Assaultive violence and the risk of posttraumatic stress disorder following a subsequent trauma

Breslau, Peterson, and Shultz (2008) reported that prior trauma alone, in the absence of PTSD, did not predict an increased PTSD risk, relative to no prior trauma. Only prior trauma that resulted in PTSD predicted an increased PTSD risk following a subsequent trauma. Recently, Cougle, Resnick, and Kilpatrick (2009) proposed that the effect of prior trauma might vary by type of prior trauma, a possibility not considered in Breslau et al. They report that childhood sexual or physical assault, in the absence of PTSD, increased the PTSD risk following a subsequent trauma. This report examines the PTSD effects of prior assaultive violence, using data from Breslau et al. (1998). The study assessed PTSD in relation to up to three events. Analysis was performed on the subset with PTSD assessment for two distinct events, the earliest trauma and a subsequent trauma (n = 967), using as reference persons with no prior trauma (n = 972). Neither prior assaultive violence nor other prior traumas, in the absence of PTSD, influenced the subsequent risk of PTSD. In contrast, prior PTSD increased considerably the PTSD risk of a subsequent trauma. The limitations in Cougle et al. (2009) and in this study and future research directions are discussed.     

Adverse Childhood Experiences,Trauma Symptoms,Mindfulness, and Intimate Partner Violence: Therapeutic Implications for Marginalized Men

Adverse childhood experiences (ACEs) and trauma symptoms have been linked with intimate partner violence (IPV) perpetration and victimization among men, yet the field lacks depth in several key areas hampering progress toward violence intervention. Specifically, posttraumatic stress disorder (PTSD) dominates the field’s scope of trauma symptoms under study, limiting understanding of other manifestations of trauma especially among men. Furthermore, most research focuses exclusively on men’s physical IPV perpetration and rarely focuses on other types of IPV, severity of violence, or men’s victimization. Also, few studies examine potential protective factors grounded in the ACE framework, such as mindfulness, among clinical populations. Finally, most research has not focused on men of color, despite some racial/ethnic minority groups disproportionate rates of IPV exposure. Therefore, the relationships between IPV frequency and severity (psychological, physical, injury) and ACEs, PTSD, trauma symptomology (separate from PTSD), and mindfulness self-efficacy were examined in a sample of 67 predominantly low-income men of color in a batterer intervention program. More than half of the sample (51.5%) reported exposure to four or more ACEs, and 31.1% met the clinical cutoff for a probable PTSD diagnosis. Higher ACE scores predicted increased rates for nearly all types of self-reported IPV perpetration and victimization. PTSD symptoms and complex trauma symptom severity together explained between 13% and 40% of IPV outcomes, and each was uniquely associated with certain types of self-reported IPV victimization and perpetration frequency and severity. Mindfulness self-efficacy was associated with decreased self-report psychological IPV perpetration and victimization frequency and severity. Clinical implications relevant to marginalized men are reviewed, including screening, training, and potential therapeutic interventions.     

Complex Trauma Symptoms in Former Ugandan Child Soldiers

Children exposed to repeated interpersonal trauma often develop symptoms that exceed those documented in criteria for post-traumatic stress disorder (PTSD) and are better described with the emerging concept of developmental trauma disorder (DTD). This study examines complex trauma symptoms in a sample of 330 former Ugandan child soldiers (age 11–17 years, 49% female). Prevalence rates were 33.0% for PTSD, 36.4% for depression, and 78.2% for DTD. Whereas PTSD symptoms were significantly related to traumatic war experiences and depression, DTD symptoms were significantly associated with experiences of domestic violence, community violence, social support, and depression. Assessment tools and tailored interventions for DTD are urgently needed.     

Gender differences in the sensitivity to posttraumatic stress disorder: An epidemiological study of urban young adults

The authors examine the relationship between 2 separate but interrelated findings in the epidemiology of posttraumatic stress disorder (PTSD): women's greater PTSD risk following traumatic events and the sensitizing effects of a prior trauma on the PTSD response to a subsequent trauma. Data come from a representative sample of 1,698 young adults from a large U.S. city. Analysis was conducted on the subset exposed to traumatic events. Women's risk for PTSD following assaultive violence was higher than men's. When assaultive violence preceded a later nonassaultive trauma in women, there was an increased risk (relative risk = 4.9) for PTSD, which was not observed in men. The relative risk estimate in women was significantly higher than in men. These findings suggest that assaultive violence elicits women's PTSD response directly and by sensitizing them to the effects of subsequent traumatic events of lesser magnitude.     

