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Childhood trauma and complex PTSD symptoms in

older adults: A study on direct effects and social-
interpersonal factors as potential mediators
ab ac a
Sandy Krammer PhD , Birgit Kleim PhD , Keti Simmen-Janevska MSc & Andreas Maercker
a
MD PhD
a
Department of Psychopathology and Clinical Intervention, University of Zurich, Switzerland
b
Forensic-Psychiatric Services, University of Bern, Switzerland
c
Department of Clinical Psychology and Psychotherapy, University of Zurich, Switzerland
Accepted author version posted online: 26 May 2015.

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To cite this article: Sandy Krammer PhD, Birgit Kleim PhD, Keti Simmen-Janevska MSc & Andreas Maercker MD PhD (2015):
Childhood trauma and complex PTSD symptoms in older adults: A study on direct effects and social-interpersonal factors as
potential mediators, Journal of Trauma & Dissociation, DOI: 10.1080/15299732.2014.991861

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 Childhood trauma and complex PTSD symptoms in
older adults: A study on direct effects and social-
interpersonal factors as potential mediators
Sandy Krammer12, PhD; Birgit Kleim13, PhD; Keti Simmen-Janevska1, MSc; Andreas

t
Maercker1, PhD MD

ip
1
Department of Psychopathology and Clinical Intervention, University of Zurich, Switzerland

cr
2
Forensic-Psychiatric Services, University of Bern, Switzerland
3
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Department of Clinical Psychology and Psychotherapy, University of Zurich, Switzerland

us
Corresponding author: Sandy Krammer, PhD, Forensic-Psychiatric Services, University of Bern,
Falkenplatz 18, 3012 Bern, Switzerland, Phone 031/631‘50’85, Fax 031/631’31’93, Email:
sandy.krammer@fpd.unibe.ch
an
Submitted as regular article (original research article) to the Journal of Trauma & Dissociation

Key words: trauma, complex posttraumatic stress disorder, social-interpersonal factors, lifespan
M
Word counting including text, references, table and figure: 5360

We gratefully acknowledge the support of the Swiss National Science Foundation to Prof. Dr.
ed

Dr. Andreas Maercker. Birgit Kleim is funded by grants from the Swiss National Science
Foundation (PZ00P1_126597, PZ00P1_150812).

Abstract
pt

Childhood traumatic events may lead to long-lasting psychological effects and contribute to the
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development of complex posttraumatic sequelae. These might be captured by the diagnostic

Ac

concept of complex posttraumatic stress disorder (CPTSD), as an alternative to ‘classic’

posttraumatic stress disorder (PTSD). CPTSD comprises a further set of symptoms in addition to

those of PTSD, namely changes in affect, self, and interpersonal relationships. Previous

empirical research on CPTSD has focused on middle-aged adults, but not on older adults.

1
 Moreover, predictor models of CPTSD are still rare. The current study investigated the

association between traumatic events in childhood and complex posttraumatic stress symptoms

in older adults. The mediation of this association by two social-interpersonal factors (social

acknowledgment as a survivor and dysfunctional disclosure) is investigated. These two factors

t
focus on the perception of acknowledgment by others and the inability to either disclose

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traumatic experiences or do so with negative emotional reactions. One hundred sixteen older

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individuals (age range 59-98 years) who had experienced childhood traumatic events completed
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standardized self-report questionnaires indexing childhood trauma, complex trauma sequelae,

social acknowledgment, and dysfunctional disclosure of trauma. The results show that traumatic

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events during childhood were associated with later posttraumatic stress symptoms, but with

‘classic’ rather than with complex symptoms. Social acknowledgment and dysfunctional
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disclosure partially mediated this relationship. These findings suggest that childhood traumatic

stress impacts individuals across the life span and may be associated with particular adverse
ed

psychopathological consequences.
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Childhood trauma and complex PTSD symptoms in older adults: A study on direct effects and

social-interpersonal factors as potential mediators

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Childhood traumatic events (CTE) are defined by the experience of physical (all forms of
Ac

physical violence that impacts the physical or psychological integrity of a child), sexual (every

sexually motivated action directed against a child), or psychological (e.g., rejection, isolation)

abuse and physical or psychological neglect (no caring or considerate actions, physical and

psychological provision is omitted; Bernstein & Fink, 1998). CTE may lie at the root of long-

2
 term emotional and psychological maladjustments (Carlson, Furby, Armstrong, & Shlaes, 1997).

