Posttraumatic Stress Disorder (PTSD)

The factors that contribute to posttraumatic stress may be categorized into those occurring before, during, and after exposure to the stressor. Prestressor factors include characteristics of the victim, family, and sociocultural environment. Stressor factors include aspects of the event and exposure. Poststressor factors include aspects of the recovery environment, coping, and treatment.

Pre-event factors. Rates of PTSD are higher in women than men (Ballenger et al. 2000), though gender differences are less clear in children (Foy et al. 1996; Pfefferbaum 1997). The influence of age and ethnicity is not well established. Age and developmental differences may be evident in the symptoms of the disorder, and may reflect prior experience, coping, and the availability of support. Ethnic minorities may be at risk for trauma exposure, but this may reflect differences in socioeconomic status or family influences rather than ethnicity. Other individual factors important in trauma response are preexisting psychopathology and prior exposure to trauma (American Psychiatric Association 1994; Asarnow et al. 1999; Ballenger et al. 2000; Davidson 1995).

Prestressor family and social factors that may influence outcome include relationships within the family and social environment, family organization, and the family's long-term adaptation (Boney-McCoy and Finkelhor 1996; McFarlane 1987; Solomon 1989). Positive family relationships are generally considered protective for traumatized children. Specifically, problems in children appear to be associated with irritable, depressed, and overprotective families (Green et al. 1991; McFarlane 1987). Family adaptability—the capacity for change—and family cohesion—the flexibility of emotional bonds—are likely to affect trauma response. Both extremes of cohesion, too distant and too close, create risk for maladaptive outcome (Laor et al. 1996), although more research is needed to help clarify these family factors.

PTSD has been described in individuals from many cultures. In fact, one would expect high rates of exposure to trauma and PTSD in individuals from those parts of the world where war, crime, and poverty prevail and in refugee populations (American Psychiatric Association 1994). Race, ethnicity, and culture shape conceptualization of events, reactions to trauma, expectations, and treatment (Parson 1994). The biologic response to trauma appears to be consistent across cultures, while the psychosocial aspects of symptom expression are influenced by pre-event, stressor, and poststressor factors (Parson 1994). Of particular concern when Western concepts of trauma are applied in non-Western cultural contexts are potential differences in notions of illness and health, symptom expression, and the phenomenology of the disorder (Marsella et al. 1994).

Stressor factors. Characteristics of the stressor and one's exposure to it influence response. For example, man-made events are thought to be more traumatizing than natural ones (American Psychiatric Association 1994). Exposure can be direct or indirect. Direct exposure involves physical presence or direct victimization; indirect exposure occurs through witnessing or learning of an event experienced by a family member or close associate (American Psychiatric Association 1994). Severity, duration, and proximity are the most important aspects of exposure in predicting the likelihood of developing the disorder (American Psychiatric Association 1994). The role of interpersonal exposure through relationship to direct victims has also been established (American Psychiatric Association 1994). Television viewing as a form of indirect exposure may be associated with posttraumatic stress reactions (Pfefferbaum et al. 2001; Schuster et al. 2001), but no studies link television exposure to the diagnosis of PTSD. One's reaction at the time of the trauma is an important predictor of post-traumatic stress (Asarnow et al. 1999; Ballenger et al. 2000; Schwarz and Kowalski 1991).

Poststressor factors. Family and social factors may influence adjustment following exposure to trauma. For example, within a family, there may be an association between child and parent symptomatology (Foy et al. 1996; Green et al. 1991; Laor et al. 1996; McFarlane 1987) that in some cases may reflect similar exposure. Parental symptoms and poor parental functioning constitute important risk factors for symptom development in traumatized children (Green et al. 1991; McFarlane 1987). Consistency in reaction and mood between parents (Handford et al. 1986), and the quality of the parent-child relationship (Boney-McCoy and Finkelhor 1996) may also affect the intensity of the child's reaction.

When a traumatic event affects large numbers, social factors, such as community disruption, competition for resources, and community response, may influence adjustment (Pfefferbaum 1998; Quarantelli and Dynes 1985; Solomon 1989). Secondary adversities associated with a traumatic event such as displacement and relocation, property and economic loss, family and social problems, and loss of interpersonal support networks affect recovery (Freedy et al. 1992; Laor et al. 1996; Pfefferbaum 1998; Shaw et al. 1995). Traumatic reminders—stimulus cues that activate symptoms—may also interfere with recovery.