvey

J. H.

Miller

E. D.

(Eds.), Loss and trauma: General and close relationship perspectives (pp. 29-44). Philadelphia, PA: Brunner-Routledge.

38.

Jun

J. Y.

Lee

Y. J. G.

Lee

S. H.

Yoo

S. Y.

Song

Kim

S. J.

(2015). Association between defense mechanisms and psychiatric symptoms in North Korean Refugees. Comprehensive Psychiatry, 56, 179-187.

39.

Kramer

(2010). Coping and defence mechanisms: What’s the difference?—Second act. Psychology and Psychotherapy: Theory, Research and Practice, 83, 207-221.

40.

Lavi

Solomon

(2005). Palestinian youth of the Intifada: PTSD and future orientation. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 1176-1183.

41.

Lee

K. A.

Vaillant

G. E.

Torrey

W. C.

Elder

G. H.

(1995). A 50-year prospective study of the psychological sequelae of World War II combat. American Journal of Psychiatry, 152, 516-522.

42.

Meiser-Stedman

(2002). Towards a cognitive–Behavioral model of PTSD in children and adolescents. Clinical Child and Family Psychology Review, 5, 217-232.

43.

Mollica

R. F.

Caspi-Yavin

Bollini

Truong

Tor

Lavelle

(1992). The Harvard Trauma Questionnaire: Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. The Journal of Nervous and Mental Disease, 180, 111-116.

44.

Nooner

Linares

L. O.

Batinjane

Kramer

R. A.

Silva

Cloitre

(2012). Factors related to posttraumatic stress disorder in adolescence. Trauma, Violence, & Abuse, 13, 153-166. doi:10.1177/1524838012447698

45.

Pat-Horenczyk

Qasrawi

Lesack

Haj-Yahia

Peled

. . . Abdeen

(2009). Posttraumatic symptoms, functional impairment, and coping among adolescents on both sides of the Israeli–Palestinian conflict: A cross-cultural approach. Applied Psychology, 58, 688-708.

46.

Perry

J. C.

Metzger

Sigal

J. J.

(2015). Defensive functioning among women with breast cancer and matched community controls. Psychiatry, 78, 156-169.

47.

Perry

J. C.

Presniak

M. D.

Olson

T. R.

(2013). Defense mechanisms in schizotypal, borderline, antisocial, and narcissistic personality disorders. Psychiatry, 76, 32-52.

48.

Petersen

Elklit

(2013). Attachment styles and PTSD in adolescents in three Nordic countries. Open Journal of Epidemiology, 3, 62-69.

49.

Pfefferbaum

Noffsinger

M. A.

Wind

L. H.

(2012). Issues in the assessment of children’s coping in the context of mass trauma. Prehospital and Disaster Medicine, 27, 272-279.

50.

Preacher

K. J.

Hayes

A. F.

(2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879-891.

51.

Punamäki

R. L.

Kanninen

Qouta

El-Sarraj

(2002). The role of psychological defences in moderating between trauma and post-traumatic symptoms among Palestinian men. International Journal of Psychology, 37, 286-296.

52.

Pynoos

R. S.

Steinberg

A. M.

Piacentini

J. C.

(1999). A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46, 1542-1554.

53.

Reardon

L. E.

Leen-Feldner

E. W.

Hayward

(2009). A critical review of the empirical literature on the relation between anxiety and puberty. Clinical Psychology Review, 29, 1-23.

54.

Roger

Jarvis

Najarian

(1993). Detachment and coping: The construction and validation of a new scale for measuring coping strategies. Personality and Individual Differences, 15, 619-626.

55.

Schafer

J. L.

Graham

J. W.

(2002). Missing data: Our view of the state of the art. Psychological Methods, 7, 147-177.

56.

Shevlin

Elklit

(2008). Modelling the role of defense styles as mediating the relationship between trauma and posttraumatic stress severity in Danish adolescents. The Irish Journal of Psychology, 29, 179-191.

57.

Skinner

E. A.

Zimmer-Gembeck

M. J.

(2011). Perceived control and the development of coping. In Folkman

(Ed.), The Oxford handbook of stress, health, and coping (pp. 35-62). Oxford, UK: Oxford University Press.

58.

Solomon

Dekel

Mikulincer

(2008). Complex trauma of war captivity: A prospective study of attachment and post-traumatic stress disorder. Psychological Medicine, 38, 1427-1434.

59.

Spear

L. P.

(2009). Heightened stress responsivity and emotional reactivity during pubertal maturation: Implications for psychopathology. Development and Psychopathology, 21, 87-97.

60.

Spinhoven

Kooiman

C. G.

(1997). Defense style in depressed and anxious psychiatric outpatients: An explorative study. The Journal of Nervous and Mental Disease, 185, 87-94.

61.

Steinberg

(2007). Risk taking in adolescence new perspectives from brain and behavioral science. Current Directions in Psychological Science, 16, 55-59.

62.

Trickey

Siddaway

A. P.

Meiser-Stedman

Serpell

Field

A. P.

(2012). A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clinical Psychology Review, 32, 122-138.

63.

Ullman

S. E.

Peter-Hagene

L. C.

Relyea

(2014). Coping, emotion regulation, and self-blame as mediators of sexual abuse and psychological symptoms in adult sexual assault. Journal of Child Sexual Abuse, 23(1), 74-93.

64.

Vaillant

G. E.

(1977). Adaptation to life. Cambridge, MA: Harvard University Press.

65.

Vaillant

G. E.

(2011). Involuntary coping mechanisms: A psychodynamic perspective. Dialogues in Clinical Neuroscience, 13, 366-370.

66.

Vieno

Gini

Santinello

(2011). Different forms of bullying and their association to smoking and drinking behavior in Italian adolescents. Journal of School Health, 81, 393-399.