25513Census figures indicate that the Latino populatio.docx

255
13
Census figures indicate that the Latino population grew from 35
million
in 2001 to 52 million in 2011, making it the largest ethnic
minority group in
the United States (U.S. Census Bureau News, 2012). This
increase does not
include the undocumented Latino immigrant population, which
is estimated
to be about 9 million people (Passel & Cohn, 2012), or the 3.7
million Puerto
Ricans who live on the island of Puerto Rico, a U.S. territory.
By 2050, the
U.S. Census Bureau projects that 29% of the nation’s population
will be of
Latino heritage (Taylor & Cohn, 2012). Mexicans are the largest
subgroup,
accounting for about 65% of the U.S. Latino population,
followed by Puerto
Ricans (9%) and Cubans (4%). Also, Latinos in the United
States include
individuals with ancestries from Central America (8%), South
America (6%),
and the Dominican Republic (3%; Lopez & Dockterman, 2011).
Individuals
of Latino heritage represent 21 Spanish-speaking countries,
each with unique
sociopolitical and historical contexts, religious and cultural
traditions, Spanish

http://dx.doi.org/10.1037/14668-014
Psychological Testing of Hispanics, Second Edition: Clinical,
Cultural, and Intellectual Issues, K. F. Geisinger
(Editor)
Copyright © 2015 by the American Psychological Association.
All rights reserved.
LATINOS AND DEPRESSION:
MEASUREMENT ISSUES
AND ASSESSMENT
AZARA L. SANTIAGO-RIVERA, GREGORY BENSON-
FLóREZ,
MARIA MAGDALENA SANTOS, AND MARISELA LOPEZ
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256 santiago-rivera et al.
language dialect(s), indigenous roots, and foods. Likewise, their
diversity is

reflected in the blending of indigenous people (e.g., Mayan,
Aztec, Inca) and
Spaniards from Spain for some groups, whereas other Latino
groups are a mix
of African or Asian and Spanish ancestries (Acosta-Belén &
Sjostrom, 1988).
UNDERSTANDING DEPRESSION IN THE LATINO
CONTEXT
The Latino population’s projected growth, prevalence of
depression,
course of illness, and service utilization rates underscore the
need to assess and
measure depression accurately among members of this diverse
demographic
group. Earlier studies examining depression rate estimates
based on aggregated
data revealed that Latinos reported lower rates of lifetime mood
disorders com-
pared with non-Latino Whites (Kessler et al., 2005). However,
Latinos with
a history of mood disorders were at greater risk of persistent
course of illness,
almost twice that of non-Latino Whites after controlling for
socioeconomic
status (Breslau, Kendler, Su, Gaxiola-Aguilar, & Kessler,
2005).
More recent investigations, accounting for the diversity within
the
population, have examined depression rates by subgroup. In
particular, the
National Latino and Asian American Study (NLAAS; Alegría et
al., 2004)
results indicated differential rates of depression by subgroup,

with Mexicans
showing the lowest rates and Puerto Ricans the highest
(Alegría, Mulvaney-
Day, et al., 2007). Consistent with NLAAS results, previous
findings showed
high prevalence rates among Puerto Ricans when compared with
other Latino
subgroups (Moscicki, Rae, Regier, & Locke, 1987). Cuban-
origin individu-
als, as a group, have shown lower levels of depression
symptomatology than
other Latino subgroups (Narrow, Rae, Moscicki, Locke, &
Regier, 1990).
Although data are limited, there is evidence suggesting higher
prevalence
rates among Latinos of Central and South American origin
compared with
Mexican Americans (Hovey, 2000a, 2000b), but lower rates
compared with
Puerto Ricans (Alegría, Mulvaney-Day, et al., 2007). In sum,
the findings of
higher rates of depression for Puerto Ricans and Central and
South Americans
indicate that the burden of depression and other potentially
related health
problems is significant.
Acculturation has been widely studied to explain how Latinos
adjust
and adapt to a new host country. Some research based on
aggregate data or on
Latino samples representing various subgroups has suggested
that increased
psychological distress and mental health problems are
associated with higher
levels of acculturation, a phenomenon known as the immigrant

paradox (Alegría,
Shrout, et al., 2007). Specifically, native-born Mexican
Americans who are
more acculturated to the American way of life demonstrate
higher lifetime
prevalence of major depression and dysthymia compared with
foreign-born
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latinos and depression 257
Mexicans who have recently arrived in the United States
(Burnam, Hough,
Karno, Escobar, & Telles, 1987). This finding suggests that
nativity may serve
as a protective factor for foreign-born Mexicans, whereas
acculturation has
potentially negative effects on mental health (Grant et al.,
2004). However,
the immigrant paradox has not been observed across all Latino
subgroups,
including those experiencing psychiatric disorders (Alegría,

Shrout, et al.,
2007). Although differences in depression rates have been
observed in indi-
viduals of Mexican origin, based on nativity (i.e., U.S. vs.
foreign born), the
same pattern has not been observed among Puerto Ricans.
Likewise, the rap-
idly growing proportion of U.S.-born Mexicans, expected to
account for most
population growth in the years to come, may lead to a
significance increase
in the rates of depression.
MEASUREMENT ISSUES IN THE ASSESSMENT OF
DEPRESSION
One of the major challenges often faced by clinicians is finding
the
appropriate measure to assess depression accurately. First and
foremost, it
is difficult to establish measurement equivalence because of
cultural differ-
ences in the meaning and expression of symptoms. This
perspective is evi-
dent in the culture-bound syndromes described in the Diagnostic
and Statistical
Manual of Mental Disorders (fourth ed.; American Psychiatric
Association,
1994) that are specific to Latinos, such as ataque de nervios
[nervous attack or
breakdown] and nervios [nervousness], susto [fright], espanto
[sudden fright],
and perdida del alma [loss of the soul], and whose symptoms
may be a manifes-
tation of distress among Mexicans, Puerto Ricans, Central
Americans, and

South Americans (Aguilar-Gaxiola, Kramer, Resendez, &
Magaña, 2008).
Likewise, there is sufficient evidence suggesting that Latinos
tend to somati-
cize mental health problems, reporting more physical symptoms
of distress
than European Americans (Canino & Alegría, 2009).
Despite these challenges, efforts to investigate measurement
equivalence
have yielded interesting results. For example, Crockett, Randall,
Shen, Russell,
and Driscoll (2005) investigated within- and across-ethnic-
group equivalence
of the Center for Epidemiologic Studies Depression Scale
(CES–D; Radloff,
1977) in a sample of Mexican, Cuban, Puerto Rican, and Anglo
American
adolescents. They found that the four factor domains (i.e.,
positive affect, nega-
tive affect, somatic, and interpersonal) were similar for the
Mexican and Anglo
American adolescents, but not for the Puerto Rican and Cuban
adolescents.
For Cuban adolescents, five different factors emerged that could
not be mean-
ingfully interpreted by the investigators.
Second, research has suggested possible gender differences in
the
expression of depression symptoms. For example, Posner,
Stewart, Marín,
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and Pérez-Stable (2001) found that the original four-factor
structure of the
CES–D proposed by Radloff (1977; i.e., depressive affect,
positive affect,
somatic, and interpersonal domains) was a good fit to the data
for the women
and, more important, when controlling for acculturation and
age, but not for
the men in the sample.
Third, it is widely acknowledged that most psychological
assessment
tools have been developed using middle class, highly educated,
and White
European samples. The lack of Latino representation in studies
designed to
develop such measures has led to a lack of culture-specific
norms, raising con-
cerns about their appropriateness (Butcher, Cabiya, Lucio, &
Garrido, 2007).
Finally, there has been a growing interest in Spanish-language

