THE EPIDEMIOLOGY OF TRAUMA, PTSD, AND OTHER POSTTRAUMA DISORDERS

Author(s): NAOMI BRESLAU

Source: Trauma, Violence & Abuse , July 2009, Vol. 10, No. 3, Special Issue, Part 1:
Violence and Women's Mental Health: the Pain Unequalled (July 2009), pp. 198-210
Published by: Sage Publications, Inc.

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 ARTICLES

THE EPIDEMIOLOGY OF TRAUMA, PTSD,

AND OTHER POSTTRAUMA DISORDERS
NAOMI BRESLAU
Michigan State University

Epidemiologie studies have reported that the majority of community residents in

the United States have experienced posttraumatic stress disorder (PTSD)-level
traumatic events, as defined in the DSM-IV. Only a small subset of trauma victims
develops PTSD (<10%). Increased incidence of other disorders following trauma
exposure occurs primarily among trauma victims with PTSD. Female victims of
traumatic events are at higher risk for PTSD than male victims are. Direct evi
dence on the causes of the sex difference in the conditional risk of PTSD is
unavailable. The available evidence suggests that the sex difference is not due to
(a) the higher occurrence of sexual assault among females, (b) prior traumatic
experiences, (c) preexisting depression or anxiety disorder, or (d) sex-related bias
in reporting. Observed sex differences in anxiety, neuroticism, and depression,
inducing effects of stressful experiences, might provide a theoretical context for
further inquiry into the greater vulnerability of females to PTSD.

Key words: posttraumatic stress disorder; sex differences; comorbidity; epidemiology

POSTTRAUMATIC STRESS DISORDER resemble the event and numbing of em

(PTSD) WAS ADOPTED by the responsiveness
American (3 out of 7 criterion sym
Psychiatric Association as part of theare official
required), and (3) increased arousa
of 5 in
classification of psychiatric disorders symptoms
the are required). These
third edition of the Diagnostic andtoms are defined in terms of their conn
Statistical
Manual of Mental Disorders (DSM-III; with the identified traumatic event that is the
American
Psychiatric Association, 1980). Thepresumed
definition cause of the disorder. Temporal
of PTSD in the DSM-III and in the ordering
subsequentis also required: These disturbances
DSM editions is based on the concept must not that
have been present before the trauma
occurred.
traumatic events, in contrast with other The criterion symptoms used in the
stress
PTSD
ful events, are linked etiologically to definition are diagnostically ambiguous.
a specific
syndrome. The PTSD syndrome is They characterize
defined by other psychiatric disorders
and are used
three symptom groups: (1) reexperiencing the in the definition of other disor
traumatic event (1 out of 5 criterion ders, such
symp as major depression and anxiety
disorder.that
toms is required), (2) avoidance of stimuli It is the specific configuration of

TRAUMA, VIOLENCE, & ABUSE, Vol. 10, No. 3, July 2009 198-210
DOI: 10.1177/1524838009334448
© 2009 The Author(s)

198

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 Breslau / TRAUMA, PTSD, AND OTHER POSTTRAUMA DISORDERS 199

