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Home > Public Resources > Trauma Blog > 2021 - December > Why Me? Why Now? Abstract Thinking Predicts the Development of PTSD Symptoms in Student Paramedics

Why Me? Why Now? Abstract Thinking Predicts the Development of PTSD Symptoms in Student Paramedics

Aimee McKinnon, PhD, DClinPsy, Hjördis Lorenz, PhD, Paul Salkovskis, PhD, & Jennifer Wild, DClinPsy

December 15, 2021

What is abstract thinking and why is it important?

Imagine that you are a student paramedic. You arrive at the scene of an accident, recognise symptoms that you learnt about recently, but you cannot remember what you need to do next. What might go through your head? You might be thinking: "Why do I always struggle to remember important stuff? Why is this happening to me? What if I never learn this stuff?”

If you imagine this is happening to you and you are thinking in this way, how might you be feeling? These unhelpful thoughts indicate an abstract-analytical processing style (Ehring & Watkins, 2008). A tendency to approach stressful situations using abstract thinking might make you feel hopeless and frustrated and can lead to low mood (Ehring & Watkins, 2008; Stöber & Borkovec, 2002; Watkins & Moulds, 2007).

Now imagine the scenario again. You still cannot remember what you should do next, but instead you think: "Howcan I get help? How can I apply what I do know to this situation? What can I do to make the patient feel comfortable?" How might you be feeling then? These helpful thoughts indicate a concrete-experiential processing style. Approaching a stressful situation with concrete thoughts can lead to more helpful solutions, better problem solving (Watkins & Moulds, 2005), and feeling more in control. You could radio for support, shout for your mentor, begin to check their breathing and prevent bleeding, and you could reassure your patient.

Abstract thinking (‘why?’ and ‘what if?’ questions) characterises rumination and worry, a thinking style also referred to as repetitive negative thinking.  Ruminating on traumatic memories is a known risk factor for posttraumatic stress disorder (PTSD) (White & Wild, 2016). Understanding risk factors for PTSD is especially important for occupational groups who are often exposed to traumatic events due to the nature of their work, such as paramedics. 

Our study

Our study explored whether an abstract thinking style operated as a risk factor for PTSD symptoms in student paramedics. The study was unique in investigating longitudinally whether a trait abstract thinking style in response to stressful ‘in the moment’ scenarios predicted PTSD symptoms. Student paramedics (N=89) from universities in the United Kingdom were assessed for baseline symptoms, abstract thinking, and cognitive responses to stressful memories. They were followed up for symptom reassessment 6 months later in their training. 

Our findings

All participants were exposed to a potentially traumatic event between baseline and follow-up, highlighting that trauma exposure is part of paramedic training. The most reported work-related traumatic events included witnessing others die or being seriously hurt, being threatened, witnessing, or coming across suicide, traffic accidents, and experiencing assault. The study found that the tendency to think abstractly in response to stress predicted the development of PTSD symptoms 6 months later. An abstract thinking style explained more variation in the symptoms observed at follow-up than could be predicted by initial symptoms or trauma history alone. 

What does this mean and what we do about it?

An individual who adopts an abstract processing style during stress, such as thinking about why an event is happening to them and the potential negative meaning of this, may be at greater risk of developing PTSD symptoms. This could be happening through multiple mechanisms. Abstract processing may disrupt the formation of a coherent, concrete narrative, making intrusive memories more likely. Since abstract thinking appears to strengthen negative appraisals and emotions, and enhance post-trauma anxiety, it’s clear how this form of thinking would be unhelpful in the aftermath of an extremely stressful event. Like rumination, abstract thinking contributes to risk and maintenance of PTSD.

Our study builds on previous work suggesting that abstract processing mode and abstract rumination are risk factors for PTSD (Michael et al., 2007; Wild et al., 2016)). Abstract thinking is a particularly interesting and relevant risk factor as it is modifiable – we can train people to think more concretely (White & Wild, 2016).  This creates a unique opportunity: We can target modifiable factors (things other than sex, age, history) in prevention or resilience interventions to help reduce the likelihood of PTSD developing for people, such as paramedics, police officers, fire fighters and emergency healthcare workers, who encounter traumatic events in their line of work.

