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Journal of Anxiety Disorders 24 (2010) 409415

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

Mindfulness and experiential avoidance as predictors of posttraumatic stress


disorder avoidance symptom severity
Brian L. Thompson , Jennifer Waltz
Department of Psychology, The University of Montana, 32 Campus Dr., Missoula, MT 59812, USA

a r t i c l e i n f o a b s t r a c t

Article history: Mindfulness reects an awareness of present moment experiences through an attitude of acceptance and
Received 23 May 2009 openness (Bishop et al., 2004; Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008). Experiential avoid-
Received in revised form 6 February 2010 ance, by contrast, refers to attempts to change, alter, or avoid private experiences (e.g., thoughts, feelings,
Accepted 15 February 2010
sensations), and it is believed to underlie a number of psychopathologies, including PTSD (Hayes, Wilson,
Gifford, Follette, & Strosahl, 1996). We were interested in the ability of mindfulness to predict the vari-
Keywords:
ance of PTSD avoidance symptom severity above and beyond experiential avoidance. 378 introductory
Trauma
psychology students were administered self-report measures of PTSD, mindfulness, experiential avoid-
Posttraumatic stress
Mindfulness
ance, thought suppression, alexithymia, and avoidant coping. Mindfulness, specically nonjudgment of
Avoidance experiences, accounted for a unique portion of the variance in PTSD avoidance symptoms.
2010 Elsevier Ltd. All rights reserved.

1. Introduction Salters, & Roemer, 2004). Additionally, they may reduce ones
exibility in dealing with situations, negatively impacting quality
Of the three symptom clusters associated with PTSD, research of life (Kashdan, Barrios, Forsyth, & Steger, 2006).
suggests that avoidance symptoms (criterion C) are the most reli- Following exposure to a traumatic event, avoidance behaviors
able indicator that an individual may meet full PTSD criteria (see may initially be focused on activities and stimuli that remind the
Nemeroff et al., 2006), and they appear to be most predictive of individual of, or are connected to the individuals experience of
overall PTSD symptom severity (Boeschen, Koss, Figuerdo, & Coan, the trauma; however, these strategies may gradually generalize
2001; Marshall et al., 2006; Marx & Sloan, 2005). Criterion C symp- to non-trauma related stimuli and contribute to the maintenance
toms include efforts to avoid experiences related to the trauma, of posttraumatic symptoms in the long-term (Polusny & Follette,
difculty recalling the trauma, diminished interest in activity, feel- 1995; Rosenthal, Rasmussen Hall, Palm, Batten, & Follette, 2005;
ings of detachment, restricted affect, and a feeling that ones future Varra & Follette, 2005. Blackledge (2004) offers three reasons for
has been foreshortened (American Psychiatric Association, 2000). why experiential avoidance may maintain PTSD symptoms over
Avoidance strategies are also thought to underlie sev- time: It limits opportunities for positive reinforcement; some types
eral psychopathologies, such as substance abuse and of avoidance behaviors such as substance abuse may increase expo-
obsessivecompulsive disorder, as well as PTSD. These pat- sure to aversive experiences; as no new learning occurs, it may
terns of behaviors have been given the umbrella term experiential maintain verbal rules which continue to limit exposure to real
avoidance within the Acceptance and Commitment Therapy world consequences (e.g., Being in crowds is dangerous). As expe-
(ACT) literature (Hayes, Strosahl, & Wilson, 1999). Experiential riential avoidance is a very broad term, we were interested in
avoidance occurs when an individual engages in strategies to examining specic avoidance strategies that have an established
blunt, alter, or control distressing private experiences, such as research base within the PTSD literature.
thoughts, emotions, and physiological sensations (Hayes et al.,
1996). A reliance on experiential avoidance strategies appears to 1.1. Types of experiential avoidance associated with PTSD
exacerbate or maintain PTSD symptoms over time (Tull, Gratz,
1.1.1. Alexithymia
The term alexithymia was rst introduced by Sifneos (1973) to
describe patients exhibiting psychosomatic symptoms who had
Corresponding author. Present address: Portland Psychotherapy Clinic,
difculty identifying and describing emotions. Recent research
Research, and Training Center, 1830 NE Grand Ave, Portland, OR, 97212, USA.
Tel.: +1 503 281 4852x2; fax: +1 503 281 4852.
suggests that alexithymic individuals have difculty drawing rela-
E-mail addresses: brian.l.thompson@gmail.com (B.L. Thompson), tionships between emotions and physiological sensations (Waller
jennifer.waltz@umontana.edu (J. Waltz). & Scheidt, 2004). Stewart, Zvolensky, and Eifert (2002) suggest that