Posttraumatic Stress Disorder and Associated Functional Impairments During Pregnancy: Some Consequences of Violence Against Women

Despite the high prevalence of violence in the lives of women of reproductive age, and the adverse consequences posed to pregnant women suffering from PTSD, few studies have examined violence-related trauma and PTSD among pregnant women. A structured research interview was administered to a convenience sample of 85 prenatal care women to collect information regarding their experiences of violence victimization, PTSD symptoms related to violence-related traumatic events, and whether these symptoms impaired various aspects of the women's daily functioning. Results indicated that 69% of the women experienced a violent traumatic event, with the majority of events occurring before the current pregnancy and being perpetrated by the women's intimate partners. The traumatized women evidenced high levels of PTSD symptoms during pregnancy, with 58% of the women meeting criteria for a PTSD diagnosis. Moreover, many of the women with PTSD symptoms reported that the symptoms adversely affected aspects of their daily functioning.     

Cognitive behavioral therapy of violence-related posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) represents the most common psychiatric condition following exposure to violence. Although an increasing number of cognitive behavioral therapy (CBT) studies point to efficacy of this approach in ameliorating PTSD following violence, the methodological rigor of many studies has not been optimal. Further, a significant proportion of traumatized individuals does not benefit from CBT. This article reviews CBT outcome studies, discusses the methodological limitations of CBT studies for PTSD, and offers suggestions for future research. This review highlights the need for more systematic studies of components of CBT with a range of trauma populations to delineate the parameters of effective CBT for individuals with PTSD.     

The cycle of violence as a function of PTSD and appetitive aggression: A longitudinal study with Burundian soldiers

During deployment, soldiers face situations in which they are not only exposed to violence but also have to perpetrate it themselves. This study investigates the role of soldiers' levels of posttraumatic stress disorder (PTSD) symptoms and appetitive aggression, that is, a lust for violence, for their engaging in violence during deployment. Furthermore, factors during deployment influencing the level of PTSD symptoms and appetitive aggression after deployment were examined for a better comprehension of the maintenance of violence. Semi-structured interviews were conducted with 468 Burundian soldiers before and after a 1-year deployment to Somalia. To predict violent acts during deployment (perideployment) as well as appetitive aggression and PTSD symptom severity after deployment (postdeployment), structural equation modeling was utilized. Results showed that the number of violent acts perideployment was predicted by the level of appetitive aggression and by the severity of PTSD hyperarousal symptoms predeployment. In addition to its association with the predeployment level, appetitive aggression postdeployment was predicted by violent acts and trauma exposure perideployment as well as positively associated with unit support. PTSD symptom severity postdeployment was predicted by the severity of PTSD avoidance symptoms predeployment and trauma exposure perideployment, and negatively associated with unit support. This prospective study reveals the importance of appetitive aggression and PTSD hyperarousal symptoms for the engagement in violent acts during deployment, while simultaneously demonstrating how these phenomena may develop in mutually reinforcing cycles in a war setting.     

A Therapist‐Assisted Internet‐Based CBT Intervention for Posttraumatic Stress Disorder: Preliminary Results

Posttraumatic stress disorder (PTSD) is a debilitating mental health condition frequently associated with psychiatric comorbidity and diminished quality of life, and it typically follows a chronic, often lifelong, course. Previous research has shown that trauma‐related psychopathology (but not necessarily clinical PTSD) can be effectively treated via the Internet. This study is the first of its kind to report on the online treatment of patients with a Diagnostic and Statistical Manual of Mental Disorders (fourth edition) clinical diagnosis of PTSD with therapist support by e‐mail only. Preliminary findings are presented of an open trial involving a 10‐week Internet‐based therapist‐assisted cognitive behavioural treatment for PTSD (PTSD Online). Pre and posttreatment measures of PTSD and related symptomatology were compared for 16 participants with a variety of trauma experiences. Participants showed clinically significant reductions in PTSD severity and symptomatology, moderate tolerance of the program content, and high therapeutic alliance ratings. No significant change was found on measures of more general psychological symptoms. The results suggest that PTSD Online appears to be an effective and accessible clinical treatment for people with a confirmed PTSD diagnosis.     

