The adverse consequences of posttraumatic stress on quality of life have been well
documented. It is, however, possible that it is not the intrusive re-experiencing and
hyperarousal posttraumatic stress symptoms that have an impact on quality of life per
se, but the inflexible efforts to avoid internal experiences and emotions related to the
traumatic event, and the way these emotions are expressed and experienced. Previous
research shows that both experiential avoidance and emotion regulation have been
found to be etiologically central to the development and maintenance of
psychological problems in trauma survivors. The degree to which experiential
avoidance and emotion regulation act together as toxic underlying mechanisms to
explain the relationship between posttraumatic stress and quality of life is, however,
yet to be examined. Quality of life is now regarded as an important outcome variable
across a broad range of conditions and problem areas. The quality of life concept has
generated a large body of research and yet its assessment has been a challenge for
researchers. The WHOQOL-BREF is considered to be one of the few genuine quality
of life measures but it has received much criticism, especially regarding the poor
psychometric performance of its social relationships domain.
The aim of the current thesis was twofold. The first aim involved the revision of the
WHOQOL-BREF through the enhancement of the social relationships domain. In
Study I 986 ill and healthy individuals from five countries worldwide completed the
Pilot Revised WHOQOL-BREF (WHOQOL-BREF-R) along with measures of life
satisfaction, anxiety, and depression for the detailed psychometric analysis of the
scale. Study I confirmed the limitations of the social relationships domain, and
despite its improvement, the performance of the overall scale was found to be poor.
In fact, findings from modern and robust techniques challenged the 4-factor structure
of the WHOQOL-BREF. Instead, results supported the performance of a 3-factor
solution, which led to the development of a psychometrically sound measure. Study II is preceded by a systematic review of the literature investigating experiential
avoidance as a mediator in trauma survivors with posttraumatic stress. Ten studies
were identified and organised in two categories assessing experiential avoidance as a
mediator between: 1) trauma exposure and posttraumatic stress, and 2) posttraumatic
stress and maladaptive behaviours. Findings suggest that the development and
maintenance of posttraumatic stress symptoms and maladaptive behaviours in the
aftermath of trauma can be explained through the use of experiential avoidance.
Methodological limitations and future directions for research are discussed.
The WHOQOL-BREF-R was then used in Study II, which explored an integrative
mediation model whereby experiential avoidance and emotion regulation were tested
as mediators in the relationship between posttraumatic stress symptomatology and
quality of life in trauma exposed adults. The two mediators were also explored for
their overlapping relationship. A total of 360 participants from the community
completed self-report measures of posttraumatic stress, experiential avoidance,
emotion regulation, and quality of life. With the use of path analysis Study II found
experiential avoidance and emotion regulation to be two distinct constructs that
together act as an underlying mechanism explaining the impact of posttraumatic
stress on quality of life. Alternative mediating models were explored.
The current study makes an important contribution in the area of trauma and in the
conceptualisation and assessment of quality of life. Findings can be considered as a
first step towards an integrative mediation model of toxic mechanisms in trauma and
quality of life. Additionally, the favourable psychometric properties of the
WHOQOL-BREF-R make it a powerful tool for use in quality of life research