APPLIED COGNITIVE PSYCHOLOGY

Appl. Cognit. Psychol. 15: S159±S170 (2001)

DOI: 10.1002/acp.839

Linguistic Predictors of Trauma Pathology

and Physical Health

JENNIFER ALVAREZ-CONRAD, LORI A. ZOELLNER*

and EDNA B. FOA
University of Pennsylvania School of Medicine, USA

SUMMARY
The present study examined how speci®c linguistic elements in trauma narratives were associated
with post-treatment psychopathology and physical symptoms. We analysed the narratives of 28
female assault victims being treated for chronic PTSD. During exposure therapy, participants were
asked to recount their assault `as if it was happening now'. These trauma narratives were videotaped,
transcribed, and analysed using a linguistic coding program. In particular, narratives containing
words about death and dying were associated with worse post-treatment functioning. This
relationship could not be accounted for by assault-related characteristics. The focus on death and
dying in the trauma narrative may re¯ect the concept of mental defeat, suggesting a possible target
for intervention in cognitive-behavioural treatment of PTSD. Copyright # 2001 John Wiley & Sons,
Ltd.

Immediately after an assault, almost all rape victims and approximately 70% of non-
sexual assault victims report symptoms severe enough to meet symptom criteria for post-
traumatic stress disorder (PTSD). With the passage of time, processes leading to recovery
occur in many victims, but some continue to have signi®cant disturbances. Indeed, by
three months after the assault, approximately half of the rape victims and 20% of non-
sexual assault victims meet diagnostic criteria for chronic PTSD (Rothbaum et al., 1992;
Riggs et al., 1995). The estimated lifetime prevalence of PTSD after sexual assault varies
from 30% to 65% and current PTSD, from 12% to 16% (Resnick et al., 1993; Kilpatrick
et al., 1987). Traumatic experiences not only cause mental health dif®culties such as
PTSD, but they also affect the victim's physical health as re¯ected in an increase in health
complaints and utilization of the health services (e.g. Beckham et al., 1997; Davidson
et al., 1991; Friedman and Schnurr, 1995; Golding et al., 1988; Kimerling and Calhoun,
1994; Koss et al., 1990). Besides physical symptoms, rates of chronic diseases such as
diabetes, arthritis, and physical disabilities are higher in assault victims than non-victims
(Golding, 1994).

 Correspondence to: Lori Zoellner, Department of Psychology, Box 351525, University of Washington, Seattle,
WA 98195. E-mail: zoellner@u.washington.edu

Contract grant sponsor: National Institute of Mental Health.

Contract grant number: MH42173.

Copyright # 2001 John Wiley & Sons, Ltd.

S160 J. Alvarez-Conrad et al.

In summary, there is ample of evidence that traumatic experiences produce chronic

psychological and physical disturbances in a substantial minority of trauma survivors,
although the exact relationship between the two types of disturbances is still unclear. Many
researchers have examined factors associated with either natural recovery or improvement
following treatment for PTSD in order to further understand mechanisms underlying
posttrauma disturbances. One factor that is thought to be necessary for recovery is the
organization of traumatic memories. Trauma experts suggest that traumatic memories
require special processing efforts (e.g. Foa and Riggs, 1993; Horowitz, 1997). Foa and
Riggs (1993) hypothesized that the recovery process involves organizing and streamlining
the traumatic memory and that individuals with disorganized memories would exhibit
psychopathology. One way to study memory organization is through the analysis of
trauma narratives, i.e. verbal accounts of the traumatic event by the victim. Using this
method of inference, clinical observations suggest that, accounts of trauma during the
initial stage of treatment for chronic PTSD are characterized by an abundance of speech
®llers, repetitions, incomplete sentences, disorientation of time and space, and general
confusion (Foa, 1997).
Using narrative analysis, two studies have found support for a relationship between
organization and articulation of the trauma memory and post-trauma disturbances. In a
study of recent rape victims, Amir et al. (1998) assessed level of articulation by calculating
the reading level of victims' descriptions of their trauma. They found that shortly after the
trauma anxiety, but not PTSD, symptoms, were inversely correlated with degree of
articulation in the trauma narratives; twelve weeks later, articulation and PTSD were
inversely correlated. These results suggest that the processes of organizing and articulating
the traumatic memories are involved in post-trauma recovery. The hypothesis that
narrative organization is related to recovery was also supported in a treatment study
conducted by Foa et al. (1995). In this study the content of the initial and last narrative
recounted by sexual and non-sexual assault victims during exposure therapy was analysed
using a coding system developed speci®cally for the study. Compared to the ®rst narratives
the last narratives were longer, contained a higher percentage of thoughts and feelings, and
were more organized. An increase in organized thoughts was related to a reduction in
depression, while a decrease in fragmentation was related to a reduction in trauma-related
symptoms. Thus, Foa and her colleagues suggested that the organization of traumatic
memories is implicated in both natural recovery and recovery following treatment for
PTSD. As trauma memories become more organized and less fragmented, PTSD and other
psychopathological symptoms decrease.
The importance of processing narratives of stressful experiences for the well-being of
the individual has emerged from a series of studies by Pennebaker and his colleagues.
With non-clinical samples, disclosure of traumatic or stressful memories enhanced
physical health and immune function (Pennebaker and Beall, 1986; Pennebaker et al.,
1987, 1988). More recently, Pennebaker and Francis (1999) developed a computer-based
program that performs content analyses on written transcripts. This program analyses
certain linguistic aspects of a narrative such as the percentage of words in particular
categories (i.e. emotion words, words about cognitive processes), the number of unique
words (ratio of actual number of different words to total number of words), and the total
number of words. Emotional expression (i.e. both negative and positive words such as
happy and good or hate and sad) and cognitive processing (i.e. words such as realize,
understand, think, know) during writing about the stressful event as well as a decrease in
unique words predicted improved physical health (Pennebaker, 1993; Pennebaker and

