Cognitive distortions - patterns of biased thinking that may encompass incorrect and at times harmful beliefs - are a common feature of psychological disorders. A typological framework for cognitive distortions in depressed patients was initially proposed by Beck (1963) which was later incorporated into Cognitive Therapy for Depression (Beck et al., 1979). This initial recognition of the role of cognitive distortions in the maintenance of depression instigated further investigation of its relevance to other psychiatric disorders. Consequently, cognitive distortions have been found to play a similar role in substance use disorders, anxiety disorders, personality pathology, and lifetime suicide attempts (Yesilyaprak et al., 2019; Kuru et al., 2018; Tanriverdi and Özgüç, 2023; Najavits et al., 2004; Puri et al., 2021; Jager-Hyman et al., 2014). Typological descriptions of cognitive distortions have also expanded significantly since Beck’s conceptualization, resulting in a diverse array of identified cognitive distortions, ranging from more traditional forms such as self-blame and overgeneralization to more disorder-specific types such as thought-action fusion (Coelho et al., 2015; Kostopoulou et al., 2013).

While theoretical accounts have outlined the relationships of cognitive distortions with psychopathology for nearly 60 years, their relevance was previously only implied in formal diagnostic criteria (APA, 1994). With the release of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), cognitive distortions were explicitly listed in the symptom criteria for posttraumatic stress disorder (PTSD; APA, 2022). Specifically, when making a DSM-5 PTSD diagnosis, clinicians and researchers must assess symptom criterion D, which denotes “Negative alterations in cognitions and mood associated with the traumatic event,” including symptom 2, described as “Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world” (APA, 2022). Previous work has suggested that these negative cognitions worsen over time in individuals with PTSD and may maintain symptoms of the disorder (Dekel et al., 2013; Dunmore et al., 1999). Indeed, several studies examining the efficacy of PTSD treatment have found that changes in posttraumatic cognitions are associated with reductions in PTSD symptoms (Kleim et al., 2013; Zalta et al., 2014), though the directionality of this association remains unclear (Held et al., 2022; Rauch et al., 2022). Foa and colleagues have previously identified three factors comprising negative posttraumatic cognitions: Negative Cognitions About Self, Negative Cognitions About the World, and Self-Blame (Foa et al., 1999). Traumatic experiences may reinforce these rigid cognitions (e.g., that the world is dangerous), preventing individuals from recognizing traumatic events as time-limited occurrences. Indeed, individuals with PTSD are more likely to hold global and persistent negative beliefs, which may prevent them from engaging in behavior that disconfirms these beliefs and motivates them towards change (Dunmore et al., 1997). Thus, the inclusion of cognitive distortions as a symptom of PTSD was justified. While cognitive distortions are explicitly recognized in PTSD formal diagnostic criteria, they remain relevant to other disorders and may be influenced by factors independent of trauma. Accordingly, further research is needed to evaluate the transdiagnostic nature of these distortions.

Belief in a dangerous world (BDW), a component of the DSM-5 conceptualization of PTSD, is an overgeneralization of particular interest given its universal nature and corresponding potential for distress. This cognitive distortion reflects an overgeneralization in which a universal belief (i.e., the world is a completely dangerous place) may be formed based on the experience of a limited number of events. Within the DSM-5, BDW is grouped with other negative beliefs about the world, including self-blame (“I am bad”) and catastrophizing (e.g., “My nervous system is completely ruined”). The practice of combining all cognitive distortions pertaining to PTSD together has been implemented in various assessments of PTSD, including the Posttraumatic Stress Disorder Checklist-5 (PCL-5), which was designed to mirror DSM-5 PTSD criteria (Blevins et al., 2015). Thus, despite its unique potential for distress and impairment, BDW has been considered less as a distinct construct in recent PTSD research due to its frequent combination with other cognitive distortions.

Though a part of formal diagnostic criteria of DSM-5 PTSD, BDW may also be related to sociodemographic and other psychiatric factors. For example, believing the world is a completely dangerous place may be associated with race, ethnicity, and sex. Previous research has indicated that experiences of racial discrimination and neighborhood disadvantage negatively effect world assumptions (e.g., that the world is inherently just; Haeny et al., 2021). In another study, women were more likely to endorse negative beliefs about the world than men (Cox et al., 2014). These associations may stem from harassment and discrimination – experiences disproportionately affecting certain demographic groups – that contribute to cognitive distortions such as BDW. Another factor that may be implicated in posttraumatic BDW is intrinsic religiosity (i.e., religious beliefs that form the foundation of an individual’s worldview). Previous work has indicated that intrinsic religiosity can influence cognitive appraisals (James and Wells, 2003). Thus, an individual’s level of religiosity may influence their endorsement of BDW following trauma, as experiences that contradict the religiously motivated belief that the world is inherently just and benevolent may lead one to believe that the world is now dangerous (Janoff-Bulman, 1992; ter Kuile and Ehring, 2014). Taken together, the relationship between sociodemographic factors and BDW has not been studied extensively, especially in large samples, representing a significant gap in our understanding of this particular cognitive distortion.

