The Association Between Trauma Centrality and Posttraumatic Stress Among Syrian Refugees: The Impact of Cognitive Distortions and Trauma-Coping Self-Efficacy

Abstract

While research suggests that the war in Syria has led to a drastic re-evaluation of oneself and elevated psychiatric symptoms among Syrian refugees, little is known whether these psychological reactions might be influenced by maladaptive beliefs about oneself and the world and their ability to cope with the effect of the trauma. This study aimed to provide further evidence on the association between trauma centrality, posttraumatic stress, and psychiatric comorbidity, and examine whether cognitive distortions and trauma-coping self-efficacy would mediate the impact of trauma centrality on distress among Syrian refugees residing in Sweden. Four-hundred seventy-five Syrian refugees completed a demographic page, the Harvard Trauma Questionnaire, General Health Questionnaire-28, Centrality of Event Scale, Cognitive Distortion Scales, and trauma-coping self-efficacy. Results showed that trauma centrality was significantly correlated with posttraumatic stress disorder (PTSD) and psychiatric comorbidity after adjusting the effects of trauma exposure characteristics. Cognitive distortions mediated the impact of trauma centrality on the two distress outcomes; trauma-coping self-efficacy did not but was negatively correlated with outcomes. To conclude, the war in Syria changed self-perception, outlook on life, and identity among Syrian refugees. These changes were related to increased psychological symptoms especially for those who had distorted beliefs about themselves and the world. Refugees’ belief in the lack of ability to cope with the effect of the trauma impacted psychological distress independently of changes in self-perception.

Keywords

cognitive distortions coping PTSD refugees

Introduction

The prevalence rates for posttraumatic stress disorder (PTSD) among Syrian refugees have been documented ranging from 24% to 52% (Al Ibraheem et al., 2017; Alpak et al., 2015; Chung et al., 2017; Kira et al., 2017). Trauma of this magnitude can lead to a drastic re-evaluation of oneself characterized by trauma centrality. In the context of the refugee experience, trauma centrality is a psychological phenomenon in which refugee status and ongoing war are constant reminders of the traumatic experience which maintain the vividness of traumatized memories leading to overestimated frequency of traumatic events, increased hypervigilance, avoidance behavior, and likelihood of retraumatization. These traumatized memories form the basis for personal reference points from which meaning is attributed to existing beliefs, feelings, and future expectations which can affect one’s outlook on life, redirecting its course. These profound internal changes become turning points in a refugee’s life and reconfigure the inner world, affecting self-understanding, self-definition, and indeed how personal identity is defined (Berntsen & Rubin, 2006a; Fitzgerald, 1988; Pillemer, 2003).

Trauma centrality is a cognitive trauma model focusing on how memories of the trauma can create cognitive schematic changes in oneself. It is, however, somewhat different from other models, for example, the schematic (Horowitz, 1976) and cognitive models of PTSD (Ehlers & Clark, 2000). Simply put, the schematic model emphasizes the need for victims to make the internal model of psychic trauma coherent with the existing mental schemas (the completion tendency). The discrepancy between them creates overwhelming emotional distress which triggers an inhibitory mechanism (avoidance and repression) to inhibit it and prevent emotional exhaustion. This response aims to keep not only distressing emotions at bay but also the individual from integrating the traumatic experience with long-term meaning representations (Horowitz, 1986).

The cognitive model of PTSD (Ehlers & Clark, 2000) argues that trauma can distort cognitions and lead victims to develop negative appraisals of the trauma which can result in a sense of current external or internal threat. They might overgeneralize from the trauma to view the world as a dangerous place (external threat) or themselves as unacceptable, helpless, hopeless, and incapable of achieving important goals in life (internal threat). These appraisals would maintain PTSD, generating distressing emotions such as anxiety and depression (Cieslak et al., 2008; Mayou et al., 2002; Owens et al., 2008).

Despite the theoretical differences between the schematic and cognitive models of PTSD, there is a shared underlying assumption that trauma memories are both involuntary and voluntary in nature. Trauma memory tends to repeat itself in an involuntary fashion (e.g., re-experiencing symptoms) which impairs the voluntary or controlled remembering of the event. The more the involuntary remembering is enhanced, the more the voluntary memory access is impaired. In other words, this involuntary remembering has privileged access to the traumatic event and such memory is fragmented and poorly integrated into victims’ autobiographical knowledge or cognitive structures supporting their life story and identity. This fragmentation or disintegration is positively correlated with PTSD symptoms.