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
 Linguistics, PTSD and health S161

Francis, 1996) and grade point average (Pennebaker and Francis, 1996). Furthermore,
emotional expression during disclosure was associated with changes in skin conductance
levels (Pennebaker, 1993). Pennebaker and his colleges suggested that emotional expres-
sion and cognitive reappraisal of a stressful event, as evidenced by the use of certain
phrases, mediate autonomic processes that foster improved physical health.
Overall, both psychological and physical factors may be related to the structure of the
trauma narrative. In the present study, we examined linguistic elements in the trauma
narratives of female sexual and non-sexual assault survivors and how these elements
related to post-treatment PTSD severity and reported physical complaints. We hypothe-
sized that presence of emotional and cognitive processing elements in the trauma
narratives (i.e. more frequent cognitive word use, more references to positive and negative
affect, fewer unique words, and fewer references to death and dying) will predict
decreased post-treatment PTSD symptoms, improved physical health perceptions, and
better functioning.

METHOD

Participants
Participants were 28 female victims of sexual (82%) or non-sexual assault (18%), met
criteria for PTSD according to the DSM-IV (APA, 1994), and sought treatment for their
symptoms. Exclusion criteria were: being in an ongoing relationship with the assailant,
organic mental disorder, current schizophrenia, bipolar disorder, and alcohol or substance
abuse or dependence. The mean age of the sample was 31 years (M ˆ 31.11, SD ˆ 9.86),
and the mean number of years since the assault was seven years (M ˆ 6.78, SD ˆ 8.34).
Seventy-®ve percent of the women completed some college, 25% completed some or
graduated from high school.

Interview measures
Structural Clinical Interview for DSM-IV Disorders (SCID-I/P; First et al., 1995)
The SCID is a semi-structured interview designed to assess major Axis I disorders
according to the DSM-IV (APA, 1994).

PTSD Symptom Scale (PSS-I; Foa et al., 1993)

The PSS-I is a 17-item interview assessing the severity of each of the DSM-III-R PTSD
symptoms during the past two weeks. Each symptom is rated on a 4-point scale from 0 (not
at all) to 3 (very much). Subscale scores are calculated by summing items in each of the
PTSD symptom clusters: re-experiencing, avoidance, and arousal. The scale has high
internal consistency (alpha ˆ 0.85) and moderate to high correlations with other measures
of psychopathology. The PSS-I has high test-retest reliability (r ˆ 0.80) and interrater
reliability (k ˆ 0.91).

Standardized Assault Interview (SAI; Rothbaum et al., 1992)

The SAI is a 136-item semi-structured interview, which gathers information regarding
demographic variables, previous victimization history, assault characteristics such as
injury and life threat, and interactions with the legal system. An earlier version of this
interview measure reported an interrater reliability of 0.90.

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
S162 J. Alvarez-Conrad et al.

Social Adjustment Scale (SAS; Weissman and Paykel, 1974)

The SAS is a semi-structured interview used to assess an individual's functioning across
eight speci®c areas: work, social and leisure, extended family, marital, sexual activity,
parental, family unit, and economic. A global adjustment score is rated on a 7-point scale,
where 1 indicates `no maladjustment with excellent rating in most areas' and 7 indicates
`very severe maladjustment with marked maladjustment in all areas'. In present analysis,
we used this global rating scale.

