C
RISK AND PROTECTIVE FACTORS

Some people who are exposed to a traumatic event will develop posttraumatic stress disorder (PTSD) while others will not. Its occurrence depends on a complex interplay between risk factors that increase the likelihood of onset and protective factors that diminish it. Other variables influence the development of PTSD, including factors that preceded the exposure to trauma, factors associated with the trauma exposure itself, and factors associated with the recovery environment.

This appendix presents an abbreviated discussion of a few of the numerous risk factors and protective factors that might influence the development of PTSD among military personnel. The topic will be considered by the committee in greater detail in a report on deployment-related stress due to be published in 2007.

RISK FACTORS

For a military population, one of the most important risk factors for the onset of PTSD is exposure to combat. Features of combat, such as its intensity, whether an injury was sustained, or whether torture or captivity occurred, are related to the severity of exposures that by definition qualify within the Diagnostic and Statistical Manual (DSM-IV) criteria as traumatic. Other risk factors that might be involved with the development of PTSD are, for example, military sexual assault, homecoming environment, sex, and ethnicity (see Table C.1).



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Posttraumatic Stress Disorder: Diagnosis and Assessment C RISK AND PROTECTIVE FACTORS Some people who are exposed to a traumatic event will develop posttraumatic stress disorder (PTSD) while others will not. Its occurrence depends on a complex interplay between risk factors that increase the likelihood of onset and protective factors that diminish it. Other variables influence the development of PTSD, including factors that preceded the exposure to trauma, factors associated with the trauma exposure itself, and factors associated with the recovery environment. This appendix presents an abbreviated discussion of a few of the numerous risk factors and protective factors that might influence the development of PTSD among military personnel. The topic will be considered by the committee in greater detail in a report on deployment-related stress due to be published in 2007. RISK FACTORS For a military population, one of the most important risk factors for the onset of PTSD is exposure to combat. Features of combat, such as its intensity, whether an injury was sustained, or whether torture or captivity occurred, are related to the severity of exposures that by definition qualify within the Diagnostic and Statistical Manual (DSM-IV) criteria as traumatic. Other risk factors that might be involved with the development of PTSD are, for example, military sexual assault, homecoming environment, sex, and ethnicity (see Table C.1).

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Posttraumatic Stress Disorder: Diagnosis and Assessment TABLE C.1 Risk Factors for PTSD in Military Populations Risk Factor References Combat Exposure   Combat and its severity Black et al. 2004; Goldberg et al. 1990; Hoge et al. 2004; Kang et al. 2003; Kulka et al. 1990; O’Toole et al. 1998; Roy-Byrne et al. 2004; Wolfe et al. 1999 Being wounded or injured Koren et al. 2005; North et al. 1999; Schreiber and Galai-Gat 1993; Witnessing death Breslau et al. 1999; Ford 1999 Witnessing grotesque death Green et al. 1990 Serving on graves-registration duty Sutker et al. 1994 Being tortured or being taken captive de Jong et al. 2001; Mollica et al. 1998; Speed et al. 1989; Sutker et al. 1993 Unpredictable and uncontrollable stressful exposure Foa et al. 1992; Southwick et al. 1993 Military Environment   Sexual trauma, including assault Fontana et al. 1997b; Kang et al. 2005 Combat preparedness Asmundson et al. 2002 Deployment to war zone without combat Ikin et al. 2004 Homecoming Environment   Lack of social support Fontana and Rosenheck 1994; Fontana et al. 1997a; Green et al. 1990; Johnson et al. 1997; Koenen et al. 2003; Stretch 1985; Stretch et al. 1985 Personal Factors   Cumulative life stress before or after the traumatic event Breslau et al. 1999; Brewin et al. 2000; King et al. 1998; Maes et al. 2001; North et al. 1999 More resource loss, lower income or education, older age Norris et al. 2002 Being female Kang et al. 2003; Wolfe et al. 1999