0887-6185/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.janxdis.2010.02.005
410 B.L. Thompson, J. Waltz / Journal of Anxiety Disorders 24 (2010) 409415

that alexithymia is a form of emotional constriction and subset traced to Kabat-Zinns (1990) Mindfulness-Based Stress Reduc-
of experiential avoidance. tion program. Mindfulness techniques have been incorporated
The relationship between alexithymia and PTSD may be bidi- into several treatments associated with improved outcomes
rectional. On one hand, there is evidence that individuals higher in (e.g., Grossman, Niemann, Schmidt, & Walach, 2004; Melbourne
alexithymia may be more likely to develop PTSD following trauma Academic Mindfulness Interest Group, 2006).
exposure (Kosten, Krystal, Giller, Frank, & Dan, 1992). Higher lev- As mindfulness-based treatments have proliferated, researchers
els of alexithymia may also be a consequence of PTSD symptoms. have attempted to operationally dene mindfulness. Denitions
Sndergaard and Theorell (2004) found that alexithymia increased tend to include an awareness component and attitudinal compo-
following exposure to trauma in a sample of war refugees assessed nent (e.g., Bishop et al., 2004; Kabat-Zinn, 1990). Most recently,
at 3-month intervals. Badura (2003) suggests that alexithymia Cardaciotto et al. (2008) have conceptualized mindfulness as a
in individuals with PTSD may be better understood as represen- general tendency towards greater awareness of ones experiences,
tative of the emotional numbing component of PTSD than as a private and public, and bringing an attitude of acceptance and non-
distinct construct, that individuals with PTSD begin to employ judgment to these experiences. They suggest that awareness of
an avoidance-based coping style to deal with reexperiencing and experience and the attitude of acceptance with which one engages
hyperarousal symptoms. Other researchers have found a strong ones experience are orthogonal constructs. This makes the attitu-
relationship between alexithymia and emotional numbing in indi- dinal component important in dening mindfulness, as awareness
viduals with PTSD (Frewen, Evans, Maraj, Dozois, & Partridge, alone may be insufcient. Baer, Smith, and Allen (2004) found
2008a; Frewen et al., 2008b; Fukunishi, Sasaki, Chishima, Anze, & that in samples largely nave to formal meditation practice, the
Saijo, 1996). Frewen et al. suggest that trauma disrupts an individ- tendency to be aware of ones experience was associated with
uals ability to interpret the relationship between mind and body greater judgment of that experience. Therefore, an attitude of open-
experiences. ness and nonjudgment towards ones experiences may be a crucial
mechanism of change in promoting the positive benets associ-
1.1.2. Thought suppression ated with mindfulness (Shapiro, Carlson, Astin, & Freedman, 2006).
Thought suppression is one of the most widely studied forms of This is consistent with an ACT denition of mindfulness, which
experiential avoidance. There are three consequences associated includes contact with the present moment, acceptance of private
with thought suppression: (1) an increased likelihood of target experiences and willingness to remain in contact with them, and
thoughts following suppression; (2) a sudden increase in target awareness of private experiences as content that are separate from
thoughts following suppression; (3) an increase in intrusive tar- the experience of ones self (Fletcher & Hayes, 2005). Within the
get thoughts during suppression when cognitive demands begin to ACT literature, acceptance of and willingness to embrace ones expe-
interfere with attempts at suppression (Wenzlaff & Wegner, 2000). rience is reective of a core ACT process that is considered the
The use of thought suppression appears to predict PTSD symptom alternative to experiential avoidance (Hayes et al., 1999). Conse-
severity (Mayou, Ehlers, & Bryant, 2002; Steil & Ehlers, 2000). In quently, awareness of experience without acceptance may not rule