Multiple experiences of CTE have been referred to as the “typical picture of childhood abuse”

(Cloitre, Cohen, & Koenen, 2006, p. 4). A series of negative health outcomes may result as a

consequence of CTE, including physical and mental disorders (Springer, Sheridan, Kuo, &

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Carnes, 2003). In accord with these findings, a recent WHO survey concluded that childhood

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adversities were associated with a series of disorders at all life stages across countries (Kessler et

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al., 2010). Moreover, a comprehensive review emphasized that depression, anxiety, and
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posttraumatic stress disorder (PTSD) were common in those older individuals with

disadvantageous parent-child-relationships (Weich, Patterson, Shaw, & Stewart-Brown, 2009).

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Only few studies focused on consequences after CTE for older individuals. Two studies

involving adults who had been children during World War II showed that around eleven percent
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of participants reported PTSD-related symptoms 60 years following the war (Kuwert, Spitzer,

Träder, Freyberger, & Ermann, 2007), alongside higher levels of anxiety, lower levels of
ed

resilience and decreased life satisfaction (Kuwert, Brähler, Glaesmer, Freyberger, & Decker,
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2009). This is in line with other studies that found negative long-term consequences decades

after traumatization (Solomon & Mikulincer, 2006).

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Traumatic events may not only lead to ‘classic’ PTSD (American Psychiatric Association
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(APA), 2013; World Health Organization (WHO), 1992), but also to the conceptual diagnosis of

complex PTSD (CPTSD). While the former is mostly caused by type 1 trauma (single traumatic

events in adulthood), CPTSD appears to be related to type 2 trauma (early, multiple or chronic

traumatic events; Terr, 1989; 1991). It is suggested that in CPTSD, type 2 traumatization fosters

3
 the development of symptoms including but also exceeding those of ‘classic’ PTSD (Briere &

Rickards, 2007; Cloitre et al., 2009; Herman, 1992).

Currently, CPTSD is receiving increased attention and may be included in the forthcoming

revision of the International Classification of Disease 11 (ICD-11; Maercker et al., 2013). The

t
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ICD-11 working group for mental disorders associated with stress recently published a proposal

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presenting a definition for CPTSD. In line with Herman (1992), this includes “enduring

disturbances in the domains of affect, self, and interpersonal relationships” (Maercker et al.,
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2013, p. 1684). Empirical studies support the determination of two types of posttraumatic stress

disorder (Cloitre, Garvert, Brewin, Bryant & Maercker, 2013; Elklit, Hyland & Shevlin, 2014;
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Knefel and Lueger-Schuster; 2013). The gap in empirical support for CPTSD mentioned a few

years ago (Cloitre et al., 2011) thus seems to be closing.

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Pathways towards understanding CPTSD development, however, remain unclear. Long-term
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associations imply the existence of mediators (Kessler et al., 2010). A meta-analysis stressed the

central role of social-interpersonal factors for ‘classic’ PTSD (Brewin, Andrews & Valentine,
pt

2000). According to the socio-interpersonal context-model of PTSD (Maercker & Horn, 2012),
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dysfunctional disclosure and social acknowledgment as a victim or survivor are important social-

interpersonal factors concerning posttraumatic adjustment processes.

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Social acknowledgment refers to the reactions of other people following an individual’s trauma,

along with the individual experience of acknowledgment or rejection by the social network as a

trauma victim (Maercker & Müller, 2004). It is associated with recovery from traumatic events

and seen as a salutogenic factor after traumatization (Maercker, Povilonyte, Lianova, &

4
 Pöhlmann, 2009). That is, if people react with understanding and acknowledgment to an

individual’s victimhood, it may prevent maladjustment. If people react with ignorance or

reluctance, it may foster negative consequences.

Pennebaker and Beall (1986) defined disclosure as the communication of life events.

