Coping as Mediator Between Personality and PTSD in Veterans

Combat Stress Reaction, PTSD, and Locus of Control

Solomon, Mikulincer, and Avitzur (1988) argue in their prospective study "Coping, Locus of Control, Social Support and Combat-Related Posttraumatic Stress Disorder" that military participation places soldiers "under intense pressures that can impair their functioning. The most widespread manifestation of psychopathology on the battlefield is combat stress reaction (CSR), also known as battle shock and battle fatigue" (Solomon, Mikulincer, & Avitzur, 1998, p. 279). Characteristics of CSR include: (1) psychomotor retardation; (2) withdrawal; (3) increased sympathetic activity; (4) stuttering; (5) confusion; (6) nausea; (7) vomiting; and (8) paranoid reactions. The most common element across all these varied manifestations is the soldier's cessation of efficient functioning, creating potential danger not only to themselves but to their comrades as well.

Locus of control is defined by Solomon, Mikulincer, and Avitzur (1998) as "internal when individuals tend to attribute environmental events to themselves and as external when individuals attribute such events to things outside their power" (p. 279). An internal locus of control is associated with better health outcomes through preventive behavior, efforts to improve functioning, and greater resistance to psychological dysfunction. By contrast, those with an external locus of control "express greater motivation to take inoculations, tend to use safety belts when driving, are more likely to have regular dental examinations, are more successful in weight reduction programs, and more often obey doctor's orders and persist in required medical treatment" (p. 280).

Regarding mental health and locus of control, Solomon, Mikulincer, and Avitzur note that "people with internal locus of control suffered less from severe psychiatric disorders, especially from chronic depression" (p. 280). They therefore hypothesize that "CSR casualties with internal locus of control will experience less severe PTSD than casualties with external locus of control" (1998, p. 279).

Coping is defined by Solomon, Mikulincer, and Avitzur as consisting of "the cognitions and behaviors that people use to assess and reduce stress and to moderate the tension that accompanies it" (1998, p. 279). Coping serves two functions: (1) a problem-focused function, which channels resources toward solving the stress-creating problem; and (2) an intrapsychic or emotion-focused function, which manages the emotional distress associated with the stressor.

Research findings indicate that these two coping styles tend to be combined according to the context and the specific problem being faced, as well as with the individual's personality (Solomon, Mikulincer, & Avitzur, 1998, p. 279). The optimal coping style comprises "the largest possible repertoire of coping responses. Even if intrapsychic coping aids in maintaining emotional balance, the non-use of problem-solving strategies will in the end have negative psychological outcomes" (1998, p. 280). Those experiencing depression tend to rely on intrapsychic coping at the expense of instrumental coping, whereas generally healthy individuals tend toward a problem-solving coping style. It could therefore be hypothesized that "among CSR casualties, a coping style that emphasizes problem-solving coping will be associated with less PTSD, whereas a coping style that emphasizes intrapsychic coping will be associated with more severe PTSD" (Solomon, Mikulincer, & Avitzur, 1998, p. 280).

Intrapsychic Coping and Its Clinical Significance

Intrapsychic coping refers to processes that exist or take place within the mind or psyche, denoting "psychological dynamics that occur inside the mind without reference to the individual's exchanges with other persons or events" (Biology Online, 2008).

The clinical significance of intrapsychic coping is addressed by Dr. Peter L. Giovacchini in his article "Intrapsychic Focus Can Have Lasting Benefits for Patients," published in Psychiatric Times (1996). Giovacchini notes that psychiatry and psychoanalysis "have been drifting apart in recent years" (p. 1). The psychoanalytic contribution is described as unique in "its adherence to the belief that patients' behavior, attitudes, and feelings are meaningful even when they appear to be most irrational. The intrapsychic focus stresses unconscious motivation, which means that the causes of emotional disturbances frequently stem from inner sources. To some degree, it assumes that patients are the masters of their own destiny, that they are not just the hapless victims of cruel circumstances. This means that, in most instances, there is a potential for control and this leads to the hope that emotional equilibrium can be established" (Giovacchini, 1996, p. 1).

Giovacchini further argues that the shift away from intrapsychic focus "takes us into the realm of biology and neurochemistry, areas that are making significant advances. Unfortunately, this movement has led to a polarization between the inner workings of the mind from a psychological perspective and external traumas as they affect the brain. The brain and the mind have once again become separated, leading to a Cartesian dualism that in the past had been considered naïve and anachronistic" (Giovacchini, 1996, p. 1). He links the reduction of intrapsychic study to "a certain notable deterioration of Western civilization" (p. 2), contending that "reflection, introspection, contemplation and even empathy have been shoved aside in favor of action which often escalates to violence. Ours is a materialistic concrete society, and our approaches to mental illness seem to be a reflection of the decline of values as exemplified by current mechanistic outlooks" (Giovacchini, 1996, p. 2).

Giovacchini notes that the most common element among contemporary therapeutic approaches is their lack of an intrapsychic focus. In many cognitive therapies, the intrapsychic is "assiduously avoided" (p. 2) in favor of narrowly behavior-focused modification. He distinguishes those who seek superficial quick fixes from those who seek to address the root of the problem before moving on to symptomatic adaptations, arguing that vulnerable patients immersed in misery are too often met with mechanistic approaches and formulaic procedures.

