PTSD: Risk Factors

Choose a section :
1. Who's at Risk?
2. Risk Factors
3. Statistics




1. Who's at Risk?

Overview
In reality, anyone can develop PTSD.  The most reliable predictor of PTSD's onset is a triggering event, or trauma, which is
necessary for the diagnosis of PTSD (DSM-IV-TR, 2000).  The National Comorbidity Survey (NCS), a nationwide study, found
that 56% of Americans experience a lifetime trauma and 8% develop PTSD (Perkonigg et al., 2000).  Furthermore, many
other studies have found variable rates of trauma and PTSD in the population, likely due to the variation among criteria defining trauma
and PTSD.  The prevailing message of these studies is that although PTSD only manifests in a portion of trauma victims, its overall
prevalence is great enough to warrant significant attention.

Who's at Risk?

Anyone who has been victimized or has witnessed a violent act or who has been repeatedly exposed to a life-threatening situation.

Survivors of::

● domestic violence
● rape, sexual assault/abuse
● physical assault
● other random violent acts in public (at work, school)

Survivors of unexpected events in everyday life:

● car accidents
● natural disasters
● major catastrophic event (e.g., terrorist attack, plane crash)
● disasters caused by human error (e.g., industrial accidents)

● Children who are neglected or sexually, physically or verbally abused or adults who were abused as children
● Combat veterans or civilian victims of war
● Those diagnosed with a life-threatening illness or who have had major medical procedures
● Professionals who respond to victims in trauma situations such as emergency medical service workers, police, and military
● Those who learn of the sudden, unexpected death of a close friend or relative

These conditions could apply to anyone at certain points in our lives, making PTSD an unpredictibly common source of distress
(Schiraldi, 2000).







2.  Risk Factors


Not all trauma survivors develop PTSD.  As a result, much attention has been paid to the factors that make a person vulnerable to
(or protect them from) developing this disorder (Wohlfarth, 2002).  Further assessment of risk factors for PTSD will aid its prevention.

3 Broad Risk Factor Categories:
1. Pre-Trauma
2. Peri-Trauma
3. Post-Trauma



1. Pre-Trauma Factors

Individual-related
        
      
       History of Trauma -
Prior trauma, especially where PTSD developed, makes individuals especially succeptable to repeated
            bouts of PTSD.  This is likely due to the ease with which unresolved past traumas are recalled and reexperienced, as well
            as the likelihood of reenacting past faulty coping behaviors (Schiraldi, 2000).  

       Life Stressors -
Recent events in a person's life that are not of traumatic magnitude (e.g., job loss, divorce, financial problems) can
            weaken the person's defenses against trauma-induced stress in the same way that hardship can weaken the immune system
           (Schiraldi, 2000).  

       Poor Coping Skills -
Deficits such as low self-esteem, emotionality, and resilience can increase a person's chance of developing
          PTSD.  The advantage of this set of vulnerability factors is that they are all learnable.  In fact, suffering through PTSD can actually
          promote improvement of these deficits Schiraldi, 2000)

       Personality - Certain long-standing traits, such as pessimism and introversion, deny a person the tools needed to deal with a
          challenging affliction such such as PTSD.  These, too, are modifiable, but not to the same degree as coping skills (Schiraldi, 2000).

       Genetics - It appears that vulnerability to PTSD can be passed on through generations, and worsened by certain behaviors such
          as drug abuse and trauma experience (Schiraldi, 2000).

      
Brain Structure - The hippocampus, which plays a role in learning and memory, has been shown to be damaged in PTSD
           sufferers (Durand, 2006). Similarly, research on rodents and primates indicates that stressful stimuli can induce adverse functional
           and structural changes in the hippocampus.  Decreased hippocampal volume results when excessive stress alters the chemical
           regulation in the brain, which harms the functionality of systems such as learning and memory.  The chemicals implicated in this
           structure mutation include glutamate, GABA, norepinephrine, serotonin, and cortisol.  A host of other chemicals and structures are
           thought to play a role in PTSD (Nutt, 2000).

                                                             Why?