The trauma centrality thesis, on the contrary, argues for “integration” in that a trauma event is perceived as central to victims’ (refugees in this case) life story and identity. Trauma memories could change the way in which victims interpret the meanings of current beliefs, feelings, future expectations, think about their life course, and define their identity (Berntsen et al., 2008). Similar to the other two cognitive models, however, trauma centrality has been associated with PTSD (Bernard et al., 2015; Berntsen & Rubin, 2006b; A. D. Brown et al., 2010) and psychiatric comorbidity (Allbaugh et al., 2016; Bernard et al., 2015; Blix et al., 2014; Chung et al., 2017; Lancaster et al., 2015; Roland et al., 2014). Based on 1,197 Syrian refugees residing in Turkey and Sweden, previous studies showed that 43% met the diagnostic criteria for PTSD; trauma centrality was positively correlated with PTSD, psychiatric comorbidity, and trauma exposure characteristics of experiencing or witnessing horror and murder, kidnapping or disappearance of family members or friends (Chung, AlQarni, et al., 2018a; Chung et al., 2017; Chung, Shakra, et al., 2018).

Although the impact of trauma centrality on PTSD and psychiatric comorbidity has been established among Syrian refugees, little is known with regard to factors which might influence this relationship. Two factors are worth considering. First, despite the differences between trauma centrality and the other cognitive models notably on the issue of integration, they all highlight the role of distorted cognitions or schemas. From the perspective of trauma centrality, distorted cognitions could act as a mediator of the impact of trauma centrality onto PTSD and psychiatric comorbid symptoms. This speculation has not been examined in research among Syrian refugees which was one knowledge gap this study aimed to address.

Second, despite the association between trauma centrality and distress through possibly distorted cognitions, social-cognitive theory (Benight & Bandura, 2004) argues that traumatized individuals can still respond proactively to it and feel an intense need for self-evaluation or management in order to regain a sense of equilibrium. In so doing, individuals would perceive their ability to organize and use resources needed to meet and manage posttraumatic recovery demands and thereby facilitate adaptive coping. Those who believe that they can exercise control over the threat from stressors (i.e., a high level of self-efficacy) tend not to feel overwhelmed by it. On the contrary, those who believe that they are unable to manage the stressor (i.e., a low level of self-efficacy) tend to experience a high level of distress. Perceived coping “inefficacy” can relate to high levels of subjective distress (Bandura, 1997).

One of the aforementioned studies (Chung et al., 2017), looking at the Syrian refugees in Turkey and Sweden, examined the role of generalized self-efficacy and found that it mediated the impact of trauma centrality on PTSD symptoms rather than psychiatric comorbidity. However, this study focused on the role of a generalized coping ability to organize and execute actions necessary to achieve a goal, as opposed to the ability to cope specifically with the effect of trauma. According to the posttraumatic self-hypothesis, since trauma can reduce self-regulatory capacity (Wilson, 2006) or self-efficacy (Bandura, 1997; A. D. Brown et al., 2015, 2016), this reduced agentic (i.e., agent of change through intentional actions) factor would lead to reduced motivation and capacity for developing resilience against the effect of trauma (Bandura, 1997; Benight & Bandura, 2004), thereby maintaining PTSD (A. D. Brown et al., 2015) and psychiatric comorbidity (Benight et al., 2008; Bosmans et al., 2016; Chung et al., 2013; DeCou et al., 2015; Thormar et al., 2016; Voller et al., 2015). One would therefore speculate that trauma centrality would be related to reduced trauma-coping self-efficacy which then relates to distress. This is another speculation which has not been examined among Syrian refugees and formed the second knowledge gap for this study to address.

What has been depicted so far are two mediational paths suggesting that trauma centrality would influence distress outcomes through distorted cognitions and reduced trauma-coping self-efficacy. This study aimed to (a) provide further evidence on the link between trauma centrality, PTSD, and psychiatric comorbidity, and (b) examine whether cognitive distortions and trauma-coping self-efficacy would mediate the impact of trauma centrality on distress among Syrian refugees residing in Sweden. In investigating these aims, trauma exposure characteristics needed to be considered since some of these characteristics, as suggested in the introduction, have been associated with trauma centrality among Syrian refugees. The hypotheses were that after controlling for trauma exposure characteristics, (a) trauma centrality would be positively correlated with PTSD and psychiatric comorbidity, (b) cognitive distortions and trauma-coping self-efficacy would mediate the impact of trauma centrality onto distress outcomes (Figure 1

Figure 1.

The hypothesized model.

Method

Participants

Participants were 475 (210 female, 265 male) Syrian refugees who were residing in Sweden. On average, they were 34 (M = 34.17, SD = 11.08, range: 18–82) years old and had escaped Syria almost three and a half years ago (M in months = 40.48, SD = 23.11) and had been living in Sweden for just over 2 years (M in month = 27.97, SD = 19.82). A large proportion came with family (70%). Over half (57%) and a third (39%) were married and single, respectively. Over half (53%) were educated up to university level.

