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Abstract

Background:

The number of Shidu parents in China is significant and expected to continue increasing. The psychological status of Shidu parents deserves more attention.

Objective:

Our objective is to investigate the impact of post-traumatic stress disorder and attachment styles among Shidu parents on post-traumatic growth, with the aim of providing valuable insights for alleviating post-traumatic stress disorder symptoms and enhancing levels of post-traumatic growth following trauma.

Design:

Demographic data, the Revised Adult Attachment Scale, the Posttraumatic Stress Disorder Checklist for DSM-5, and the post traumatic growth inventory were used to investigated 297 Shidu parents.

Method:

Two samples t-test was employed to evaluate disparities in post-traumatic growth inventory scores based on post-traumatic stress disorder and diverse attachment styles. Pearson’s correlation analysis was used to investigate the association between Post-traumatic Stress Disorder Checklist for DSM-5 scores and post-traumatic growth inventory scores, as well as the association between different attachment styles and post-traumatic growth inventory scores. We performed multiple mediator analyses to further confirm the influence of post-traumatic stress disorder and attachment styles on post-traumatic growth inventory.

Results:

(1) A total of 35% of the people tested positive for post-traumatic stress disorder; (2) A total of 56.9% of the participants exhibited secure attachment, while 43.1% exhibited insecure attachment; (3) The results unveiled a substantial negative correlation between the Posttraumatic Stress Disorder Checklist for DSM-5 scores and the post traumatic growth inventory scores; (4) A significant positive correlation was evident in relation to attachment dependence/closeness and post-traumatic growth inventory, while a significant negative correlation was established between attachment anxiety and post-traumatic growth inventory.

Conclusion:

Our study suggests that post-traumatic growth inventory is associated with post-traumatic stress disorder and attachment styles in Shidu parents. It might offer new insights into influencing levels of post-traumatic growth through post-traumatic stress disorder intervention.

Keywords

Attachment styles post-traumatic stress disorder post-traumatic growth Shidu parents

Introduction

Shidu parents (SDP) are defined as couples who have experienced the loss of their sole child due to illness or accidents and are no longer of childbearing age.¹ The implementation of China’s one-child policy in the late 1970s has resulted in a significant increase in the number of SDP in China.² Some studies have predicted that the overall number of SDP in China will exceed 10 million by 2035.³ In Chinese society, influenced by Confucianism, not having offspring is regarded as one of the most disrespectful act toward parents.⁴ Influenced by this view, SDP in China may experience greater mental trauma than the loss of other family members. Previous researches have reported that SDP are associated with anxiety, depression and PTSD.^2,3

Post-traumatic stress disorder (PTSD) is a psychiatric illness that arises from exposure to severe psychological trauma, characterized by symptoms such as re-experiencing, avoidance, negative emotions and cognitive changes, as well as hyperarousal.⁵ According to the definition in Diagnostic and Statistical Manual (DSM-5), a diagnosis of PTSD must meet Criterion A, the exposure criterion, which means that the individual must have been exposed to, either directly or indirectly, an actual or threatened death, serious injury, or sexual violence.⁶ It is a reflection of people serious psychological trauma and can persist for years or even decades in some survivors of trauma exposure.⁷ PTSD is associated with increasing incidence of depression, suicide attempts, anxiety, sleep problems, hopelessness, and guilt.^8–10

Post-traumatic growth (PTG) can be defined as the positive adaptations that emerge as a result of a traumatic experience.^5,11 It is often accompanied by mental trauma. After experiencing a crisis, people tend to exhibit higher and more significant PTG.^11,12 According to the research of other scholars, PTG can be reflected in five aspects, including (1) appreciation of others; (2) greater sense of personal strength (PS); (3) closer relationships; (4) perception of new opportunities; and (5) spirituality or religion.¹³ It is important to note that the concept of PTG is a topic of contention among researchers. Due to factors such as flaws in measurement tools, emotional biases, and cultural influences, it is possible that the majority of self-reported instances of PTG may be exaggerated. Recent reviews, such as the commentary by Boals,¹⁴ suggest that perceived PTG is often illusory rather than genuine. Approximately more than half of trauma victims report moderate or higher levels of PTG, yet studies indicate that much of this is illusory PTG. Previous studies have shown that the relationship between PTSD and PTG is complex. A meta-analysis¹⁵ examining the relationship between PTSD and PTG using Pearson’s correlation coefficients revealed a positive correlation (with an overall effect size estimate of 0.22). However, some studies have proposed that, as the positive and negative aspects of post-traumatic experiences, PTG and PTSD, often demonstrate a negative correlation.^16–18 Additionally, there have been reviews¹⁹ that have suggested a significant curvilinear relationship between PTSD and PTG, whereby moderate levels of PTG are associated with higher severity of PTSD symptoms, while lower and higher levels of PTG are associated with lower severity of PTSD symptoms.