       Pathway Dysregulation - The dysregulation of GABA & glutamatergic pathways is implicated in development and maintenance of
         PTSD.  These two amino acids (GABA, glutamate) work in tandem to translate experience and stimuli into memory.  Extreme stress
         can advesely affect these pathways, eventually causing long-term synaptic changes that leads to abnormal, often excessive, encoding
         of memory.  In essence, memories can become deeply ingrained when these pathways are overstimulated by stress.  This mechanism
         helps to explain the re-experiencing (e.g, flashbacks) symptoms of PTSD (Nutt, 2000).  These flashbacks serve as retraumatization,
         submitting the victim of the intial trauma to repeated experiences that can be just as distressing as the original (McFarlane, 2000).

      
Gender -  Gender is an especially important and well researched risk factor for PTSD.  According to a recent study, men report having
          experienced  more traumatic events in their lives, but women have a higher prevalence of PTSD (Perkonigg et al., 2000).  A similar
          study found that, indeed, men are exposed to more traumas throughout life, except for sexual violence,  to which women are more prone
          to experience.  This exception is significant, as sexual traumas bring about PTSD at the highest rates (Kimerling et al., 2002).  Another
          notable study
          
          Although men experience more traumas, women's subjective experience of trauma is usually more threatening than that of men. 
          Hence, trauma exposure differences amongst the genders generally dissolve once subjective elements are considered.  In addition, not
          only are women twice as likely to develop PTSD in their lives but the disorder's course in women tends to be more chronic(Breslau et al., 1999). 
          This chronicity is not accounted for by the different nature of traumas that women experience.  Lastly, it is likely that male's risk for PTSD
          catches up with women's in settings that are chronically affected by war or violence (Kimerling et al., 2002).  This finding is supported
          by a Wolfe et al. (1999) study that found that PTSD rates following Gulf War combat experience were higher in men than women.

  Family-related

       A healthy family setting can provide a child with good protection from PTSD.  In family dynamics, the child can learn effective coping
       strategies, develop self-confidence, and most importantly, establish a solid, loving support system to protect them.  Often learning
       through role-modeling, a child of a divorced family may witness behaviors and thoughts that are detrimental to their mental health
       (mistrust, blaming of others)(Schiraldi, 2000).

      Family History -
A family history of anxiety can predispose an individual to PTSD, which itself is an anxiety disorder (Durand, 2006).
          Likewise, a family history of PTSD and trauma may predispose family members to the disorder.  Often, parents who have been
          trauma victims will teach their children maladaptive methods of coping with these stressors.   These parents might also be emotionally
          unsupportive as a result of their distressing experiences, leaving their children with a lack of support which predisposes them to PTSD. 



2. Peri-Trauma Factors

    A traumatic event is more likely to adversely affect the victim if, in the initial period following the event, he or she (1) dissociates,  (2) believes
     that they are responsible in some way or did not do all they could to remedy the situation as it occurred, and (3) feels alone or isolated. 
     Each of these conditions creates artificial separation from or unnecessary shame in regards to the event (Schiraldi, 2000). 

   
Severity of Trauma -  With low-level stress or trauma, personal vulnerabilities weigh more heavily in determining the development of
       PTSD (Durand, 2006).  Also, more severe traumas tend to lead to PTSD more often and result in more chronic cases. 
   
    Proximity to Trauma - A person's proximity to a trauma has been found to be directly related to their degree of resulting distress and
       PTSD development.   An interesting demonstration of this phenomenon was found in the 1987 study of children at an Los Angeles
       elementary school who survived a sniper shooting at their playground.  The closer the children were to the playground (where the bullets
       were fired, some were killed, and many were injured), the higher their reported stress reaction scores and incidence and severity of PTSD
       (Pynoos et al., 1987).

    Type of Trauma -  Trauma type (e.g., sexual assault, natural disaster) interacts with various other factors (e.g., age, gender, trauma severity)
        to reveal differing susceptibilities to PTSD per type.  See the bottom of this page for specific probabilities of PTSD associated with certain
        traumas. 