Procedure

Data were collected in two cities in Sweden using a convenience sampling procedure. Syrian refugees were approached in two language centers and in a district designated by the government. A snowball technique was also used to enlarge the sample size. The aim of the research was explained to them with an information sheet and a consent form. Before signing the form, participants were assured that information collected would be kept anonymous and that they were free to withdraw from the study at any time without giving a reason. After giving consent, questionnaires described in the measures section were distributed to refugees for completion, all of which had gone through the back-translation procedure. The inclusion criteria were: (a) 18 years old or older, (b) Syrian in ethnicity, and (c) of official refugee status. Ethical approval for the study was granted by the ethics committee at the Chinese University of Hong Kong.

Measures

Demographic information on age, gender (1 = female, 2 = male), education level (1 = no education, 2 = primary school, 3 = secondary school, 4 = university), marital status (1 = single, 2 = married, 3 = divorced/separated, 4 = widowed), time since leaving Syria, time spent in Sweden, and whether they had ﬂed alone or with family members (1 = No family members, 2 = Some family members) was collected using a demographic page.

The Harvard Trauma Questionnaire (Mollica et al., 1992) measures whether refugees experienced a series of traumatic events while ﬂeeing Syria. These traumatic events have been categorized into three domains and constituted trauma exposure characteristics for the study: (a) invasion/oppression (e.g., present while your home was searched for people or things; oppressed because of ethnicity, religion, or sect), (b) witnessed or experienced horror (e.g., rape; exposed to combat situation), and (c) experiencing murder/disappearance (e.g., murder or violent death of family member; family member kidnapped or taken hostage). The questionnaire also measures PTSD symptoms using the rating scale: 1 = Not at all to 4 = All the time. Based on the Diagnostic and Statistical Manual of Mental Disorders: 4^th Edition (DSM-IV) diagnostic criteria, a probable PTSD diagnosis was achieved if refugees reported at least one intrusion, three avoidance, and two hypervigilance symptoms. An item was endorsed if the score was ≥3. The questionnaire has 88% concordance with the clinical structured interview for PTSD (First et al., 2007). Based on the current sample, the Cronbach’s α for the total score was .94.

The General Health Questionnaire-28 (Goldberg & Hillier, 1979) aims to estimate the likelihood of refugees being diagnosed as suffering from general psychiatric morbidity at interview using the rating scale of 1 through 4. The questionnaire yields four subscales: somatic problems, anxiety, social dysfunction, and depression. Reliability coefficients for the total score ranged from .78 to .95 (Goldberg & Bridges, 1987). Based on the current sample, the Cronbach’s α was .95 for the total score.

The Centrality of Event Scale (Berntsen & Rubin, 2006a) measures the extent to which the war had become a reference point from which refugees generated expectations for the future and attributed meaning to other events in their lives—a turning point in their lives and a central component of personal identity. It is based on the rating scale 1 = totally disagree to 5 = totally agree. The total trauma centrality score has an excellent Cronbach’s α of .94. For the current sample, the α was .93.

Cognitive Distortion Scales (Briere, 2000) measure dysfunctional cognitions and yield five subscales: self-criticism, helplessness, hopelessness, self-blame, and preoccupation with danger. It is based on the rating scale from 1 = never to 5 = very often. The internal reliability scores were high: self-criticism = .94, self-blame = .93, helplessness = .93, hopelessness = .92, preoccupation with danger = .94. For the current sample, the Cronbach’s α was .98 for the total score.

Trauma-Coping Self-Efficacy (Benight et al., 2015) aims to measure the perceived ability to cope with challenges and demands from a traumatic event using the rating scale 1 = not at all capable to 7 = totally capable. Based on hospital and disaster survivor samples, test–retest reliability scores were found ranging from .57 to .81. For the current sample, .87 was the Cronbach’s α for the total score.

Data Analysis Plan

Descriptive statistics were used to describe demographic information, trauma exposure characteristics, and percentages of no, partial, and full-PTSD. Multivariate analysis of variance (MANOVA) was used to compare diagnostic group differences in trauma exposure characteristics, trauma centrality, cognitive distortion, trauma-coping self-efficacy, and psychiatric comorbidity. Correlation coefficients with Bonferroni correction were used to establish significant association between demographic variables and distress outcomes (PTSD and psychiatric comorbidity). Structural equation modeling (SEM) was used to examine the model fit of the hypothesized model. Meeting the criteria as follows would be indicative of a good fit to the data: (a) a ratio of chi-square/df under 3, (b) values ≥.95 for the Tucker–Lewis index (TLI), and (c) incremental fit index (IFI), (d) a value ≤.06 for the root mean square error of approximation (RMSEA), (e) a value closer to 1 for the comparative fit index (CFI), and (f) the normal fit index (NFI), (g) a value for the goodness-of-fit index (GFI) ≥.95 was not recommended. Chi-square was not used, the reason being that the χ² value is almost always statistically significant for models with a sample size of 400 or more, even in the case of small discrepancies between implied and obtained covariance matrices (Maruyama, 1998).