In Bowlby’s attachment theory, the concept of “attachment style” is defined as the relatively stable relational structure that is established between children and their primary caregivers during their developmental stages.²⁰ Once established, attachment styles are typically considered to be enduring.²¹ According to Bowlby, adult attachment styles can be classified into two categories: secure and insecure. The latter is further subdivided into three subcategories: anxious, avoidant, and fearful attachment styles.²² Attachment theory is widely used to explain various psychiatric disorders.^23,24 Researches have demonstrated a significant correlation between attachment style and PTSD symptoms. Specifically, insecure attachment, notably attachment anxiety, exhibits a positive correlation with PTSD symptoms, whereas secure attachment displays a negative correlation. Furthermore, when compared to attachment avoidance, attachment anxiety demonstrates a stronger association with PTSD symptoms.^25,26 Emotion-focused therapy, an attachment-based approach, has shown promise in the treatment of PTSD in couples.²⁷ Further research examining the relationship between attachment, PTSD, and PTG may reveal the potential benefits of attachment-based psychotherapies for promoting PTG.

In summary, it is of significance to investigate the impact of PTSD and attachment styles on PTG. We collected data from SDP to analyze and examine the influence of PTSD and attachment styles on PTGI, with the hope that this research will contribute to guiding the alleviation of PTSD symptoms and enhancing the levels of PTG following trauma.

Methods

Data collection and samples

This cross-sectional study employed a stratified random sampling method to recruit and investigate the mental health status of parents who have lost their only child in two districts of Shanghai. The inclusion criteria were (1) losing the only child; (2) participants aged 50 years or older (considered to be beyond the typical female reproductive age); (3) no adoption of other children or fertility plans. The exclusion criteria were (1) individuals diagnosed with serious mental disorders, such as schizophrenia, by a qualified psychiatrist; (2) individuals with cognitive impairments, specifically those unable to understand and respond to questions. The sample size calculation was performed utilizing G-Power software, specifically version 3.1 (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany). Using an anticipated correlation coefficient of r = 0.2, a significance level of α = 0.05, and a desired statistical power of 1 − β = 0.90, an a priori analysis was conducted to determine the necessary sample size. The result of this analysis indicated that a sample size of N = 209 was required to achieve the desired statistical power and significance levels. The research team consisted of a professional psychology professor, two graduate students, and a social worker. The research team conducted face-to-face surveys with 297 parents who have lost their only child from 2015 to 2023. Prior to participating in the survey, all recruits signed a written informed consent form and were informed that they could halt or withdraw from the survey at any time. The ethical review for this study was conducted and approved by the Ethics Committee of Naval Medical University.

Measures

Demographic data collection

A self-administered scale was utilized to gather demographic and sociological information on subjects’ gender, age, education, marital status, religious belief, and period of bereavement of the only child.

The Revised Adult Attachment Scale

The Revised Adult Attachment Scale (RAAS) was developed and revised by Collins to measure types of adult attachment²⁸ and demonstrated adequate validity and reliability in China.²⁹ It consists of 18 questions in 3 dimensions, and uses a 5-point scale (1 for complete noncompliance and 5 for complete compliance) to calculate the scores for the 3 dimensions of closeness, dependence, and anxiety. The scale distinguishes between secure and insecure attachment based on the scores of these three dimensions. The dimensions of closeness and dependence were combined to form the composite dimension of closeness/dependence. Secure attachment was defined when the total closeness/dependence dimension score was greater than 36 and the anxiety dimension score was less than 18, with the remainder being insecure attachment. Based on the Cronbach’s alpha coefficient, the reliability of the RAAS scale in this study was 0.60 (closeness), 0.57(dependency), 0.80 (anxiety), and 0.72 (closeness/dependency).

