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BRIEF REPORT: Investigating the relationships between self-consistency, trauma-themed self-concept and posttraumatic stress symptoms 

Tal Moore*
Central Norfolk Youth Service, Norfolk and Suffolk NHS Foundation Trust

Laura Jobson
Medical Research Council Cognition and Brain Sciences Unit, Cambridge UK and University of East Anglia, Norwich UK 


* Corresponding Author: Dr Tal Moore, Clinical Psychologist
Central Norfolk Youth Service, Norfolk and Suffolk NHS Foundation Trust
80 St Stephens Road, Norwich NR1 3RE
Email: Tal.Moore@nsft.nhs.uk

Phone: +44 1603201486 
Laura Jobson is funded by a Postdoctoral Research Fellowship award from the National Institute for Health Research.



Abstract
The aim of the current study was to investigate the relationships between self-consistency, trauma-centered self-concept and PTSD symptoms. Participants (N = 97) completed the Centrality of Events Scale, a measure of self-consistency and the Posttraumatic Diagnostic Scale. As previously found, trauma-centered self-concept was found to be positively associated with PTSD symptoms. Self-consistency was found to be negatively associated with PTSD symptoms and trauma-centered self-concept. Mediation analyses indicated that trauma-centered self-concept mediated the relationship between self-consistency and PTSD symptoms. The findings suggest that self-consistency is related to better posttraumatic psychological adjustment. 
BRIEF REPORT: Relationships between self-consistency, trauma-themed self-concept and posttraumatic stress symptoms 
In the aftermath of trauma, the self can become altered and dominated by thoughts and memories of the trauma experience (Brewin, 2011). Accumulating research has demonstrated a significant connection between alteration in the self-concept following trauma and posttraumatic stress disorder (PTSD). In an initial study, McNally, Lasko, Macklin, and Pitman (1995) noted that Vietnam veterans with PTSD who wore Vietnam War regalia to the laboratory disproportionately retrieved memories from the Vietnam War. It seemed that these participants� identity and personal memories had become centered round their trauma experience. More recently, studies have found that when trauma survivors are asked to provide autobiographical memories of experiences that significantly reflect and inform their self-concept, the responses of those with PTSD, when compared to trauma survivors without PTSD, tend to be strongly associated with their trauma experience (e.g., Jobson, Moradi, Rahimi-Movaghar, Conway, & Dalgleish, in press; Jobson & O�Kearney, 2006, 2008; Sutherland & Bryant, 2006).   A significant body of research has also repeatedly demonstrated that the traumatic experience forming a central component of personal identity significantly correlates with higher levels of PTSD symptoms (e.g., Berntsen & Rubin, 2006, 2007; Berntsen, Rubin, & Siegler, 2011; Brown, Antonius, Kramer, Root, & Hirst, 2010; Byrne, Hyman, & Scott, 2001; Robinaugh, & McNally, 2011). This relationship has been identified independently of trauma type and severity and in clinical and non-clinical samples. 
The self-memory system (SMS; Conway & Pleydell-Pearce, 2000) has been drawn upon to account for these alterations in the self-concept. The SMS posits that a motivational hierarchy of goals (the working self) encodes and integrates memories of experiences into a database of autobiographical memories. A fundamental element of the SMS is the premise the individuals have a need for self-consistency and coherence. The SMS suggests that in the instance of trauma, the trauma memory can pose a threat to current goals to which the working self cannot readily adapt and hence, for those with PTSD the trauma memory is not integrated into the life story. The SMS suggests that in response to this the working self aims to reduce the inconsistency between desired goals of the self-concept and the present state. Coherence between the trauma and the self may be accomplished, to a point, through inhibition or distortion of the trauma memory. Over time, however, these inconsistencies may prove too psychologically demanding and result in transformations to the existing self-concept leading to the development of a self that is trauma-centered and which is reflected in self-related remembering (Conway, 2005). Brewin (2011) similarly highlights that in the aftermath of trauma, the trauma memory of those with PTSD may be inconsistent with the desired goals of the self-concept and be hard to integrate with previously held assumptions about the self and world. Consequently, the trauma becomes central to people�s mental life as they struggle to resolve these discrepancies resulting in the trauma becoming highly associated with the self-concept. A self-concept centered round the trauma experience is likely to result in continual internal threat to the self (e.g. a threat to one's view of oneself as a capable and acceptable individual who is able to achieve important life goals), which has been found to maintain PTSD symptoms (Ehlers & Clark, 2000, p. 320). In both these accounts, trauma is suggested to threaten the consistency and coherence of one�s self-concept (Conway, 2005). 
