Assessment of PTSD's E2 Criterion: Development, Pilot Testing, and Validation of the Posttrauma Risky Behaviors Questionnaire.

Abstract

Posttraumatic stress disorder (PTSD) is highly prevalent, with recent evidence suggesting that 8.30%, or approximately 27 million Americans according to the recent U.S. Census data (2018), will develop PTSD in their lifetime (Kilpatrick et al., 2013). Unsurprisingly, PTSD is both widely researched and a key consideration in clinical practice. One important clinical and empirically-established correlate of PTSD is engagement in reckless and self-destructive behaviors (RSDBs; Lusk, Sadeh, Wolf, & Miller, 2017; Tull, Weiss, & McDermott, 2015; Weiss, Tull, Sullivan, Dixon-Gordon, & Gratz, 2015). Among theoretical explanations for the PTSD-RSDB link, the disinhibition viewpoint indicates that individuals with PTSD may have difficulties inhibiting rewarding RSDBs (Casada & Roache, 2005); the emotion dysregulation perspective indicates that individuals engage in RSDBs to reduce the negative affect or increase the blunted positive affect characteristic of PTSD (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004); and the cognitive explanation suggests the trauma’s effects on decreasing attention span and information processing capacity may increase the likelihood of impulsive RSDBs (Ben-Zur & Zeidner, 2009). Of clinical salience, engagement in RSDBs among trauma-exposed samples has a detrimental impact on physical and mental health outcomes. For instance, in a study of veterans receiving treatment for PTSD, a significant number of deaths were related to RSDBs such as substance misuse and suicide (Drescher, Rosen, Burling, & Foy, 2003). Additionally, another study found that engagement in RSDBs was associated with greater psychological, emotional, and behavioral problems (Contractor, Weiss, Dranger, Ruggero, & Armour, 2017). With this empirical, theoretical, and clinically-significant foundation, the E2 symptom assessing posttrauma RSDBs was added to the DSM-5 PTSD diagnostic criteria (American Psychiatric Association, 2013). However, the lack of a comprehensive (yet brief) validated screening measure to assess E2 poses a barrier to its measurement and consideration in treatment. In fact, existing assessments of PTSD’s E2 criterion lack clinical utility and empirical support in a number of ways. First, the assessment of PTSD’s E2 criterion in adults has relied either on a single-item (E2 symptom) included in PTSD assessments or requires a time-intensive battery of multiple distinct measures of a range of specific RSDBs (e.g., substance use, aggressive behaviors). With evidence supporting the co-occurrence of RSDBs (Cooper, 2002) representing an underlying unified latent factor (Shaw, Wagner, Arnett, & Aber, 1992; Weiss, Tull, Dixon-Gordon, & Gratz, 2016), using multiple RSDB measures may have less utility than a measure assessing a unified RSDB construct. Second, one could use existing comprehensive risky behavior measures such as the Risky Impulsive and Self-Destructive Questionnaire (Sadeh & Baskin-Sommers, 2017), the Risky Behaviors Questionnaire (Weiss et al., 2016), and the Risk-Taking Behavior Scale (Pat-Horenczyk et al., 2007). However, these are lengthy (e.g., 38, 29, and 87 items), assess more than just frequency of engaging in RSDBs (e.g., functionality of RSDBs), and/or are restricted to a specific developmental period (e.g., adolescence). Further, these measures do not include items to specifically examine posttrauma manifestations of RSDBs, a necessary criterion for evaluating PTSD’s E2. Indeed, while the types of RSDBs may be similar among trauma-exposed and non-trauma-exposed samples, there is a demonstrated uniqueness in the presentation, function, and course of RSDBs among trauma-exposed populations. For instance, trauma-exposed individuals may functionally engage in RSDBs as an emotion regulation strategy to cope with PTSD symptoms/distress (Marshall-Berenz, Vujanovic, & MacPherson, 2011; Weiss et al., 2015; Weiss, Tull, Viana, Anestis, & Gratz, 2012), implying their onset after trauma/PTSD symptoms. Given the aforementioned limitations of existing measures, we need a comprehensive (yet brief enough to ensure clinical utility) and validated screening measure to examine the unidimensional E2 criterion. We developed the Posttrauma Risky Behaviors Questionnaire (PRBQ) to assess extent of engagement in posttrauma RSDBs and examined its factor structure, reliability, and validity (content, convergent, construct, incremental) in a trauma-exposed community sample recruited via Amazon’s MTurk platform. We further replicated this factor structure and examined its validity (construct and convergent) with a different trauma-exposed sample of college students (Hinkin, 1998; Holmbeck & Devine, 2009). We hypothesized good psychometric properties and ability to represent distinct RSDBs as a unidimensional construct.