Posttraumatic stress disorder checklist for DSM-5

The posttraumatic stress disorder checklist for DSM-5 (PCL-5) was developed in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnostic criteria for PTSD in conjunction with symptom descriptions.³⁰ The scale comprises 20 items and is scored on a 5-point scale. A total score of ⩾33 is indicative of symptom positivity for PTSD screening, with the results demonstrating a high degree of consistency with the DSM-V diagnosis. The scale was employed to subjectively assess the symptoms of PTSD in four subscales: B, C, D, and E.³¹ The criterion B is referred to as “reexperiencing symptoms,” with a total of five items. The criterion C is referred to as “avoidance symptoms” with a total of two items. The criterion D is referred to as “Negative Alterations in Cognitions and Mood,” with a total of seven entries. The criterion E is referred to as “Hyperarousal symptoms,” with a total of six entries. The Chinese version of the PCL-5 scale was validated by Cheng et al.,³² and they found that the seven-factor mixed model fitted better than the other models. The Chinese version of the PCL-5 scale has been extensively used among Chinese trauma populations³³ and has exhibited robust reliability and validity.³⁴ The internal consistency coefficients of the PCL-5 ranged from 0.87 to 0.94 in this study.

The post traumatic growth inventory

The post-traumatic growth inventory (PTGI) was revised by Tedeschi and Calhoun¹¹ and consists of 21 items. In this study, we utilized the revised Chinese version of the PTGI with 20 items,³⁵ which excluded the item “My religious beliefs have become stronger.” The original version was modified to utilize a 6-point Likert scale, ranging from 0 to 5 (with 0 representing complete noncompliance and 5 representing complete compliance). The total score was calculated to range from 0 to 100, with higher scores indicating higher levels of PTG. The scale reflects positive post-traumatic changes in five domains: New Possibilities (NP), Relating to Others (RO), PS, Spiritual Change (SC), and Appreciation of Life (AL). The Cronbach’s α coefficients for the consistency of the dimensions and total scales in this study were 0.83 (NP), 0.82 (RO), 0.79 (PS), 0.65 (SC), 0.87 (AL), and 0.95 (total scales).

Statistical analysis

The statistical analyses were conducted using the IBM SPSS 26.0 (IBM Corp., Armonk, NY) and the PROCESS 3.3 by Hayes. The program was employed to analyze basic descriptive statistics and the distribution of variables. The relationships between attachment, PTSD symptoms, and PTG were examined using t-tests, correlation analyses, and mediation analyses. To test the hypothesis that attachment plays a mediating role in the relationship between PTSD symptoms and PTGI scores, we employed the PROCESS 3.3 plugin in SPSS to conduct a mediation effect analysis. Based on the correlation analysis of each variable, we constructed a multiple mediation model with the PCL-5 total score as the independent variable, PTGI as the dependent variable, and the three sub-dimensions of RAAS (closeness, dependence, and anxiety) as the mediating variables. The p-value was set at less than 0.05, which was considered statistically significant.

Result

Descriptive statistics

The demographic and sociological information of the sample is presented in Table 1. In this study, a total of 297 SDP were investigated, with an average age of 66.49 ± 7.79 years. The mean duration of the loss of an only child was 10.68 ± 8.08 years. The study population consisted of 59.6% women and a male-to-female ratio of approximately 4:6. Eighteen (6.1%) of the SDP were over 80 years old. The largest age group was the 60–69 years, accounting for 49.5% of the total. Two hundred and eleven (71.04%) remained married, while 40 (13.5%) were widowed. Only 26 (8.75%) had university education or above. In contrast, 52.53% of the SDP had only completed junior high school. There are 20 parents who lost their only child within 1 year, accounting for 6.7% of the total. Seventy-six parents lost their only child between 1 year and 5 years, accounting for 25.6%; 67 parents lost their only child between 6 and 10 years, accounting for 22.6%; 47 parents lost their only child between 10 and 15 years, accounting for 15.8%; 87 parents lost their only child over 15 years, accounting for 29.3%. Only 39 (13.1) reported having a religious affiliation.