There may also be trauma characteristics that are associated with BDW. Within the context of trauma-derived BDW, previous work has indicated that interpersonal trauma types (e.g., sexual assault and other forms of physical violence) are associated with BDW (Cox et al., 2014; Whiteman et al., 2019). Since interpersonal trauma types are not likely to be perceived as accidental or situational (such as might be the case with natural disasters), an individual may be more likely to feel unsafe in a world where others have demonstrated the potential of inflicting harm. Consequently, for those who endorse BDW as part of a posttraumatic cognitive response, the nature of the instigating traumatic event may play a role in its endorsement.

Trauma-related BDW may also contribute to the etiology and of maintenance of psychiatric disorders above and beyond PTSD. Anxiety disorders such as generalized anxiety disorder, panic disorder, and agoraphobia are characterized by broad overestimations of the likelihood of threats occurring (Chen and Lovibond, 2020; Rosebrock et al., 2022), which may generalize to BDW. Depression is also characterized by global negative beliefs about the world (Beck, 1979), which could also be related to perceptions of its dangerousness. In line with these conceptualizations, posttraumatic negative cognitions about the world have been linked to depression, anxiety, and personality disorders (Lu et al., 2023; Su and Chen, 2008). However, an important limitation of this literature is that BDW is still grouped with other distortions, and so findings specific to BDW cannot be parsed. Additionally, since BDW is only assessed as a posttraumatic cognitive distortion, it is possible that these findings may be partially driven by elevated rates of comorbidity with PTSD (Rytwinski et al., 2013; Shorter et al., 2015; Pietrzak et al., 2011). While cognitive distortions are not explicitly included in diagnostic criteria for other disorders, they have still demonstrated significant relationships with disorders other than PTSD, and so investigating the unique role of BDW independent of PTSD diagnosis is crucial to better understand its significance.

Taken together, research examining BDW is limited by several obstacles. First, given the practice of grouping cognitive distortions together (as is the case for DSM-5 PTSD), there is a considerable lack of research examining BDW specifically. This is a notable gap in the literature, as specific cognitive distortions have previously been associated with differential effects on symptoms. For instance, one study found that in the treatment of military sexual trauma-related PTSD, reductions in self-blame cognitions were associated with improvement in PTSD symptoms, while other cognitions were not (Holliday et al., 2018). On the other hand, overgeneralized beliefs (such as the belief that the world is a completely dangerous place) have been linked to mental health symptoms in youth with PTSD (Ready et al., 2015). Consequently, there is much more to be understood regarding the relationship between specific cognitive distortions such as BDW and factors pertaining to psychiatric disorders. Additionally, cognitive distortions are often examined within small clinical samples, without consideration of comorbidity, demographics, or other factors that might influence their occurrence. While these issues have limited empirical examinations of BDW, its inclusion in a large epidemiological study would allow for greater precision in evaluating its unique relationship with different outcomes.

The current study aimed to evaluate correlates of posttraumatic BDW using a large, nationally representative sample. We used data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) to examine relationships between sociodemographic factors, trauma history, psychiatric diagnoses, and BDW among participants endorsing a traumatic event (a majority of the sample: 65.9 %). Additionally, we examined clinical correlates within a subgroup that met diagnostic criteria for PTSD.

We had several hypotheses related to sociodemographic factors, trauma history, and psychiatric diagnoses. First, we predicted that female sex and non-White racial status would be associated with BDW. Given the role of cognitive distortions in multiple psychiatric disorders (Yesilyaprak et al., 2019; Kuru et al., 2018; Tanriverdi and Özgüç, 2023; Navajits et al., 2004; Puri et al., 2021; Jager-Hyman et al., 2014), we hypothesized that individuals who endorse BDW would be more likely to meet criteria for anxiety disorders and depression, as well as substance use disorders and personality pathology. Additionally, we hypothesized that individuals exposed to trauma caused by another person (e.g., sexual assault, physical violence) would be more likely to endorse BDW. Analyses addressing sexual orientation and religiosity were exploratory, given the absence of research investigating relationships between these sociodemographic factors and BDW.