what they call the theory of ironic processes, Wenzlaff and Wegner out experiential avoidance.
(2000) argue that the continued monitoring for unwanted thoughts Although individuals higher in mindfulness may experience
interferes with the overarching goal of thought suppression, mak- negative thoughts, they appear to exhibit a greater ability to let
ing unwanted thoughts more salient and thus priming a rebound go of negative thoughts and focus their attention on health-
effect. Shipherd and Beck (1999, 2005) have found that individuals ier ways of relating to their experiences (Frewen et al., 2008a).
with PTSD exhibited a rebound effect in trauma-related thoughts Greater mindfulness may enhance the ability of individuals to label
following a deliberate suppression, but trauma survivors without negative affective stimuli, which may, in turn, allow them some
PTSD did not exhibit a rebound effect, suggesting that the rebound degree of distance or detachment from these experiences (Creswell,
effect may play a role in the maintenance of PTSD symptoms. Way, Eisenberger, & Lieberman, 2007). Consequently, cultivation
of mindfulness can create a sea change in the way one approaches
1.1.3. Avoidant coping ones experience, allowing one to develop greater stability, mean-
Avoidant coping refers to the tendency to respond to distressing ing, exibility, and less reactivity (Shapiro et al., 2006).
stimuli through distraction, such as through socializing or watching The last ten years has seen an increase in the use of mindfulness-
television (Endler & Parker, 1990, 1994). Following trauma, individ- based treatments and techniques, in part to counter avoidance and
uals may engage in strategies to avoid stimuli that remind them of help people engage their experiences more mindfully (see Baer,
the traumatic event (Steil & Ehlers, 2000). Although avoidant cop- 2003). Although researchers have begun to explore the use of mind-
ing may be adaptive in the short term in some situations (Chafn, fulness in the treatment of trauma survivors (Batten, Orsillo, &
Wherry, & Dykman, 1997), studies have found that an avoidant Walser, 2006; Follette, Palm, & Rasmussen Hall, 2004), there has
coping style is predictive of PTSD symptomatology (e.g., Gil, 2005; been little research exploring the relationship between mindful-
Scarpa, Haden, & Hurley, 2006). In the Gil study, the researcher had ness and PTSD; thus, the relationship between mindfulness and
collected his sample of coping styles for another study 2 weeks prior PTSD symptoms remains unclear.
to a terrorist attack and was able to collect a posttrauma measure
of coping 1 month after the attack. PTSD was assessed 5 months
later. Similar to alexithymia, the results of this research suggest 1.3. Mindfulness as a predictor of avoidance symptoms
a bidirectional relationship between avoidant coping and PTSD:
Avoidant coping may create a vulnerability to developing PTSD fol- The main purpose of this study was to incorporate mindfulness
lowing trauma exposure, and trauma survivors may begin applying into an experiential avoidance understanding of PTSD. Relation-
avoidant coping strategies following trauma. ships between measures of mindfulness and experiential avoidance
have been explored in previous research (Baer et al., 2004; Baer,
1.2. Mindfulness Smith, Hopkins, Krietemeyer, & Toney, 2006; Hayes et al., 2004),
but not within a trauma population. Understanding the relation-
The concept of mindfulness was originally inspired by 2500 ship between mindfulness and PTSD could help researchers to tailor
year-old Buddhist meditation practices. Much of the recent inter- mindfulness and acceptance-based treatments for the treatment of
est in mindfulness and mindfulness-based treatments can be trauma survivors. We were interested in exploring the relationship
B.L. Thompson, J. Waltz / Journal of Anxiety Disorders 24 (2010) 409415 411