PROCESS, version 3.4 (Hayes, 2017) was downloaded onto SPSS, version 26, for examining mediational effects and is an alternative to the causal steps approach (Baron & Kenny, 1986). Bias-corrected bootstrapping is used in PROCESS to generate confidence intervals which addresses the problem of power resulting from the asymmetric and non-normal sampling distributions of an indirect effect (MacKinnon et al., 2004). In this study, the bootstrapping sampling (N = 1,000) distributions of the indirect effects were produced by selecting a sample of cases from the complete data set and calculating the indirect effects in the resamples. The indirect effects were estimated based on point estimates and confidence intervals (95%). When the confidence interval did not contain zero, point estimates of indirect effects were considered significant. Expectation maximization (EM) algorithm (Enders, 2011) was used to replace missing data. Regression imputation is considered a valid method in dealing with missing data (Schafer & Graham, 2002) when omitted questionnaire items total less than 5%. For this study, 1% of responses were missing.

Results

In terms of trauma exposure characteristics, participants were categorized into three domains: invasion/oppression, witnessing or experiencing horror, and experiencing murder/disappearance. Turning first to invasion/oppression, the majority (77%) reported the experience of having no shelter because their property was confiscated or destroyed (51%). For 32% of refugees, terrorists invaded their privacy by coming to their home and looking for things or people. Less than half (44%) experienced shortages of food or water and had no access to medical care (34%). A smaller proportion (23%) reported that they had been oppressed due to ethnicity or religion and imprisoned by terrorists (12%).

In terms of witnessing or experiencing horror, almost half (49%) witnessed arrest, torture, and execution of religious leaders, although witnessing execution of civilians was much less (20%). Otherwise, over a third (37%) witnessed physical assault, sexual abuse, rape, and murder. Over half (56%) were exposed to combat situations such as explosion or shelling and sustained injury as a result. For the domain of experiencing murder/disappearance, close to half (44%) of the sample had family members or close friends who sustained physical injury from a combat situation or were murdered. Some (39%) had family members or friends kidnapped or taken hostage. Compared to female refugees, males reported significantly more oppression and witnessed or experienced more horror.

Based on the Harvard Trauma Questionnaire, 26% and 39% met the diagnostic criteria for full-PTSD and partial-PTSD, respectively; 35% had no PTSD. No PTSD referred to refugees who did not meet any of the diagnostic criteria for the three clusters of PTSD symptoms. Partial-PTSD referred to those who had met the diagnostic criteria for one or two of the symptom clusters (Chung & Wall, 2013). There were significant diagnostic group differences in trauma exposure characteristics and all the other psychological constructs examined in this study (Table 1

Table 1.

Diagnostic Group Differences in Trauma Exposure Characteristics, Trauma Centrality, Cognitive Cognition, Trauma-Coping Self-Efficacy, and Psychiatric Comorbidity.

Construct	No-PTSD		Partial-PTSD		Full-PTSD		F (2, 472)	η ²	Female		Male		T	Cohen’s d
Construct	M	SD	M	SD	M	SD	F (2, 472)	η ²	M	SD	M	SD	T	Cohen’s d
Oppression	1.21	1.45	2.10	1.47	2.75	1.72	36.99**	0.13	1.66	1.47	2.19	1.73	−3.52*	0.33
Witnessed horror	0.97	1.10	1.89	1.35	2.11	1.33	35.68**	0.13	1.48	1.25	1.73	1.42	−2.04*	0.18
Horror	1.05	1.28	1.57	1.31	2.33	1.57	30.73**	0.11	1.41	1.35	1.72	1.52	−2.24*	0.21
Trauma centrality	63.36	19.63	74.04	14.54	83.21	12.38	55.08**	0.18	73.63	17.57	71.82	17.98	1.10	0.10
Cognitive distortion	60.64	21.20	76.38	24.08	104.99	34.07	102.46**	0.30	78.07	28.51	78.24	33.27	−0.05	0.00
Trauma coping	42.33	13.69	39.80	10.69	36.85	12.76	6.98**	0.02	38.85	12.17	40.80	12.73	−1.68	0.15
Psy comorbidity	47.63	11.90	59.85	14.70	74.48	18.93	112.80**	0.32	60.17	17.55	58.58	18.78	0.93	0.08
PTSD	23.38	5.49	34.65	6.58	50.13	8.10	569.79**	0.70	34.42	2.15	34.81	12.41	−0.34	0.04

Note. PTSD = posttraumatic stress disorder.

p < .05. **p < .01.

). The full-PTSD group reported significantly more oppression, witnessing of and direct exposure to horror than the other two groups, although there were no differences between the full-PTSD and partial-PTSD in witnessing horror. The full-PTSD group also reported significantly higher levels of trauma centrality, cognitive distortions, and psychiatric comorbidity, while they reported a significantly lower level of trauma self-efficacy than the other groups. The differences were mostly at the α level of .001.