measures
because of the significant number of monolingual Spanish-
speaking Latinos
in the United States. Recent surveys show that 30% to 35% of
Latinos are not
fluent in English (e.g., Taylor & Cohn, 2012). The lack of
Spanish-language
psychological assessments has been problematic in accurately
diagnosing and
treating depression. In an attempt to address this concern, more
attention
has been given to the translation from English to Spanish of
well-established
measures of depression such as the Beck Depression
Inventory—II (A. T.
Beck, Steer, & Brown, 1996), CES–D (Radloff, 1977), and the
Geriatric
Depression Scale (Yesavage et al., 1982) and in investigating
the psychomet-
ric properties of the translated version (e.g., Penley, Weibe, &
Nwosu, 2003).
It is important to note that having a translated version of a
commonly used
English-language depression inventory may seem better than not
having
one; however, simply translating the measure does not make it
viable. It is
essential to determine that the English and Spanish versions of a
particu-
lar measure are equivalent in content, reliability, and validity
(Fernandez,
Boccaccini, & Noland, 2007).
ASSESSMENTS
The focus of this section is to describe a number of commonly

used
assessment instruments for depression screening for which the
psychometric
properties have been examined. However, this listing of
measurement tools is
not exhaustive due to the chapter page limitations. The
measures described
are those used to assess depression in Latino adults who reside
in the United
States.1
1For a more detailed review of assessments for both adults and
children, please refer to Aguilar-Gaxiola
and Gullotta, 2008.
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Beck Depression Inventory—II
The Beck Depression Inventory (BDI; A. T. Beck, Ward,
Mendelson,

Mock, & Erbaugh, 1961) is one of the most widely used and
well-established
self-report measures of depression symptoms in nonclinical and
clinical
samples. There is an extensive body of research indicating that
it has sound
psychometric properties. The BDI–II (A. T. Beck et al., 1996) is
a revised
version of the BDI consisting of 21 items assessing a variety of
symptoms
occurring in the 2 weeks prior to assessment and that
correspond more closely
to major depressive disorder (Penley et al., 2003). On a scale
from 0 to 3
(0 = no depressive symptom and 3 = severe depressive
symptom), participants
rate the 21 items, with higher scores indicating more depression
symptoms.
The total score indicates the level of depression as minimal (1–
13), mild
(14–19), moderate (20–28), or severe (29–63). According to
Wiebe and
Penley (2005), the BDI–II was translated into Spanish by a
diverse group of
psychologists, but normative data are virtually nonexistent.
Results of earlier studies provide considerable support for the
use of the
English version of the BDI among older Mexican Americans.
The internal
consistency coefficient was .80 for this group (Gatewood-
Colwell, Kaczmarek,
& Ames, 1989); .98 for a community sample of diverse
bilingual Latinos from
Mexico, South and Central America, Cuba, and Puerto Rico
(Novy, Stanley,

Averill, & Daza, 2001); and .82 for a college student sample
(Contreras,
Fernandez, Malcarne, Ingram, & Vaccarino, 2004). More
recently, Gloria,
Castellanos, Kanagui-Muñoz, and Rico (2012) conducted a
comparison study
of the BDI–II, CES–D, and Self-Rating Depression Scale (SDS;
Zung, 1965)
to explore the internal consistency, as well as the construct and
convergent
validity of these measures. For purposes of this discussion, they
found that the
BDI–II yielded an internal consistency coefficient of .88 and
was significantly
correlated with the CES–D (.75) and the SDS (.61).
Several studies have examined the English and Spanish versions
of the
BDI–II, adding another level of complexity to the internal
consistency and
factor structure of the scale. Specifically, Novy et al. (2001)
used an elaborate
translation and adaptation process for the BDI–II and other
measures and
found that the correlation between the Spanish and English
versions was .94
in a bilingual community sample. More recently, Wiebe and
Penley (2005)
examined the internal reliability and factorial validity of both
language ver-
sions of the BDI–II and found the following: (a) the English
version yielded
a reliability coefficient of .89, (b) the Spanish version yielded a
coefficient
of .91, (c) respectable test–retest reliability coefficients for the
English and

Spanish versions were obtained (.73 and .86, respectively), and
(d) confir-
matory factor analysis for each version resulted in a good fit
with A. T. Beck
and colleagues’ (1996) model. Essentially, this study showed
strong support
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for the language equivalence of the English and Spanish
versions in a college
student sample.
The psychometric properties of the Spanish version of the BDI–
II with
Latinos residing in the United States has also received some
attention in
recent years. Penley and colleagues (2003) recognized, like
many others,
the need to develop reliable Spanish translations of measures to
accurately

assess depression symptoms in those who are either Spanish
dominant or
Spanish monolinguals. In their study, they examined the
Spanish BDI–II in
a sample of Mexican Americans undergoing hemodialysis for
end-stage renal
disease and found good internal consistency (.92) and a less
than ideal factor
structure that, according to the researchers, still provided “an
adequate fit to
the Spanish BDI–II patient data” (p. 574). Furthermore, when
comparing the
English and Spanish versions of the BDI–II, they found no
statistical difference
between the English and Spanish total scores, suggesting
equivalency. However,
the authors recommended interpreting these results with caution
because of the
small sample size in the comparison of the two measures (n =
23). Nonetheless,
their study was one of the first to examine the equivalence of
the Spanish and
English BDI–II and showed promising results.
Likewise, Bonilla, Bernal, Santos, and Santos (2004) revised,
pilot
tested, and conducted a study with a Puerto Rican college
student sample (on
the island of Puerto Rico) and found that their Spanish version
of the BDI
(BDI–S) demonstrated high internal consistency (.88) and a
factor structure
that, according to the authors, is comparable with the domains
identified by
other studies (e.g., sadness, hopelessness, somatic, negative
thoughts) and

consistent with how depression has been conceptualized. In
sum, these stud-
ies have clearly demonstrated that the Spanish version of the
BDI, either
the BDI–S developed by Bonilla et al. (2004) or the Spanish
version of the
BDI–II (e.g., Penley et al., 2003), is a reliable screening tool
that can be used
with a diverse Latino population.
Center for Epidemiologic Studies Depression Scale
The CES–D was originally developed to assess somatic and
affective
symptoms of depression in adult community samples. It is a 20-
item, self-
report, paper-and-pencil measure that assesses depression
symptoms and mood
during the past week. The responses to each item are: 0 (less
than one day),
1 (one to two days), 2 (three to four days), and 3 (five to seven
days). The items
include symptoms such as depressed mood, feelings of guilt and
worthlessness,
feelings of helplessness, loss of appetite, and sleep disturbance
(Gloria et al.,
2012). Although the CES–D is widely used, studies have shown
differences
in mean scores and prevalence rates among various ethnic and
racial groups
(e.g., Kim, Chiriboga, & Jang, 2009). Moreover, a recent meta-
analytic study
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by Kim, DeCoster, Huang, and Chiriboga (2011) examined the
factor struc-
ture of the CES–D using confirmatory factor analyses and found
support for
the original four-factor structure in African Americans,
American Indians,
Latinos, and Whites, but not in Asians. Using exploratory factor
analysis,
they discovered that the four original factors were present in all
five ethnic
and racial groups; however, they found that for Latinos the
structure was
actually different in that the item loadings of depressed affect
and somatic
symptoms “switched between the two factors” (p. 388).
The Spanish version has shown adequate internal consistency,
with
alphas ranging from .88 to .90 (Piedra & Byoun, 2012). A meta-
analysis
investigating the practicality of the measure in primary care
settings showed

