Abstract
The COVID-19 epidemic is a novel collective traumatic event. Different types of traumatic events lead to different symptomatic structures of posttraumatic stress disorder (PTSD). To understand the symptom structure of PTSD in the context of this particular traumatic event and its possible development, we explored the interrelationships among PTSD symptoms and the interrelationships between PTSD symptoms and anxiety, depression, suicidal ideation, and quality of life. Participants were recruited from the psychological assistance hotline platform based at Central China Normal University. 308 participants who met the provisional diagnosis of PTSD were included in the analysis. This study estimated the interrelationships among PTSD symptoms, with the symptom in addition to four covariates of anxiety, depression, suicidal ideation, and quality of life by network analysis to construct Gaussian graphical models and directed acyclic graphs. The core of the PTSD symptom network was nightmares. Five pairs of symptoms showed the strongest connections: Hypervigilance and exaggerated startle response, avoidance of thoughts and avoidance of reminders, negative beliefs and negative trauma-related emotions, nightmares and flashbacks, and flashbacks and emotional cue reactivity. The network did not change significantly with the inclusion of anxiety, depression, suicidal ideation, and quality of life. Nightmares may be the core of the development of PTSD resulting from the COVID-19 epidemic. In this particular context, interventions for PTSD focus on nightmares may contribute to the relief of other symptoms and improve the efficiency and effectiveness of the intervention.
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The data sets analysed during the current study are available from the first author on reasonable request.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
Armour, C., Fried, E. I., Deserno, M. K., Tsai, J., & Pietrzak, R. H. (2017). A network analysis of DSM-5 posttraumatic stress disorder symptoms and correlates in U.S. military veterans. Journal of Anxiety Disorders, 45, 49–59. https://doi.org/10.1016/j.janxdis.2016.11.008
Birkeland, M. S., & Heir, T. (2017). Making connections: Exploring the centrality of posttraumatic stress symptoms and covariates after a terrorist attack. European Journal of Psychotraumatology, 8(sup3), 1333387. https://doi.org/10.1080/20008198.2017.1333387
Borsboom, D. (2017). A network theory of mental disorders. World Psychiatry, 16(1), 5–13. https://doi.org/10.1002/wps.20375
Borsboom, D., & Cramer, A. O. J. (2013). Network analysis an integrative approach to the structure of psychopathology. Annual Review of Clinical Psychology, 9, 91–121. https://doi.org/10.1146/annurev-clinpsy-050212-185608
Braule Pinto, A. L. C., Serpa, A. L. O., de Paula, J. J., Costa, D. S., Robis, K., Diaz, A. P., Joaquim, R. M., Da Silva, A. G., de Miranda, D. M., & Malloy-Diniz, L. F. (2021). Increased risk of health professionals to feel traumatized during the COVID-19 pandemic. Scientific Reports, 11(1). https://doi.org/10.1038/s41598-021-97783-6
Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic stress disorder. Clinical Psychology Review, 23(3), 339–376. https://doi.org/10.1016/S0272-7358(03)00033-3
Bridgland, V. M. E., Moeck, E. K., Green, D. M., Swain, T. L., Nayda, D. M., Matson, L. A., Hutchison, N. P., & Takarangi, M. K. T. (2021). Why the COVID-19 pandemic is a traumatic stressor. PLoS One, 16(1), e0240146. https://doi.org/10.1371/journal.pone.0240146
Chao, M., Xue, D., Liu, T., Yang, H., & Hall, B. J. (2020). Media use and acute psychological outcomes during COVID-19 outbreak in China. Journal of Anxiety Disorders, 74, 102248. https://doi.org/10.1016/j.janxdis.2020.102248
Ehlers, A. (2015). Intrusive reexperiencing in posttraumatic stress disorder: Memory processes and their implications for therapy. Clinical Perspectives on Autobiographical Memory, 12, 109–132.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319–345. https://doi.org/10.1016/S0005-7967(99)00123-0
Eli, B., Liang, Y., Chen, Y., Huang, X., & Liu, Z. (2021). Symptom structure of posttraumatic stress disorder after parental bereavement–a network analysis of Chinese parents who have lost their only child. Journal of Affective Disorders, 295, 673–680. https://doi.org/10.1016/j.jad.2021.08.123