Correlation coefficients with the α level of .01 from Bonferroni correction showed that there were no significant correlations between demographic variables (age, gender, education level, marital status, how long ago they escaped Syria, how long they had lived in Sweden, whether they came with family members) and both PTSD and psychiatric comorbid symptoms. Consequently, no demographic variables were controlled for in examining the model fit using SEM. The estimated correlation matrix between the variables with indicators and the two distress outcomes used in the model is shown in Table 2

Table 2.

The Estimated Correlation Matrix Between the Demographic Variables, Variables with Indicators, and the Two Distress Outcomes.

Construct	1. Gender	2. Age	3. MS	4. Education	5. When left	6. How long	7. Come family	8. Ref point	9. Per ID	10. Turn point	11. SelfC	12. SelfB	13. HelpL	14. HopeL	15. Dan	16. SE1	17. SE2	18. SE3	19. Psy	20. PTSD
1	1	−0.05	−0.24	0.03	0.03	−0.06	0.09	−0.03	−0.02	−0.06	0.03	0.02	−0.05	−0.05	0.01	0.04	0.09	0.06	−0.04	0.03
2		1	0.42	−0.08	0.06	0.16	−0.04	0.09	0.09	0.09	−0.06	−0.05	0.02	0.01	−0.00	−0.04	−0.03	−0.13	0.10	0.08
3			1	−0.02	0.04	0.03	−0.11	0.07	0.08	0.09	−0.11	−0.05	−0.01	−0.03	−0.08	0.08	−0.00	−0.02	0.00	−0.03
4				1	0.02	0.04	0.06	0.04	−0.00	0.02	−0.07	−0.10	−0.03	−0.04	0.00	0.11	0.03	0.10	0.03	0.00
5					1	0.71	0.02	−0.01	0.00	−0.03	−0.02	0.01	0.00	0.03	0.05	0.09	0.00	−0.01	−0.05	0.03
6						1	0.02	0.02	−0.01	−0.02	−0.02	−0.00	0.00	0.04	0.03	0.08	−0.01	0.01	0.02	0.03
7							1	0.03	0.02	0.04	0.02	0.00	−0.02	−0.03	−0.01	0.04	0.02	0.05	0.04	0.06
8								1	0.84	0.71	0.20	0.23	0.30	0.29	0.26	0.01	0.02	0.08	0.38	0.41
9									1	0.73	0.22	0.22	0.32	0.34	0.27	0.00	-0.00	0.02	0.38	0.43
10										1	0.16	0.18	0.28	0.26	0.23	−0.04	−0.03	0.03	0.36	0.39
11											1	0.82	0.73	0.71	0.71	−0.13	−0.09	−0.10	0.42	0.56
12												1	0.74	0.72	0.76	−0.16	−0.10	−0.09	0.38	0.54
13													1	0.85	0.80	−0.24	−0.18	−0.18	0.57	0.64
14														1	0.79	−0.25	−0.17	−0.20	0.57	0.63
15															1	−0.20	−0.14	−0.17	0.49	0.63
16																1	0.62	0.54	−0.24	−0.20
17																	1	0.65	−0.24	−0.20
18																		1	−0.26	−0.20
19																			1	0.66
20																				1

Note. Significant correlations (p < .01) were written in bold; point biserial correlation (r_bp) was carried out for gender, marital status, education, and whether they fled Syria with family members. Age = age of refugees; MS = marital status (dummy: 1 = not married, 2 = married); Education (dummy variable: 1 = up to secondary school level, 2 = up to university level); when left = how long ago they escaped Syria; How long = how long they lived in Sweden; Come family = whether they came to Sweden with family members; Ref point = Reference point; Per ID = personal identity; Turn point = turning point; SelfC = self-criticism; SelfB = self-blame; HelpL = helplessness; HopeL = hopelessness; Dan = danger; SE1 = trauma-coping self-efficacy item parcel 1; SE2 = trauma-coping self-efficacy item parcel 2; SE3 = trauma-coping self-efficacy item parcel 3; Psy = psychiatric comorbidity; PTSD = posttraumatic stress disorder symptoms.

. Three item parcels were generated for trauma-coping self-efficacy.

To begin examining the model fit, the measurement aspect of the model was examined by fitting the model with the indicator variables without inserting the paths between the residuals. The loadings of all reflective indicators were significantly different from zero ranging from .70 to .93 (Table 3

Table 3.

The Loadings of Reflective Indicators Used in the Model.