Gender differences in susceptibility to posttraumatic stress disorder

We examined data from a community survey of trauma exposure and DSM-IV PTSD in Winnipeg, Canada to explore factors associated with the higher rate of PTSD in women than men. Women were found to be at significantly increased risk for PTSD following exposure to serious trauma (odds ratio approximately 5), even when sexual trauma--which predominates in women--was excluded (odds ratio approximately 3). Adjusting for gender differences in the number of lifetime traumata, or in the likelihood of the trauma being associated with particular reactions to or consequences of the event (i.e. thinking that one would be killed or seriously injured; sustaining a serious physical injury; seeing someone else seriously injured or killed) did not result in a lessening of the PTSD risk in women. Women were found to be at increased risk for PTSD following nonsexual assaultive violence (e.g. mugging or other physical attack) but not following non-assaultive trauma (e.g. fire, witnessing injury to others). Understanding the basis of (and parameters for) this increased susceptibility to PTSD in women compared to men following trauma exposure should be a priority for future traumatic stress research.     

Testing Posttraumatic Stress as a Mediator of Childhood Trauma and Adult Intimate Partner Violence Victimization

This study examined whether potential posttraumatic stress disorder (PTSD) mediated the relationships between different forms of childhood trauma (sexual abuse, physical abuse, violence between caregivers) and intimate partner violence (IPV) victimization (psychological, physical, sexual). Participants were 1,150 female nurses and nursing personnel. Path analytic findings revealed potential PTSD partially mediated the relationships between childhood sexual abuse and psychological IPV and childhood sexual abuse and sexual IPV. Potential PTSD did not mediate the relationship between other types of childhood trauma and IPV. This study adds to the literature indicating PTSD as a risk factor for revictimization in the form of adult IPV among women. Screening for and treatment of PTSD among female child sexual abuse survivors could prevent future IPV victimization.     

Behavioral Inhibition and Risk for Posttraumatic Stress Symptoms in Latino Children Exposed to Violence

Latino children in urban contexts marked by poverty are at high risk of being exposed to violence and developing posttraumatic stress disorder (PTSD). Nonetheless, there is great variability in individual responses to violence exposure. This study examines risk for developing re-experiencing, avoidance, and arousal symptoms of PTSD as a function of individual differences in behavioral inhibition and exposure to community violence. Participants were 148 Latino students (M age =11.43 years, SD?=?0.69; 55 % girls) living in an area marked by poverty and crime. Children completed self-report measures of behavioral inhibition and posttraumatic stress symptoms during a baseline assessment. During a follow-up interview 6 months later, children completed self-report measures of exposure to community violence since the baseline assessment and posttraumatic stress symptoms. Structural equation models revealed that behavioral inhibition at baseline was positively associated with PTSD avoidance and arousal symptoms at follow-up, after controlling for symptoms at baseline. Furthermore, behavioral inhibition moderated the association between violence exposure and symptoms such that violence was more strongly associated with the development of PTSD avoidance symptoms as behavioral inhibition increased. Results suggest that individual differences in behavioral inhibition contribute to risk for specific PTSD symptoms and are important for understanding variation in responses to trauma exposure. By examining diathesis-­stress models within a disorder, we may be better able to elucidate the etiology of a disorder and translate this improved understanding into personalized intervention approaches that maximize effectiveness.     

Posttraumatic stress disorder among battered women: analysis of legal implications

The diagnosis of posttraumatic stress disorder (PTSD) has recently been applied to the psychological experiences of victims of intimate violence, including physical and sexual assault. The use of trauma theory to explain battered women's responses to violence has laid a foundation for expert testimony on PTSD, where relevant, within more general testimony concerning partner violence. This article discusses the relevance of the PTSD diagnosis within the legal context for explaining battered women's responses to violence.     