criterion symptoms that the DSM requires 82.8%. Much lower estimates of exposure to any
and their connection with a distinct traumatic traumatic event have been reported in surveys
event that transforms theses nonspecific sympin Germany and Switzerland (20% to 28%).
toms into a specific syndrome. Only a small proportion of victims of traumatic
Since 1980, research on PTSD has focusedevents meet criteria for PTSD. Table 1 presents
chiefly on Vietnam War veterans and to a lesserpublished estimates of lifetime cumulative inci
degree on victims of specific types of traumas,dence and 12-month prevalence of PTSD from
such as natural disaster or rape. With thesurveys in the United States, Canada, Germany,
growth of psychiatric epidemiology, PTSD has the Netherlands, Switzerland, Lebanon, and
been studied in samples of the general popula Australia. Estimates of PTSD are higher in the
tion in the United States and other countries. In United States than in other countries. However,
the latest edition of the DSM), the definition even in the United States, where the vast major
of traumatic events that can potentially cause ity of the population has been exposed to one
PTSD—the stressor criterion—has been or more traumatic event, only a minority of
enlarged to include a wider range of events
trauma victims (<10%) has developed PTSD.
than the typical traumatic events of theA initial
consistent finding across epidemiologic
studies
definition (i.e., combat, concentration campis the higher PTSD prevalence in
confinement, natural disaster, rape,women compared with men. Although men
or physi
are more likely to experience trauma, the like
cal assault). The stressor definition in Diagnostic
and Statistical Manual of Mental Disorders
lihood of developing PTSD following exposure
(DSM-IV; 4th ed., American Psychiatric to traumatic events is higher in women. Table
Association, 1994) requires that "the personsex-specific data on exposure to
2 presents
traumatic
experienced, witnessed or was confronted with events and PTSD from U.S. commu
nity studies published from 1991 to 2005.
an event(s) that involved actual or threatened
death or serious injury or a threat to the physi in exposure across studies reflects
Variability
differences
cal integrity of self and others," and whichin the inclusiveness of the stressor
evoked "intense fear, helplessness, or criterion
horror"that defines qualifying events. They
(emphasis added). Learning that someonealso reflect
elsedifferences in the methods used to
was threatened with serious harm qualifies
measurein exposure to traumatic events, chiefly,
the DSM-IV as a traumatic event. DSM-IV whether the study used a list of events or a
introduced a new criterion, namely, thesingle
distur
item that describes (with examples) the
bance causes clinically significant distress or
type of traumatic events that qualify for diag
impairment, in recognition that distressnosing
per sePTSD. Recent studies that used the
and commonly experienced symptoms, such DSM-IV asenlarged definition of stressors and a
sleep problems or concentration problems, are
list of qualifying stressors based on the exam
not equivalent to a mental disorder. Survey
ples in the DSM-IV text have reported esti
data from the United States, where results
mates of exposure greater than 80%. All these
based on earlier definitions are available for
studies have reported a higher lifetime preva
comparison, show that the broader definition lence of exposure in men than in women.
of stressors in the DSM-IV has resulted in a Although consistent across studies, the sex dif
considerably higher proportion of the popula ferences in exposure is modest, with a preva
tion having been exposed to traumatic events lence ratio in men versus women of <1.2 to 1.
that qualify for the PTSD diagnosis (Breslau & The average number of traumatic events expe
Alvarado, 2007). rienced by men exceeds the corresponding
In the United States, the vast majority of com average in women.
munity residents (approximately 80%) have
experienced one or more traumatic events. A
TRAUMATIC EVENTS AND PTSD: THE 1996
similarly high figure has been reported in a
DETROIT AREA SURVEY OF TRAUMA
Canadian community. The lifetime cumulative
exposure to any traumatic event in a national To illustrate the pattern of the epidemiologi
sample of the U.S. population in 2000 was cal findings, data are presented from the 1996

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200 TRAUMA, VIOLENCE, & ABUSE / July 2009

TABLE 1 : Cumulative Incidence of Lifetime and 12-Months of DSM-IV PTSD

Lifetime 12 Months

Study Sample Interview Total Total

Breslau et al. (1998) Detroit PMSA, United States WHO-CIDI (telephone interview) 12.2%
Age 18-45 (8.3%)
(n = 2,181)
Breslau et al (2004) Mid-Atlantic City, United States WHO-CIDI (personal interview) 7.1%
Age 19-22
(n= 1,698)
Kessler, Chiu, Demier, United States National
inai WMH-CIDI (personal interview) 6.8% 3.5%
Merikangas, & Walters (2005) Age >18
(n = 9,282)
Stein, Walker, Hazen, & Forde Winnipeg, Canada PTSD symptom scale (telephone 2.0%
(1997) Age >18 interview)
(n = 1,002)
Hapke et al. (2005) Luebeck, Germany M-CIDI 1.4%
Age 18-64
(n = 4,075)
Perkonigg, Kessler, Storz, & Munich, Germany WHO-CIDI 1.3% 0.7%

Wittchen (2000) Age 14-24 (personal interview)

(n = 3,021)
van Zelst, de Beurs, Beekman, The Netherlands WHO-CIDI (personal interview) 0.9%

Deeg, & van Dyck (2003) Age 55-85

(n = 422)
Hepp et al. (2006) Zurich, Switzerland Zurich Cohort Study 0.0%

Age 34/35 and 40/41 (personal interview)

Karam et al. (2006) Lebanon National
Age >18 WHO-CIDI 2.0%

(n = 308) (personal interviews)

Creamer, Burgess, & Australia National WHO-CIDI modified (personal 1.3%

McFarlane, (2001) Age >18 interview)

(n= 10,641)

NOTE: M-CIDI = Munich-Composite International Diagnostic Interview; WHO-CIDI = The World Health Organization Composi
International Diagnostic Interview; WMH-CIDI = World Mental Health Composite International Diagnostic Interview.