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Posttraumatic Stress Disorder: Diagnosis and Assessment Table C.1 calls attention to a variety of risk factors for PTSD identified in studies of military populations. Most of the studies cited were conducted in Vietnam or Gulf War veteran populations. A few of the risk factors noted above are discussed below because they are important or frequent predictors of PTSD in veterans. Combat Exposure Combat exposure and its severity are well-established risk factors documented in carefully designed studies of Vietnam and Gulf War veterans (e.g., Goldberg et al. 1990; Kang et al. 2003; Kulka et al. 1990; O’Toole et al. 1996). Combat exposure, in this context, includes many specific types of related exposures, such as prisoner-of-war status and witnessing gruesome injuries, torture, and death. Generally speaking, the greater the degree of combat exposure, the greater the likelihood of developing PTSD and the longer the duration of symptoms (Hoge et al. 2004; Kang et al. 2003; Koenen et al. 2003; Wolfe et al. 1999; Wolfe et al. 1999). A nationally representative study of 30,000 veterans of the Gulf War era found that the likelihood of PTSD increased as the number of combat-related stressors increased (Kang et al. 2003). Likewise, combat troops returning from Iraq report increased rates of PTSD compared to troops before deployment and compared to rates after deployment to Afghanistan (Hoge et al. 2004; Koenen et al. 2003; Roy-Byrne et al. 2004). For many soldiers and other military personnel, deployment to a war zone is the most traumatic event in their lives. Relative to other common types of trauma, men who name combat trauma as the most traumatic event of their lives are at the highest risk for PTSD, according to a nationally representative study. They were 7 times more likely to have PTSD than those who named other events as their “worst lifetime traumatic event” (Prigerson et al. 2001). Nearly 42% of men who regarded combat as their worst lifetime experience met criteria for PTSD at some point in their lives. That rate was higher than that for any of the other common types of trauma reported by men in the study, including being sexually molested or raped and being physically abused or neglected as a child (Table C.2). Combat-related PTSD also was more likely to be associated with serious occupational and marital problems. In

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Posttraumatic Stress Disorder: Diagnosis and Assessment a separate analysis in the same epidemiologic study, combat-related PTSD was found responsible for nearly 30% of all PTSD diagnoses in the United States (Prigerson et al. 2002)

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Posttraumatic Stress Disorder: Diagnosis and Assessment TABLE C.2 Rates of PTSD, Occupational Problems, and Marital Problems in Traumatized Men in National Comorbidity Survey   Lifetime PTSD Occupational and Marital Problems Associated with Combat Trauma (%) Traumatic Incident Identified as Worst Lifetime Event N % Currently Unemployed Recently Fired Ever Divorced Spousal Abuse Combat 96 41.8 20.2 13.6 39.0 15.2 Life-threatening accident 292 5.5 7.9 9.7 18.8 7.6 Natural disaster I 178 3.9 13.4 4.9 9.5 4.0 Witnessing someone being badly beaten or killed 492 6.1 7.7 4.4 11.3 5.4 Raped or sexually molested 32 32.5 4.8 3.0 12.0 3.7 Physical attack, threatened with weapon, or held captive 273 1.6 4.4 4.3 12.0 10.4 Physically abused or seriously neglected as child 58 24.2 2.6 4.0 28.3 1.5 Other qualifying trauma 152 5.1 8.3 6.3 12.2 8.0 Shock on learning of trauma to a person close to you 130 4.4 3.0 22 7.8 3.9 SOURCE: Adapted with permission from Prigerson et al. 2001.

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Posttraumatic Stress Disorder: Diagnosis and Assessment Military Sexual Assault Several factors in the military environment may be risk factors for development for PTSD but sexual assault is an important one. Suris et al. (2004) noted that woman veterans were 9 times more likely to develop PTSD if they had a history of military sexual assault. Another study (Kang et al. 2005) examined self-reported in-theater experiences of sexual harassment or assault and combat exposure and found statistically significant increases in PTSD associated with sexual assault in female and male veterans of the Gulf War. Homecoming Environment Lack of social support, particularly after the traumatic event, is a significant risk factor for PTSD. As soldiers return home, lack of social support from family, friends, and community is associated with PTSD, according to studies of Vietnam veterans (Fontana and Rosenheck 1994; Fontana et al. 1997a; Green et al. 1990; Johnson et al. 1997; Koenen et al. 2003; Stretch 1985; Stretch et al. 1985). The Vietnam War was unpopular and many veterans returning from combat were greeted with disrespect, hostility, or condemnation. Although many Iraq and Afghanistan veterans might be returning to more welcoming attitudes, the role of strong social, family, and community support is still important. In a meta-analysis of more than 50 studies on risk factors for PTSD in military and civilian populations, researchers found that lack of social support was a leading risk factor for development of PTSD compared with such other risk factors as lack of education, life stress, trauma severity, and other previous trauma (Figure C.1) (Brewin et al. 2000). A later meta-analysis by a team of investigators who used somewhat different methods also found that lack of social support was a strong risk factor for development of PTSD (Ozer et al. 2003).

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Posttraumatic Stress Disorder: Diagnosis and Assessment FIGURE C.1 Meta-analysis of Risk Factors for PTSD. SOURCE: Adapted with permission from Brewin et al. 2000

