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Objective Cognitive models posit negative trauma appraisals as maintaining symptoms of posttraumatic stress disorder. Recent research has demonstrated that alienation appraisals (feeling disconnected from the self and others) are salient in trauma-related distress. Studies show that alienation appraisals fully mediated the relationship between trauma exposure and symptoms of posttraumatic stress disorder (PTSD) in trauma-exposed adults. This study explored alienation appraisals in student and clinical samples, assessing whether alienation significantly mediated the relationship between cumulative trauma and trauma-related distress. It also explored whether alexithymia, social support, and loneliness also mediated the relationship between cumulative trauma and markers of trauma-related distress, clarifying the role of alienation. Method Mediation and hierarchical regression models were tested with questionnaire data from a student sample (N = 100) and clinical sample of trauma-exposed treatment-seeking adults (N = 93). Results In the student sample, alienation (B = 1.27) fully mediated the relationship between cumulative trauma and posttraumatic stress, but not depression. When alexithymia, social support, and loneliness were entered as parallel mediators, only alienation appraisals (B = 1.03) significantly mediated the relationship between cumulative trauma and posttraumatic stress. For the clinical sample, alienation appraisals (β = .53) were the only significant predictor of posttraumatic stress, while alienation appraisals (β = .75) and, to a lesser extent, social support (β = .19) and loneliness (β = .30) significantly predicted depression. Conclusions Alienation was a salient predictor of posttraumatic distress. Clinical assessment of alienation appraisals is recommended to inform psychological interventions for trauma survivors. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

It has been suggested that treatments for posttraumatic stress disorder (PTSD) be framed within a staged or phase-oriented model, particularly in cases of increased trauma symptom severity and complex PTSD. However, ambiguity remains around this model's definition and efficacy. The present literature review aimed to examine the efficacy of treatments adopting a phase-oriented model for individuals with PTSD symptoms with a subanalysis of a potential high complexity sample. A systematic search of the literature found 1,180 articles, of which 13 met predefined criteria. To analyze effect sizes, a random effects meta-analysis was conducted. The analysis showed a large effect size in the differences between the beginning and end-of-treatment timepoints on PTSD symptoms (d = 1.77, 95% confidence interval [CI] [1.45, 2.08], z = 10.97; p < .001) with moderate heterogeneity. A subanalysis showed that the large effect size was maintained when compared with control groups (d = 0.82, 95% CI [0.29, 2.29], z = 3.04; p < .005). Further subanalysis of a predefined potential high complexity population also revealed a large effect size (d = 1.39, 95% CI [0.99, 1.79], z = 6.79; p < .001). Results concurred with previous literature supporting the effectiveness of phase-oriented models for PTSD symptoms, but limitations existed in finding appropriate definitions of the model, symptom severity, appropriate control groups, and generalizing findings.