that the 20- and 10-item versions of the measure are valid for
depression
screening (Reuland et al., 2009). Another study found the CES–
D to be
an accurate measure of depression symptoms in a sample of 303
middle-
aged Spanish-speaking Puerto Ricans living in the northeastern
United
States (Robison, Gruman, Gaztambide, & Blank, 2002). As
stated earlier,
Posner et al. (2001) gathered data from three studies of urban
Latinos and
found gender differences, concluding that the measure was not a
good fit
for Latino men.
With respect to Latino subgroup differences, Crockett and
colleagues
(2005) found equivalent factor structures for Anglo and
Mexican Americans
but not for Puerto Rican and Cuban youth. The authors
attributed these
results to potential cultural differences in the expression of
depression symp-
tomatology. Another study using a short version of the CES–D
found it to
be an accurate measure of depression symptoms for Mexican
American farm
workers (Grzywacz et al., 2010).
Patient Health Questionnaire—9
The Patient Health Questionnaire—9 (PHQ–9; Spitzer, Kroenke,
& Williams, 1999) is a nine-item self-report measure that
assesses depres-
sion and is mainly used in primary care settings. The PHQ is a

version of
the Primary Care Evaluation of Mental Disorders (Kroenke &
Spitzer,
2002). Respondents indicate the degree to which nine symptoms
are pres-
ent (depressed mood, difficulties sleeping, changes in appetite,
suicidality,
difficulties concentrating, anhedonia, worthlessness or guilt,
agitation, and
fatigue; Merz, Malcarne, Roesch, Riley, & Sadler, 2011) and are
experienced
during the 2 weeks prior to assessment using a 4-point scale
from 0 (not at all)
to 3 (nearly every day). Scores range from 0 to 27, with higher
scores indicting
more depression symptoms. Scores ranging from 5 to 9 are
considered mild,
10 to 14 moderate, 15 to 19 moderately severe, and 20 to 27
severe (Kroenke
& Spitzer, 2002). Alpha reliability coefficients ranging from .86
to .89 and
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good criterion validity were found using the clinical diagnostic
interview
(Spitzer, Williams, Kroenke, Hornyak, & McMurray, 2000).
More than 3 decades of research and practice have determined
that
the PHQ–9 is a valid and reliable measure of depression among
racial and
ethnic populations, including Latinos (Huang, Chung, Kroenke,
Delucchi,
& Spitzer, 2006). In a study examining the internal consistency
of the
PHQ–9 with a mostly female mixed Spanish- and English-
speaking sample,
researchers found a coefficient alpha of .80, demonstrating good
reliability
(Huang et al., 2006). This measure has been translated into
many languages,
including Spanish, making it popular for use with different
ethnic and cul-
tural groups.
Although research is limited, a few studies have examined the
appro-
priateness of the PHQ–9 for Spanish-speaking Latinas. Merz et
al. (2011)
assessed the structural validity of the English and Spanish
versions of the
PHQ–9 with a community sample of English- and Spanish-
speaking Latinas.
In this mixed sample of primarily Mexican descent, the internal
consistency
of the English and Spanish versions showed coefficient alphas

of .84 and .85,
respectively. Exploratory factor analysis determined that the
PHQ–9 had good
structural validity. In addition, the PHQ–9 has been found to be
an adequate
measure of depression in Latina college students (Granillo,
2012). Although
these studies show promising results, future studies using the
PHQ–9 should
include men and a more heterogeneous sample.
ASSESSMENTS IN CRITICAL NEED AREAS
Latinas and Postpartum Depression
There is considerable concern that postpartum depression is on
the rise,
and yet, according to Le, Perry, and Ortiz (2010), as much as
“50% of post-
partum cases go undetected and untreated” (p. 249). There has
been a grow-
ing interest in validating measures for Latinas residing in the
United States
and in South America because of their high risk of developing
postpartum
depression (e.g., Affonso, De, Horowitz, & Mayberry, 2000;
Kuo et al., 2004).
One of the measures receiving attention in recent years is the
Postpartum
Depression Screening Scale Spanish version (PDSS; C. T. Beck
& Gable,
2005), a 35-item self-report measure that assesses symptoms of
postpartum
depression and consists of seven dimensions: sleeping and
eating distur-
bances, anxiety and insecurity, emotional lability, cognitive

impairment, loss
of self, guilt and shame, and thought of hurting oneself. In
addition, a shorter
seven-item version exists, consisting of one item from each of
the dimensions.
Respondents indicate the level of agreement with each item
using a 5-point
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scale ranging from 1 (strongly disagree) to 5 (strongly agree),
with higher scores
indicating depression. The total score can range from 7 to 175
on the full ver-
sion and 7 to 35 on the short version; 59 or less is considered
normal adjust-
ment, 60 to 79 indicates minor symptoms of postpartum
depression, and
80 or greater indicates major postpartum depression. The
English version of
the PPSD has adequate reliability and validity, yielding an

internal consis-
tency coefficient of .98 for the total scores, and content validity
ranging from
.80 to .91 (C. T. Beck & Gable, 2002).
C. T. Beck and Gable (2003) studied the Spanish version of the
PPDS
(PPDS–S) in a diverse sample of primarily Latinas of Puerto
Rican and
Mexican heritage and found a reliability coefficient of .95 for
the total scores,
with a range of .76 to .90 for the seven dimensions. Likewise,
C. T. Beck
and Gable (2005) reported strong reliability coefficients for
Mexicans (.95),
Puerto Ricans, (.96), and Central and South Americans (.95).
Interestingly,
they reported a cutoff score of 60 for both minor and major
postpartum
depression, meaning that the Spanish version was unable to
differentiate
these two levels. In a more recent study Le and colleagues
(2010) examined
the psychometric properties of the short and long forms of the
PPDS–S
in a sample of women, mostly from different countries in
Central America,
in particular, El Salvador and Mexico, and found good internal
consistency
across the three subgroups (.97). They also found that the short
seven-item
version did not perform as well but was still within what those
researchers
considered acceptable ranges (i.e., .85 for women from El
Salvador, .77 for
Mexican women, .83 for women from other Central American