Table 1.

Sociology-demographic information of the study sample (n = 297).

Variables	N	%
Gender
Males	120	40.4
Females	177	59.6
Age (years)
50–59	59	19.9
60–69	147	49.5
70–79	73	24.6
⩾80	18	6.1
Marital status
Married	211	71.0
Divorced	27	9.1
Remarriage	19	6.4
Widowed	40	13.5
Education level
Junior high school or below	156	52.5
High school or technical secondary school	115	38.7
College/University or above	26	8.8
Religious belief
No	258	86.9
Yes	39	13.1
Period of bereavement of the only child (years)
<1	20	6.7
1–5	76	25.6
6–10	67	22.6
11–15	47	15.8
>15	87	29.3

Two samples t-test

The PCL-5 total score was 28.07 ± 16.11, and 104 (35%) of the sample exhibited positivity on the PTSD symptom screen with a cutoff of 33. The differences in sociodemographic variables among the groups categorized based on PCL-5 scores (below or above 33) are presented in Supplemental Material e-table 1. Two samples t-test was used to compare the differences in PTGI scores between the two groups. The findings are presented in Figure 1(a), which indicates that there are statistically significant differences in PTGI scores between the two groups. The RAAS scale was utilized to assess the adult attachment styles of the SDP. The mean score for the closeness/dependency composite dimension was 38.54 ± 6.57, while the mean score for the anxiety dimension was 13.87 ± 4.57. According to the established criteria, those with a closeness/dependency score above 36 points and an anxiety score below 18 points were classified into the secure attachment category. The results indicated that 169 (56.9%) of the participants exhibited secure attachment, while 128 (43.1%) demonstrated insecure attachment. The differences of sociodemographic variables between groups categorized by secure and insecure attachment are presented in Supplemental Material e-table 2. Two samples t-test was used to compare the differences in PTGI scores across various dimensions between the two groups. The findings are presented in Figure 1(b), which indicates that there are statistically significant differences in PTGI scores across various dimensions between the two groups. The SDP with secure attachment exhibited higher scores than those with insecure attachment on all dimensions of PTGI (p < 0.001).

Figure 1.

The impact of PCL-5 and attachment type on PTGI scores.

Pearson’s correlation analyses

The findings for Pearson’s correlation coefficients are shown in Table 2. The results demonstrated a statistically significant inverse correlation between the PCL-5 scores and the PTGI scores. A significant positive correlation was observed between attachment dependence/closeness and the total score and scores of each dimension of the PTGI. Conversely, a significant negative correlation was found between attachment anxiety and the total score and scores of each dimension of the PTGI. The correlation coefficients between RAAS-closeness and the dimensions of PTGI, including “NP,” “RO,” “PS,” “SC,” and “AL,” were 0.287, 0.312, 0.385, 0.286, and 0.385, respectively. The correlation coefficients between RAAS-dependence and each dimension of PTGI are 0.378, 0.434, 0.281, 0.291, and 0.347, respectively. The correlation coefficients between RAAS-anxiety and each dimension of PTGI are −0.332, −0.244, −0.450, −0.288, and −0.414, respectively.

Table 2.

Correlations between RAAS, PCL-5, and PTGI scores.