Self-consistency is understood as a congruent view of oneself, free from conflict or ambivalence (Boucher, 2011) and refers to congruency across roles, relationships and contexts (Cross, Gore, & Morris, 2003). It has long been regarded as fundamental for psychological well-being, self-actualization and maintaining the integrity of the self (Cross et al., 2003; James, 1929; Jourard, 1965; Lecky, 1945; Maslow, 1954; Rogers, 1951). Individuals are therefore motivated to establish and maintain a consistent self-identity through time and thus, preserve world-views that perpetuate their conception of their sense of self and recall events that align with current self-views (Elliott, 1986; Swann et al., 1987; Wilson & Ross, 2003). Moreover, empirical work has demonstrated that self-consistency is an important indicator of successful adaptation and good psychological adjustment (e.g., Cross et al., 2003; Donahue et al., 1993; Roberts & Donahue, 1994). An inconsistent and fragmented self-concept has been found to be associated with a painful and psychologically unstable state, reduced self-esteem and higher depression, anxiety and somatisation symptoms (Block, 1961; Cross et al., 2003; Donahue et al., 1993; Sheldon, Ryan, Rawsthorne, & Ilardi, 1997). Elliott (1986) highlights that aversive situations, such as trauma experiences, can influence the achievement of a consistent self-concept and that discordant pieces of information about the self cannot be easily assimilated; such states may require difficult repair work, which may in time even involve reformulation of the self-concept.
In sum, both the PTSD accounts (e.g. Brewin, 2011; Conway, 2005) and self-consistency theories (e.g. Elliott, 1986) highlight the importance of self-consistency in maintaining psychological adjustment and the potential threat trauma poses to self-consistency. Specifically, for some trauma survivors there can be difficulties in assimilating discordant trauma-related information with the self-concept. Such difficulties are proposed to drive repair work, which may even involve alterations to the self-concept, leading to the development of a self that is trauma-centered. A self-concept that is centered round the trauma experience is likely to result in continual threat to the self as a capable and acceptable individual who is able to achieve valued life goals, thus maintaining PTSD symptoms (Ehlers & Clark, 2000). While these relationships have been suggested theoretically, to date, very limited research has investigated these associations empirically. The aim of the current study, therefore, was to investigate the relationships between trauma-centered self-concept, self-consistency and PTSD symptoms. First, we hypothesized that higher levels of self-consistency would be associated with fewer PTSD symptoms, as self-consistency has continuously been found to be associated with successful psychological adaptation. Second, we hypothesized that lower levels of self-consistency (i.e. a more fragmented and inconsistent self-concept) would be associated with greater trauma-themed self-concept, as it is theoretically suggested that a fragmented self-concept can drive repair work which may in time involve alterations to the self-concept leading to the development of a self that is trauma-centered (Brewin, 2011; Conway, 2005; Elliott, 1986). Third, we will use a meditational analysis approach to investigate the above theoretical proposition; that trauma�s threat to self-consistency motivates repair work, which can result in the development of a self-concept that is trauma-centered; a self-concept found to maintain PTSD symptoms. Specifically, we will investigate whether trauma-themed self-concept has a mediating role in the relationship between self-consistency and PTSD symptoms.  
Method
Participants
Trauma survivors (N = 97; Mage = 38.70, SD = 13.30; male n = 18) from the general community were recruited. All participants reported at least one trauma experience (range 1-6 trauma experiences; M = 2.49, SD = .24) that would meet PTSD criterion A in the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR; APA, 2004) on the Posttraumatic Stress Diagnostic Scale (PDS; Foa, Cashman. Jaycox, & Perry, l997). Participants reported that the trauma experiences that they considered most traumatic were accident (n = 21); disaster (n = 4); non-sexual assault (n = 24); sexual assault (n = 8); life-threatening illness (n = 23); and other (suicide attempts, witnessing a sudden death and violent relationship) (n = 17). Participants reported that time since trauma was less 6 months (n = 4); 6 months-3years (n = 18); 3-5years (n = 13); and more than 5 years (n = 58) (four participants did not specify time). Participants mean PTSD symptom severity score was 13.67 (SD = 10.23) and mean depression score was 29.10 (SD = 9.90). Participants� mean trauma-themed identity (i.e. CES) score was 66.24 (SD = 18.62) and self-consistency index (SCI) was 65.88 (SD = 12.54).