countries).
The overall coefficient for the short version was .83. In essence,
the PPDS,
both the English and the Spanish versions, shows adequate
usefulness.
Older Latino Adults
The interest in accurately assessing depression in older adults is
gaining
momentum because the population of individuals age 65 and
older is grow-
ing quickly (U.S. Census Bureau, 2010), and as a group, a
significant per-
centage of older adults experience depression (Chavez-Korell et
al., 2012).
Although the body of research is limited, several studies have
shown that
older Latino adults may be at greater risk of depression (e.g.,
Falcón & Tucker,
2000). More recently, Diefenbach, Disch, Robison, Baez, and
Coman (2009)
reported higher prevalence of major depressive disorder and
anxiety among
Puerto Ricans compared with African Americans age 60 and
older living
in an urban setting. One of the challenges in assessing
depression in older
adults is that it is often difficult to differentiate the symptoms
of depression
from those associated with the natural aging process, such as
deterioration
of cognitive functioning, as well as changes in physical heath
and activity
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(Fernández-San Martín et al., 2002). Nonetheless, it is
important to assess
and treat depression in older adults.
The Geriatric Depression Scale (GDS; Yesavage et al., 1982) is
a popu-
lar measure used to assess depression symptoms in older adults.
There is a
30-item and 15-item version of the GDS. Respondents are asked
to answer
yes or no to a series of questions about how they felt during the
past week. The
15-item version has received considerable attention and has
been translated
and validated in Spanish. The GDS–15 scores range from 0 to
15, with 0 to 4
considered normal, 5 to 8 mild depression, 9 to 11 moderate
depression, and
12 to 15 severe depression. Validation studies have shown that
the GDS is

91% to 100% sensitive and 72% to 82% specific (e.g., Scogin &
Shah, 2006).
In a recent meta-analysis comparing the diagnostic accuracy of
both the
GDS 15- and 30-item measures in a primary care setting, the 15-
item scale
was 81% sensitive and a 78% specific for the presence of
depression, whereas
the 30-item measure was 77% sensitive and 65% specific
(Mitchell, Bird,
Rizzo, & Meader, 2010). The results are mixed for the Spanish
version of the
GDS. In a review of the literature on the diagnostic accuracy of
measures of
depression in the Spanish language, Reuland et al. (2009) found
sensitivities
ranging from 76% to 89% and specificities ranging from 64% to
98%, suggest-
ing that there is support for the GDS’s utility.
FUTURE DIRECTIONS
On the basis of the literature review, we make a number of
suggestions
for further work with respect to the reliability and validity of
measures of
depression. First, future studies should expand the sample to
include other
subgroups that have been largely ignored. A good example is Le
et al.’s (2010)
study that examined the psychometric properties of the PDSS–S
with a sam-
ple of mothers predominantly from El Salvador. In particular,
they pointed out
that many of these women experienced significant trauma due to

the politi-
cal unrest in their country of origin. Equally important, they
recommended
conducting interviews with participants from the different
subgroups when
validating measures to see how the items on the measure are
understood.
Second, there is a small but significant body of work on the
validation
of measures in Spanish, primarily from Spain. Examples of such
efforts are
(a) a brief version of the CES–D (CES–D–7) administered to a
community
sample of adults, ages 18 to 80, living in a metropolitan area
(Herrero &
Garcia, 2007); (b) the Hospital Anxiety and Depression Scale
administered
to a sample of patients with various chronic diseases, including
a control
group of students and community participants (Quintana et al.,
2003); and
(c) the GDS administered to a sample of older adults 64 and
older treated
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an
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ol
og
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t
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.
in a primary care setting (Fernández-San Martín et al., 2002).
Considering
the strong support for the translated versions, perhaps future
studies should
focus on comparing U.S. Latinos with those from other Spanish-
speaking
countries to determine the reliability and validity of the scores
emerging from
the measure.
Third, a significant number of studies did not consider levels of
accul-
turative stress in determining the utility of a particular measure,
which
is surprising given the extensive research on the psychological
impact of
acculturation and acculturative stress (e.g., Hovey, 2000a,
2000b; Wiebe
& Penley, 2005). As such, it is recommended that a measure of
accultura-
tion and acculturative stress be included when examining the
psychometric
properties of any measure that assesses depression.
Fourth, measurement equivalency continues to be a challenge.
For
instance, there is a need to address gender differences reported
in the litera-
ture suggesting that some measures may not be appropriate to
use with males

(Posner et al., 2001; Rivera-Medina, Caraballo, Rodríguez-
Cordero, Bernal,
& Dávila-Marrero, 2010). Measurement equivalency includes
conducting
comparative studies within and across Latino subgroups, as well
as compar-
ing English and Spanish versions of the same measure (e.g.,
Crockett et al.,
2005). Although this is a complex process, it is necessary to
address this issue
to accurately screen, diagnose, and treat individuals.
Fifth, we found that few studies described the steps taken to
translate
a measure or the method(s) used. Considering that there are
regional vari-
ants of the Spanish language (i.e., various Spanish dialects) that
can result
in using different words to describe psychological phenomena,
it is impera-
tive that translation processes address this issue. Novy and
colleagues (2001)
provided a thorough description of various steps taken to
translate measures
that only had English versions, as well as measures that had
Spanish versions.
For instance, one of the steps involved a review of the measures
by a group
of bilingual individuals from various Latino subgroups (Mexico,
Central
America, and South America). Their elaborate method addressed
not only
the need to establish cultural equivalence of translated measures
but also
word or phrase equivalence. Thus, future attempts to establish
measurement

equivalency should incorporate similar translation approaches.
Sixth, more attention should be given to how language choice
influ-
ences the reporting of symptoms. Research has suggested that
the sever-
ity of symptoms is greater when assessment of bilinguals is
conducted in
Spanish compared with English (e.g., Guttfreund, 1990).
Therefore, the
severity of symptoms may be reported differently depending on
the lan-
guage being used.
Finally, computer-assisted methods of screening for depression
may be
a viable alternative. Some of the advantages noted are that it (a)
increases
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ol
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fo
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bu
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.

the accuracy and ease with which the test is administered and
reduces
possible human error and (b) may be more cost-effective by
streamlining the
screening process (González, 2008). For example, research has
shown that
a computerized Spanish version of the BDI–II has good
reliability and
validity (González & Shriver, 2004). Likewise, computer-
assisted meth-
ods developed by Gerardo González (2008), such as the Voice-
Interactive
Depression Assessment System, and the earlier work by Ricardo
Muñoz
and colleagues (e.g., Muñoz, McQuaid, González, Dimas, &
Rosales, 1999)
using voice recognition, demonstrate sound psychometric
properties.
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Available online at www.sciencedirect.com
ScienceDirect
Comprehensive Psychiatry 78 (2017) 107–114
www.elsevier.com/locate/comppsych
The role of anxiety sensitivity in reactivity to trauma cues in
treatment-seeking adults with substance use disorders
R. Kathryn McHugha,b,⁎, Kim L. Gratzc, Matthew T. Tullc
aDivision of Alcohol and Drug Abuse, McLean Hospital, 115
Mill Street, Belmont, MA 02478, United States
bDepartment of Psychiatry, Harvard Medical School, 25
Shattuck Street, Boston, MA 02115, United States
cDepartment of Psychology, University of Toledo, 2801 West
Bancroft Street, Toledo, OH 43606, United States
Abstract
Background: Exposure to traumatic events and posttraumatic
stress disorder (PTSD) are common among individuals with
substance use
disorders (SUDs). Although the presence of trauma exposure