between experiential avoidance and PTSD avoidance symptoms, ate convergent and discriminant validity with other measures of
and whether mindfulness adds any additional predictive power. coping styles (Endler & Parker, 1994).
It was hypothesized that greater experiential avoidance would Toronto Alexithymia Scale-20 (TAS-20; Bagby, Parker, & Taylor,
be predictive of greater PTSD avoidance symptoms severity, and 1994a, 1994b). The TAS-20 is a 20-item self-report measure of alex-
that greater mindfulness would be predictive of lower PTSD avoid- ithymia. Each item is rated on a 5-point Likert scale ranging from
ance symptom severity above and beyond measures of experiential 1(strongly disagree) to 5 (strongly agree). Factor 1 (identify feelings)
avoidance. assesses the ability to identify feelings and distinguish them from
physical sensations that accompany emotional arousal. Factor 2
(describe feelings) assesses the ability to describe feelings to others.
2. Method
Factor 3 (externally oriented) assesses externally oriented think-
ing, a tendency towards concrete thinking, often to the exclusion
2.1. Participants
of emotional responses to stimuli. A recent re-assessment of the
psychometric properties of the TAS-20 found internal consistency
Participants consisted of Introductory Psychology students
alphas above .70 for each factor in a community sample (Parker,
(N = 378; 267 females), 18 years or older. (One demographics
Taylor, & Bagby, 2003).
form was left incomplete.) Ages ranged from 18 to 51 (M = 19.56,
Posttraumatic Stress Diagnostic Scale (PDS; Foa, Cashman, Jaycox,
SD = 3.44), with 18 being the modal age (45.2%) and 19 being the
& Perry, 1997). The PDS is a self-report measure of PTSD symp-
median age.
toms that corresponds to DSM-IV criteria. Participants are offered a
checklist of 12 traumatic events (including other) that they may
2.2. Measures have experienced and are then asked which disturbed them the
most in the past month. They then rate 17 items corresponding to
Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006). each of the DSM-IV PTSD criteria: Reexperiencing (5), avoidance
The FFMQ is a 39-item self-report measure of ve facets of mind- (7), and hyperarousal (5). Summing the 17 symptom items pro-
fulness derived from a factor analysis of ve existing mindfulness vides a symptom severity score. Coefcient alphas were .92 for total
measures. Items are rated on a Likert scale from 1 (never or very symptom severity, .78 for reexperiencing, .84 for avoidance, and .84
rarely true) to 5 (very often or always true). The ve subscales for arousal. It exhibited strong convergent validity with structured
reect tendencies towards: Observing ones experience (observe); clinical interviews for PTSD.
describing or putting words to ones experience (describe); acting
with awareness in everyday life (act with awareness); nonjudging
2.3. Procedure
of experience (nonjudgment); and nonreactivity towards inter-
nal stimuli (nonreactivity). The observe subscale does not appear
Participants signed up for the study in order to receive exper-
to load signicantly on an overall mindfulness factor, and it has
imental class credit. They completed questionnaire packets in
been found to correlate to maladaptive constructs in nonmed-
private, individual rooms. Four participants were eliminated due
itating samples but not in samples with meditation experience
to incomplete data.
(Baer et al., 2006, 2008). Internal consistency was acceptable
Forty-four participants (11.6%; 33 females) of the total sample
(alphas were .75 and above), and the FFMQ has also exhibited
(N = 378) met PDS criteria for PTSD, and 39.3% reported a criterion
acceptable convergent and discriminatory validity with measures
A qualifying trauma but did not meet PDS PTSD criteria (n = 147).
of thought suppression and experiential avoidance (Baer et al.,
Of those who met PDS PTSD criteria, 9 (20.5%) endorsed sex-
2006).
ual assault and 8 endorsed life-threatening illness (18.2%). In
Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004).
addition, 10 (43.2%) wrote in a trauma type: These included child
The AAQ is 9-item self-report measure of psychological exibil-
abuse (n = 2), witnessing a partners suicide or attempted suicide
ity and experiential avoidance rated on 7-point Likert scale from 1
(n = 3), and death in the family (n = 2). Because our sample of par-
(never true) to 7 (always true). Higher scores are related to greater
ticipants who met PDS PTSD criteria was too small to analyze, and
experiential avoidance. Test-retest reliability was .64 over a 4-
to capture greater variance across posttraumatic stress symptoms,
month period. Internal consistency was acceptable ( = .70). The
the PDS PTSD (n = 44) sample was combined with the sample of
AAQ has been found to have good convergent and discriminatory
individuals who reported a Criterion A trauma but who did not
validity with measures of thought suppression, coping, and PTSD.
meet PDS PTSD criteria (n = 147). We labeled this sample Posttrau-
White Bear Suppression Inventory (WBSI; Wegner & Zanakos,
matic Stress Symptoms (PSS; n = 191). Subsequent analyses were
1994). The WBSI is a 15-item self-report measure of thought
computed with this sample. Means and Standard Deviations are
suppression. Items are rated on a 5-point scale from 1 (strongly dis-
reported in Table 1.
agree) to 5 (strongly agree). Items are totaled for a unidimensional
score. WBSI is a widely used measure of thought suppression and
has exhibited good internal consistency (above .70) and appropri- 3. Results
ate convergent and discriminant validity.
Coping in Stressful Situations (CISS; Endler & Parker, 1994). The 3.1. Internal consistency
CISS is a 48-item self-report measure of coping that categorizes
coping strategies according to one of three styles: Task oriented, The following Cronbachs coefcient alphas were computed for
emotion oriented, and avoidance oriented. Items are rated on a 5- the entire sample. FFMQ subscales were: Observe ( = .77); describe
point Likert scale from 1 (not at all) to 5 (very much). It was based ( = .90); act with awareness ( = .88); nonjudgment ( = .89); and
on the 70-item Multidimensional Coping Inventory (MCI; Endler nonreactivity ( = 75). Measures of experiential avoidance were:
& Parker, 1990) and has been used with college, adult, and ado- AAQ ( = .67); WBSI ( = .87); CISS emotion oriented coping ( = .88)
lescent samples. Both emotional oriented and avoidance oriented and avoidance oriented coping ( = .80); TAS-20 subscales Factor
coping styles appear to be related to the construct of experiential 1 (identify feelings; = .82), Factor 2 (describe feelings; = .79),
avoidance (Walser & Hayes, 1998); consequently, both were exam- and Factor 3 (externally oriented thinking; = .63). The AAQ, WBSI,
ined in this study. The CISS appears to have excellent psychometric CISS, and TAS-20 are referred to as our measures of experiential
properties. Alphas were all above .75, and it exhibited appropri- avoidance throughout the text.
412 B.L. Thompson, J. Waltz / Journal of Anxiety Disorders 24 (2010) 409415