Variables	MEAN	SD	1	2	3	4	5	6	7	8	9	10	11	12	13	14
1. RAAS closeness	19.80	3.81	1.000
2. RAAS dependency	18.75	3.73	0.521**	1.000
3. RAAS anxiety	13.87	4.57	−0.574**	−0.374**	1.000
4. PCL-5 B	8.23	4.40	−0.228**	−0.157**	0.280**	1.000
5. PCL-5 C	3.68	2.34	−0.142*	−0.158**	0.130*	0.675**	1.000
6. PCL-5 D	8.90	6.29	−0.401**	−0.282**	0.487**	0.678**	0.583**	1.000
7. PCL-5 E	7.14	5.04	−0.355**	−0.283**	0.319**	0.686**	0.531**	0.692**	1.000
8. PCL-5 total	28.07	16.11	−0.356**	−0.266**	0.387**	0.883**	0.748**	0.888**	0.876**	1.000
9. PTGI NP	5.89	4.43	0.287**	0.378**	−0.332**	−0.298**	−0.198**	−0.438**	−0.365**	−0.399**	1.000
10. PTGI RO	5.14	3.74	0.312**	0.434**	−0.244**	−0.274**	−0.158**	−0.361**	−0.377**	−0.361**	0.782**	1.000
11. PTGI PS	6.09	3.75	0.385**	0.281**	−0.450**	−0.213**	−0.088	−0.392**	−0.353**	−0.339**	0.662**	0.628**	1.000
12. PTGI SC	6.83	4.18	0.286**	0.291**	−0.288**	−0.059	0.011	−0.279**	−0.198**	−0.181**	0.588**	0.584**	0.700**	1.000
13. PTGI AL	11.91	7.05	0.385**	0.347**	−0.414**	−0.237**	−0.062	−0.406**	−0.366**	−0.351**	0.739**	0.737**	0.855**	0.797**	1.000
14. PTGI total	35.86	20.48	0.380**	0.391**	−0.400**	−0.247**	−0.107	−0.429**	−0.379**	−0.372**	0.855**	0.840**	0.878**	0.840**	0.958**	1.000

PCL-5 B: re-experiencing; PCL-5C: avoidance; PCL-5 D: negative alterations in cognition and mood; PCL-5 E: hyper-arousal; NP: new possibilities; RO: relating to others; PS; personal strength; SC: spiritual change; AL: appreciation of life.

p < 0.05, ** p < 0.01.

Multiple mediator analyses

Based on the results of the correlation analysis, a mediation effect model with PTGI total score as the dependent variable, PCL-5 total score, and RAAS scores as the mediator variables was constructed to test the mediating role of attachment in PTSD symptoms and posttraumatic growth. The model also included demographic sociological factors as covariates, explaining a total of 32% of the PTGI total score (R-squared = 0.321, F = 16.852, p < 0.001). The parameter estimates along with the 95% CI for the total, direct, and specific indirect effects of PTSD symptoms on PTGI scores were presented in Table 3. RAAS-closeness, RAAS-dependence, and RAAS-anxiety were simultaneously added to the mediation model as the mediator variables (see Figure 2). The performed analysis revealed that RAAS-dependence and RAAS-anxiety had a significant mediating effect between PTSD symptoms and PTGI (total indirect effect = −0.177, SE = 0.045, 95% CI = −0.272 to −0.095). The direct effect of the impact of PTSD symptoms on PTGI was statistically significant (cʹ = −0.258, 95% CI: −0.400 to −0.116).

Table 3.

Unstandardized total, direct and indirect effect of PTSS on PTGI score through RAAS.

Effects on PTGI score	Variables	Effects	SE	p-Value	Bootstrap 95% CI
Effects on PTGI score	Variables	Effects	SE	p-Value	Lower	Upper
Total effect (c)	PCL-5 score	−0.435	0.070	<0.001	−0.572	−0.299
Direct effect (cʹ)	PCL-5 score	−0.258	0.072	<0.001	−0.400	−0.116
Indirect effect	Total	−0.177	0.045	<0.001	−0.272	−0.095
	RAAS-closeness	−0.033	0.034	0.2934	−0.104	0.029
	RAAS-dependency	−0.069	0.026	<0.001	−0.127	−0.025
	RAAS-anxiety	−0.075	0.035	0.016	−0.150	−0.013

Figure 2.

Multiple mediator model.

Discussion

In China, there exists a substantial population of SDP, and this number is projected to continue increasing.³⁶ While existing research has predominantly focused on the negative repercussions of Shidu trauma,^37,38 there has been limited attention given to the potential positive impacts. Consequently, our study seeks to examine the PTGI among SDP and its correlation with PTSD and attachment styles. We collected demographic data from SDP and employed two-sample t-tests to evaluate disparities in PTGI scores based on PTSD and diverse attachment styles. In addition, we conducted a Pearson’s correlation analysis to investigate the association between PCL-5 scores and PTGI scores, as well as the association between different attachment styles and PTGI scores. Furthermore, based on the results of our correlation analysis, we performed multiple mediator analyses to further confirm the influence of PTSD and attachment styles on PTGI.