Measures
Self-Consistency.
	The Self-Consistency Index (SCI) has been used in previous research to estimate self-consistency in community samples (e.g., Donahue et al., 1993). The SCI consists of two parts. Part 1 requires participants to rate the extent to which 16 personality traits (e.g. tolerant, serious) described their �general self� on a 7-point Likert scale from 1 (not at all like myself) to 7 (very much like myself). Following Suh�s (2002) procedure, participants then completed several scales unrelated to self-consistency (in the present study this included the remaining measures). Following this, participants completed Part 2 by rating how accurately the Part 1 personality traits describe them in the context of three interpersonal relationships: self with romantic partner, parent, and friend. To randomize the order of appearance of each trait � context, a set of random numbers was produced using the Excel programme and assigned to each of the 48 trait*interpersonal context pairs; the assigned random numbers were then put in number order, so that the trait*context items became randomly ordered. The final order of the 48 items was identical for each participant. The index score on the SCI is the percentage of variance explained by the first factor. It can range between 0 and 100%. Higher values denote increased levels of self-consistency. The SCI has been shown to have adequate psychometric properties (e.g., Suh, 2002). 
Trauma-centred self-concept.
The Centrality of Event Scale (CES; Berntsen & Rubin, 2006) is a self-report questionnaire that assesses the predominance of a stressful life event in respondents� identity. It has 20 items that are rated on a 5-point Likert scale from 1 (totally disagree) to 5 (totally agree). Respondents were instructed to complete the CES in regard to the trauma selected on the PDS. The CES has good psychometric properties (Berntsen & Rubin, 2006). In the current study internal consistency was good (Cronbach�s alpha = .93). 
PTSD symptoms.
PTSD symptoms were measured using the PDS (Foa et al., 1997), a 49-item self-report widely used in research and clinical settings. The scale assesses trauma history and screens for the DSM-IV (APA, 1994) PTSD stressor criterion A. Respondents rate the severity and duration of 17 symptoms that correspond with the core PTSD diagnostic symptoms (criteria B through E) from 0 (not at all or only one time) to 3 (5 or more times a week / almost always) and how much their symptoms affected their level of functioning over the past month (criteria F). The PDS has good psychometric properties (Foa et al., 1997) and in the current study internal consistency was good (Cronbach�s alpha = .91).
	Depression.
	Given high levels of co-morbidity between depression and PTSD, depression was measured using Part II of the Hopkins Symptom Checklist (HSCL-25; Derogatis, Lipman, Rickels, & Cori, 1974). The HSCL-25 Part II has 15 items that measure depression symptoms. Participants are required to indicate how much each symptom bothered them in the past week from 1 (not at all) to 4 (extremely). The HSCL-25 depression subscale has good psychometric properties (Derogatis et al., 1974). 
Procedure
	The study received ethical approval from the National Health Service National Research Ethics Services. The study was advertised via posters in public places, advertisements in local newspapers, hospitals and health services. Interested individuals contacted the researcher by phone or email and received additional information about the study. Participants completed the questionnaire on-line. Participants were instructed to complete the measures in one sitting and in the following order: SCI-part I, CES, PDS, HSCL-25, SCI-part II, and demographics. 
Results
Relationships between Self-Consistency, Trauma-Centered Self-Concept and PTSD symptoms 
As found in previous research, a higher degree of trauma-centered self-concept was found to be significantly correlated with higher levels of PTSD symptoms, r(94)= .33, p = .001, and depression symptoms, r(94)= .34, p = .001.
In terms of the first hypothesis, as predicted lower levels of self-consistency was found to be significantly correlated with greater PTSD symptoms, r(94)= -.26, p < .01, and also with greater depression symptoms, r(94)= -.38, p < .001. In terms of the second hypothesis, as expected, lower levels of self-consistency were significantly correlated with greater trauma-themed self-concept, r(93)= -.31, p < .01. Given the influence multiple traumas, interpersonal-type trauma and childhood trauma may have had on findings, the correlations were also conducted partialling out each of these variables. The findings were still significant.
Mediation Analyses