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Confrontation may help a trauma survivor to process aversive events. Such functional disclosure

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leads to positive and health-relevant outcomes after specific events (Pennebaker & Beall, 1986;

Ullman & Filipas, 2005). However, disclosure may become dysfunctional under specific
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circumstances. This refers to the inability or reluctance to talk about past traumatic experiences,

in spite of the need or urge to do so. Dysfunctional disclosure may thus be regarded as negative
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emotional expression in the aftermath of a traumatic event, and is associated with PTSD

(Maercker et al., 2009; Müller & Maercker, 2006; Ullman & Filipas, 2005).
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Taken together, exposure to CTE may lead to withdrawal, seeking less social support, and not
ed

disclosing the event. This may foster the development and maintenance of ‘classic’ PTSD

symptoms. The role of these factors has not yet been investigated in reference to CPTSD.
pt

As far as is known, there has only been sparse investigation concerning CTE and CPTSD in
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older adults. Furthermore, though there is evidence for the role of social-interpersonal factors in

the development of PTSD, no study has yet investigated trauma-specific social-interpersonal

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factors (social acknowledgement, dysfunctional disclosure) as mediators in the context of CTE

and CPTSD in older adults. Understanding mechanisms underpinning CPTSD over the life-span

may help more accurately advance therapies and tailor interventions according to the needs of

older trauma victims.

5
 The present study has two aims. It intends to investigate (1) the association between CTE and

later CPTSD symptoms in non-clinical older individuals exposed to CTE, and (2), in an

exploratory approach, whether this association is mediated by the two social-interpersonal

factors of social acknowledgment and dysfunctional disclosure.

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Methods

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Participants
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Participants in this study were older adults from the Swiss-German part of Switzerland (N = 116,

40.5% women), with an age range of 59-98 years (M = 77.0, SD = 7.1). This non-clinical sample
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was part of a larger project on long-term effects after CTE (N = 141). Inclusion criterion was a

history of ‘Verdingung’ (indentured child labor) and/or foster care during childhood. The
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completion of the Trauma Symptom Inventory (TSI; Briere, 1995) was of central importance to

the current analysis and thus an inclusion criterion. So, 17.7% of the original sample had to be
ed

omitted due to not providing a completed TSI (without declaration of reason).

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‘Verdingung’ was a Swiss phenomenon that lasted until the 1960s, but which occurred in similar

forms throughout Europe. For various reasons, biological parents had to give their children
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(‘Verdingkinder’) away to farmers, where they endured harsh physical labor and were often
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exposed to severe physical and sexual trauma. According to historical research and personal

accounts in the media, these children were often molested, sexually harassed, neglected, ignored,

beaten, treated as of minor value, and more (e.g., Leuenberger & Seglias, 2008).

6
 Previous publications with this dataset showed that CTE influenced self-efficacy,

conscientiousness and self-control (Simmen-Janevska, Horn, Krammer & Maercker, 2014),

cognitive functioning (Burri, Maercker, Krammer, & Simmen-Janevska, 2013), and depression

(Kulman, Maercker, Bachem, Simmen & Burri, 2013). Another earlier analysis demonstrated

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that 26.3% were diagnosed with ‘classic’ PTSD and that 82.8% reached the cut-off for clinically

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relevant CTE (Krammer, Simmen-Janevska & Maercker, 2013). The most frequent type of

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childhood trauma was shown to be emotional neglect. To the disadvantage of women, the extent
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of sexual abuse was shown to be significantly different between genders.

On average, participants reported 10.8 years duration of CTE (range: 1-26 years, SD = 5.2). The
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age of onset, i.e. the commencement of ‘Verdingung’ or foster care, was 5.8 years (range: 0-16

years, SD = 4.4). Participants reported 10.5 years of education on average. Almost 40% were
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married at the time of assessment, 46.6% were living alone, 45.7% with a partner/friend, and

7.8% in a senior residency home. There were significant gender differences concerning marital
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status (more married men, more widowed women) and living situation (more women living
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alone), but none concerning age, years of education, age of onset, and duration of CTE.
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Procedure

The project started in May 2010 and its first assessment wave lasted two years. Participants were
Ac

recruited through advertisements in newspapers, by contacting specific associations, or by

directly addressing former ‘Verdingkinder’ that had publicly talked or written about their past.

Prior to voluntary participation, each participant provided written informed consent following an

oral and written briefing about the study. Data assessment occurred either at the Department of

7
 Psychopathology at the University of Zurich, or at the participant’s home. The study was

conducted in the German speaking part of Switzerland. The questionnaires were administered

once, during a personal meeting that lasted approximately two hours.

Measures

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This study administered standardized questionnaires in the German language.

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Additionally, questions about sociodemographic variables were asked.
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Childhood Trauma Questionnaire (CTQ). Traumatic events during childhood were

measured using the self-report CTQ, which assesses five subscales with 25 items: emotional,
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physical, and sexual abuse, as well as emotional and physical neglect (Bernstein & Fink, 1998).