Epskamp, S., Cramer, A. O., Waldorp, L. J., Schmittmann, V. D., & Borsboom, D. (2012). Qgraph: Network visualizations of relationships in psychometric data. Journal of Statistical Software, 48, 1–18. https://doi.org/10.18637/jss.v048.i04
Epskamp, S., Borsboom, D., & Fried, E. I. (2017). Estimating psychological networks and their accuracy: A tutorial paper. Behavior Research Methods, 50(1), 195–212. https://doi.org/10.3758/s13428-017-0862-1
Fried, E. I., Eidhof, M. B., Palic, S., Costantini, G., Dijk, H. M. H., Bockting, C. L. H., Engelhard, I., Armour, C., Nielsen, A. B. S., & Karstoft, K. (2018). Replicability and generalizability of PTSD networks: A cross-cultural multisite study of PTSD symptoms in four trauma patient samples. Clinical Psychological Science, 6(3), 335–351. https://doi.org/10.17605/OSF.IO/2T7QP
Fruchterman, T. M. J., & Reingold, E. M. (1991). Graph drawing by force-directed placement. Software, Practice & Experience, 21(11), 1129–1164. https://doi.org/10.1002/spe.4380211102
Galatzer-Levy, I. R., & Bryant, R. A. (2013). 636,120 ways to have posttraumatic stress disorder. Perspectives on Psychological Science, 8(6), 651–662. https://doi.org/10.1177/1745691613504115
Gamonal-Limcaoco, S., Montero-Mateos, E., Lozano-Lopez, M. T., Macia-Casas, A., Matias-Fernandez, J., & Roncero, C. (2021). Perceived stress in different countries at the beginning of the coronavirus pandemic. International Journal of Psychiatry in Medicine, 57(4), 309–322. https://doi.org/10.1177/00912174211033710
Haslbeck, J., & Waldorp, L. J. (2015). mgm: Estimating time-varying mixed graphical models in high-dimensional data. arXiv preprint arXiv:1510.06871. https://doi.org/10.48550/arXiv.1510.06871
Ho, C. S., Chee, C. Y., & Ho, R. C. (2020). Mental health strategies to combat the psychological impact of coronavirus disease 2019 (COVID-19) beyond paranoia and panic. Annals of the Academy of Medicine, Singapore, 49(3), 155–160.
Hofmann, S. G., Curtiss, J., & McNally, R. J. (2016). A complex network perspective on clinical science. Perspectives on Psychological Science, 11(5), 597–605. https://doi.org/10.1177/1745691616639283
Hoge, C. W., Riviere, L. A., Wilk, J. E., Herrell, R. K., & Weathers, F. W. (2014). The prevalence of posttraumatic stress disorder (PTSD) in US combat soldiers: A head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist. The Lancet Psychiatry, 1(4), 269–277. https://doi.org/10.1016/S2215-0366(14)70235-4
Horesh, D., & Brown, A. D. (2020). Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities. Psychological Trauma: Theory, Research, Practice, and Policy, 12(4), 331–335. https://doi.org/10.1037/tra0000592
Hsing, A., Zhang, J. S., Peng, K., Lin, W., Wu, Y., Hsing, J. C., LaDuke, P., Heaney, C., Lu, Y., & Lounsbury, D. W. (2020). A rapid assessment of psychological distress and well-being: Impact of the COVID-19 pandemic and shelter-in-place. Available at SSRN 3578809.
Jiang, W., Ren, Z., Yu, L., Tan, Y., & Shi, C. (2020). A network analysis of posttraumatic stress disorder symptoms and correlates during the COVID-19 pandemic. Frontiers in Psychiatry, 11, 568037. https://doi.org/10.3389/fpsyt.2020.568037
Jones, P. J., Mair, P., Riemann, B. C., Mugno, B. L., & McNally, R. J. (2018). A network perspective on comorbid depression in adolescents with obsessive-compulsive disorder. Journal of Anxiety Disorders, 53, 1–8. https://doi.org/10.1016/j.janxdis.2017.09.008
Kroenke, K., Spitzer, R. L., & Williams, J. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64(2), 258–266. https://doi.org/10.1097/00006842-200203000-00008
Lazarov, A., Suarez-Jimenez, B., Levi, O., Coppersmith, D. D. L., Lubin, G., Pine, D. S., Bar-Haim, Y., Abend, R., & Neria, Y. (2020). Symptom structure of PTSD and co-morbid depressive symptoms – A network analysis of combat veteran patients. Psychological Medicine, 50(13), 2154–2170. https://doi.org/10.1017/S0033291719002034