Detroit Area Survey of Trauma (Breslau et al.,violence, (2) other injury/shocking event expe
1998). The survey is a representative sample of rience directly, (3) learning of trauma to another
2,181 persons 18 to 45 years of age in the Detroit person, and (4) learning of a sudden unexpected
primary metropolitan statistical area, which is death
a of a loved one.

6-county area that contained more than 4 million

residents at the time of the 1990 census and
EXPOSURE TO TRAUMATIC EVENTS
close to 2 million in the 18-to-45 age range. A
IN THE DETROIT AREA SURVEY
random digit dialing was used to select the
sample. Information on the sampling, popula The overall lifetime prevalence of exposure
tion and assessment is presented elsewhere to any traumatic event was 89.6%. Prevalence
was higher in men than in women, 92.2 vs.
(Breslau et al., 1998). The telephone interview
began with a complete enumeration of trau 87.1%. The sex difference in exposure was
matic events, using a list of 19 types of traularger for events grouped under assaultive
violence or other injury/shock than for learn
matic events, which operationalize the DSM-IV
ing about trauma to another person or learn
definition as explicated in its accompanying
ing of a sudden unexpected death of a loved
text. An endorsement of an event type was fol
lowed by questions on the number of times anone. Figure 1 depicts the occurrence rates of
exposure to trauma by age, using standard life
event of that type had occurred and the respon
table methods. The rates of occurrence of all
dent's age at each time. The list of 19 events
four classes of trauma peaked sharply at age
were grouped into 4 categories: (1) assaultive

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 Breslau / TRAUMA, PTSD, AND OTHER POSTTRAUMA DISORDERS 201

TABLE 2: Lifetime Prevalence (Rate/100)

Exposure PTSD

Male Female Male Female

Breslau, Davis, Andreski, & Peterson, (1991) 43.0 36.7 6.0 11.3
Norris (1992) 73.6
73.6 64.8 — —
Resnick, Kilpatrick, Dansky, Saunders,
st (1993) — & Best (1993) — 69.0 — 12.3
Kessler, Sonnega, Bromet, Hughes,
>n (1995) & Nelson (1995) 60.7 51.2 5.0 10.4
60.7
Breslau, Davis Peterson et al. — 40.0 — 13.8
Stein, Walker, Hazen, & Forde (1997) 81.3 74.2 — —
Breslau et al. (1998) 92.2 87.1 6.2 13.0
Breslau, Wilcox, Storr et al. 87.2 78.4 6.3 7.9
Kessler, Chiu, Demier, Merikangas, & Walters (2005)a • — — 3.6 9.7

a. NCS-R tables on line, overall exposure = 82.8%, overall PTSD = 6.8%.

exposed to traumatic events, are presented in

0.10 :
Assaultive Violence

qi qq
0.09 j / Other Injuries/Shock
Other Injuries/Shock
Trauma
/ s A. Trauma to to Others
Others Table 3. The estimates are based on the randomly
0.08 -! \ ■ Unexpected Unexpected
0.08 - Death Death

0.07 :
selected events from the list of qualifying
0.07 ;

^ 0.06
^ 0.06 - A. ■
events reported by each respondent. The condi
tional risk of PTSD associated with any trauma
cc

8 JL ^
S 0.05s
-| 0.05 - ■ 4

5S 0.04 I|
was 13.0% in females and 6.2% in males (p <
0.03 i ^
0.03 -j
.001). The overall sex difference was due pri
0.021
0.02 1 '< marily to females' greater risk of PTSD follow
0.01 ing exposure to assaultive violence. Specifically,
0.00 the conditional risk of PTSD associated with
11-15 16-20 21-25
21-2526-30
26-30
Age
Age Category,
Category, yy assaultive violence was 35.7% in females ver