Self-report measures
Beck Anxiety Inventory (Beck et al., 1988)
The BAI is a 21-item self-report inventory covering a variety of emotional and somatic
symptoms. Participants were asked to assess their level of bother (not at all, mildly,
moderately, severely) during the past week for each of the symptoms. The BAI has high
internal consistency with acceptable reliability and acceptable convergent and discrimi-
nant validity (Fydrich et al., 1992; Hewitt and Norton, 1993).

Beck Depression Inventory (BDI; Beck et al., 1961)

The BDI is a 21-item inventory used to assess depression, each rated on a 0 to 3 scale. This
instrument has moderate to good internal consistency, with alpha ranges between 0.58 and
0.93, and good test±retest reliability, ranging from 0.69 to 0.90.

Anger Expression Scale (AEX; Spielberger, 1988)

The AEX is a 24-item scale used to assess differences in the expression, suppression, and
control of anger. Each item is rated on a 4-point frequency scale with higher scores
representing greater anger. Only the anger suppression scale (anger-in), which provides a
general index of the frequency of inward-directed anger, was used in the study. The AEX
scale has good internal consistencies with alphas ranging from 0.72 to 0.89 and is
moderately correlated with other measures of anger (Hersen and Bellack, 1988).

Pennebaker Inventory of Limbic LanguidnessÐModi®ed (PILL; Pennebaker et al., 1977)

The PILL measures frequency of physical complaints and medical utilization. In the
present study, participants were asked to rate symptoms they had experienced in the past
month. Because both gynecological (e.g. yeast or vaginal infections, irregular vaginal
bleeding) and gastrointestinal problems (e.g. urgency in urination, diarrhoea), are common
in victims of sexual assault, we added 23 items to the original PILL to further examine
these problems. The ®nal measure includes 77 items. Participants rated the frequency of
each symptom from 0 (not at all) to 5 (more than once a day), the level of discomfort for
each symptom endorsed from 0 (no discomfort) to 5 (severe discomfort), and indicated
whether they went to a doctor and received treatment for that symptom. Two main
scores were utilized: total physical symptoms (i.e. total number occurring 2 or more times
per week) and average discomfort (i.e. average discomfort per symptom endorsed).

Quality of Life Self-Report-Health Subsection (QOL-SR; Berman et al., unpublished

manuscript, 1994)
The QOL-SR is self-report measure modi®ed from the Quality of Life Interview (Lehman,
1988). We utilized the main measure of perception of general health in the last 3 months
rated on a scale of 1 (excellent) to 5 (poor).

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
 Linguistics, PTSD and health S163

Narrative coding measures

Linguistic Inquiry and Word Count (LIWC; Pennebaker and Francis, 1999)
LIWC is a computer program that analyses the structure and linguistic content of text ®les.
The program consists of a main text-processing module and an external support dictionary.
The dictionary is composed of over 2000 words and word stems that are assigned to one or
more of 61 subdirectories. Each of the subdirectories is composed of groups of related
words that re¯ect a particular dimension of language. LIWC calculates the total number of
words, sentences, percentages of unique words, and dictionary words. The sum of each
subdirectory is converted to a percentage of total words. In the validation of the measure
(Pennebaker and Francis, 1996), judge agreement for category assignment with the
computer program was high. In the present study, we utilized only the following
categories: cognitive processes (words suggestive of causal and insightful thinking),
negative emotions, positive emotions, words about death and dying, total word count,
unique words (ratio of actual number of different words to total number of words), and
speech ®llers.

Procedures
All participants were part of a large, ongoing treatment study for chronic PTSD. As part of
that study, they were interviewed by trained female evaluators who had either a masters or
PhD degree in psychology and had extensive training in instrument administration before
and after treatment (9-12 weeks). Participants also completed self-report measures at those
assessments. During the third or fourth therapy session, they were asked to recount their
trauma for the ®rst time `as if it were happening now'. These narratives were videotaped
and transcribed by individuals blind to therapeutic outcome. Each narrative contained
three sections: pre-threat (material prior to the ®rst expressed realization of danger), threat,
and post-threat (material after the ®rst expressed realization that the threat had termi-
nated). These transcripts were utilized in a previous study (Zoellner et al., `Peritraumatic
dissociative experiences, trauma narratives, and trauma pathology', in press). Transcripts
were coded for linguistic elements by the LIWC computer coding program (Pennebaker
and Francis, 1999).