Le, X. T. T., Dang, A. K., Toweh, J., Nguyen, Q. N., Le, H. T., Do, T. T. T., Phan, H. B. T., Nguyen, T. T., Pham, Q. T., Ta, N. K. T., Nguyen, Q. T., Nguyen, A. N., Van Duong, Q., Hoang, M. T., Pham, H. Q., Vu, L. G., Tran, B. X., Latkin, C. A., Ho, C. S. H., & Ho, R. C. M. (2020). Evaluating the psychological impacts related to COVID-19 of Vietnamese people under the first Nationwide partial lockdown in Vietnam. Frontiers in Psychiatry, 11, 824. https://doi.org/10.3389/fpsyt.2020.00824
Mancini, A. D., Littleton, H. L., Grills, A. E., & Jones, P. J. (2019). Posttraumatic stress disorder near and far: Symptom networks from 2 to 12 months after the Virginia Tech campus shootings. Clinical Psychological Science, 7(6), 1340–1354. https://doi.org/10.1177/2167702619859333
McNally, R. J., Robinaugh, D. J., Wu, G. W. Y., Wang, L., Deserno, M. K., & Borsboom, D. (2015). Mental disorders as causal systems. Clinical Psychological Science, 3(6), 836–849. https://doi.org/10.1177/2167702614553230
McNally, R. J., Heeren, A., & Robinaugh, D. J. (2017). A Bayesian network analysis of posttraumatic stress disorder symptoms in adults reporting childhood sexual abuse. European Journal of Psychotraumatology, 8(sup3), 1341210–1341276. https://doi.org/10.1080/20008198.2017.1341276
Mihashi, M., Xin, Y., Otsubo, Y., Nagatomi, K., Hoshiko, M., & Ishitake, T. (2009). Predictive factors of psychological disorder development during recovery following SARS outbreak. Health Psychology, 28(1), 91–100. https://doi.org/10.1037/a0013674
Phillips, R. D., Wilson, S. M., Sun, D., & Morey, R. (2018). Posttraumatic stress disorder symptom network analysis in U.S. military veterans: Examining the impact of combat exposure. Frontiers. Psychiatry, 9, 608. https://doi.org/10.3389/fpsyt.2018.00608
Price, M., Legrand, A. C., Brier, Z. M. F., & Hébert-Dufresne, L. (2019). The symptoms at the center examining the comorbidity of posttraumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Journal of Psychiatric Research, 109, 52–58. https://doi.org/10.1016/j.jpsychires.2018.11.016
Rodebaugh, T. L., Tonge, N. A., Piccirillo, M. L., Fried, E., Horenstein, A., Morrison, A. S., Goldin, P., Gross, J. J., Lim, M. H., & Fernandez, K. C. (2018). Does centrality in a cross-sectional network suggest intervention targets for social anxiety disorder? Journal of Consulting and Clinical Psychology, 86(10), 831–844. https://doi.org/10.1037/ccp0000336
Rossi, R., Socci, V., Talevi, D., Niolu, C., Pacitti, F., Di Marco, A., Rossi, A., Siracusano, A., Di Lorenzo, G., & Olff, M. (2021). Trauma-spectrum symptoms among the Italian general population in the time of the COVID-19 outbreak. European Journal of Psychotraumatology, 12(1), 1855888. https://doi.org/10.1080/20008198.2020.1855888
Scutari, M. (2010). Learning Bayesian networks with the bnlearn R package. Journal of Statistical Software, 35, 1–22. https://doi.org/10.48550/arXiv.0908.3817
Scutari, M., & Nagarajan, R. (2013). Identifying significant edges in graphical models of molecular networks. Artificial Intelligence in Medicine, 57(3), 207–217. https://doi.org/10.1016/j.artmed.2012.12.006
Soh, H. L., Ho, R. C., Ho, C. S., & Tam, W. W. (2020). Efficacy of digital cognitive behavioural therapy for insomnia: A meta-analysis of randomised controlled trials. Sleep Medicine, 75, 315–325. https://doi.org/10.1016/j.sleep.2020.08.020
Spiller, T. R., Schick, M., Schnyder, U., Bryant, R. A., Nickerson, A., & Morina, N. (2017). Symptoms of posttraumatic stress disorder in a clinical sample of refugees: A network analysis. European Journal of Psychotraumatology, 8(sup3), 1318032. https://doi.org/10.1080/20008198.2017.1318032
Sullivan, C. P., Smith, A. J., Lewis, M., & Jones, R. T. (2018). Network analysis of PTSD symptoms following mass violence. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 58–66. https://doi.org/10.1037/tra0000237
Tang, W., Hu, T., Hu, B., Jin, C., Wang, G., Xie, C., Chen, S., & Xu, J. (2020). Prevalence and correlates of PTSD and depressive symptoms one month after the outbreak of the COVID-19 epidemic in a sample of home-quarantined Chinese university students. Journal of Affective Disorders, 274, 1–7. https://doi.org/10.1016/j.jad.2020.05.009
Tee, M. L., Tee, C. A., Anlacan, J. P., Aligam, K. J. G., Reyes, P. W. C., Kuruchittham, V., & Ho, R. C. (2020). Psychological impact of COVID-19 pandemic in the Philippines. Journal of Affective Disorders, 277, 379–391. https://doi.org/10.1016/j.jad.2020.08.043