We carried out a mediation analysis using bootstrapping procedures (Preacher & Hayes, 2008) with 5,000 resamples with replacement to examine whether trauma-centered self-concept mediated the relationship between self-consistency and PTSD symptoms As Figure 1 illustrates, self-consistency was a significant predictor of PTSD and of trauma-centeredness. Trauma-centeredness was also a significant predictor of PTSD symptoms while controlling for self-consistency. The standardized regression coefficient between self-consistency and PTSD symptoms decreased substantially when controlling for trauma-centeredness. Nonparametric bootstrapping analyses found that trauma-centeredness did mediate the relationship between self-consistency and PTSD symptoms, Sobel statistic = 2.09, p = .03, lower 95% CI= -.15, upper 95% CI= -.02 (statistical significance is indicated by the 95% confidence intervals not crossing zero). 
Discussion
The aim of the current study was to investigate the relationships between self-consistency, trauma-centered self-concept and PTSD symptoms. In line with our hypotheses, higher levels of self-consistency were significantly correlated with fewer PTSD symptoms (hypothesis 1) and lower levels of trauma-centered self-concept (hypothesis 2). Furthermore, as predicted, a self-construct that is centered round trauma was found to mediate the relationship between self-consistency and PTSD symptoms. Trauma survivors with lower levels of self-consistency tended to have worse PTSD symptoms; however, this relationship was influenced by the extent to which their self-concept had become trauma-centered.  
These findings align with theoretical propositions outlined in both PTSD models and the self-consistency literature. Firstly, they highlight the importance of self-consistency in maintaining posttraumatic psychological adjustment as those with higher levels of self-consistency had fewer PTSD symptoms. Secondly, they support the notion that in response to difficulties in assimilating discordant trauma-related information with the self-concept, the trauma may become central to people�s mental life as they struggle to resolve these discrepancies resulting in a motivation for self-concept repair work. In time this may involve alterations to the self-concept leading to the trauma becoming highly associated with the self-concept. A self-concept that is centered round the trauma experience is likely to result in continual threat to the self, which Ehlers and Clark (2000) posit plays a fundamental role in maintaining PTSD symptoms. The findings also suggest that those with higher levels of self-consistency may be generally better at achieving self-consistency and coherence and thus, better able to reconcile the trauma event with the self-system without negative impacts on the self and associated negative psychological consequences (Conway, 2005). A self-consistent sense of self may also mean greater retention of pre-trauma aspects of self, which may offer some protection against the trauma resulting in an internal threat to self (Ehlers & Clark, 2000). 
	If the findings are robust, there are potential clinical implications. Specifically, the findings support PTSD interventions targeting trauma-centeredness and self-consistency. Brewin and Holmes (2003) suggest that PTSD interventions encourage consistency between the trauma narrative and one�s pre-trauma identity as a mode for challenging trauma-related, negative cognitions. The findings support current emphasis of PTSD interventions in targeting self-concept, such as the self as fragmented, altered and dominated by thoughts and memories of the trauma (Brewin, 2011). However, the findings suggest that an additional element of self that may be worth considering clinically is consistency of self. 
The limitations of this study are acknowledged. First, a non-clinical sample was employed and thus, our sample had relatively low levels of PTSD symptoms, which may have influenced findings. Future research should investigate these relationships in those with a diagnosis of PTSD. Second, the cross-sectional design precludes causal inferences. Thus, it is uncertain whether self-consistency was a protective factor in preventing PTSD symptom development or following trauma in some trauma survivors there was a reduction in self-consistency. Despite these limitations, the findings of this study suggest that greater self-consistency was significantly correlated with fewer PTSD symptoms and trauma-centered self-concept mediated the relationship between self-consistency and PTSD symptoms. 
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Figure 1. Standardized regression coefficients for the relationship between self-consistency and PTSD symptoms as mediated by trauma-centeredness. 




Note. The standardized regression coefficient between self-consistency and PTSD symptoms controlling for trauma-centeredness is in parentheses.
** p d" .01.  












 PAGE   \* MERGEFORMAT 13



Self-Consistency

Trauma-Centeredness

PTSD Symptoms

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