and/or PTSD among those with SUDs is associated with a range
of negative
outcomes, much remains to be understood about the factors
contributing to these outcomes. Anxiety sensitivity (the
tendency to respond
fearfully to the signs and symptoms of anxiety) has been linked
to greater PTSD symptoms and the use of substances to cope
with PTSD
symptoms, and is a promising factor for understanding the
negative outcomes associated with co-occurring PTSD and
SUDs.
Methods: This study examined the association between anxiety
sensitivity and trauma cue reactivity among 194 trauma-exposed
patients
with SUDs (27.3% met criteria for current PTSD). Participants
completed ratings of negative affect and substance cravings
prior to and after
exposure to a personally-relevant trauma cue.
Results: Results indicated that anxiety sensitivity was
associated with greater emotional reactivity (but not craving
reactivity) to the trauma
cue; neither PTSD symptom severity nor PTSD diagnosis
moderated these associations. PTSD symptom severity was
associated with greater
emotional and craving reactivity to the trauma cue.
Conclusions: Results highlight the potential utility of targeting
anxiety sensitivity in treatments for trauma-exposed patients
with SUDs with
and without PTSD.
© 2017 Elsevier Inc. All rights reserved.
1. Introduction
Exposure to traumatic events is common among those
with substance use disorders (SUDs) [1,2], with studies
finding that more than 95% of patients with a SUD report a
history of trauma exposure [3,4]. Consequently, it is not

surprising that posttraumatic stress disorder (PTSD) is also
highly prevalent in this population [5,6]. For example,
almost half of the participants in a large SUD treatment study
either met full criteria for PTSD (25%) or had sub-threshold
PTSD (23%) [7]. The co-occurrence of PTSD and SUDs is
also associated with a range of negative consequences,
including SUD treatment dropout [8], quicker relapse to
substance use following treatment [3], more severe substance
⁎ Corresponding author at: McLean Hospital, 115 Mill Street
MS 222,
Belmont, MA 02478, United States.
E-mail address: [email protected] (R.K. McHugh).
http://dx.doi.org/10.1016/j.comppsych.2017.07.011
0010-440X/© 2017 Elsevier Inc. All rights reserved.
use [9,10], greater PTSD symptom severity [11], additional
psychiatric disorders [6,9], suicidal and non-suicidal
self-injurious behaviors [6,12], and risk-taking behavior
[13]. Furthermore, these findings are not necessarily unique
to the presence of a PTSD diagnosis; trauma exposure has
also been strongly associated with both problematic
substance use [14,15] and negative SUD treatment outcomes
[16]. In recent years, great progress has been made in
enhancing outcomes in this population, particularly through
the use of integrated treatments that concurrently target
symptoms of both PTSD and SUDs [17–19]. However,
much remains to be understood about the specific factors that
increase risk for negative outcomes among trauma-exposed
individuals with SUDs.
One factor that warrants attention in this regard is anxiety
sensitivity, or the tendency to respond fearfully to the signs
and symptoms of anxiety [20]. Anxiety sensitivity is
prospectively associated with the onset of anxiety disorders
[21,22], as well as the experience of PTSD symptoms

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108 R.K. McHugh et al. / Comprehensive Psychiatry 78 (2017)
107–114
[23–25]. In addition, individuals with PTSD exhibit elevated
levels of anxiety sensitivity [26], and higher anxiety
sensitivity is linked to greater PTSD symptom severity and
posttraumatic distress following trauma exposure [27,28].
Anxiety sensitivity is also associated with negative
reinforcement expectancies (i.e., the belief that using
substances will relieve distress) [29] and the use of
substances to cope with negative affect [30,31], including
among those with PTSD [32,33]. Higher anxiety sensitivity
has also been linked to greater PTSD severity in
cocaine-dependent adults [34] and worse treatment out-
comes among those with co-occurring PTSD and alcohol
dependence [25]. Furthermore, although much of the
research on anxiety sensitivity and substance use has utilized
nonclinical or unselected samples, anxiety sensitivity has
been linked to a number of negative substance use-related
outcomes, including alcohol problems among current
drinkers [35], treatment dropout among patients with
cocaine dependence [36], and benzodiazepine misuse in
patients with opioid use disorder [37]. Thus, anxiety
sensitivity appears to be a pertinent risk factor across an

array of substances of abuse.
Taken together, findings that anxiety sensitivity is
associated with greater PTSD symptom severity, poorer
outcomes, and the use of substances to cope with negative
affect suggest that anxiety sensitivity may be an important
vulnerability for negative outcomes among trauma-exposed
adults with SUDs. These findings are consistent with the
perspective that anxiety sensitivity may serve to amplify
affective responding to stressors. Anxiety sensitivity is
associated with greater emotional reactivity to stressors (e.g.,
repeated exposure to CO2-enriched air) [38] and the
development of psychiatric symptoms following a stressor
[39]. However, it is unknown whether anxiety sensitivity is
associated with amplified emotional or craving reactivity to
traumatic cues among those with SUDs. Among those with
SUDs who have been exposed to trauma, reminders of the
trauma increase both negative affect and substance cravings
[40–42]. If indeed anxiety sensitivity is a risk factor for
heightened reactivity to such cues, it would provide a
promising therapeutic target among trauma-exposed adults
with SUDs. Although anxiety sensitivity is a stable and
trait-like construct [43], it is modifiable with both behavioral
and pharmacological treatment [44,45]. Thus, better under-
standing of the role of anxiety sensitivity in negative
outcomes among those with co-occurring SUD and PTSD
may aid in the identification of at-risk patients, as well as
inform the development and refinement of treatment
approaches for this population.
Therefore, the aim of this study was to examine the
association between anxiety sensitivity and reactivity (both
emotional and craving-related) to trauma cue exposure
among trauma-exposed patients with SUDs. We hypothe-
sized that anxiety sensitivity would be associated with 1)
greater emotional reactivity (i.e., increase in negative affect)

and 2) greater craving reactivity (i.e., increase in substance
cravings) in response to a personally-relevant trauma cue. In
addition, given evidence that PTSD symptom severity may
moderate the association between anxiety sensitivity and
alcohol coping motives [32], we examined whether PTSD
symptom severity moderated the association between
anxiety sensitivity and trauma cue reactivity. Specifically,
we hypothesized that the association between anxiety
sensitivity and trauma cue reactivity would be stronger
among those with more severe PTSD symptoms.
2. Material and methods
2.1. Participants
Participants were recruited for this study from a
residential SUD treatment facility. Standard treatment at
this facility involves a mix of strategies from Alcoholics
Anonymous and Narcotics Anonymous, as well as a variety
of groups focused on relapse prevention, social skills, and
coping skills. The center requires complete abstinence from
drugs (including nicotine) and alcohol. Methadone mainte-
nance is not available. Drug testing is done, and any use
results in immediate dismissal from the facility. Aside from
scheduled activities, residents are not permitted to leave the
treatment facility. Contract durations for the treatment
facility average 30 days.
Eligibility criteria included: (1) age 18–65 years, (2) a
history of traumatic event exposure consistent with Criterion
A for PTSD as defined in the Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition (DSM-IV) [46], and
(3) a current diagnosis of DSM-IV alcohol and/or cocaine
dependence. Potential participants were excluded if they
exhibited significant cognitive impairment (Mini-Mental
State Exam score b24) [47] or were diagnosed with a current
psychotic disorder.