Psychological Construct	Estimate
Trauma centrality
Reference point	0.93
Personal identity	0.88
Turning point	0.81
Cognitive distortion
Self-criticism	0.81
Self-blame	0.85
Helplessness	0.86
Hopelessness	0.86
Preoccupation with danger	0.85
Posttraumatic stress
Intrusion	0.73
Avoidance	0.93
Hyperarousal	0.91
Psychiatric comorbidity
Somatic problems	0.84
Anxiety	0.92
Social dysfunction	0.78
Depression	0.70
Trauma-coping self-efficacy
Self-efficacy 1	0.70
Self-efficacy 2	0.83
Self-efficacy 3	0.74

). The residuals on trauma centrality to correlate with PTSD and psychiatric comorbidity, distorted cognitions, and trauma-coping self-efficacy were then allowed. The residuals on distorted cognitions and trauma coping to correlate with the two distress outcomes were also entered. Trauma characteristics were also allowed to correlate with trauma centrality. These adjustments were correspondent to the paths depicted in the theoretical model. The model fit was, however, poor with substantial departure between the observed covariance matrix and that predicted by the model (CMIN/DF: 5.68; TLI: .84; IFI: .86; RMSEA: .09, 90% confidence interval [CI]: .09–.10; CFI: .86; NFI: .84; GFI: .79).

The modification indices suggested removal of the path leading from trauma centrality to trauma-coping self-efficacy. The revised model generated the final model with a substantial improvement in the fit (CMIN/DF: 2.41; TLI: .95; IFI: .96; RMSEA: .05, 90% CI: .04–.06; CFI: .96; NFI: .94; GFI: .92). Trauma centrality was positively correlated with PTSD and psychiatric comorbidity. It was also positively correlated with distorted cognition which was positively correlated with the two distress outcomes. Trauma-coping self-efficacy was negatively correlated with PTSD and psychiatric comorbidity. Based on the estimated standard errors, all significant correlations were at 5% or better. To simplify the presentation, only significant paths were shown in the figure without the covariance relationships (Figure 2

Figure 2.

The final model. All paths shown are significant at 5% or better.

). Mediational analysis showed that distorted cognitions mediated the impact of trauma centrality onto PTSD and psychiatric comorbidity (Table 4

Table 4.

The Impact of Trauma Centrality onto PTSD and Psychiatric Comorbidity with Distorted Cognitions as Mediator.

Total Effect of X (Trauma Centrality) on Y (PTSD)
Effect	SE	t	P	LLCI	ULCI	BootSE	BootLLCI	BootULCI
0.30	0.02	10.87	0.00	0.25	0.36	—	—	—
Direct effect of X (trauma centrality) on Y (PTSD)
0.19	0.02	8.28	0.00	0.14	0.24	—	—	—
Indirect effect(s) of X (trauma centrality) on Y (PTSD)
Cognitive distortions
0.11	—	—	—	—	—	0.02	0.07	0.15
Total Effect of X (trauma centrality) on Y (psy comorbidity)
0.40	0.04	9.23	0.00	0.31	0.48	—	—	—
Direct effect of X (trauma centrality) on Y (psy comorbidity)
0.26	0.04	6.68	0.00	0.18	0.34	—	—	—
Indirect effect(s) of X (trauma centrality) on Y (psy comorbidity)
Cognitive distortions
0.13	—	—	—	—	—	0.02	0.08	0.18

Note. SE = standard error; LLCI = lower level confidence interval; ULCI = upper level confidence interval; PTSD = posttraumatic stress disorder.

Discussion

The purpose of this study was twofold. First, it provided further evidence for the association between trauma centrality, PTSD, and psychiatric comorbidity among Syrian refugees. Second, it investigated whether cognitive distortions and trauma-coping self-efficacy would mediate the path between trauma centrality and distress outcomes. The first hypothesis was supported in that after controlling for trauma exposure characteristics, trauma centrality was significantly correlated with PTSD and psychiatric comorbidity. The second hypothesis was partially supported in that while cognitive distortions mediated the impact of trauma centrality onto two distress outcomes, trauma-coping self-efficacy did not but was negatively correlated with distress outcomes.

Prior to discussing the main findings, it is worth noting that the prevalence rate for PTSD among refugees fell within the range mentioned in literature, although over a third also met the diagnostic criteria for partial-PTSD. PTSD occurs along a continuity of normal to abnormal stress reactions. The diagnostic threshold simply aims to exclude PTSD cases with fewer-than-average symptoms (Brewin, 2003). In other words, although some refugees might not have met the diagnostic criteria for PTSD, their symptoms can still be distressing. Partial or subsyndromal-PTSD has been associated with increased impairment in social functioning, and physical and psychiatric comorbidity. Clinical interventions are still needed for this group of individuals (Brewin, 2003; Cukor et al., 2010; Pietrzak et al., 2011; Varela et al., 2013; Zlotnick et al., 2002).