Event centrality and posttraumatic outcomes in the context of pervasive violence: a study of teachers in El Salvador

It is well established that the importance assigned to a trauma can affect one's recovery and psychological health in numerous ways. Event centrality is an increasingly popular construct that captures the tendency among survivors to reevaluate and possibly accommodate their worldviews posttrauma. The centrality given to trauma appears to serve as a “double-edged sword” in that this construct might factor prominently in both posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG). Focusing on 257 violence-exposed teachers from educational departments throughout El Salvador, we examined whether the centrality assigned by the teachers to stressful life events uniquely predicted both PTSD symptomatology and PTG. Results revealed that event centrality was positively related to both PTSD and PTG, even when controlling for demographic factors, violence exposure, and depression. In addition, PTSD symptomatology and PTG were not associated with one another in this sample. In summary, these findings support the role of event centrality as a contributing factor for PTSD and PTG among persons exposed to pervasive trauma.     

Post-traumatic stress disorder symptom severity in service members returning from Iraq and Afghanistan with different types of injuries

IntroductionRisk for post-traumatic stress disorder (PTSD) varies in part due to the nature of the traumatic event involved. Both injury and return from combat pose high risk of PTSD symptoms. How different injuries may predispose towards PTSD is less well understood. METHODS: A retrospective record review was conducted from 1402 service members who had returned to Naval Medical Center San Diego from Iraq or Afghanistan and who had completed the PTSD Checklist as part of their post-deployment screening. Rates of PTSD were examined in relation to mechanism of injury. RESULTS: Of those without injury, 8% met Diagnostic and Statistical Manual criteria for PTSD. Thirteen percent of those with a penetrating injury, 29% with blunt trauma, and 33% with combination injuries met criteria for PTSD. PTSD severity scores varied significantly according to type of injury.DiscussionThe World War I concept of "shell shock" implied that blast-related injuries were more likely to result in psychological symptoms than were other injuries. These data may support that idea. Circumstance of injury, population differences, and reporting bias could also have influenced the results.ConclusionThese results suggest that service members with blunt or combination injuries merit particular attention when screening for PTSD.     

A randomized clinical trial comparing affect regulation and social problem-solving psychotherapies for mothers with victimization-related PTSD

Addressing affect dysregulation may provide a complementary alternative or adjunctive approach to the empirically supported trauma memory processing models of cognitive behavior therapy (CBT) for posttraumatic stress disorder (PTSD). A CBT designed to enhance affect regulation without trauma memory processing—trauma affect regulation: guide for education and therapy (TARGET)—was compared to present centered therapy (PCT) and wait-list (WL) conditions in a randomized clinical trial with 146 primarily low-income and ethnoracial minority mothers with PTSD. TARGET achieved statistically and clinically significant improvement on PTSD and affect regulation measures compared to WL, with more consistent and sustained (over a 6-month follow-up period) evidence of improvement than PCT. Drop-out rates (~ 25%) were comparable in TARGET and PCT, similar to those previously reported for trauma memory processing CBTs. Symptom worsening was rare (2–8%) and transient. Affect regulation-based CBT without trauma memory processing warrants further research as a potentially efficacious therapy for victimization-related PTSD.     

Posttraumatic Stress Symptom Clusters,Trauma History,and Substance Use among College Students

Previous research found associations between experiencing specific posttraumatic stress disorder (PTSD) symptom clusters and use of specific substances among combat veterans, women exposed to domestic violence, and an inpatient sample; however, research has not utilized a college sample when considering this association. This study assessed trauma history, PTSD symptoms, alcohol use, and nonexperimental use of depressants, stimulants, opioids, cannabinoids, hallucinogens, inhalants, and steroids in college students. Results indicate unique associations between the PTSD symptom cluster of reexperiencing and use of depressants, avoidance/numbing with use of depressants and opiates, and hyperarousal with use of opiates. Further, the individual subclusters of behavioral avoidance and emotional numbing were associated with use of depressants and avoidance was associated with hallucinogen use. Implications are discussed.     