The study sample included 202 participants who were
eligible for the study and completed the experimental
sessions. Of this sample, 8 participants did not complete
the measure of anxiety sensitivity and were thus excluded
from analyses. This resulted in a final sample of 194
participants (50% female). The mean age of the sample
was 34.3 years (SD = 10.0). Participants identified their
race/ethnicity as: 60.3% White, 36.6% Black/African
American, and less than 2% each of Asian/Southeast
Asian, Hispanic/Latino, and Native American. Educa-
tional attainment was heterogeneous: 27.8% less than
high school, 34.5% high school graduate (or equivalent),
21.6% some college, 6.2% technical school, and 9.7%
college graduate or graduate school. The majority of the
sample was unemployed (66%), followed by employed
full-time (21.1%).
The sample consisted of 27.3% participants with a
diagnosis of PTSD, 26.3% with cocaine dependence,
33.0% with alcohol dependence, and 40.7% with both
cocaine and alcohol dependence.
109R.K. McHugh et al. / Comprehensive Psychiatry 78 (2017)
107–114
2.2. Procedures
The current study is a secondary analysis of data from a
study of trauma cue reactivity and risk-taking propensity
among trauma-exposed cocaine- and alcohol-dependent
patients receiving residential treatment for SUDs. Partici-
pants were recruited for a multi-session study.
All procedures were reviewed and approved by the

relevant Institutional Review Boards. Eligible partici-
pants were recruited for this study no sooner than 72 h
after entry into the facility (to limit the possible
interference of withdrawal symptoms on study engage-
ment). Patients dependent on cocaine and/or alcohol were
provided with information about the study. Those who
provided informed consent were then further screened
for eligibility.
Eligible participants completed a 3-session protocol.
These sessions were scheduled approximately 2 days apart.
In the first session, participants completed a series of
diagnostic interviews, including the Clinician-Administered
PTSD Scale [48,49] for PTSD diagnosis and the Structured
Clinical Interview for DSM-IV Diagnoses [50] for other
psychiatric diagnoses (including SUDs). Participants also
completed a battery of self-report questionnaires (see below).
Finally, participants were asked to complete a brief interview
about their most traumatic event to create a personalized
trauma script that would be used for cue exposure in a later
session. For those with PTSD, participants were asked about
their index traumatic event (i.e., the event from which their
PTSD diagnosis stemmed). Participants without a current
diagnosis of PTSD were asked to describe the potentially
traumatic event that was currently associated with the most
distress. The second and third sessions consisted of the cue
exposure, with presentation of either the personalized trauma
cue or a neutral cue (the order of these sessions was
counter-balanced). Participants were provided monetary
reimbursement for their participation.
The trauma cue protocol consisted of the development of
a personally relevant script that was audio-recorded by a
member of the research team and played to the participant
during the cue exposure. To generate the script, participants
were asked to picture the situation in their mind and try to

remember as vividly as possible what the event entailed and
their feelings at the time. Participants were then asked to
describe the incident in as much detail as possible. The
interviewer probed for key aspects of the event (e.g., time
and place of the event, as well as emotions, thoughts, and
bodily sensations experienced during the event). This
interview was recorded, transcribed, and then used to create
a 1-min audio recording of the event in first-person
present-tense. During the trauma cue exposure, participants
listened to the trauma script recording for 1 min, followed by
a 1-min visualization of the event. These procedures were
adopted from previous studies, and have been found to
reliably induce emotional responses in trauma-exposed
populations [51,52]. Self-reported negative affect and
substance cravings were assessed immediately before and
after presentation of the trauma cue (see Measures below).
2.3. Measures
The Clinician-Administered PTSD Scale for DSM-IV
(CAPS) [48,53] was used to assess current PTSD symptoms.
The CAPS is a structured clinician-administered measure of
PTSD diagnosis and symptom severity, and is widely used in
both research and clinical settings. It assesses the frequency
and intensity of the 17 DSM-IV PTSD symptoms (plus eight
associated symptoms). Frequency items are rated from 0
(never or none/not at all) to 4 (daily or almost every day or
more than 80%). Intensity items are rated from 0 (none) to 4
(extreme). Given evidence that PTSD is best represented as a
dimensional construct [54–56], we utilized overall CAPS
severity scores in the primary analyses. However, the Item
Severity ≥4 (ISEV4) rule, which requires that at least one
re-experiencing, three avoidance/emotional numbing, and
two hyperarousal symptoms have a severity rating (frequen-
cy + intensity) of ≥4, was also used to establish current
PTSD diagnoses. The CAPS has demonstrated strong

psychometric properties, including strong internal validity
and concurrent validity with other measures [53]. The
internal consistency of the CAPS total score in this sample
was excellent (Cronbach's alpha = .96).
The Anxiety Sensitivity Index 3 (ASI-3) [57] is an
18-item self-report measure of anxiety sensitivity, revised
from the Anxiety Sensitivity Index [20,58]. The ASI-3 has
demonstrated strong psychometric properties, including
strong reliability and validity in both clinical and
nonclinical samples [57]. The internal consistency reliabil-
ity of the ASI-3 in this sample was excellent (Cronbach's
alpha = .93).
Reactivity to the trauma cue was assessed using two
measures. The primary outcome for the current study was
self-reported state negative affect on the Positive and
Negative Affect Schedule (PANAS) [59], administered
immediately before and after the trauma script. The
PANAS is a 20-item self-report measure that includes
subscales for both positive and negative affect; however,
only the negative affect subscale was administered in this
study. The internal consistency of the PANAS negative
affect scale was strong (Cronbach's alpha ≥.85 at all time
points). Additionally, severity of cravings for substances was
assessed prior to and following the presentation of the trauma
script. Specifically, and consistent with past research (e.g.,
[60–62]; see also [63]), participants were asked to rate the
intensity of their cravings for substances “at this very
moment” using an 11-point Likert-type scale ranging from 0
(no cravings) to 10 (very strong cravings).
2.4. Data analysis
All variables of interest were first screened using
descriptive statistics to identify the appropriate statistical

approach. Manipulation checks were conducted to examine
Table 1
Participant demographic and clinical characteristics and
descriptive data.
PTSD diagnosis SUD diagnosis Total sample
No (n = 141) Yes (n = 53) t/χ2 Cocaine (n = 51) Alcohol (n =
64) Cocaine/alcohol (n = 79) F/χ2
Age (mean, SD) 33.9 (10.2) 35.4 (9.6) 0.31 33.5 (9.9) 34.1
(10.2) 35.0 (10.0) 0.70 34.3 (10.0)
Gender (% female) 48.9% 52.8% 0.23 70.60% 48.4% 38.0%
13.28* 50.0%
Race (%) 0.95 6.42*
White 62.4% 54.7% 47.1% 70.3% 60.8% 60.3%
Black/African American 35.5% 39.6% 49.0% 28.1% 35.4%
36.6%
Hispanic/Latino 2.1% 0.0% 3.9% 0.0% 1.3% 1.5%
Education 1.03 4.50
b High school 27.0% 30.2% 33.3% 28.1% 24.1% 27.8%
High school or GED 37.6% 26.4% 41.2% 28.1% 35.5% 34.5%
Some college 22.7% 18.9% 17.6% 25.0% 21.5% 21.6%
Technical school 4.3% 11.3% 2.0% 7.8% 7.6% 6.2%
College graduate 8.5% 13.2% 5.9% 11.0% 11.4% 9.7%
Employment 2.93 1.20
Full-time employed 20.6% 22.6% 19.60% 18.8% 24.1% 21.1%
Part-time employed 9.9% 1.9% 9.80% 14.1% 1.3% 7.7%
Unemployed 62.4% 75.5% 66.70% 60.9% 69.6% 66.0%