In this study, the PCL-5 and RAAS was used to test PTSD levels and attachment styles of SDP. Thirty-five percent of the people tested positive for PTSD, much higher than the 7% positive rate in the normal population.³⁹ This may be related to the trauma caused by the loss of the only child.⁴⁰ Besides, the results indicated that 56.9% of the participants exhibited secure attachment, while 43.1% exhibited insecure attachment. A cutoff score of 33 on the PCL-5 scale was employed to divide the SDP into two groups: those with PCL-5 scores of 33 or above and those with PCL-5 scores below 33. A two-sample t-test was subsequently employed to ascertain the disparities in PTGI scale scores between the two groups. The findings indicated that parents with PCL-5 scores below 33 reported significantly higher PTGI scores. Furthermore, based on the RAAS scale, the SDP were categorized into two groups according to their attachment style: secure and insecure. A two-sample t-test was employed to compare the PTGI scale scores between these two attachment groups, and it was found that parents in the secure attachment group reported greater levels of PTG, as measured by the PTGI scale. It reveals a positive correlation between secure attachment and PTG, which is consistent with the results of related studies.^25,41

Furthermore, Pearson’s correlation analyses were employed for further investigation. The results unveiled a substantial negative correlation between the PCL-5 scores and the PTGI scores. This is consistent with some relevant research.⁴² A significant positive correlation was evident in relation to attachment dependence/closeness and both the overall score and scores of each dimension of the PTGI. Conversely, a significant negative correlation was established between attachment anxiety and both the total score and scores of each dimension of the PTGI. Depending on their relevance, we may discover strategies to aid trauma patients in ameliorating symptoms of PTSD and fostering their PTG.

Based on the relevant analysis results, we conducted multiple mediator analyses to explore the mediating role of attachment in relation to PTSD symptoms and PTG. Considering the influence of demographic factors, we take demographic sociological factors as covariates, which can also partially explain the total score of PTGI. The findings suggest that both attachment dependence and attachment anxiety significantly mediate the association between PTSD symptoms and PTGI. Furthermore, there is a statistically significant direct impact of PTSD symptoms on PTGI.

Acknowledging the limitations of our study is crucial, particularly when utilizing the PTGI scale to quantify posttraumatic growth in SDP. As previously documented in reviews, the questionnaire-based approach to assessing posttraumatic growth often tends to overestimate actual positive transformations, conflating genuine PTG with illusory positive changes that serve as coping mechanisms. Furthermore, the RAAS scale employed in this study exhibited a relatively lower reliability coefficient in comparison to the PCL-5 and PTGI scales, which could potentially exert a certain influence on our research findings.

Conclusion

The number of SDP in China is significant and expected to continue increasing, prompting concerns regarding their psychological state. Our investigation into SDP revealed a significant negative correlation between PCL-5 scores and PTGI scores. Furthermore, attachment dependence/closeness exhibited a significant positive correlation with PTGI total score and scores of each dimension, whereas attachment anxiety demonstrated a marked negative correlation with PTGI total score and scores of each dimension. This study offers new insights into influencing levels of PTG through PTSD intervention. Additionally, underscoring the fostering of secure attachment relationships is also crucial.

Supplemental Material

sj-docx-1-smo-10.1177_20503121251324990 – Supplemental material for The role of attachment styles in post-traumatic stress disorder and posttraumatic growth in the Shidu parents of China

Supplemental material, sj-docx-1-smo-10.1177_20503121251324990 for The role of attachment styles in post-traumatic stress disorder and posttraumatic growth in the Shidu parents of China by Zhilei Shang, Na Zhou, Buhang Xu, Han Diao, Suhui Cheng, Yanpu Jia, Lili Wu, Wenjie Yan, Weizhi Liu and Geyu Chen in SAGE Open Medicine

Supplemental Material

sj-docx-2-smo-10.1177_20503121251324990 – Supplemental material for The role of attachment styles in post-traumatic stress disorder and posttraumatic growth in the Shidu parents of China