In line with literature (Chung, AlQarni, et al., 2018a; Chung et al., 2017), trauma exposure characteristics were correlated with trauma centrality. Witnessing physical assault, rape, and murder, execution of religious leaders or civilians as well as being exposed directly to bombing or shelling were associated with trauma centrality. A recent study also shows that bombing exposure can generate schematic changes among Iraqi citizens (Chung & Freh, 2019). Trauma centrality was also associated with kidnapping, physical injury, or murder of family members or friends. Contrary to a previous study focusing on Syrian refugees (Chung, AlQarni, et al., 2018b; Chung et al., 2017); however, this study found an association between trauma centrality and oppression particularly in terms of violation of basic needs such as privacy, confiscation of personal property, no access to medical care, food, and water. Oppression has been argued as a form of trauma aiming to bring changes to different aspects of individual, social, or collective identity (Kira et al., 2018).

Trauma centrality was correlated with PTSD and psychiatric comorbidity, with all three subscales of trauma centrality being correlated with outcomes ranging from r (475) = .36 to .43. In other words, posttrauma distressing changes in meaning, values, beliefs, ideology, and identity were accompanied by or expressed through psychological distress (K. E. Miller & Rasco, 2004). Also, in line with the cognitive model of PTSD, trauma centrality impacted PTSD and psychiatric comorbidity via cognitive distortions. The mediating effect of cognitive distortions has been demonstrated elsewhere (Browne & Winkelman, 2007; Fang & Chung, 2019). Some of the constituents of cognitive distortions could have been influenced by feelings of uncertainty. At the time of the study, almost all refugees felt uncertain about their future because they were still waiting to be officially resettled. This feeling of uncertainty was accompanied by an awareness of the danger of returning home, all of which could have contributed to the feelings of hopelessness, helplessness, preoccupation with danger or even self-blame (i.e., their current situation was their own making). To enhance understanding of trauma reactions among refugees then, it is important to explore how the subjective experience of change in different aspects of oneself resulting from highly accessible and vivid personal memories of the war might play a major role in the development of maladaptive cognitive appraisals of oneself and the world. It is worth noting that all the subscales of trauma centrality and cognitive distortion were significantly correlated ranging from .16 to .34 in r values.

The lack of correlation between trauma centrality and trauma-coping self-efficacy was unexpected and posed a challenge to some well-established theoretical postulates. Contrary to the social-cognitive model, for example, refugees who experienced a drastic re-evaluation of their self did not necessarily experience reduced adaptational skills or agentic ability to exercise control over trauma-related thoughts or feelings and facilitate posttraumatic recovery (Benight & Bandura, 2004; Bosmans et al., 2013; Cieslak et al., 2008; Lambert et al., 2013; Luszczynska et al., 2009; Samuelson et al., 2017; Smith et al., 2015). Also contrary to some assumptions of the traumatized self, while trauma might change the self-structure, it might not reduce self-regulatory, goal-directing capacity (Wilson, 2006) leading to a feeling of powerlessness (Brewin, 2003), diminishing adaptation but maintaining PTSD and psychiatric comorbidity (Bandura, 1997; Benight & Bandura, 2004; A. D. Brown et al., 2015, 2016; K. W. Brown & Ryan, 2004).

In this study, changes in the attribution of meaning in one’s existing belief system and future expectations, and outlook on life and identity through trauma seemed to be a psychological process independent of that involved in facilitating self-efficacy in coping with the aftermath effects of trauma. Trauma-coping self-efficacy seemed to make an independent and unique contribution to elevated distress outcomes. For these refugees, possessing a high level of trauma-coping self-efficacy seemed to be a generic resilience factor for determining their ability to regulate functioning, and buffer against the adverse effects of trauma and other psychological symptoms. Regardless of changes in self-perception, those who had a high level of self-efficacy would engage in an inherent enabling and protective process to regulate emotions, confront trauma and thereby alleviate trauma reactions and other psychological symptoms (Benight & Bandura, 2004). Having a low level of self-efficacy, on the other hand, would mean difficulties in regulating emotions, avoiding facing up to the trauma and having traumatic thoughts intruding into consciousness. The effect of trauma cannot be managed and its severity is therefore magnified (Bandura, 1997; Benight & Bandura, 2004). The inverse relationship between self-efficacy and trauma has been demonstrated in literature among victims of different kinds (Benight & Harper, 2002; Flatten et al., 2008; Hirschel & Schulenberg, 2009; Hoelterhoff & Chung, 2013; Hyre et al., 2008; Weisenberg et al., 1991).

A few words need to be said about the results in terms of diversity. While the present findings depict the trauma reactions of Syrian refugees, it would be premature to conclude that they represent other types of refugees. Our results showed that trauma exposure characteristics can influence trauma reactions. It is likely that the reason for fleeing, be it religious, racial, or political persecution, civil war, gender/sexual orientation or hunger, is also a constituent for trauma characteristics along with the subjective experience of what happens to them while fleeing. For example, based on anecdotal evidence, many refugees from our sample felt determined to return and rebuild their country, having been forced to leave home due to war. Their stay in Sweden was only temporary. Such self-determination could affect trauma-coping self-efficacy which in turn could impact distress outcomes. However, there is no reason to assume that this trauma response would emerge for Rohingya refugees who were victims of ethnic cleansing or refugees from countries such as Bangladesh or Pakistan who fled due to anti-LGBT (lesbian, gay, bisexual, transgender) legislation.