FIGURE 1
1: : Age-specific
Age-specific occurrence
occurrence rates
rates of
of 4 classes of
sus 6.0% in males (p < .001), whereas the s
traumatic events. At each age interval, the differences in the three other categories of tr
occurrence rate is estimated from the number
matic events were not significant. Controllin
of exposures divided by the number of person
years at that interval. for sociodemographic characteristics did n
alter these results. Females' higher risk of PT
applied to all but one event type subsume
16 to 20 years. However, marked differences
were observed across classes of trauma in the under assaultive violence on which sex com

pattern of the rates over the life span of parisons

the could be made (Table 3). To addr
the
respondents. The probability of assaultive vio disparity between the sexes in the perce
lence declined precipitously after the age age of persons exposed to rape, we compar
of 20
years, continued to decline in the third the conditional risk of PTSD between the sex
and
fourth decades of life, and remained low up deleting
to from the comparison those who
age 45 years. In contrast, the probabilities of randomly selected event was rape. In t
other classes of trauma, which also declined remaining subset of the sample (n = 1,925),
after age 20 years, did not continue to decline conditional risk of PTSD associated with
in subsequent years. Sudden unexpected deathassaultive violence was 32.3% (SE = 6.4) in
of a loved one was the only trauma type to females and 6.0% (SE = 3.3) in males (p < .001).
remain at the high level it reached at the The conditional risk of PTSD associated with

16-to-20 age interval until the age of 40 years. any trauma in this subset was 11.5% (SE = 1.6
in females and 6.2% (SE = 1.2) in males (p < .01
THE CONDITIONAL RISK
In a separate analysis, we estimated the sex d
FOR PTSD IN FEMALES AND MALES ferences in the conditional risk of PTSD by th
method of direct standardization. The female
IN THE DETROIT AREA SURVEY
to male ratio of PTSD associated with assault
ive violence, based on the standardized data,
Sex-specific estimates of the conditional risk
of PTSD, that is, the risk of PTSD among those was 2.24 and for any trauma, 1.64.

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 202 TRAUMA, VIOLENCE, & ABUSE / July 2009

TABLE 3: The Conditional Risk of PTSD Among Respondents Exposed to Specific Traumas by Sex

Females Males

PTSD (%) (se) PTSD (%) (SE)

Assaultive violence 35.7 (5.6) 6.0 (3.3)

Military combat * — 0 (0.0)
Rape 49.0 (12.2) t D
Held captive/tortured/kidnapped 78.2 (18.3) 0 (0.0)
Shot/stabbed 0
0 (0.0) 18.1 (15.8)
Sexual assault other than
24.4 rape 24.4 (11-7) 15.7 (15.5)

Mugged/held up/threatened
17.5 with weapon 17.5 (9.0) 2.4 (1.4)

Badly beaten up56.256.2 (12.1) 6.4 (5.4)

Other injury or shocking event 5.4 (2.0) 6.6 (1.9)
Serious car accident 3.6 (2.8) 1.6 (1.2)
Other serious accident 28.3 (10.8) 10.4 (7.3)
Natural disaster 0 (0.0) 7.3 (5.6)
Life-threatening illness 1.0 (1.2) 1.2 (1.3)
Child's life-threatening illness 0 (0.0) 17.8 (15.7)
Witnessed killing/serious injury 2.8 (2.8) 9.1 (3.3)
Discovering a dead body 0.5 (0.5) 0 (0.0)
Learning of traumas to others 3.2 (1.3) 1.4 (0.8)
Sudden, unexpected death of relative/friend 16.2 (3.6) 12.6 (3.6)
Any trauma 13.0 (1.6) 6.2 (1.2)

1.0
Female and Event to Self
Female and Event to Other
%\ = 10.568, p =.002), with median duration of
0.9
Male and Event to Self 48.1 months in females versus 12.0 months in
Male and Event to Other
0.8
0.8

males. PTSD persisted longer in cases resulting

8 070.7*
from traumas experienced directly, that is,
M 0.6
0.6 -

assaultive violence and injury or shock, com

0.5
*3 0.5
J? pared with learning about traumas to others or
0.4
■s 0-4

0.3
a sudden, unexpected death of a loved one
0.2
(log-rank y?l = 6.534, p = .01) with median dura
0.1
tion of 48.1 months versus 12.1 months, respec
0.0
tively. Using Cox proportional hazards model,
0 6 612
1218
1824
2430
3036
3642
4248
4854
5460
60 66
66 72
72 78
78 84
84 90
90 96
96 102
102 108
108 114
114 120 no interaction was detected between sex and
Months From Onset of PTSO

trauma type {y}l = 0.001, p = .99). Females w

FIGURE 2: Remission of posttraumatic stress disorder
(PTSD) by sex and trauma type PTSD had longer duration of affect than ma
with PTSD regardless of trauma type, assa
ive versus other.