Table 1 avoidance in the PSS sample. For each analysis, one experien-
Means and standard deviations for PSS sample (N = 191).
tial avoidance measure was entered into Block 1, and the four
M SD FFMQ subscales (i.e., describe, act with awareness, nonjudgment,
FFMQ observe 27.11 5.02 and nonreactivity subscales) that correlated signicantly with PDS
FFMQ describe 27.57 5.88 PTSD avoidance symptom severity were entered into Block 2. PDS
FFMQ act 26.01 5.77 PTSD avoidance symptom severity was the dependent variable.
FFMQ nonjudge 27.37 6.41 All measures of experiential avoidance individually accounted
FFMQ nonreact 21.13 3.78
for a signicant portion of the variance in PDS PTSD avoidance
AAQ 33.96 6.85
WBSI 50.41 9.96 symptom severity in the rst step: AAQ [F(1, 88) = 25.24, p < .01];
TAS-20 F1 15.27 5.69 WBSI [F(1, 185) = 40.45, p < .01]; TAS-20 Factor 1 (identify feelings)
TAS-20 F2 12.79 4.58 [F(1, 188) = 56.58, p < .01]; and CISS emotion oriented coping sub-
TAS-20 F3 19.39 4.87
scale [F(1, 175) = 31.81, p < .01]. When adding four of the ve FFMQ
CISS emotion 4.88 2.92
CISS avoidance 4.88 3.29 subscales (i.e., describe, act, nonjudge, nonreact) in the second
step, mindfulness specically, the facet nonjudgment accounted
Note: M = mean; SD = standard deviation; FFMQ = Five Facet Mindfulness Question-
naire; AAQ = Acceptance and Action Questionnaire; WBSI = White Bear Suppression
for a signicant portion of the variance of PTSD avoidance symp-
Inventory; TAS-20 = Toronto Alexithymia Scale-20; CISS = Coping in Stressful Situa- tom severity beyond the contribution of experiential avoidance:
tions. AAQ [F Change(4, 184) = 4.26, p < .01]; WBSI [F Change(4, 181) = 3.16,
p = .02]; TAS-20 Factor 1 (identify feelings) [F Change(2, 184) = 2.50,
p = .04]; and CISS emotion oriented coping [F Change(4, 171) = 2.93,
3.2. Avoidance symptom severity, mindfulness, and experiential p = .02]. See Table 3 for regression analyses with adjusted R2 and
avoidance in a sample with posttraumatic stress symptoms semipartial R2 .
In summary, mindfulness and experiential avoidance together
We were looking at the relationship between mindfulness and signicantly contributed to predicting the variance in PTSD symp-
experiential avoidance with PTSD avoidance symptom severity in tom severity above and beyond experiential avoidance alone. Of the
a sample of people who had experienced a traumatic event, the four mindfulness subscales entered in each model, the FFMQ non-
PSS sample. Normality, linearity, and the presence of outliers were judgment subscale was signicant across all separate regression
assessed through normal probability plots and scatterplots of the models.
standardized residuals. None of these assumptions appear to have
been violated. Standardized residuals were less than 3.3 and greater 4. Discussion
than 3.3, per Tabachnick and Fidells (1996) recommendations.
Multicollinearity was examined among the measures of experi- This study sought to investigate the degree to which measures
ential avoidance and mindfulness prior to running the regression of experiential avoidance predicted PTSD avoidance symptoms
analyses, and Pearson product-moment correlation coefcients severity, and whether mindfulness adds to the prediction of PTSD
were calculated. We used Tabachnick and Fidells (1996) rec- avoidance symptoms, above and beyond the predictive ability of
ommendation that variables with a bivariate correlation of .7 measures of experiential avoidance. This question was explored
or higher not be included in the regressions. The relationship in a nonclinical sample of individuals who reported a Criterion
between the TAS-20 Factor 2 subscale and the FFMQ describe sub- A trauma on a self-report PTSD measure, but who did not meet
scale was the only bivariate correlation to violate this assumption full PTSD criteria according to the measure. We labeled this our
(r = .73, p < .01); consequently, the TAS-20 Factor 2 subscale was posttraumatic stress symptoms (PSS) sample. Overall, mindful-
not included in the regression analyses. Only independent variables ness, particularly the facet nonjudgment or acceptance of everyday
(i.e., experiential avoidance and mindfulness) that exhibited sig- experiences, predicted additional variance in avoidance symptom
nicant correlations with the dependent variable (PTSD avoidance severity. As one reviewer suggested, because self-report measures
symptoms severity) were included in the regression analyses. These of experiential avoidance require an awareness that one is avoid-
values are displayed in Table 2. ing, the inclusion of experiential avoidance measures may have
Hierarchical multiple regression analyses were conducted to served as a control variable for our measure of trauma-related
examine the extent to which mindfulness measures predicted avoidance. Consequently, controlling for what may be viewed as
PTSD avoidance symptom severity beyond measures of experiential a more pathological form of awareness (i.e., being aware of dis-