A score can be built reflecting the general occurrence and frequency of CTE, which was used in
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the current analysis. Within this sample, Cronbach α measured .89 for the score.
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Trauma Stress Inventory (TSI). Long-term effects following trauma can be measured

using the TSI (Briere, 1995). It assesses the spectrum of symptoms attributed to CPTSD (100
pt

items): anxious arousal, depression, anger/irritability, intrusive experiences, defensive avoidance,

dissociation, sexual concerns, dysfunctional sexual behavior, impaired self-reference, and

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tension reduction behavior. The original version of the TSI (English) was translated by the
Ac

authors of this study in a translation-backtranslation process and the translation was approved by

the original author of the TSI. The German version of the TSI previously showed acceptable

validity and reliability, reasonable intercorrelations, and factor analysis confirmed latent

variables of this measure. Cronbach α for the subscales were all above .72 (Krammer et al.,

8
 2013). In this study, subscales were analyzed, as the formation of a score is not intended within

the TSI. These scales were previously described by the original author of the TSI, Briere (1995),

in more detail.

Social Acknowledgment Questionnaire (SAQ). The SAQ is a 16-item self-report

t
ip
questionnaire assessing perceived social acknowledgment as a trauma victim (Maercker &

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Müller, 2004). Participants are asked to score items on a 0-3 Likert scale. Results may be

interpreted according to a general score or according to three subscales: social recognition (e.g.,
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“My friends feel sympathy for what happened to me”), general (e.g., “Most people cannot

understand what I went through”) and family disapproval (e.g., “My family feels uncomfortable
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talking about my experiences”). The present study reports the general average score. In a former

study, Cronbach α = .86 for the general score in a sample of political prisoners, and Cronbach α
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= .79 in a sample of victims of crime. Furthermore, test-retest reliability was good: r tt = .80

(Maercker & Müller, 2004). In the present sample, psychometrics were good (Cronbach α = .73).
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Dysfunctional Disclosure of Trauma Questionnaire (DTQ). The DTQ follows the finding
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that communication about a trauma fosters adjustment (Müller & Maercker, 2006). It consists of
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34 items and includes three scales, namely reluctance to talk (e.g., “I find it difficult to talk to

people about the incident”), urge to talk (e.g., “I feel compelled to talk about my experiences
Ac

again and again”), and emotional reaction during disclosure (e.g., “Describing the event makes

me feel very sad”). Currently, a short-form was applied (12 items), and only the general score

was used. Participants answered on a 6-point Likert scale. In a sample of political prisoners,

DTQ scales showed good internal consistency (α = .82 - .88) and test-retest reliability (r tt = .76 -

9
 .89; Müller & Maercker, 2000). The short-form had previously also demonstrated good

psychometrics (Pielmaier & Maercker, 2011). For the present sample, it achieved good internal

consistency, Cronbach α = .84.

Data Analyses

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First, the association between CTE and CPTSD symptoms was investigated (ten subscales:

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anxious arousal, depression, anger/irritability, intrusive experiences, defensive avoidance,
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dissociation, sexual concerns, dysfunctional sexual behavior, impaired self-reference, tension

reduction behavior) using bivariate correlations. Second, regression analyses were employed to

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test for social-interpersonal factors as potential mediators, each in a simple mediation model

(Hayes, 2009). A mediation is significant when there is a significant correlation between the
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independent variable and the mediator (path a), between the mediator and the dependent variable

(path b), and between the independent and the dependent variable (Baron & Kenny; 1986;
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unmediated: path c; mediated: path c’). Age, gender, and years of education were controlled for.

All analyses were conducted by SPSS 19.0. Figure 1 presents a graphical depiction of the
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mediational model investigated.

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In the case of a missing value, it was substituted by the mean score of the corresponding scale of

this individual. If more than 33% of a scale was missing, then this scale was omitted from
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analysis. However, missing values were rare, since scale completeness was controlled for while

the study was conducted. Those missing values that did occur were mostly comprised of women

not wanting to disclose sexual concerns and dysfunctions.

