Ehlers and Clark's (2000) cognitive model of posttraumatic stress disorder (PTSD) highlights the importance of negative appraisals in maintaining posttraumatic stress. Recent research suggests that alienation appraisals, defined as feeling disconnected from the self and others, mediate the association between traumatic experiences and subsequent PTSD symptoms. To our knowledge, no systematic review has yet explored the relation between alienation appraisals and PTSD symptoms in trauma-exposed adults, despite the important clinical implications posed by this association. A systematic search of the SCOPUS, Web of Science, PsycInfo, MEDLINE, CINAHL Plus, and PILOTS databases resulted in 470 studies, nine of which met full inclusion criteria. Studies were quality-assessed for risk of bias using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD) quality assessment tool. A random-effects meta-analysis for the association between alienation appraisals and PTSD symptoms showed a large total effect size, r = .57, 95% CI [.46, .66], z = 8.41, p < .001. This large effect suggests that as alienation appraisals increase, PTSD symptoms increase. Although a strong positive association was found between alienation and PTSD symptoms, the mechanism of this association remains unclear. Limitations of the research included significant heterogeneity across studies and the fact that data were correlational. Future research to explore why alienation appraisals are significant in posttraumatic stress may further help to inform therapeutic approaches to targeting alienation appraisals in trauma survivors. Recommendations are made for the clinical assessment of alienation appraisals when exploring the impact of the traumatic experience on the survivor. Exposure to traumatic events is common; however, most people who witness or experience traumatic events do not develop posttraumatic stress disorder (PTSD; Schnurr, Friedman, & Bernardy, 2002). A large-scale survey of 2,953 adults in the United States found that although 89.7% of the sample had been exposed to a traumatic event, only 8.3% of the sample met the diagnostic criteria for PTSD per the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; Kilpatrick et al., 2013).

Objective: Cognitive models posit negative trauma appraisals as maintaining symptoms of posttraumatic stress disorder. Recent research has demonstrated that alienation appraisals (feeling disconnected from the self and others) are salient in trauma-related distress. Studies show that alienation appraisals fully mediated the relationship between trauma exposure and symptoms of posttraumatic stress disorder (PTSD) in traumaexposed adults. This study explored alienation appraisals in student and clinical samples, assessing whether alienation significantly mediated the relationship between cumulative trauma and trauma-related distress. It also explored whether alexithymia, social support, and loneliness also mediated the relationship between cumulative trauma and markers of trauma-related distress, clarifying the role of alienation. Method: Mediation and hierarchical regression models were tested with questionnaire data from a student sample (N ϭ 100) and clinical sample of trauma-exposed treatment-seeking adults (N ϭ 93). Results: In the student sample, alienation (B ϭ 1.27) fully mediated the relationship between cumulative trauma and posttraumatic stress, but not depression. When alexithymia, social support, and loneliness were entered as parallel mediators, only alienation appraisals (B ϭ 1.03) significantly mediated the relationship between cumulative trauma and posttraumatic stress. For the clinical sample, alienation appraisals (␤ ϭ .53) were the only significant predictor of posttraumatic stress, while alienation appraisals (␤ ϭ .75) and, to a lesser extent, social support (␤ ϭ .19) and loneliness (␤ ϭ .30) significantly predicted depression. Conclusions: Alienation was a salient predictor of posttraumatic distress. Clinical assessment of alienation appraisals is recommended to inform psychological interventions for trauma survivors. Clinical Impact StatementAlienation appraisals are an important predictor of posttraumatic distress in student and clinical samples. Alexithymia, social support, and loneliness do not appear to better explain the role of alienation in posttraumatic stress. However, alienation appraisals, alongside the weaker predictors of social support and loneliness, are important factors to consider in trauma survivors with depression. Alienation makes an independent contribution to the prediction of posttraumatic distress, unique from loneliness, social support, and alexithymia. Recommended clinical treatments include sensitive cognitive restructuring of alienation appraisals and fostering a strong therapeutic alliance.