RESULTS

Preliminary analyses
Prior to the data analysis, all variables were examined for univariate and
multivariate outliers as well as violations of normalcy. One case with an univariate outlier
was detected for post-treatment health symptom severity with Malahobus distance
p < 0.001. The in¯uence of this case was reduced using one unit greater than the next
case (Tabachnick and Fidell, 1996). After substitution, all variables met normalcy
standards.
To examine whether data could be collapsed across the three narrative sections, we
conducted within-subjects ANOVAs on pre-threat, threat, and post-threat sections of the
narratives for each linguistic variable. Pre-threat (M ˆ 985.00, SD ˆ 962.49), threat
(M ˆ 1046.46, SD ˆ 947.03), and post-threat sections (M ˆ 787.68, SD ˆ 731.89) did

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
S164 J. Alvarez-Conrad et al.

not reliably differ in terms of actual word count, F(2, 54) ˆ 0.83, p ˆ 0.44. However, there
were differences between sections for main dependent variables.1 For cognitive words,
there was a main effect of Section, F(2, 54) ˆ 7.88, p < 0.05, with the threat section
(M ˆ 7.65, SD ˆ 2.43) containing more cognitive words than both the pre-threat
(M ˆ 5.54, SD ˆ 2.34) and post-threat sections (M ˆ 6.41, SD ˆ 2.15). For negative
emotion words, there was a main effect of Section, F(2, 54) ˆ 14.90, p < 0.05, with
both the threat section (M ˆ 2.44, SD ˆ 1.31) and post-threat section (M ˆ 2.14,
SD ˆ 1.31) containing more negative emotion words than the pre-threat section
(M ˆ 1.15, SD ˆ 0.89). For positive emotion words, there was main effect of Section,
F(2, 54) ˆ 4.84, p< 0.05, with the pre-threat section (M ˆ 1.88, SD ˆ 1.19) containing
more positive emotion words than both the threat section (M ˆ 1.39, SD ˆ 0.94) and
post-threat sections (M ˆ 1.26, SD ˆ 0.56). For death and dying words, there was a main
effect of Section, F(2, 54) ˆ 13.36, p < 0.05, with the threat section (M ˆ 0.16, SD ˆ 0.23)
containing more death words than both the pre-threat section (M ˆ 0.01, SD ˆ 0.05)
and the post-threat section (M ˆ 0.04, SD ˆ 0.12) and the post-threat section containing
more death words than the pre-threat section. Because of these section differences across
the linguistic variables subsequent analyses were conducted using sections of the
narratives.

Pre- and post-treatment psychological and physical symptoms

As would be expected, severity of PTSD, depression, anxiety, and anger decreased from
pre- to post-treatment and social adjustment increased. In addition, reported physical
symptoms, but not physical discomfort and general health decreased from pre- to post-
treatment. These are presented in Table 1.

Table 1. Pre- and post-treatment psychopathology and physical symptoms

Pre-treatment Post-treatment
(n ˆ 28) (n ˆ 22)
M (SD) M (SD) t

Psychopathology measures
PTSD severity (PSS-I) 32.59 (9.01) 10.40 (10.88) 11.86*
Depression (BDI) 21.69 (10.47) 9.33 (12.05) 7.57*
Anxiety (BAI) 23.84 (14.76) 9.69 (13.70) 6.87*
Global functioning (SAS) 4.05 (0.78) 3.47 (0.90) 2.25*
Anger (STAXI) 11.29 (6.20) 8.76 (5.46) 3.38*
Health measures
Physical symptoms (PILL) 14.17 (10.46) 6.78 (7.50) 5.63*
Physical discomfort (PILL) 1.66 (0.83) 1.90 (1.20) 1.12
General health (QOL) 3.13 (1.06) 3.04 (1.30) 0.46
Note: *p < 0.05.

1
Given the lack of a reliable difference in word count between pre-threat, threat, and post-threat sections and
further restriction of range of scores, we chose to utilize the raw number of words for the main linguist variable
analyses rather than proportion of words. Utilizing proportion of words, rather than raw number of words, did not
substantially alter the pattern of results in the study.