Target Article

McKinnon, A., Lorenz, H., Salkovskis, P., & Wild, J. (2021). Abstract thinking as a risk factor for the development of posttraumatic stress disorder symptoms in student paramedicsJournal of traumatic stress.

Discussion Questions

  1. Is this risk factor specific to PTSD? Why/ why not?
  2. How could addressing risk factors early help paramedics and other emergency workers?
  3. Which other evidence-based risk factors should be addressed in at-risk populations? 

About the Authors

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Aimee McKinnon 
(PhD, DClinPsy) is a clinical research psychologist at the Oxford Centre for Anxiety Disorders and Trauma at the University of Oxford. Her PhD and DClinPsy research were focussed on traumatic stress, and she currently works on developing and expanding a model of early intervention for PTSD and depression in NHS healthcare workers affected by the COVID-19 pandemic, led by Dr Wild.

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Hjördis Lorenz
 (PhD) is a doctoral candidate in clinical psychology at the Oxford Institute of Clinical Psychology Training. Prior to this, she completed a PhD in Experimental Psychology at the University of Oxford, focusing on wellbeing and preventing PTSD in student paramedics.  Dr Lorenz developed and validated the Concrete and Abstract Thinking measure (CAT) for student paramedics, as part of her PhD. Her clinical experience and research interests focus on populations at high risk for PTSD.
 
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Paul Salkovskis (PhD) is the director of the Oxford Institute of Clinical Psychology Training and the Oxford Centre for Psychological Health and Professor of Clinical Psychology at the University of Oxford, department of Experimental Psychology. He has a long-standing career and publication record focused on obsessive compulsive disorder, as well as expertise in cognitive behaviour therapy for anxiety disorders, including panic, agoraphobia, and health anxiety. 
 
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Jennifer Wild (DClinPsy) is a Consultant Clinical Psychologist and Associate Professor at the University of Oxford, working in the Oxford Centre for Anxiety Disorders and Trauma. She has 25 years of experience working with emergency workers and is currently leading trials on preventing PTSD and depression in paramedics and healthcare workers. Dr Wild's research is supported by MQ and the Oxford Health NIHR Biomedical Research Centre.

References Cited

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy38(4), 319–345. https://doi.org/10.1016/S0005-7967(99)00123-0 
Ehring, T., & Watkins, E. R. (2008). Repetitive negative thinking as a transdiagnostic process. International Journal of Cognitive Therapy1(3), 192–205. https://doi.org/10.1521/ijct.2008.1.3.192

Laposa, J. M., & Rector, N. A. (2012). The prediction of intrusions following an analogue traumatic event: Peritraumatic cognitive processes and anxiety-focused rumination versus rumination in response to intrusions. Journal of Behavior Therapy and Experimental Psychiatry43(3), 877–883. https://doi.org/10.1016/j.jbtep.2011.12.007

Michael, T., Halligan, S. L., Clark, D. M., & Ehlers, A. (2007). Rumination in posttraumatic stress disorder. Depression and Anxiety24(5), 307–317. https://doi.org/10.1002/da.20228

Stöber, J., & Borkovec, T. D. (2002). Reduced concreteness of worry in generalized anxiety disorder: Findings from a therapy study. Cognitive Therapy and Research26(1), 89–96. https://doi.org/10.1023/A:1013845821848

Watkins, E. R., & Moulds, M. (2005). Distinct modes of ruminative self-focus: Impact of abstract versus concrete rumination on problem solving in depression. Emotion5(3), 319–328. https://doi.org/10.1037/1528-3542.5.3.319

Watkins, E. R., & Moulds, M. L. (2007). Reduced concreteness of rumination in depression: A pilot study. Personality and Individual Differences43(6), 1386–1395. https://doi.org/10.1016/j.paid.2007.04.007

White, R., & Wild, J. (2016). “Why” or “how”: The effect of concrete versus abstract processing on intrusive memories following analogue trauma. Behavior Therapy47(3), 404–415. https://doi.org/10.1016/j.beth.2016.02.004

Wild, J., Smith, K. V., Thompson, E., Béar, F., Lommen, M. J. J., & Ehlers, A. (2016). A prospective study of pre-trauma risk factors for post-traumatic stress disorder and depression. Psychological Medicine46(12), 2571–2582. https://doi.org/10.1017/S0033291716000532