Table 2
Pearson product-moment correlation coefcients for PSS sample (N = 191).

Measures 1 2 3 4 5 6 7 8 9 10 11 12

1. PDS avoidance
2. FFMQ observe .05
3. FFMQ describe .18* .21**
4. FFMQ act .32** .01 .36**
4. FFMQ nonjudge .37** .11 .13 .33**
6. FFMQ nonreact .20** .26** .20** .28** .19**
7. AAQ .34** .06 .37** .48** .57** .40**
8. WBSI .42** .18* .17* .44** .52** .24** .49**
9. CISS emotion .39** .05 .18* .47** .58** .44** .66** .62**
10. CISS avoidance .03 .07 .016* .12 .03 .08 .08 .07 .17*
11. TAS factor 1 .48** .11 .36** .48** .44** .24** .45** .50** .54** .03
12. TAS factor 2 .32** .07 .73** .40** .30** .08 .40** .33** .29** .16* .45**
13. TAS factor 3 .05 .21** .40** .28** .04 .18* .26** .06 .16* .05 .22** .36**

Note: FFMQ = Five Facet Mindfulness Questionnaire; AAQ = Acceptance and Action Questionnaire; WBSI = White Bear Suppression Inventory; CISS = Coping in Stressful
Situations; TAS-20 = Toronto Alexithymia Scale; PDS = Posttraumatic Stress Diagnostic Scale.
*
p < .05.
**
p < .01.
B.L. Thompson, J. Waltz / Journal of Anxiety Disorders 24 (2010) 409415 413