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
 Linguistics, PTSD and health S165

Table 2. Pre-threat section linguistic variables and post-treatment pathology

Post-treatment Post-treatment health
Psychopathology (n ˆ 22) perceptions (n ˆ 22)

Pre-threat PSS-I BDI Social BAI Anger Physical Physical General

linguistic adjustment symptoms discomfort health
variables

Cognitive 0.22 0.02 0.41 0.02 0.38 0.06 0.26 0.01

words
Negative 0.10 0.05 0.41 0.09 0.38 0.01 0.07 0.11
emotion words
Positive 0.09 0.16 0.02 0.21 0.18 0.10 0.18 0.13
emotion words
Death and 0.43* 0.37 0.42 0.14 0.04 0.25 0.59* 0.27
dying
Word count 0.27 0.06 0.07 0.03 0.12 0.62* 0.71* 0.02
Unique words 0.10 0.11 0.27 0.13 0.03 0.50* 0.33 0.09
Fillers 0.05 0.03 0.36 0.10 0.37 0.12 0.08 0.01
Note: *p < 0.05.

Linguistic elements and post-treatment psychopathology

Next, we examined one of our main hypotheses that the linguistic elements would be
related to post-treatment psychopathology, using Pearson correlations with a Bonferroni
correction for family-wise error. These are presented in Tables 2, 3, and 4. As can be seen
in Table 2, for the pre-threat section of the narrative, only the use of death words was
signi®cantly related to PTSD severity.
For the threat section of the trauma narratives, as can be seen in Table 3, cognitive
words were negatively related to post-treatment anxiety. Similar to the pre-threat section,

Table 3. Threat section linguistic variables and post-treatment pathology

Post-treatment Post-treatment health
Psychopathology (n ˆ 22) perceptions (n ˆ 22)

Pre-threat PSS-I BDI Social BAI Anger Physical Physical General

linguistic adjustment symptoms discomfort health
variables

Cognitive 0.19 0.26 0.00 0.45* 0.08 0.35 0.07 0.21

words
Negative 0.18 0.03 0.42 0.22 0.11 0.01 0.17 0.32
emotion words
Positive 0.31 0.27 0.25 0.27 0.26 0.20 0.49* 0.06
emotion words
Death and 0.45* 0.60* 0.27 0.27 0.02 0.06 0.25 0.48*
dying
Word count 0.00 0.21 0.29 0.11 0.06 0.28 0.07 0.35
Unique words 0.05 0.09 0.23 0.04 0.22 0.19 0.08 0.27
Fillers 0.08 0.12 0.19 0.10 0.34 0.11 0.00 0.35
Note: *p < 0.05.

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
S166 J. Alvarez-Conrad et al.

Table 4. Post-threat section linguistic variables and post-treatment pathology

Post-treatment Post-treatment health
Psychopathology (n ˆ 22) perceptions (n ˆ 22)

Pre-threat PSS-I BDI Social BAI Anger Physical Physical General

linguistic adjustment symptoms discomfort health
variables

Cognitive 0.19 0.14 0.08 0.10 0.37 0.06 0.22 0.16

words
Negative 0.08 0.02 0.15 0.04 0.34 0.21 0.15 0.32
emotion words
Positive 0.24 0.24 0.12 0.33 0.49* 0.18 0.14 0.08
emotion words
Death and dying 0.40 0.34 0.44* 0.06 0.08 0.22 0.57* 0.39
Word count 0.18 0.13 0.19 0.09 0.24 0.24 0.40 0.22
Unique words 0.06 0.14 0.07 0.24 0.28 0.28 0.32 0.14
Fillers 0.25 0.19 0.23 0.27 0.33 0.13 0.15 0.04
Note: *p < 0.05.

death words were related to more severe PTSD and depression. In addition, there was a
trend toward negative emotion words being related to poorer social adjustment.
For the post-threat section, as can be seen in Table 4, positive emotion words were
negatively related to anger. Death words were signi®cantly correlated with poor social
adjustment.

Linguistic variables and health perceptions

As shown in Table 2, for the pre-threat section of the narrative, death words were
positively correlated with physical discomfort and unique words were negatively corre-
lated to reported physical symptoms. In addition, a higher total word count was also
associated with more reported physical symptoms and physical discomfort. For the threat
section of the narrative, positive emotion words were associated with greater physical
discomfort, and death words were related to worse overall physical health (see Table 3).
Finally, for the post-threat section, death words were again related to greater physical
discomfort (see Table 4).
Because both death and negative emotion words were positively related to worse post-
treatment pathology and health and because perception of possible death and injury had
been found related to post-trauma psychopathology (Foa and Riggs, 1993), we examined
the relationship between reported injury or life threat during the assault and the use of
these death and negative emotion words. Speci®cally, we examined the post-hoc hypo-
thesis that the use of these words may simply be a byproduct of assault characteristics.
Negative emotion, but not death words, were related to reported to injury during the
assault, r ˆ 0.45, p < 0.05. Neither was related to perception of life threat, p > 0.10.