DURATION OF PTSD
IN THE DETROIT AREA SURVEY OTHER POSTTRAUMA DISORDERS

Kaplan-Meier survival methods were used Epidemiological studies of general popu

to estimate the time to remission of PTSD in
lation samples have confirmed earlier obse
persons who met criteria for the disorder
vations from clinical samples and samples o
(Figure 2). Approximately 26% of PTSDVietnam
cases veterans that persons diagnosed
with PTSD have high rates of other psychi
remitted by 6 months and 40% by 12 months.
From that point on, remission tapered off. atric
Thedisorders (Breslau, Davis, Andreski, &
median time to remission was 24.9 months, Peterson, 1991; Kessler, Sonnega, Bromet,
and, in more than one third of cases, PTSD Hughes, & Nelson, 1995). These include major
persisted for more than 60 months. PTSD per depression, anxiety disorders other than
sisted longer in females than males (log-rank PTSD and substance use disorders. Alternative

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 Breslau / TRAUMA, PTSD, AND OTHER POSTTRAUMA DISORDERS 203

explanations have been proposed for the asso events cause various disorders apart from
ciation of PTSD and these disorders. First, pre PTSD and that there may be distinct diatheses
existing psychiatric disorders may increase the determining the specific psychiatric conse
likelihood of PTSD by increasing the risk for quences of trauma originated in observations
exposure to traumatic events of the type that of high rates of various disorders among
lead to PTSD or increase susceptibility to the trauma victims. For example, rates of depres
PTSD-inducing effects of trauma. For example, sion and anxiety disorders (other than PTSD)
drug use disorder has been suspected of increas appeared elevated in trauma patients admitted
ing the likelihood of PTSD because it is associ to the emergency room (Shalev et al., 1998).
ated with lifestyles that involve an elevated Similarly, an elevated rate of major depression
risk for exposure to violence. There is evidence that was equal to the rate of PTSD was found
that history of major depression increases the in a survey of New York City residents several
risk for exposure to traumatic events (Breslau, months after the attacks on the World Trade
Davis, Andreski, Peterson, & Schultz, 1997), as Center of September 11, 2001 (Galea et al.,
it does for exposure to ordinary stressful life 2002). However, these data, in themselves, do
events (Kendler, Kessler, Neale, Heath, & Eaves, not indicate that exposure to traumatic events
1993). Second, PTSD may be a causal risk factor was the cause of the other disorders.
for other psychiatric disorders. Use of alcohol To test whether exposure to traumatic events
or drugs to relieve the distressing symptoms of increases the risk for a psychiatric disorder other
PTSD may increase the likelihood of depend than PTSD (e.g., major depression), it is neces
ence; major depression may develop as a com sary to compare the disorder's incidence in per
plication of PTSD and its associated impairment. sons exposed to trauma who did not develop
Third, the associations may be noncausal, PTSD with the incidence in persons not exposed
reflecting shared genetic or environmental to trauma. That is, with respect to psychiatric
factors. Genetic factors common to PTSD and disorders other than PTSD, evaluating the poten
substance use disorders as well as depressiontial causal role of exposure to trauma requires a
have been reported. Also, personality traits different approach from that used to estimate
(primarily, neuroticism) and family history of the risk for PTSD. By the DSM definition, PTSD
major depression have been implicated separequires a causal link to an identifiable qualify
rately in the development of PTSD, as well as ing stressor, and the symptoms of PTSD are
in the development of major depression. closely connected with the memory of that
A suspected shared environmental risk facstressor; there can be no PTSD among persons
tor for PTSD and other psychiatric disorders iswho were not exposed to a traumatic event. In
the trauma that gave rise to PTSD. It has beenconsequence, the risk for PTSD in trauma vic
suggested that traumatic events leading totims is measured by a conditional probability
PTSD also induce diatheses for other disor
or conditional risk (i.e., risk among those
ders (Friedman & Yehuda, 1995). Although
exposed to the stressor). In contrast, the defini
PTSD has been defined as the signature disor
tions of major depression, anxiety, or substance
der in victims of traumatic events, stressors—
use disorder do not require a link to a stressor,
both those that qualify for the diagnosis as of
these disorders can occur without a stressor.
PTSD and those that do not—may alsoInpre consequence, the association between trauma
cipitate other disorders. According to this
exposure and subsequent occurrence of major
hypothesis, some trauma victims develop depression (or another disorder) is measured
PTSD, whereas others develop major depres
by a ratio of risks or by a relative risk estimate
sion or substance use disorder, depending onrisk for depression among those exposed
(i.e.,
their preexisting vulnerabilities. Comorbidity divided by risk among those not exposed).
of PTSD with other disorders would thus Without such a comparison of risks, we cannot
reflect the co-occurrence of distinct diatheses test whether the risk among exposed persons is
(Friedman & Yehuda, 1995; Yehuda, McFarlane, in fact higher than it would have been if they
& Shalev, 1998). The notion that traumatic were not exposed to trauma. PTSD has no such