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Posttraumatic Stress Disorder: Diagnosis and Assessment Sex In the US general population, women are about twice as likely as men to have PTSD at some point in their lives. Their lifetime prevalence is 10–12% versus 5% for men (Kessler et al. 1995; Resnick et al. 1993). It is not clear why women have higher rates of PTSD than men. That sex difference, however, is not peculiar to PTSD; women generally have higher rates of depression and anxiety disorders (Kessler et al. 1995). Women veterans serving in the Gulf War were more likely than men to screen positive for likelihood of PTSD (Kang et al. 2003; Wolfe et al. 1999). Studies have not determined whether that is due to different exposures or specifically to inherent sex differences in the development of PTSD. Ethnicity After Vietnam, there was no difference in prevalence of PTSD between black, American Indian, and white veterans. Rates among blacks were higher until the investigators performed analyses to remove the effects of their having had greater combat exposure (Beals et al. 2002; Kulka et al. 1990). Still, questions linger about the ethnic minority differences, because several less representative studies reported higher rates of PTSD among black Vietnam veterans (e.g., Allen 1986; Penk et al. 1989). Latino Vietnam veterans, especially Puerto Rican veterans, had higher PTSD prevalence and more severe symptons even after adjustment for combat exposure (Ortega and Rosenheck 2000). Members of ethnic minorities appear to have a more chronic course of PTSD as well (King et al. 1998; Koenen et al. 2003). Distinct ethnic groups might differ in how they manifest symptoms, how they describe the symptoms, how they cope, what support systems they use, and whether they seek or stay in care (Department of Health and Human Services 2001).

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Posttraumatic Stress Disorder: Diagnosis and Assessment PROTECTIVE FACTORS Just as risk factors likely increase a person’s chances of developing PTSD, protective factors might reduce the risk. Researchers have found that protective factors include coping with the traumatic event in positive and active ways rather than by avoiding it (Benotsch et al. 2000; Norris et al. 2002; North et al. 2001), better training and preparation to respond to a traumatic event (Alvarez and Hunt 2005; Basoglu et al. 1997), higher education and income, a sense of mastery or self-esteem, and male sex (Brewin et al. 2000; Kulka et al. 1990; Orcutt et al. 2004); (Coker et al. 2005; Norris et al. 2002). Beginning in the 1980s, research has shown that after a traumatic event, social support is associated with reduced likelihood of PTSD (e.g., Cohen and Wills 1985; Kaniasty and Norris 1997; Koenen et al. 2003; Ozer et al. 2003). The research involved largely civilians exposed to community or domestic violence. Social support is often defined as help with physical activities, emotional support, and having someone to talk with about traumatic experiences or to turn to for advice. Such social support might be provided by a network of health care and mental health care professionals as well as by family and community members (Flannery 1990). Studies of veterans have shown that social support, particularly after homecoming, is also associated with reduced likelihood and severity of PTSD (Fontana and Rosenheck 1994; Fontana et al. 1997b; King et al. 1998). It was found that the protective effects of homecoming were greatest among those veterans who had the greatest war-zone exposures (Fontana et al. 1997a). Interestingly, Fontana et al. (1997a) also showed that having been part of a cohesive military unit did not have the protective effect of postwar social support. One study (King et al. 1998), conducted in a sample of 1,632 Vietnam veterans from the National Vietnam Veterans Readjustment Study, found that hardiness as a personality trait was protective. Hardiness was a construct defined as having a sense of control over life, feeling that life is meaningful, and being open to change.

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Posttraumatic Stress Disorder: Diagnosis and Assessment CONCLUSION This appendix provided a very brief discussion of some of the risk and protective factors that might influence who will develop PTSD. Not all people who are exposed to traumatic events develop a psychiatric disorder, such as depression or PTSD. Its development can depend on the intensity of the traumatic event or stressor and on a host of pretrauma and posttrauma factors. REFERENCES Allen IM. 1986. Posttraumatic stress disorder among black Vietnam veterans. Hospital and Community Psychiatry 37(1):55–61. Alvarez J, Hunt M. 2005. Risk and resilience in canine search and rescue handlers after 9/11. Journal of Traumatic Stress 18(5):497–505. Asmundson GJ, Stein MB, McCreary DR. 2002. Posttraumatic stress disorder symptoms influence health status of deployed peacekeepers and nondeployed military personnel. Journal of Nervous and Mental Disease 190(12):807–815. Basoglu M, Mineka S, Paker M, Aker T, Livanou M, Gok S. 1997. Psychological preparedness for trauma as a protective factor in survivors of torture. Psychological Medicine 27(6):1421–1433. Beals J, Manson SM, Shore JH, Friedman M, Ashcraft M, Fairbank JA, Schlenger WE. 2002. The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: Disparities and context. Journal of Traumatic Stress 15(2):89–97. Benotsch EG, Brailey K, Vasterling JJ, Uddo M, Constans JI, Sutker PB. 2000. War zone stress, personal and environmental resources, and PTSD symptoms in Gulf War veterans: A longitudinal perspective. Journal of Abnormal Psychology 109(2):205–213. Black DW, Carney CP, Peloso PM, Woolson RF, Schwartz DA, Voelker MD, Barrett DH, Doebbeling BN. 2004. Gulf War veterans with anxiety: Prevalence, comorbidity, and risk factors. Epidemiology 15(2):135–142.

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