Prediction of good endstate functioning

In order to explore prediction of later functioning, participants were classi®ed as those
with good endstate functioning and those without. Good endstate functioning was de®ned
as having two of the following three conditions: a score of less that 10 on the PSS-I, less

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
 Linguistics, PTSD and health S167

than 4 on the SAS, and less than 15 on the PILL. Overall, at post-treatment, 60% of the
participants quali®ed as having good endstate functioning. A stepwise logistic regression
analysis was then performed. Injury during the assault was included as a covariate entered
at the initial step. Cognitive words, negative emotions, death words, unique words, and
total word count were used as independent variables and endstate functioning was used as
the dependent variable. After controlling for injury during the assault, according to Wald
criterion, only death words (R ˆ 0.27, z ˆ 3.63, p < 0.05) emerged as reliably different
from the constant-only model, 2 (N ˆ 22) ˆ 5.50, p < 0.05, with the use of more death
words being related to worse post-treatment functioning. Overall correct prediction was
86%, with 92% correct prediction of good endstate functioning and 78% correct prediction
of poor endstate functioning.

DISCUSSION

The present study lends support to the hypotheses that the linguistic elements of trauma
narratives are associated with post-trauma psychopathology and physical health. As
hypothesized, greater use of words regarding death and dying in the trauma narrative
was associated with more severe post-treatment psychopathology, poorer perception of
physical health, and lower overall well-being. Perceived injury or threat during the actual
assault could not account for these relationships. These results coincide with those found
by Pennebaker et al. (1997) which suggest that greater use of death words was related to
subsequent distress. Also in support of our hypotheses, a greater use of cognitive words in
the threat section of the narrative was related to lower post-treatment anxiety. These results
are similar to those found by Pennebaker and his colleagues (Pennebaker, 1993;
Pennebaker and Francis, 1996), suggesting that cognitive processing, as measured by
the use of cognitive words, is related to better outcome. Further, our results are consistent
with a large body of theory suggesting that those who process a traumatic event will
evidence better treatment outcome (Foa and Kozak, 1986; Foa and Riggs, 1993).
A possible explanation for the ®nding that death words were related to poor well-being
is that those words re¯ect a sense of mental defeat. The concept of mental defeat focuses
on wishing or accepting one's own death, giving up, or loss of personal will or autonomy.
Indeed, in a previous study of trauma narratives, mental defeat surrounding the traumatic
event was related to worse post-treatment psychopathology, following exposure therapy
(Ehlers et al., 1998). The authors suggested that, for individuals who exhibit a focus on
defeat, repeated reliving during the exposure therapy may con®rm their negative beliefs
regarding the nature and implications of the traumatic event, rather than provide corrective
information.
Interestingly, our results suggested that the use of death words was not related to assault
characteristics. This ®nding is consistent with those of Ehlers et al., (1998) conclusion that
the cognitive differences between those who responded well and less well to treatment
were not due to assault characteristics alone. Our results are also consistent with Foa and
Riggs' (1993) suggestion that the impact of assault brutality is mediated by cognitive
factors such as evaluation of danger. Thus, it seems that the representation of mental defeat
and the focus on death in the trauma memory may be more associated with recovery from
a traumatic event than assault-related characteristics themselves.
The assertion that trauma-related negative cognitions underlie poor well-being in
traumatized individuals is supported by the ®ndings that three speci®c cognitive factors,

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
S168 J. Alvarez-Conrad et al.