10
 Results

CTE exposure and later complex PTSD symptoms

As expected, CTE exposure was significantly associated with most of the ten CPTSD symptoms

t
investigated, namely anxious arousal (r = .38; p < .001), depression (r = .27; p = .004),

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anger/irritability (r = .23; p = .013), intrusive experiences (r = .33; p < .001), defensive

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avoidance (r = .34; p < .001), dissociation (r = .30; p = .001), sexual concerns (r = .22; p = .018),
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and impaired self-reference (r = .24; p = .009), but not with dysfunctional sexual behavior or

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tension reduction behavior. The latter two CPTSD subscales were thus omitted from further

mediational testing, described next. an

After Bonferroni correction, the following five significant correlational results remained: anxious
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arousal, depression, intrusive experiences, defensive avoidance, and dissociation.

Anger/irritability, sexual concerns, and impaired self-reference were not significant after
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Bonferroni correction. As the nature of this study was explorative, these subscales were

nevertheless submitted into the following mediation analyses.

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Social-interpersonal factors as mediators of the association between CTE and complex

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PTSD symptoms
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First, correlational analyses were conducted in order to establish significant associations between

the two social-interpersonal factors and CTE, as well as CPTSD symptom clusters, respectively

(see Figure 1). As expected, CTE was significantly correlated with social acknowledgment

(SAQ mean; r = -.30; p = .001; path a 1 ) and dysfunctional disclosure (DTQ mean; r = .25; p <

11
 .008; path a 2 ). Both social-interpersonal factors were significantly correlated with TSI scales,

with the exception of sexual concerns and dysfunctional sexual behavior (paths b 1 and b 2 ,

respectively). As previously mentioned, tension reduction behavior was omitted from further

analyses. Mediation analyses were thus computed for seven TSI scales, namely anxious arousal,

t
depression, anger/irritability, intrusive experiences, defensive avoidance, dissociation, and

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impaired self-reference, with SAQ and DTQ as mediators (see Table 1). Again, as a result of not

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meeting basic requirements for mediational analysis, the three TSI scales dysfunctional sexual
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behavior, tension reduction behavior, and sexual concerns were not analyzed further.

There was evidence for mediation in each mediation model, whereby the critical path c’ turned
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non-significant or the association was reduced following insertion of one of the two mediators,

as depicted in table 1. With reference to social acknowledgment, c’ turned non-significant in the

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case of depression, anger/irritability, and impaired self-reference – analogous results were

obtained for dysfunctional disclosure. For all other mediational models, beta-weights of path c’
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were reduced, as confirmed by Sobel tests.

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Discussion
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The primary objective of this study was to examine the associations between childhood traumatic

events (CTE) and complex PTSD (CPTSD) symptoms in older adults. This was based on the
Ac

assumption that over the lifespan, CTE may initiate and maintain maladaptive paths leading to

negative long-term consequences. To our knowledge, this is the first study investigating CPTSD

symptoms operationalized by means of the Trauma Symptom Inventory (Briere, 1995) in older

adults after CTE.

12
 The results showed that CTE were indeed associated with a series of CPTSD symptoms in later

life. Following correction for multiple testing, correlational analyses remained significant for the

core symptoms of ‘classic’ PTSD (anxious arousal, intrusive experiences, defensive avoidance)

and symptoms strongly related to it depending on its definition (depression and dissociation).

t
This indicates that there are negative long-term consequences for mental health after CTE.

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Generally, results are in line with previous findings on long-term consequences following early

traumatic stress (Kuwert et al., 2007; 2009), and support the potential chronicity of a wide range
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of maladaptive processes. Results from the present study confirm the potential maladaptive

nature of exposure to traumatic events in early life, as consequences seemed to still be present in
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participants more than half a century after trauma exposition.
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There was no evidence for a direct effect of CTE on dysfunctional sexual and tension reduction

behavior. This may be due to a floor effect, as many (mainly female) participants did not want to
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disclose this information.

Effects were stronger for ‘classic’ than for complex PTSD symptoms. There are several possible
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explanations for this. First, it may indeed indicate the presence of specific PTSD phenotypes,
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namely ‘classic’ and complex, in line with two previous studies with adults (Elklit et al., 2014;

Knefel & Lueger-Schuster, 2013), and with the proposal of the ICD-11 working group
Ac

(Maercker et al., 2013). But one of the phenotypes (CPTSD) may not have been present to a full-

blown degree in the sample investigated by this study. Specific symptom clusters characteristic

of ‘classic’ and complex PTSD should be investigated in future studies with larger sample sizes,

in different settings, and for different age groups. Second, methodological artefacts may have