A cultural diversity interpretation of the present findings might offer support for research indicating ethnic disparity in PTSD symptom expression and exposure to different trauma and coping resources following trauma exposure (Hall-Clark et al., 2016). For example, victims coming from a collectivist culture tend to be interdependent individuals who maintain well-being by emphasizing connectedness with others, carrying out social obligations and restricting individual emotional expression for group harmony (e.g., Jayawickreme et al., 2013). This cultural orientation can influence PTSD symptom presentation (Lopez & Guarnaccia, 2000) in that victims might “internalize” symptoms by directing them inwardly through avoidance or numbness (M. W. Miller et al., 2004). The refugees in our sample would have been interdependent individuals who, as was mentioned, had a tendency to restrict individual expression to maintain harmonious group relationships (Jayawickreme et al., 2013). In so doing, their level of trauma-coping self-efficacy could have been affected which in turn affects levels of psychological distress. Research shows that Arabic individuals tend to have a lower level of self-efficacy in managing emotions than people from individualistic cultures (Megreya et al., 2018). However, cultural diversity in managing emotions is not restricted by collectivistic and individualistic differences. Such diversity is also evident among individuals with a similar cultural orientation. For example, people from Germany and the Netherlands have been shown to be different from those in Spain, Italy, Portugal, and Hungary in endorsing different levels of cognitive strategies to manage their emotions (Potthoff et al., 2016).

Last but not least, the diversity issue for this study can be conceptualized in terms of refugees’ experiences of living in Sweden. Their trauma reactions and psychological distress can be exacerbated by stressful issues pertaining to resettlement to Sweden. These Arabic-speaking individuals, mostly Muslim, collectivist in culture, were living in a country with individuals who were mostly non-Muslim and individualistic in culture. Daily discrimination and the nonrecognition of human rights among refugees have emerged as a cause of difficulty in integrating across cultures. These social issues along with environmental changes, reduced social support, and socio-economic status have contributed to resettlement or postmigration distress among these refugees. The impact of these stressors on mental health has been shown to vary depending on country of resettlement (Bentley et al., 2012; D’Avanzo & Barab, 2000; Ellis et al., 2008; Kartal & Kiropoulos, 2016; Weaver & Roberts, 2010).

The current findings could have implications for designing and implementing psychological interventions for Syrian refugees. First, since trauma exposure characteristics were correlated with changes in self-perception and identity, one component of psychological interventions should address the trauma experience of escaping from Syria and help them to manage their posttraumatic stress symptoms. Second, since changed self-concept interacted with distorted thoughts to influence distress, psychological interventions should also address issues pertaining to these two components. Exploratory, interpersonal as well as prescriptive (e.g., cognitive behavioral therapy) types of interventions might be useful for refugees. Third, trauma-coping strategies have been shown to reduce distress; psychological interventions should incorporate training on enhancing these coping styles.

Several limitations of the study need to be acknowledged. First, this study was conducted using convenience sampling making generalizability of the findings questionable. Second, the fluidity of refugees meant that a longitudinal study was almost impossible to carry out. As a result, comments on causality could not be made. The mediational results need to be interpreted with caution since a cross-sectional design could have yielded bias in mediational analysis due to the lack of temporal precedence (Cole & Maxwell, 2003). Nevertheless, the “mediational” results were an attempt primarily to explore indirect effects (i.e., the structural relationship of the model) rather than causality inference (Holland, 1986). Third, information on subjective experiences or postmigration stress could have been an important “victim variable.”

Conclusion

This cross-sectional study examined whether Syrian refugees’ altered self-perception would impact PTSD along with other psychiatric symptoms and whether their distorted cognitions and trauma-coping self-efficacy would influence such impact. The horror that Syrian refugees experienced did alter their self-perception in terms of existing beliefs, future expectations, outlook on life, and identity. These changes impacted trauma reactions and other psychological symptoms especially for those who had dysfunctional beliefs about themselves and the world. On the contrary, their distorted belief in their ability to cope with the aftermath of the trauma affected distress independently of changes in self-perception.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research reported in this paper was funded by a grant from the Chinese University of Hong Kong.

ORCID iD

Man Cheung Chung

Author Biographies

Man Cheung Chung earned his B.A. in Psychology and Sociology (University of Guelph, Canada), PhD in Psychology (University of Sheffield, U.K.) and PhD in Philosophy (University of Durham, U.K.). He is associate fellow of the British Psychological Society. He is also a Chartered Scientist and Psychologist. He is currently professor of psychology at the Chinese University of Hong Kong.

Mudar Shakra is a doctoral researcher at Uppsala University, Sweden. He went to Sweden as a refugee and was also one of the research assistant for the project.

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