negative cognitions about the self (e.g.`I am a wimp'), negative cognitions about the world
(e.g. `the world is a dangerous place'), and self-blame (e.g. `it happened to me because of
the way I acted') are related to post-trauma psychopathology (Foa et al., 1999). These
cognitive factors discriminated between traumatized individuals with and without PTSD
and predicted PTSD severity, depression, and general anxiety in traumatized individuals
(Foa et al., 1999).
Pennebaker and Francis (1996) found that greater use of emotional words and an
increase in cognitive utterances over time predicted health perception. In the present study,
we found a small-moderate correlation between cognitive utterances and perceived
physical health, only in the threat section of the narratives. Our study differed from that
of Pennebaker and Francis in two ways. First, the nature of the narratives in the two studies
is quite different, as we studied narratives of severely traumatized individuals with chronic
PTSD whereas Pennebaker and Francis studied narratives of stressful experiences of
college students. Second, the methods of the two studies were different: we examined only
the ®rst trauma narrative whereas, Pennebaker and Francis examined linguistic changes in
repeated narratives of the same event.
The present study can be expanded in several directions. First, it would be interesting to
examine linguistic changes during natural recovery following a traumatic event as well as
changes that occur during treatment of post-trauma psychopathology. Second, it is
important to examine similarities and differences of narratives of different types of trauma.
The investigation of the relationship between the linguistic structure of trauma
narratives provides a unique avenue for understanding the mechanisms underlying the
development and maintenance of PTSD and other post-trauma pathology. Speci®cally, this
line of research may shed new light on cognitive mechanisms of emotional processing
after traumatic events. Clinically, understanding the linguistic elements and the changes in
the linguistic structure of trauma narratives that foster recovery may help improve
treatments for trauma survivors suffering from PTSD, anxiety, depression, and physical
health problems. The results of the present study suggest that a victim's focus on trauma-
related death and dying may be an important area of intervention during treatment.

ACKNOWLEDGEMENTS

Preparation of this manuscript was supported by a grant to Edna B. Foa from the National
Institute of Mental Health # MH42173. We like to thank Rosemary Gruber and Heidi
Arner for their help with narrative transcription.

REFERENCES

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders
(4th ed.). Washington, DC: American Psychiatric Press.
Amir N, Stafford J, Freshman MS, Foa EB. 1998. Relationship between trauma narratives and
trauma pathology. Journal of Traumatic Stress 11(2): 385±392.
Beck AT, Epstein N, Brown G, Steer RO. 1988. An inventory for measuring clinical anxiety:
psychometric properties. Journal of Consulting and Clinical Psychology 56: 893±897.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. 1961. An inventory for measuring
depression. Archives of General Psychiatry 4: 561±571.

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
 Linguistics, PTSD and health S169

Beckham JC, Crawford AL, Feldman ME, Kirby AC, Hertzberg MA, Davidson JRT, Moore SD.
1997. Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans. Journal
of Psychosomatic Research 43(4): 379±389.
Davidson JRT, Hughes D, Blazer DG, George LK. 1991. Posttraumatic stress disorder in the
community: an epidemiological study. Psychological Medicine 21: 713±721.
Ehlers A, Clark DM, Dunmore E, Jaycox L, Meadows E, Foa EB. 1998. Predicting the response to
exposure treatment in PTSD: the role of mental defeat and alienation. Journal of Traumatic Stress
11(3): 457±471.
First MB, Spitzer RL, Gibbon M, Williams JB. 1995. Structures Clinical Interview for DSM-IV Axis
I Disorders-Patient Edition (SCID-I/P, Version 2). Biometrics Research Department, New York
State Psychiatric Institute: New York.
Foa EB. 1997. Psychological processes related to recovery from a trauma and an effective treatment.
In Psychobiology of Posttraumatic Stress Disorder, Annals of the New York Academy of Science,
Yehuda R, McFarlane AC (eds). New York Academy of Sciences: New York. 821.
Foa EB, Ehlers A, Clark DE, Tolin DF, Orsillo SM. 1999. The posttraumatic cognitions inventory
(PTCI): development and validation. Psychological Assessment 11(3): 303±314.
Foa EB, Kozak MJ. 1986. Emotional processing of fear: exposure to corrective information.
Psychological Bulletin 99(1): 20±35.
Foa EB, Molnar C, Cashman L. 1995. Change in rape narrative during exposure therapy for
posttraumatic stress disorder. Journal of Traumatic Stress 8(4): 675±690.
Foa EB, Riggs DS. 1993. Posttraumatic stress disorder and rape. In Review of Psychiatry, Oldham
JM, Riba RB, Tasman A (eds). American Psychiatric Press, Inc: Washington, DC. 12.
Foa EB, Riggs DS, Dancu CV, Rothbaum BO. 1993. Reliability and validity of a brief instrument for
assessing post-traumatic stress disorder. Journal of Traumatic Stress 6: 459±473.
Friedman MJ, Schnurr PJ. 1995. The relationship between trauma, post-traumatic stress disorder,
and physical health. In Neurobiological and Clinical Consequences of Stress: From Normal
Adaptation to PTSD, Friedman MJ, Charney DS, Deutch AY (eds). Lippencott-Raven Publishers:
Philadelphia, PA.
Fydrich T, Dowdall D, Chambless DL. 1992. Reliability and validity of the Beck Anxiety Inventory.
Journal of Anxiety Disorders 6: 55±61.
Golding JM. 1994. Sexual assault history and physical health in randomly selected Los Angeles
women. Health Psychology 13(2): 130±138.
Golding JM, Stein JA, Siegel JM, Burnam MA, Sorenson SB. 1988. Sexual assault history and use of
health and mental health services. American Journal of Community Psychology 16(5): 625±644.
Hersen M, Bellack AS. 1988. Dictionary of Behavioral Techniques. Pergamon Press: New York.
Hewitt PL, Norton GR. 1993. The Beck Anxiety Inventory: a psychometric analysis. Psychological
Assessment 4: 408±412.
Horowitz MJ. 1997. Stress Response Syndromes: PTSD, Grief, and Adjustment Disorders (3rd edn).
Jason Aronson, Inc: New Jersey.
Kilpatrick DG, Saunders BE, Veronen LJ, Best CL. 1987. Criminal victimization: lifetime
prevalence, reporting to police, and psychological impact. Crime and Delinquency 33: 479±489.
Kimerling R, Calhoun KS. 1994. Somatic symptoms, social support and treatment seeking among
sexual assault victims. Journal of Consulting and Clinical Psychology 62(2): 333±340.
Koss MP, Woodruff J, Koss PG. 1990. Relation of criminal victimization to health perceptions
among woman medical patients. Journal of Consulting and Clinical Psychology 58(2): 147±152.
Lehman AI. 1988. A Quality of Life Interview for the chronically mentally ill. Evaluation and
Program Planning 11(1): 51±62.
Pennebaker JW. 1993. Putting stress into words: health, linguistic, and therapeutic implications.
Behavior Research and Therapy 31(6): 539±548.
Pennebaker JW, Beall SK. 1986. Confronting a traumatic event: toward and understanding of
inhibition and disease. Journal of Abnormal Psychology 93(3): 274±281.
Pennebaker JW, Burnam MA, Schaeffer MA, Harper MA. 1977. Lack of control as a determinant of
perceived symptoms. Journal of Personality and Social Psychology 35(3): 167±174.
Pennebaker JW, Francis ME. 1996. Cognitive, emotional, and language processes in disclosure.
Cognition and Emotion 10(6): 601±626.
Pennebaker JW, Francis ME. 1999. Linguistic Inquiry and Word Count. Erlbaum: Mahwah, NJ.