13
 occurred. It may be that the Trauma Symptom Inventory, in its German version, does not

adequately capture the symptom presentations of CPTSD, cultural differences may have played a

role, or this inventory may only be partly appropriate for older adults. Third, our sample may

have been selective. Possibly, trauma victims willing to participate in such a study are not those

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suffering the most from their victimization. In line with trauma theory, those suffering the most,

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and thus showing more complex symptoms in line with CPTSD, may have avoided study

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participation. This would indicate that finding more evidence for ‘classic’ PTSD, as opposed to
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complex PTSD symptoms in this study, may be the result of recruitment strategy and selection

bias. Fourth, CPTSD symptoms may vary over time just like ‘classic’ PTSD symptoms

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(Solomon & Mikulincer, 2006). Such a recurrence and intensification is also acknowledged by

DSM 5 (APA, 2013). It may be that the present sample currently was in a low state of symptom
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manifestation. Fifth, CPTSD symptoms may not (yet) be present due to successful coping

strategies, but trauma may be reactivated after latency and in the process of ageing later on (e.g.,
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Ziegler, 2013). Finally, the current conceptualization of CPTSD may not apply to older adults, as

corresponding symptoms may manifest phenomenologically different. It is important to

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acknowledge that not providing much evidence for the distinction drawn between ‘classic’ and
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complex PTSD does not indicate its non-existence. It rather points to the fact that more research

is needed to clarify the situation for older adults with traumatic events during childhood with
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reference to ‘classic’ PTSD and the conceptual diagnosis of complex PTSD.

Results of this study indicated support for the second and exploratory aim. Several direct effects

were partially mediated by social acknowledgment and dysfunctional disclosure, respectively.

Evidence was found for the CPTSD symptoms anxious arousal, depression, anger/irritability,

14
 intrusive experiences, defensive avoidance, dissociation, and impaired self-reference in older

adults, respectively. This was the first study that introduced social-interpersonal variables

derived from a theoretical model originally developed in the context of ‘classic’ PTSD

(Maercker & Horn, 2012) to CPTSD. The results showed that these social-interpersonal variables

t
are not only relevant for ‘classic’ PTSD, but up to a certain extent also for CPTSD in older age.

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This is in agreement with previous studies pointing to the central role of these two social-

interpersonal factors for posttraumatic adjustment and highlights specific pathways and
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mechanisms in the aftermath of CTE. It is noteworthy that these two factors are not independent

of each other; a cascade appears to be present. Previous studies found that social
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acknowledgment influences dysfunctional disclosure, which in turn influences posttraumatic

symptoms (Müller, Forstmeier, Wagner, & Maercker, 2011). In fact, post hoc analysis in the
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current sample revealed that social acknowledgment and dysfunctional disclosure are

significantly associated with each other (r = -.26, p < .01). The present study sought to
ed

investigate independent effects of these two social-interpersonal factors. However,

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acknowledging the dependency of these two factors, future studies might be interested in

investigating these factors in a more dependent manner with reference to complex PTSD.
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However, it is important to temper interpretations based on the current mediation models.

Ac

Though social-interpersonal factors may indeed play a central role for posttraumatic adjustment

processes (Brewin et al., 2000; Maercker & Horn, 2012), there are possibly many more

mediators intervening between CTE and CPTSD, which were not focused on in the current study

(e.g., biological factors; Miller, Chen & Parker, 2011). Nevertheless, the findings highlight that

15
 among other possible mediators, social-interpersonal factors play an important role. Accordingly,

therapeutic interventions should target such factors in order to alleviate posttraumatic sequelae in

older adults. With reference to psychotherapy, Ziegler (2013; Maercker, 2002) suggests

implementing the same therapies in older traumatized adults as in younger ones. In addition, and

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integrating the present study results, trainings on social competence should be delivered,

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including the training of the ability to talk about past events and to cope with potential negative

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reactions from friends and family. In a more general sense, treatment of older adults should
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always integrate the exploration of CTE, which may lie at the root of their symptoms.

Results must be considered in light of several limitations. First, this study employed a cross-
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sectional design and thus precludes causal explanations. Only a longitudinal design can test for

causality and satisfy additional aspects of meditational testing, such as temporal precedence of
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the mediator. Associated therewith, an important prerequisite for mediational analysis remained

unfulfilled, as temporal ordering of the variables occurred only theoretically. Second, a control
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group is lacking and the sample was relatively homogenous regarding the amount of CTE. Third,
pt

this study disregarded traumatic events or other stressors that may have occurred after childhood.