Table 3
Hierarchical regression analyses for PTSD avoidance symptoms for the PSS sample (N = 191).

adj R2 B SE B p Semipart R2

Step 1: Experiential avoidance .11


1. AAQ .23 .05 .34 <.01* .12

Step 2: Mindfulness .17


1. AAQ .05 .06 .08 .41 <.01
2. FFMQ describe .03 .06 .04 .57 <.01
3. FFMQ act .13 .06 .17 .04* .02
4. FFMQ nonjudge .18 .06 .25 <.01* .04
5. FFMQ nonreact .08 .09 .06 .39 <.01

Step 1: Experiential avoidance .18


1. WBSI .20 .03 .42 <.01* .18

Step 2: Mindfulness .21


1. WBSI .12 .04 .26 <.01* .04
2. FFMQ describe .05 .06 .06 .40 <.01
3. FFMQ act .08 .06 .11 .18 <.01
4. FFMQ nonjudge .13 .06 .18 .02* .02
5. FFMQ nonreact .07 .08 .06 .39 <.01

Step 1: Experiential avoidance .23


1. TAS-20 F1 (identify) .39 .05 .48 <.01* .23

Step 2: Mindfulness .25


1. TAS-20 F1 (identify) .29 .06 .36 <.01* .08
2. FFMQ describe .11 .05 .01 .85 <.01
3. FFMQ act .06 .06 .08 .30 <.01
4. FFMQ nonjudge .13 .05 .18 .01* .02
5. FFMQ nonreact .07 .08 .06 .39 <.01

Step 1: Experiential avoidance .15


CISS emotion oriented 2.76 .49 .39 <.01* .15

Step 2: Mindfulness .19


1. CISS emotion 1.34 .68 .19 .05* .02
2. FFMQ describe .05 .06 .06 .39 <.01
3. FFMQ act .11 .07 .13 .11 .01
4. FFMQ nonjudge .15 .06 .20 .02* .03
5. FFMQ nonreact .03 .09 .02 .75 <.01

Note: WBSI = White Bear Suppression Inventory; TAS-20 = Toronto Alexithymia Scale-20; AAQ = Acceptance and Action Questionnaire; CISS = Coping in Stressful Situations;
FFMQ = Five Facet Mindfulness Questionnaire.
*
p < .05.

tressing experiences in order to attempt to control them) may have Among the specic types of experiential avoidance, alexithymia
allowed a clearer view of the predictive power of specic mind- particularly difculty identifying feelings and thought suppres-
fulness facets, particularly nonjudgment. Nonjudgment may have sion were the most robust predictors of PTSD avoidance symptom
been the strongest predictor because it is especially contrary to severity. Because of the cross-sectional nature of this study, we
experiential avoidance, more so than other aspects of mindful- cannot determine a relationship between experiential avoidance
ness that reect basic awareness only (i.e., the capacity to observe, and PTSD avoidance symptoms. There is some evidence that alex-
describe, or mindfully engage ones experience). Cardaciotto et ithymic individuals may be more likely than non-alexithymic
al. (2008) recently developed a mindfulness measure consisting individuals to develop PTSD after a trauma exposure (Kosten et al.,
of two orthogonal constructs: Awareness and acceptance. Mind- 1992); other evidence suggests that higher levels of alexithymia
ful acceptance was negatively correlated to forms of experiential in PTSD samples are associated with the emotional numbing ele-
avoidance such as rumination and thought suppression whereas ment of PTSD (Frewen et al., 2008b; Fukunishi et al., 1996). Trauma
mindful awareness was not (Cardaciotto et al., 2008). The predic- may disrupt an individuals ability to interpret bodily sensations
tive power of nonjudgment in this study, above and beyond other (Frewen et al., 2008b), and trauma survivors may rely on avoidance-
facets of mindfulness, supports the importance of an acceptance based coping strategies that engender emotional numbing (Badura,
component in conceptualizations of mindfulness (e.g., Bishop et 2003). The use of thought suppression to manage distressing post-
al., 2004; Cardaciotto et al., 2008; Fletcher & Hayes, 2005). traumatic symptoms may serve to make these thoughts more
Given that a tendency towards self-criticism or negative salient, creating a rebound effect and maintaining PTSD symptom
self-appraisal is predictive of developing PTSD following a trau- severity (e.g., Shipherd & Beck, 2005; Tull et al., 2004). Additionally,
matic event (Bryant & Guthrie, 2007; Cox, MacPherson, Enns, & studies have found that thought suppression explained a signicant
McWilliams, 2004), and that trauma symptom severity has been portion of the variance of total PTSD symptom severity and medi-
positively associated with lower acceptance of emotional expe- ated the relationship between PTSD and negative mood, even when
riences (Tull, Barrett, McMillan, & Roemer, 2007), the predictive general psychiatric symptom distress was accounted for (Rosenthal
power of nonjudgment in the PSS sample is not surprising. Cultivat- et al., 2005; Tull et al., 2004).
ing an open and nonjudgmental attitude towards ones experience The AAQ, our general measure of experiential avoidance, was a
may be important in the treatment of trauma and PTSD, and/or it weaker predictor of PTSD avoidance symptom severity than alex-
may have a prophylactic effect in protecting against the develop- ithymia and thought suppression. Other researchers have found
ment of PTSD in traumatized individuals. that the relationship between the AAQ and PTSD symptom sever-
414 B.L. Thompson, J. Waltz / Journal of Anxiety Disorders 24 (2010) 409415

