Internalizing and Externalizing Subtypes in Female Sexual Assault Survivors: Implications for the Understanding of Complex PTSD

Abstract

This study replicated and extended findings of internalizing and externalizing subtypes of posttraumatic psychopathology (Miller, M. W., Greif, J. L., & Smith, A. A. (2003). Multidimensional Personality Questionnaire profiles of veterans with traumatic combat exposure: Internalizing and externalizing subtypes. Psychological Assessment, 15, 205-215; Miller, M. W., Kaloupek, D. G., Dillon, A. L., & Keane, T.M. (2004). Externalizing and internalizing subtypes of combat-related PTSD: A replication and extension using the PSY-5 Scales. Journal of Abnormal Psychology, 113,[636][637][638][639][640][641][642][643][644][645]) to a female sample of rape survivors with chronic PTSD. Cluster analyses of Schedule for Nonadaptive and Adaptive Personality (Clark, L. A. (1996). SNAP-Schedule for Nonadaptive and Adaptive Personality: Manual for administration, scoring, and interpretation. Minneapolis: University of Minnesota Press.) temperament scale profiles from 143 women with PTSD partitioned the sample into a simple PTSD cluster, defined by normal range personality scores and moderate symptomatology, and 2 more "complex" clusters distinguished by more severe tendencies towards externalizing or internalizing psychopathology. Externalizers were characterized by disinhibition, substance dependence, and Cluster B personality disorder features; internalizers by low positive temperament, high rates of major depressive disorder, and elevations on measures of schizoid and avoidant personality disorder.The human response to psychological trauma is characterized by extensive inter-individual variability in the severity, form, and expression of posttraumatic distress. Posttraumatic stress disorder (PTSD) may be the most common psychiatric syndrome to develop following trauma (Green, Lindy, Grace, & Leonard, 1992;Kulka et al., 1990), but other conditions frequently co-occur with the disorder, or develop independently of it, including other anxiety disorders and the unipolar depressive, substance-related, and personality disorders (Breslau, Davis, Andreski, & Peterson, 1991;Breslau, Davis, Peterson, Schultz, 2000;Davidson, Hughes, Blazer, & George, 1991;Golier et al., 2003;Helzer, Robins, & McEvoy, 1987;Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995;Kulka et al., 1990;Orsillo et al., 1996). Considerable interindividual variability exists in patterns of comorbidity and other manifestations of posttraumatic distress. Predominant negative affects vary widely across individuals, spanning the spectrum from anger and rage through shame and sadness. In the interpersonal domain, responses to trauma range from withdrawal/avoidance to pronounced antagonism and aggression.Two prior studies that examined the heterogeneity of posttraumatic psychopathology found evidence of qualitatively distinct personality-based subtypes of posttraumatic adjustment that differed on dimensions related to internalizing versus externalizing psychopathology (Miller, Grief, & Smith, 2003;Miller Kaloupek, Dillon, & Keane, 2004). In both studies, cluster Addre...

Posttraumatic stress disorder: Anxiety or traumatic stress disorder?

“…These findings, and those reviewed previously, suggest that PTSD may arise as a function of latent liabilities towards either internalizing or externalizing psychopathology. This proposition is consistent also with recent studies of personality-based subtypes of PTSD, which have shown that many adults with PTSD exhibit a predominantly externalizing pattern of comorbidity characterized by problems in the domain of impulse-control, antisociality, and substance abuse (Miller, Greif, & Smith, 2003;Miller, Kaloupek, Dillon, & Keane, 2004;Miller & Resick, 2007).…”

Escala de Gravedad de Síntomas Revisada (EGS-R) del Trastorno de Estrés Postraumático según el DSM-5: propiedades psicométricas

“…la muestra clínica, aun habiendo sido muy amplia (mucho mayor que en los estudios previos: por ejemplo, crespo y gómez, 2015 o Foa et al, 2016), ha estado limitada a mujeres víctimas de violencia de género. aun siendo estos grupos en los que es más frecuente el tept y los que mayor demanda terapéutica generan en nuestro medio en relación con este cuadro clínico (Miller y Resick, 2007), convendría Enrique Echeburúa, Pedro J. Amor, Belén Sarasua, Irene Zubizarreta, Francisco Pablo Holgado-Tello, José Manuel Muñoz.…”

Personality Assessment Inventory internalizing and externalizing structure in veterans with posttraumatic stress disorder: Associations with aggression

“…VA Author Manuscript on internalizing or externalizing behavior (see, e.g., Forbes et al, 2010;Miller, Greif, & Smith, 2003;Miller, Kaloupek, Dillon, & Keane, 2004;Miller & Resick, 2007). While these studies have supported the internalizing/externalizing distinction as a useful heuristic for studying the structure of posttraumatic psychopathology, they are limited by a reliance on cluster-analytic models which are not optimal for examining higher order factor structure of psychopathology thought to be dimensional (Miller, Fogler, Wolf, Kaloupek, & Keane, 2008).…”

“…other studies that have used cluster-analytic methods to classify participants as belonging to either an "internalizing," "externalizing," or "low pathology" subtypes of PTSD (e.g., Miller et al, 2004;Miller & Resick, 2007). It would be helpful in future research to compare the utility of these approaches as they relate to relevant outcomes among individuals with PTSD.…”

“…Other researchers have suggested that some of the variability in the clinical presentation of PTSD may be explained by comorbid psychopathology or by personality variables (Forbes, Creamer, Hawthorne, Allen, & McHugh, 2003;Forbes, Elhai, Miller, & Creamer, 2010;Krueger, Caspi, & Moffitt, 2000;Markon, Krueger, Bouchard, & Gottesman, 2002;Miller, 2003;Miller & Resick, 2007;Miller et al, 2012). From this perspective, broad-based measures of psychopathology and personality may be useful in assessing comorbid psychiatric symptoms that explain variance in behavioral difficulties such as aggression among help-seeking patients with PTSD.…”