    Nature of Trauma -  A victim's vulnerability to PTSD increases if the trauma is sudden, unpredicted, enduring, or recurring.  Also, the risk
         of developing PTSD rises if the event poses a real threat of harm to the victim,
if the trauma is multidimensional (potential harm in multiple
         ways, e.g., natural disaster followed by drought), and if the trauma
occurs early in life (here, the trauma has a more profound effect on a
         developing personality) (Schiraldi, 2000).




3. Post-Trauma Factors

    Lack of social support -  The most crucial protective factor from PTSD after a trauma is the ability to rely on family, friends, and community
       to prevent isolation and distract the victim from the traumatic memories.  Often others are unavailable because they too experienced the
       trauma or perhaps because of their lack of connection with their own emotions.  Seemingly supportive individuals sometimes make the victim
       feel that they should "just get over it" (Briere, 2004).

      Blaming the Victim - For whatever reason, some victims of trauma (most notably rape victims) are shamed or disbelieved in regard to
        the occurrence of the event.  This rejection serves only to compound the distress of the victim.  Another prime example of this was the
        reception of Vietnam veterans after the war.  On top of the "shell shock" they were struggling with, the soldiers had to deal with a public
       disapproving of the war for which they sacrificed (Schiraldi, 2000). 

      Secondary Victimization - This occurs when those who are supposed to help victims in the posttraumatic period actually worsen the
          stress by subtly blaming the victim.  An example is when police officers might ask a rape victim if she thinks the crime could have been
          prevented had she worn less revealing clothes (Schiraldi, 2000).

      Lack of Treatment - Whether intentional or ignorant, not seeking treatment further isolates the victim and allows PTSD to progress
          chronically.  The most effe
ctive, empirically-based treatment is currently Cognitive Behavioral therapy, specifically exposure therapy. 
          Progressively and safely reexposing the
victim to aspects of the trauma can associate new, positive memories with the event (Schiraldi, 2000).  
         Current research estimates that only 38% of PTSD sufferers are undergoing treatment during a given year.  The most popular reason for
          not seeking treatment was that they did not think they had a problem.  This treatment rate, however, is comparable to or higher than the
          same rates of treatment for depression and anxiety related disorders (Kessler, 2000). 

   
Additional Note:
Wohlfarth et al. are working to develop a reliable assessment tool that can identify victims at high risk for PTSD.  They are focusing not just
   on the risk factors involved, but how predictive each of these factors is in the subsequent onset of PTSD.   They hope that this instrument
   can be used to connect those at high risk for PTSD with treatment/psychoeducation services soon after the trauma.






3. Statistics      


Estimates of adults in the US that have experienced a traumatic event at least once in their lives range from 40-90%
    (depending on the definition of trauma), and up to 20% of these people go on to develop PTSD (Perkonigg et al., 2000).
● An estimated 5%  of Americans – more than 13 million people – have PTSD at any given time.
● Approximately 8% of all adults – one of 13 people in this country – will develop PTSD during their lifetime (DSM-IV-TR). 
    This qualifies PTSD as the most prevalent anxiety disorder in the general population (Ballenger et al., 2000).  These lifetime
     prevalences vary greatly, from 1-30%, depending on the trauma type and exposure (Wilson & Keane, 2004).  
● An estimated one out of 10 women will get PTSD at some time in their lives. Women are about twice as likely as men to
    develop PTSD.  This may be due to the fact that women tend to experience interpersonal violence (such as domestic violence
    or rape) more often than men.
Almost 13% of men and 10% of women have experienced more than three traumatic events in their lives (Kessler et al., 1995).
● The estimated risk for developing PTSD for people who have experienced the following traumatic events is:
                    →Rape (49%)
                    →Physical Assault (32%)
                    →Other sexual assault (24%)
                    →Serious accident or injury (17%)
                    →Shooting/Stabbing (15%)
                    →Unexpected death of relative/friend (14%)
                    →Child's life-threatening illness (10%)
                    →Witness killing/serious injury (7%)
                    →Natural disaster (4%)


          (Perkonigg et al., 2000; Kessler et al., 1995; Ballenger et al., 2000)