Supplemental material, sj-docx-2-smo-10.1177_20503121251324990 for The role of attachment styles in post-traumatic stress disorder and posttraumatic growth in the Shidu parents of China by Zhilei Shang, Na Zhou, Buhang Xu, Han Diao, Suhui Cheng, Yanpu Jia, Lili Wu, Wenjie Yan, Weizhi Liu and Geyu Chen in SAGE Open Medicine

Footnotes

Acknowledgements

The authors would like to thank Yaxin Fan for his hard work and dedication in data collection and acknowledge the volunteers who participated in the study.

ORCID iDs

Zhilei Shang

Weizhi Liu

Statements and Declarations

References

Cai

Yan

, et al PTSD among Shidu parents in China: the roles of personality types and social support. Yale J Biol Med 2022; 95(1): 33–44.

Yin

Shang

Zhou

, et al An investigation of physical and mental health consequences among Chinese parents who lost their only child. BMC Psychiatry 2018; 18: 45.

Wang

Ren

, et al The relationship between hope and post-traumatic stress disorder in Chinese Shidu parents: the mediating role of perceived stress. J Affect Disord 2019; 251: 23–30.

Zheng

Lawson

Anderson Head

“Our only child has died”—a study of bereaved older Chinese parents. Omega (Westport) 2017; 74: 410–425.

Auxéméry

Post-traumatic psychiatric disorders: PTSD is not the only diagnosis. La Presse Méd 2018; 47: 423–430.

Williamson

Jaffee

Jorge

RE.

Posttraumatic stress disorder and anxiety-related conditions. Continuum (Minneap Minn) 2021; 27: 1738–1763.

Gevonden

Shalev

Prevention of post-traumatic stress disorder after trauma: current evidence and future directions. Curr Psychiat Rep 2016; 18: 20.

Warshaw

Fierman

Pratt

, et al Quality of life and dissociation in anxiety disorder patients with histories of trauma or PTSD. Am J Psychiatry 1993; 150(10): 1512–1516.

Yan

Shang

, et al The impact of isolation on comorbidity of PTSD symptoms and depression: evidence from PTRP-5-6 in China. BMC Public Health 2024; 24: 21.

10.

Shang

Pan

Cheng

, et al Prevalence and risk factors of PTSD symptoms: a 3-month follow-up study. Ther Adv Psychopharm 2024; 14: 1957216128.

11.

Tedeschi

Calhoun

LG.

Posttraumatic growth: conceptual foundations and empirical evidence. Psychol Inq 2004; 15: 1–18.

12.

Roepke

AM.

Psychosocial interventions and posttraumatic growth: a meta-analysis. J Consult Clin Psych 2015; 83: 129–142.

13.

Tedeschi

Calhoun

LG.

The posttraumatic growth inventory: Measuring the positive legacy of trauma. J Trauma Stress 1996; 9(3): 455–471.

14.

Boals

Illusory posttraumatic growth is common, but genuine posttraumatic growth is rare: a critical review and suggestions for a path forward. Clin Psychol Rev 2023; 103: 102301.

15.

Liu

Wang

, et al Correlation between posttraumatic growth and posttraumatic stress disorder symptoms based on Pearson correlation coefficient: a meta-analysis. J Nerv Ment Dis 2017; 205: 380–389.

16.

Tomaszek

Muchacka-Cymerman

Thinking about my existence during COVID-19, I feel anxiety and awe-the mediating role of existential anxiety and life satisfaction on the relationship between PTSD symptoms and post-traumatic growth. Int J Env Res Pub Health 2020; 17: 7062.

17.

Frazier

Conlon

Glaser

Positive and negative life changes following sexual assault. J Consult Clin Psychol 69(6): 1048–1055.

18.

Kang

Fischer

Dickinson

, et al Posttraumatic growth in U.S. military veterans: results from the national health and resilience in veterans study. Psychiat Quart 2024; 95: 17–32.

19.

Kleim

Ehlers

Evidence for a curvilinear relationship between posttraumatic growth and post-trauma depression and PTSD in assault survivors. J Trauma Stress 2009; 22: 45–52.