ity disappears when general psychiatric distress is accounted for in 4.2. Limitations
the model and suggest that the AAQ may be too broad a measure to
uniquely account for posttraumatic symptoms, or it may mediate There are several limitations of this study. Perhaps the largest
PTSD (Morina, 2007; Tull et al., 2004). is that, as with any convenience sample of college students, the
Interestingly, although emotion oriented coping was related majority of whom are between 18 and 19 years of age, the results
to PTSD avoidance symptom severity, avoidant coping was not. may not be a truly representative sample. This sample may be
One would expect that avoidant coping would be associated with higher functioning than a clinical sample; consequently, they
PTSD avoidance symptoms, as avoidant coping has been associated may possess more adaptive coping skills than a clinical sample
with general PTSD symptom severity (e.g., Gil, 2005; Scarpa et al., seeking treatment. Future research may explore the relationship
2006). None of these studies used the Coping in Stressful Situations between mindfulness and experiential avoidance with PTSD avoid-
(CISS) scale, however. The items of the avoidant coping subscale ance symptoms in a clinical sample.
of the CISS reect more externally oriented and concrete actions Also, because of the cross-sectional design of the study, it
(e.g., Window shop or Phone a friend), whereas the emotional is impossible to discern if the development of PTSD symptoms
coping subscale reects more internal experiences (e.g., Become leads to lower mindfulness and greater experiential avoidance,
very tense or Get angry). For individuals experiencing posttrau- or if pre-existing factors dispose traumatized individuals towards
matic stress symptoms, distress-related avoidance strategies may developing PTSD. As the sample included both individuals who met
be more pervasively applied to private than public experiences. and who did not meet PTSD criteria according to the PDS, there may
This makes intuitive sense, as it is easier to avoid physical trauma- be differences between these two samples. In addition, although
related triggers than to avoid ones own thoughts, emotions, and the PDS has exhibited excellent psychometrics and appears to map
bodily sensations. onto DSM PTSD criteria very clearly, a self-report measure of PTSD
is not a substitute for a clinical interview. Research with PTSD clin-
ical samples is needed to test more complicated models of the role
4.1. Treatment implications of mindfulness in predicting PTSD avoidance symptom severity.

Empirical research supporting the use of mindfulness and


Acknowledgments
acceptance-based interventions in treating PTSD is a scant but
promising literature. Recent case studies support the use of ACT in
This study was adapted from the rst authors dissertation.
treating PTSD (Batten & Hayes, 2005; Twohig, 2009). Additionally,
He would like to thank David, Schuldberg, Gyda Swaney, Bryan
an 8-week Mindfulness-Based Stress Reduction (MBSR; Kabat-
Cochran, and Rita Sommers-Flanagan for their input.
Zinn, 1990) adapted for child sexual abuse survivors was associated
with reductions in PTSD symptoms, particularly avoidance symp-
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