ASI-3 total (mean, SD) 20.3 (15.6) 27.3 (17.1) 2.71* 20.6
(15.2) 21.8 (16.4) 23.5 (16.9) 0.50 22.2 (16.3)
CAPS total (mean, SD) 8.3 (12.6) 71.0 (22.4) 24.45** 21.6
(31.3) 21.0 (30.8) 31.8 (33.3) 2.56 25.6 (32.2)
Note. * p b .05, ** p b .001; ASI-3 = Anxiety Sensitivity Index
3; CAPS = Clinician Administered PTSD Scale
107–114
the validity of the experimental manipulation and ensure that
the trauma cue elicited sufficient distress and cravings;
separate repeated-measures ANOVAs were used to examine
self-reported emotional and craving reactivity to the trauma
script. Effect sizes are reported as Cohen's d. To examine
whether anxiety sensitivity was associated with reactivity to
the trauma script, we conducted linear regressions with
post-script negative affect and craving variables serving as
the dependent variable and the ASI-3 as the focal
independent variable, controlling for pre-script negative
affect and craving variables (respectively), age, gender,
diagnosis of cocaine dependence, diagnosis of alcohol
dependence, and PTSD symptom severity (CAPS total
score). To determine whether the relation of anxiety
sensitivity to trauma cue reactivity was stronger among
those with greater PTSD severity, we added the CAPS by
ASI-3 interaction term to these analyses to investigate the
moderating role of PTSD. These interaction terms were
added as a second step in the regression analyses to
examine their contribution to the model (R2 change).
Variables included in the interaction term were
mean-centered. Standardized estimates are reported for
these regression models.
1 Results did not change when PTSD diagnosis was included in
the
model instead of PTSD symptom severity.

3. Results
Sample demographic and clinical characteristics are
presented in Table 1. Consistent with previous studies
[27,28], ASI-3 was significantly positively associated with
PTSD symptom severity (r = .25, p b .001) and higher
among those with a current diagnosis of PTSD (27.3%) than
those without (mean difference = −6.99, t [192] = −2.71,
p = .007). ASI-3 was not associated with SUD group
(F [2, 191] = 0.50, p = .55). The SUD groups differed
with respect to gender (higher representation of women in
the cocaine dependence group) and race (higher representa-
tion of White participants in the alcohol dependence group),
but did not differ with respect to other socio-demographic
variables or PTSD severity (see Table 1).
Manipulation checks indicated a significant increase in
self-reported negative affect (F [1,193] = 150.24, p b .001)
and substance cravings (F [1,189] = 35.57, p b .001) from
pre- to post-trauma cue among all participants. The
magnitude of effect for these changes was large for negative
affect (d = 0.92) and small for cravings (d = .23).
Results of the regression analysis examining the associ-
ation between ASI-3 and self-reported emotional reactivity
are presented in Table 2. Results revealed a significant
association between ASI-3 and post-script negative affect
(Beta = 0.20, t = 3.31, p b .001), such that higher anxiety
sensitivity was associated with greater post-script negative
affect. PTSD symptom severity was also associated with
greater post-script negative affect (Beta = 0.26, t = 4.21,
p b .001). The PTSD symptom severity by ASI-3 interaction
was not significant (p = .48).1
Results of the regression analysis examining craving
reactivity to the trauma cue are presented in Table 3. ASI-3

was not associated with post-script cravings (Beta = 0.04,
t = −0.92, p = .36). PTSD symptom severity was modestly
Table 2
Regression examining the association between anxiety
sensitivity and
post-script negative affect.
B t p R2
Step 1. Main effects 0.39
Age 0.12 2.01 .046
Gender −0.02 −0.39 .70
Alcohol use disorder −0.08 −1.24 .22
Cocaine use disorder -0.04 -0.63 .53
Pre-script negative affect 0.40 6.57 b.001
PTSD Symptom Severity (CAPS) 0.26 4.21 b.001
Anxiety Sensitivity Index (ASI) 0.20 3.31 b.001
Step 2. Interaction effects 0.39
ASI × PTSD 0.05 0.71 0.48
Note. Step 1 presents results prior to inclusion of the interaction
effect.
PTSD = posttraumatic stress disorder, CAPS = Clinician
Administered
PTSD Scale. B = standardized coefficient.
able 3
egression examining the association between anxiety sensitivity
and
ost-script craving.
B t p R2

tep 1. Main effects 0.70
Age −0.12 −2.74 .007
Gender 0.02 0.46 .65
Alcohol use disorder 0.04 0.76 .45
Cocaine use disorder 0.05 1.11 .27
Pre-script craving 0.78 18.13 b.001
PTSD Symptom Severity (CAPS) 0.09 2.09 .04
Anxiety Sensitivity Index (ASI) 0.04 0.92 .36
tep 2. Interaction effect 0.70
ASI × PTSD 0.07 1.55 .12
ote. SUD = substance use disorder, PTSD = posttraumatic stress
disorder,
APS = Clinician Administered PTSD Scale
107–114
associated with post-script cravings (Beta = 0.09, t = 2.09,
p = .04). Once again, the interaction between PTSD
symptom severity and ASI-3 was not significant (p = .12).2
4. Discussion
This secondary analysis examined the association be-
tween anxiety sensitivity, PTSD symptoms, and trauma cue
reactivity in a sample of trauma-exposed patients with
alcohol and/or cocaine dependence. Our results supported
the hypothesis that anxiety sensitivity would be associated
with trauma-cue reactivity. Specifically, anxiety sensitivity
was associated with greater self-reported emotional reactiv-
ity to the trauma script. This finding suggests that elevated
anxiety sensitivity may exacerbate distress reactions to
trauma cues following exposure to a traumatic stressor.
Notably, the type of substance use disorder (alcohol,
cocaine, or both) did not have a significant impact on
findings, providing further support for the applicability of

anxiety sensitivity across substances of abuse, including
stimulants [34,36,64].
Contrary to hypotheses, although exposure to the trauma
cue resulted in a significant increase in cravings, anxiety
sensitivity was not significantly associated with greater
cravings in response to the trauma cue above and beyond the
contribution of PTSD symptom severity. However, it is
important to note that the increase in cravings reported
following the trauma cue, although statistically significant,
was relatively small, which may have limited our power and
interfered with our ability to detect significant relations.
Future research utilizing more powerful trauma cues is
2 When PTSD diagnosis was included in the model instead of
PTSD
symptom severity, neither the main effects of ASI-3 and PTSD
diagnosis
nor their interaction were significantly associated with post-
script craving.
Exploratory analyses investigating the anxiety sensitivity by
symptom
cluster interaction similarly yielded no significant moderation
effects for
negative affect or substance cravings.
T
R
p
S
S
N
C
needed to clarify the relation of anxiety sensitivity to
trauma-cue related craving reactivity within this population.