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)
S170 J. Alvarez-Conrad et al.

Pennebaker JW, Hughes CF, Heeron RC. 1987. The psychophysiology of confession: linking
inhibitory and psychosomatic processes. Journal of Personality and Social Psychology 52(4):
781±793.
Pennebaker JW, Kiecolt-Glaser JK, Glaser R. 1988. Disclosure of traumas and immune function:
health implications for psychotherapy. Journal of Consulting and Clinical Psychology 56(2):
239±245.
Pennebaker JW, Mayne TJ, Francis ME. 1997. Linguistic predictors of adaptive bereavement.
Journal of Personality and Social Psychology 72(4): 863±871.
Resnick HS, Kilpatrick DG, Dansky BS, Saunders BE, Best CL. 1993. Prevalence of civilian trauma
and posttraumatic stress disorder in a representative national sample of women. Journal of
Consulting and Clinical Psychology 61: 984±991.
Riggs DS, Rothbaum BO, Foa EB. 1995. A prospective examination of symptoms of posttraumatic
stress disorder in victims of nonsexual assault. Journal of Interpersonal Violence 10(2):
201±214.
Rothbaum BO, Foa EB, Riggs DS, Murdock M, Walsh M. 1992. A prospective examination of post-
traumatic stress disorder in rape victims. Journal of Traumatic Stress 5(3): 455±475.
Spielberger CD. 1988. Manual for the state-trait anger expression scale. In Dictionary of Behavioral
Techniques, Hersen M, Bellack AS (eds). Pergamon Press: New York; 27±29.
Tabachnick BG, Fidell LS. 1996. Using Multivariate Statistics (3rd ed.). HarperCollins College
Publishers: New York.
Weissman MM, Paykel ES. 1974. The Depressed Woman: A Study of Social Relations. University of
Chicago Press: Chicago.
Zoellner, Lori A, Alvarez-Conrad J, Foa EB. in press. Peritraumatic dissociative experiences, trauma
narratives, and trauma pathology. Journal of Traumatic Stress.

Copyright # 2001 John Wiley & Sons, Ltd. Appl. Cognit. Psychol. 15: S159±S170 (2001)