Trajectories of Posttraumatic Stress Among Urban Residents

Urban residents experience a wide range of traumatic events and are at increased risk of assaultive violence. Although previous research has examined trajectories of posttraumatic stress (PTS) through latent class growth analysis (LCGA) among persons exposed to the same index events (e.g., a natural disaster), PTS trajectories have not been documented among urban residents. The aims of this study were to conduct LGCA with a sample of trauma survivors from Detroit, Michigan (N = 981), and to explore predictors of trajectory membership. Participants completed three annual telephone surveys, each of which included the posttraumatic stress disorder (PTSD) Checklist-Civilian Version. Four PTS trajectories were detected. Although the majority evidenced a trajectory of consistently few symptoms (Low: 72.5 %), 4.6 % were in a trajectory of chronic severe PTSD (High), and the remainder were in trajectories of consistently elevated, but generally subclinical, levels of PTS (Decreasing: 12.3 %; Increasing: 10.6 %). Socioeconomic disadvantage (e.g., lower income), more extensive trauma history (e.g., childhood abuse), and fewer social resources (e.g., lower social support) were associated with membership in higher PTS trajectories, relative to the Low trajectory. The results suggest that efforts to reduce PTS in urban areas need to attend to socioeconomic vulnerabilities in addition to trauma history and risk for ongoing trauma exposure.     

Racial Differences in Posttraumatic Stress Disorder in Military Personnel: Intergenerational Transmission of Trauma as a Theoretical Lens

Various theorists have explored how intergenerational transmission of trauma impacts minority groups. Intergenerational trauma theories suggest that trauma(s) endured by a community have long-standing effects that can be passed on through generations. However, much of the research has focused on indigenous populations or Holocaust survivors despite the historical experiences of the African American community. The minority stress model adds support to intergenerational trauma theories, in that racial minority groups might suffer worse health due to a variety of stressors. Racial minorities are also at greater risk of developing posttraumatic stress disorder (PTSD). Within military populations, PTSD is one of many mental health issues and has been labeled one of the signature injuries of the recent wars in Iraq and Afghanistan. However, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria for PTSD do not take into account the effects of intergenerational trauma, discrimination, or racism. This article proposes that intergenerational trauma theories and the minority stress model provide explanations for why many studies have found that African American military personnel have higher rates of PTSD compared to their White peers. Indeed, African American military personnel with PTSD might be better understood through more culturally inclusive frameworks (e.g., complex trauma, race-based traumatic stress), because the stressors they experience as racial minorities might exacerbate or lead to symptoms of PTSD.     

Exposure to Violence in Young Inner-City Adolescents: Relationships With Suicidal Ideation, Depression, and PTSD Symptomatology

This study examined the relationship of exposure to violence to suicidal ideation, depression, and post-traumatic stress disorder (PTSD) symptomatology in 94 young adolescents from an inner-city school. Participants completed self-report measures of the Reynolds Adolescent Depression Scale, the Suicidal Ideation Questionnaire—Junior, Adolescent Psychopathology Scale—Posttraumatic Stress Disorder Subscale, and the Exposure to Violence Questionnaire. Using a hierarchical multiple regression design, exposure to violence demonstrated a unique relationship with PTSD symptomatology. Specifically, the relationship between violence exposure and PTSD symptomatology remained significant after controlling for depression and suicidal ideation severity. Controlling for PTSD symptomatology resulted in nonsignificant relationships between violence exposure and depression and suicidal ideation in adolescents. Additional analyses suggest that PTSD functions as a mediating variable between exposure to violence and depression and suicidal ideation. The implication of these results and suggestions for future research are discussed.     

A review of acute stress reactions among victims of violence:

This article reviews research pertaining to the psychological trauma occurring in the immediate aftermath of interpersonal violence. The literature surveyed includes studies of victims and observers of various forms of interpersonal violence: rape, threats by a patient, legal execution, terrorist attack, ambush, and assassination, mass shootings, and other forms of homicide. The empirical evidence indicates that individuals commonly experience disruptive psychological symptoms immediately following violence. Further, there is evidence that acute stress reactions can lead to posttraumatic stress disorder (PTSD). The limited amount of research conducted on treatment interventions on acute stress reactions to violence indicates that there is not one best intervention. However, the high prevalence of acute stress reactions among victims immediately following interpersonal violence, coupled with evidence that acute stress symptoms predict PTSD, underscore the importance of providing early intervention to victims of interpersonal violence.