Notably, and also contrary to hypotheses, neither PTSD
symptom severity nor PTSD diagnosis moderated the
relation of anxiety sensitivity to trauma-cue reactivity. The
absence of a significant interaction between PTSD symptom
severity and anxiety sensitivity in either model suggests that
the severity of PTSD symptoms did not modulate the
association between anxiety sensitivity and self-reported
reactivity to trauma cues. Overall, the results of this study
suggest that interventions aimed at targeting heightened
anxiety sensitivity among trauma-exposed individuals
with SUDs – regardless of PTSD severity – may help
decrease emotional reactivity in response to cues or
reminders of the traumatic event, potentially reducing risk
for a variety of negative outcomes observed within this
population (e.g., relapse).
PTSD symptom severity was also associated with greater
self-reported emotional and craving reactivity to the trauma
cue. This finding is consistent with past findings of
heightened emotional reactivity to personally-relevant trau-
ma cues among substance-dependent individuals with PTSD
[40–42] and suggests that trauma-exposed individuals who
go on to develop greater PTSD symptoms may be more
reactive to reminders of the traumatic event. Moreover, the
finding that greater PTSD symptom severity was associated
with greater cravings for substances following trauma cue
exposure is consistent with theories emphasizing a functional
relationship between PTSD symptoms and substance use
[65]. Nonetheless, it is important to note that the design of
this study precludes determining the precise nature of the
relation between PTSD and trauma cue reactivity, and it is
unclear if this reactivity preceded or followed the develop-
ment of PTSD symptoms. Future longitudinal research is
needed to clarify the role of emotional reactivity in the
development and maintenance of PTSD among trauma-

exposed patients with SUDs.
These findings have implications for the treatment of
trauma-exposed substance users. Anxiety sensitivity has
long been a core therapeutic target for panic disorder [66,67],
107–114
which shares both phenotypic [68,69] and genotypic [70]
overlap with PTSD. Cognitive-behavioral therapies have
been shown to effectively decrease anxiety sensitivity [45],
including in the context of PTSD [71]. Even an ultra-brief
(i.e., single session) treatment aimed at reducing anxiety
sensitivity has shown promise among trauma-exposed
individuals [72], and anxiety sensitivity-targeted interven-
tions have been associated with reductions in PTSD
symptoms [73]. Given that much of this research has been
conducted among individuals without SUDs, replication of
these findings in samples of trauma-exposed adults with
SUDs is needed to understand the potential impact of treating
anxiety sensitivity in this population.
There are several limitations to this study. First, given the
cross-sectional nature of the study, we cannot establish that
the observed level of anxiety sensitivity was consistent with
the level prior to the traumatic event. Moreover, it is not
possible to determine if either trauma exposure or the
development of PTSD was associated with an increase in
anxiety sensitivity. However, findings that anxiety sensitiv-
ity predicts the onset of anxiety disorders [21,22] and PTSD
symptoms [23–25], and is relatively stable over time [74,75]
somewhat mitigate this concern. It also warrants consider-
ation that our diagnostic interview for PTSD was designed to
assess DSM-IV diagnostic criteria for PTSD. The symptoms

associated with PTSD and the criteria for determining a
PTSD diagnosis changed with the publication of the DSM-5
[76]. Future studies are needed to examine these relations
among patients meeting DSM-5 criteria for PTSD. In
addition, this sample consisted of adults receiving residential
treatment for substance dependence and, thus, reflects a
relatively severe subset of those with SUDs. Replication of
these findings in samples with greater heterogeneity of SUD
severity is needed to establish their generalizability.
Additionally, less than 30% of the sample met criteria for a
current diagnosis of PTSD. Thus, it is possible that
associations unique to those with PTSD (relative to those
with exposure to trauma but no PTSD) may have been
obscured in the current sample. The absence of interaction
effects somewhat mitigate this concern; nonetheless, con-
sideration of the association between anxiety sensitivity and
trauma cue reactivity in samples with greater PTSD
symptoms and a higher proportion of PTSD is needed to
better understand the contribution of PTSD diagnosis to
this association. Finally, the sample was heterogeneous
with respect to the primary substance of abuse. Although
no differences based on SUD diagnosis were detected in
our analyses, consideration of the role of anxiety
sensitivity in trauma-cue reactivity and other negative
outcomes across different substance types is an important
topic for further study.
Anxiety sensitivity has been found to be associated with
PTSD diagnosis, symptom severity, and the use of
substances to cope with negative affect [24,26,27,33,77].
Among those with a SUD, both the presence of trauma
exposure and a PTSD diagnosis are associated with greater
SUD severity [7,9,15] and may contribute to ongoing
substance use to relieve PTSD-related negative affect and
somatic distress. The results of this study provide support for
the hypothesis that anxiety sensitivity amplifies emotional

reactivity to stress. As such, anxiety sensitivity may be a key
therapeutic target among trauma-exposed individuals with
SUDs to reduce risk for negative clinical outcomes
commonly observed within this population (e.g., relapse,
treatment dropout).
Acknowledgments
This work was supported by the National Institute of
Drug Abuse grants DA030587 and DA035297.
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The role of anxiety sensitivity in reactivity to trauma cues in
�treatment-seeking adults with substance use disorders1.
Introduction2. Material and methods2.1. Participants2.2.
Procedures2.3. Measures2.4. Data analysis3. Results4.
Discussionsection9AcknowledgmentsReferences
PROCEEDINGS PAPER
Broadening perspectives on trauma and recovery:
a socio-interpersonal view of PTSD$

Andreas Maercker* and Tobias Hecker
Division of Psychopathology and Clinical Intervention,
Department of Psychology, University of
Zurich, Zurich, Switzerland
Posttraumatic stress disorder (PTSD) is one of the very few
mental disorders that requires by definition an
environmental context*a traumatic event or events*as a
precondition for diagnosis. Both trauma sequelae
and recovery always occur in the context of
social�interpersonal contexts, for example, in interaction with
a partner, family, the community, and the society. The present
paper elaborates and extends the social�
interpersonal framework model of PTSD. This was developed to
complement other intrapersonally focused
models of PTSD, which emphasize alterations in an individual’s
memory, cognitions, or neurobiology. Four
primary reasons for broadening the perspective from the
individual to the interpersonal�societal contexts are
discussed. The three layers of the model (social affects, close
relationships, and culture and society) are outlined.
We further discuss additional insights and benefits of the
social�interpersonal perspective for the growing
field of research regarding resilience after traumatic
experiences. The paper closes with an outlook on therapy
approaches and interventions considering this broader
social�interpersonal perspective on PTSD.
Keywords: Post-traumatic stress disorder; interpersonal

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