Wang, W., Bian, Q., Zhao, Y., Li, X., Wang, W., Du, J., Zhang, G., Zhou, Q., & Zhao, M. (2014). Reliability and validity of the Chinese version of the patient health questionnaire (PHQ-9) in the general population. General Hospital Psychiatry, 36(5), 539–544. https://doi.org/10.1016/j.genhosppsych.2014.05.021
Wang, S. B., Jones, P. J., Dreier, M., Elliott, H., & Grilo, C. M. (2019). Core psychopathology of treatment-seeking patients with binge-eating disorder: A network analysis investigation. Psychological Medicine, 49(11), 1923–1928. https://doi.org/10.1017/S0033291718002702
Wang, C., Chudzicka-Czupała, A., Grabowski, D., Pan, R., Adamus, K., Wan, X., Hetnał, M., Tan, Y., Olszewska-Guizzo, A., Xu, L., McIntyre, R. S., Quek, J., Ho, R., & Ho, C. (2020a). The association between physical and mental health and face mask use during the COVID-19 pandemic: A comparison of two countries with different views and practices. Frontiers in Psychiatry, 11, 569981. https://doi.org/10.3389/fpsyt.2020.569981
Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., & Ho, R. C. (2020b). Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of Environmental Research and Public Health, 17(5), 1729. https://doi.org/10.3390/ijerph17051729
Wang, C., Chudzicka-Czupala, A., Tee, M. L., Nunez, M., Tripp, C., Fardin, M. A., Habib, H. A., Tran, B. X., Adamus, K., Anlacan, J., Garcia, M., Grabowski, D., Hussain, S., Hoang, M. T., Hetnal, M., Le, X. T., Ma, W., Pham, H. Q., Reyes, P., et al. (2021a). A chain mediation model on COVID-19 symptoms and mental health outcomes in Americans, Asians and Europeans. Scientific Reports, 11(1), 6481. https://doi.org/10.1038/s41598-021-85943-7
Wang, C., Fardin, M. A., Shirazi, M., Pan, R., Wan, X., Tan, Y., Xu, L., McIntyre, R. S., Tran, B., Quek, T. T. C., Husain, S. F., Wang, J., Ho, C., & Ho, R. (2021b). Mental health of the general population during the 2019 coronavirus disease (COVID-19) pandemic: A tale of two developing countries. Psychiatry International, 2(1), 71–84. https://doi.org/10.3390/psychiatryint2010006
Wang, C., López-Núñez, M. I., Pan, R., Wan, X., Tan, Y., Xu, L., Choo, F., Ho, R., Ho, C., & Aparicio García, M. E. (2021c). The impact of the COVID-19 pandemic on physical and mental health in China and Spain: Cross-sectional study. JMIR Formative Research, 5(5), e27818. https://doi.org/10.2196/27818
Wang, C., Tripp, C., Sears, S. F., Xu, L., Tan, Y., Zhou, D., Ma, W., Xu, Z., Chan, N. A., Ho, C., & Ho, R. (2021d). The impact of the COVID-19 pandemic on physical and mental health in the two largest economies in the world: A comparison between the United States and China. Journal of Behavioral Medicine, 44(6), 741–759. https://doi.org/10.1007/s10865-021-00237-7
Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220–233. http://www.jstor.org/stable/3766749
Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., Schnurr, P.P. (2013). The PTSD checklist for DSM-5 (PCL-5). Scale available from the national center for PTSD. Retrieved from http://www.ptsd.va.gov. (Accessed on 10 May 2020).
Zhang, M. W. B., & Ho, R. C. M. (2017). Moodle: The cost effective solution for internet cognitive behavioral therapy (I-CBT) interventions. Technology and Health Care, 25(1), 163–165. https://doi.org/10.3233/THC-161261
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
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The authors are grateful to the Mental Health Service Platform at Central China Normal University, Ministry of Education for data collecting.
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This work was supported by the National Natural Science Foundation of China (grant no. 32171086) and Philosophy and Social Sciences Research Project of the Education Department of Hubei Province, China.
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Zhao, C., Jiang, W., Zhang, H. et al. Exploring the development of posttraumatic stress disorder symptoms in COVID-19 epidemic in China: a network analysis. Curr Psychol 43, 18701–18710 (2024). https://doi.org/10.1007/s12144-023-04862-0
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DOI: https://doi.org/10.1007/s12144-023-04862-0