20.

Iribarren

Prolo

Neagos

, et al Post-traumatic stress disorder: evidence-based research for the third millennium. Evid Based Complement Alternat Med 2005; 2: 503–512.

21.

Bowlby

A secure base: clinical applications of attachment theory. London, UK: Routledge, 1988.

22.

Bartholomew

Horowitz

LM.

Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991; 61(2): 226–244.

23.

Mikulincer

Shaver

PR.

An attachment perspective on psychopathology. World Psychiatry 2012; 11: 11–15.

24.

Riem

Doedee

Broekhuizen-Dijksman

, et al Attachment and medically unexplained somatic symptoms: the role of mentalization. Psychiat Res 2018; 268: 108–113.

25.

Benoit

Bouthillier

Moss

, et al Emotion regulation strategies as mediators of the association between level of attachment security and PTSD symptoms following trauma in adulthood. Anxiety Stress Copin 2010; 23: 101–118.

26.

Marshall

Frazier

PA.

Understanding post-trauma reactions within an attachment theory framework. Curr Opin Psychol 2019; 25: 167–171.

27.

Greenman

Johnson

SM.

Emotionally focused therapy: attachment, connection, and health. Curr Opin Psychol 2022; 43: 146–150.

28.

Collins

Read

SJ.

Adult attachment, working models, and relationship quality in dating couples. J Pers Soc Psychol 1990; 58: 644–663.

29.

Zhang

Liu

XH.

[The reliability and validity of adult attachment scale (AAS-1996 revised edition): a report on its application in China]. Sichuan Da Xue Xue Bao Yi Xue Ban 2004; 35: 536–538.

30.

Blevins

Weathers

Davis

, et al The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress 2015; 28: 489–498.

31.

Ito

Takebayashi

Suzuki

, et al Posttraumatic stress disorder checklist for DSM-5: psychometric properties in a Japanese population. J Affect Disord 2019; 247: 11–19.

32.

Cheng

Zheng

, et al Psychometric property study of the posttraumatic stress disorder checklist for DSM-5 (PCL-5) in Chinese healthcare workers during the outbreak of corona virus disease 2019. J Affect Disord 2020; 277: 368–374.

33.

Wang

Ouyang

Jiao

, et al The application of machine learning techniques in posttraumatic stress disorder: a systematic review and meta-analysis. NPJ Digit Med 2024; 7: 121.

34.

Jia

Xing

, et al More fear reduction, better posttraumatic stress symptoms resilience: 1 year longitudinal study based on the psychological trauma recover project-5-6. Psychol Trauma 2024; 17(1): 177–185.

35.

Yao

Yanbo

, et al Revision of the Posttraumatic Growth Inventory and testing its reliability and validity. J Nurs Sci 2011; 26(14): 26–28.

36.

Zhao

Ren

Wang

, et al Predictors of prolonged grief disorder in Chinese elderly Shidu parents: the role of perceived stigma and perceived stress. Asia Pac Psychiatry 2022; 14(2): e12489.

37.

Shi

Wen

, et al Culture-related grief beliefs of Chinese Shidu parents: development and psychometric properties of a new scale. Eur J Psychotraumatol 2019; 10: 1626075.

38.

Luo

, et al Persistence of post-traumatic stress disorder in Chinese Shidu parents is associated with combined gray and white matter abnormalities. Psychiatry Res Neuroimaging 2023; 335: 111715.

39.

Kessler

Sonnega

Bromet

, et al Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry 1995; 52(12): 1048–1060.

40.

Wang

Zhang

Wang

, et al Prevalence and risk factors of posttraumatic stress disorder among Chinese Shidu parents: a systemic review and meta-analysis. J Affect Disord 2021; 282: 1180–1186.

41.

Tsai

El-Gabalawy

Sledge

, et al Post-traumatic growth among veterans in the USA: results from the National Health and Resilience in Veterans Study. Psychol Med 2015; 45: 165–179.

42.

Hall

Hobfoll

Palmieri

, et al The psychological impact of impending forced settler disengagement in Gaza: trauma and posttraumatic growth. J Trauma Stress 2008; 21: 22–29.

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