To illustrate the clinical value of intrapsychic focus, Giovacchini describes the case of a patient referred to here as "John." John was a man nearing 30 years of age who was hospitalized due to auditory hallucinations that had become disruptive, although he had been hearing voices since adolescence without disclosing this to anyone. John lived alone with practically no social relationships, maintaining only minimal contact with an older brother who lived far away. At work he was largely isolated but highly respected — described as "a wizard in programming computers" who could solve complicated technical problems independently (Giovacchini, 1996, p. 2). John had initially seen a psychiatrist for depression and eventually confided that he was hearing voices; he was placed on both an antidepressant and a phenothiazine, neither of which had much effect. He did not follow the psychiatrist's advice on socializing and continued following a fixed routine until a significant event disrupted it.

When John's employer gave him a promotion that would place him in regular contact with subordinate employees, rather than feeling pleased with his achievement, he experienced a psychotic decompensation. The voices that had previously only engaged him in conversation turned "threatening and accusatory. They reviled him as being wicked and worthless and vowed that eventually they were going to tear him apart limb by limb. He suffered intense panic and had to be hospitalized" (Giovacchini, 1996, p. 2). John was placed on a moderately heavy dose of haloperidol (Haldol), which caused the hallucinations to disappear and stabilized his mood. During his first session with Dr. Giovacchini, John "ironically remarked that he was cured, because that was what he was told at the hospital. He confirmed that he no longer heard voices, but, oddly enough, he wanted them back" (Giovacchini, 1996, p. 2).

Personality Dimensions and Coping Strategy Selection

It emerged that John was the youngest child of elderly parents, with an older brother who had already left for college when John was very young. He had grown up without companionship and had never developed social skills. Because John was miserable without the voices, Dr. Giovacchini discontinued the Haldol; the voices returned in their previously benign form, and over time John gradually experimented with socializing. Eventually "the voices lost their significance, and his need to make up plots and fantasize diminished as he became more engaged in the real world" (Giovacchini, 1996, p. 2).

Giovacchini concludes that research into the psychodynamics of individuals' current adjustments and symptom formation is "much more interesting and fulfilling than monitoring surface behavior. These processes are innately fascinating and their study creates dimensions and viewpoints that expand our appreciation of the versatility of the psyche" (Giovacchini, 1996, p. 2). He regards unconscious motivation as the essence of the intrapsychic focus, one that transforms patients into "interesting human beings rather than the passive recipients of pharmacological ministrations," enabling them to pursue autonomy and mastery of their emotions (p. 2).

Halil (2004), in "Personality and Coping: A Multidimensional Research on Situational and Dispositional Coping," defines coping as "a constantly changing cognitive and behavioral effort to manage specific internal and/or external demands that are appraised as taxing or exceeding the resources of the person." Three basic cognitive characteristics distinguish coping from defense mechanisms: (1) consciousness; (2) intentionality; and (3) capacity for revision. Individual differences are posited to affect the coping process in two ways: (1) stable coping strategies (dispositional) may be used without reference to the specific demands of stressful events; and (2) coping may be calibrated based on the nature of events (situational) and available personal resources. Halil (2004) reports that the hypothesis linking situational and dispositional coping styles to each other was validated in the study.

The Big Five personality dimensions are found by DeLongis and Holtzman (2005) in "Coping in Context: The Role of Stress, Social Support and Personality in Coping" to be linked to "the likelihood of engaging in certain coping strategies and the effectiveness or outcomes of these coping strategies." They also note that "the effect of personality on coping and stress outcomes may vary by the situational context in which stress occurs."

Amirkhan, Risinger, and Swickert (1995), in "Extraversion: A 'Hidden' Personality Factor in Coping," present evidence of a larger role for personality determinants in the coping response than previously recognized. Their two studies assessed the influence of personality on social support use and other coping strategies, finding that "extraversion was related to social support seeking, optimism was related to problem solving, and both dispositions were negatively related to avoidance." The second study used an experimental approach with multiple personality measures and again confirmed that extraversion is associated with help-seeking behavior. The authors conclude: "It would appear that the most pervasive and replicable factors in coping are closely related to the major personality dimensions of neuroticism and extraversion" (Amirkhan, Risinger, & Swickert, 1995). They further argue that people carry "person-bound" factors from stressor to stressor — whether personality dispositions, motivational tendencies, or accumulated coping resources — that produce consistency in responses across stressful situations.

Conclusion: Coping as the Mediating Link

Across the studies reviewed, coping consistently emerges as the mechanism through which stable personality traits — particularly neuroticism and extraversion — translate into psychological outcomes under stress. Problem-focused coping is linked to better adjustment, while avoidance and intrapsychic coping without complementary instrumental strategies are associated with greater distress and poorer functioning. In the specific context of combat veterans, this literature supports the hypothesis advanced by Solomon, Mikulincer, and Avitzur (1998) that coping style mediates the relationship between personality and PTSD severity. Veterans with an internal locus of control and a disposition toward problem-focused coping are better positioned to resist the most debilitating effects of combat stress reaction. Conversely, those whose personality predisposes them to avoidance or to exclusive reliance on intrapsychic coping face a heightened risk of chronic PTSD. Future research and clinical intervention design should therefore attend carefully to both the personality profiles and the coping repertoires of returning combat veterans.