Such effects may have contributed to the direct and mediational effects reported. Further factors
ce

related to PTSD and CTE (e.g., duration and age of onset of these events, perceived life threat,

coping, self-blame) were not controlled for. Fourth, a previous study showed that the ‘classic’
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PTSD scales of the TSI did not correlate with another measure of ‘classic’ PTSD. However,

there are methodological explanations for this (Krammer et al., 2013). Fifth, retrospective

assessment of potentially traumatic events may be vulnerable to distortion. However, reviews

show that these effects are negligible (Hardt & Rutter, 2004).

16
 In conclusion, and despite the aforementioned limitations, the present study has a number of

important strengths. To the best of knowledge, this is the first study to investigate the association

of CTE and CPTSD in older individuals, adding empirical evidence to the state of art concerning

CPTSD in later life. It is also the first to include social-interpersonal factors as partial mediators

t
of this effect. This study is a first step into an important area of research. Future studies should

ip
investigate causal paths to CPTSD in older adults. Such studies could offer more in-depth

cr
implications with respect to intervention and treatment strategies for older individuals exposed to
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trauma in their early life.

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 Figure 1 Graphic representation of the multiple mediation model, whereby childhood traumatic

events predict seven complex PTSD symptom clusters via two social-interpersonal factors

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Note. This graphic representation includes two separate mediational analyses. Path a1 leads to
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the first proposed mediator social acknowledgment (SAQ). Path a2 leads from the proposed

mediator SAQ to the TSI subscales, which were analysed separately. Path a2 leads to second
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proposed mediator dysfunctional disclosure (DTQ). Path b2 leads from the proposed mediator

DTQ to the TSI subscales, which again were analysed separately.

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 Table 1 Social aknowledgement and dysfunctional disclosure mediate associations between
childhood trauma and complex PTSD symptoms

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Unmediated associations:

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TS Childhood Trauma (CTQ) Social Acknowledgement Dysfunctional disclosure

I (SAQ) (DTQ)
Path c
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Path b 1 Path b 2
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β F R2 β F R2 β F R2
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A .32*** 3.61** .09 -.20* 1.73 .03 .38*** 5.15*** .13

A
pt
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DE .28** 3.04* .07 -.30** 3.54** .08 .54*** 12.47** .29

*
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AI .22* 2.49* .05 -.32*** 4.29** .11 .25** 2.96* .07

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 IE .33*** 3.24* .07 -.24* 1.82 .03 .47*** 7.63*** .19

D .30** 4.35** .11 -.35*** 5.79*** .15 .48*** 10.36** .25

A *

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DI .33*** 3.57** .08 -.31*** 3.36* .08 .40*** 5.87*** .15

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IS .23* 1.87 .03 -.32*** 3.51** .08 .36*** 4.52** .11

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Mediated associations:
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TS SAQ as mediator DTQ as mediator

I
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between CTQ and TSI between CTQ and TSI

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Path c’/b 1 Path c’/b 2 )

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β F R2 β F R2

A .28* / -.12 3.04* .08 .24** / .32*** 5.72*** .17

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 A

DE .19 / -.25* 3.64** .11 .16 / .51*** 10.87*** .31

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AI .17 / -.27** 4.06** .12 .17 / .21* 3.00* .08

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IE .27** / -.16 3.03* .08 .22* / .42*** 7.62*** .23
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D .21* / -.30** 5.76*** .18 .19* / .43*** 9.59*** .28

A
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DI .22* / -.25** 3.81** .11 .24* / .35*** 6.31*** .19
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IS .17 / -.28** 3.40** .10 .15 / .33*** 4.12** .12
ed

R
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Note. TSI = Trauma Symptom Inventory (Complex PTSD descriptors): Anxious arousal (AA),
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depression (DE), anger/irritability (AI), intrusive experiences (IE), defensive avoidance (DA),

dissociation (DI), impaired self-reference (ISR). CTQ = Childhood Trauma Questionnaire (score
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of potentially traumatic events during childhood). SAQ = Social Acknowledgment

Questionnaire. DTQ = Disclosure of Trauma Questionnaire. Age, gender, and years of education

were controlled for in every analysis. * p < .05 ** p < .01 *** p < .001

27