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204 TRAUMA, VIOLENCE, & ABUSE / July 2009

an alternative. A relative risk for PTSD with with PTSD, but not in those without PTSD,
compared with unexposed persons (Breslau,
respect to the presence or absence of a stressor
cannot be estimated. Davis, & Schultz, 2003). The results on nicotine
Furthermore, to evaluate the role of trauma
dependence are equivocal, and a modestly
exposure in the onset of a disorder other than elevated risk in trauma victims in the absence
PTSD, it is not sufficient to show that the disor
of PTSD has not been safely ruled out (Breslau
et al., 2003).
der's rate is higher in persons exposed to trauma
than those not exposed to trauma. Support for The extent to which a diathesis shared with
the hypothesis that trauma is associated with anPTSD accounts for the elevated risk for other
increased risk for major depression (or anotherdisorders may vary across disorders The PTSD
disorder), independent of its PTSD-inducingmajor depression association is likely to primar
effects, requires evidence of a higher incidenceily reflect a shared diathesis (Breslau et al.,
of the disorder in exposed persons who did not2000). Added evidence supporting this inter
develop PTSD, compared with nonexposed per pretation comes from evidence that preexisting
sons. Evidence of an increased risk (relative tomajor depression and family history of major
unexposed persons) for the disorder in traumadepression are associated with increased risk
victims with PTSD but not in trauma victims for PTSD following trauma exposure (Breslau
without PTSD would not support the hypotheet al., 2000; Bromet, Sonnega, & Kessler, 1998;
sis. It would suggest instead that PTSD might Connor & Davidson, 1997). The PTSD-drug use
cause the disorder or that shared antecedent fac disorder association may reflect primarily a
tors other than the trauma account for the PTSD— causal effect of PTSD (Chilcoat & Breslau, 1998),
other disorder link. although a common genetic contribution to the
Reports based on prospective and retrospec association has also been reported (McLeod
tive data show a markedly increased risk for et al., 2001; Xian et al., 2000).
major depression in trauma-exposed persons Recent results on the relation between PTSD
with PTSD (Breslau, Davis, Peterson, & Schultz, and the risk for alcohol use disorders in exposed
2000). Elevated risk for major depression was not persons suggest the possibility that female, but
observed in trauma-exposed persons without not male, trauma victims who did not develop
PTSD, compared with nonexposed persons PTSD may be at increased risk for alcohol use
(Breslau, Davis, Peterson, et al., 1997; Breslau disorder. Previous research in Vietnam combat
et al., 2000). This pattern of a markedly higher veterans and civilian victims of traumatic
rate of major depression in victims with PTSD events generally found considerably stronger
can also be observed in reports from other associations between trauma exposure and
studies that did not explicitly address this alcohol use disorder when PTSD was present
question, including postdisaster studies (Galea rather than absent. Some studies found weak
et al., 2002; North et al., 1999). For example, or no association between trauma exposure
although the New York City survey conducted and drinking or alcohol use disorder. Notably,
after the attacks on the World Trade Center there is little support for the notion that male
found similar rates of PTSD and major deprestrauma victims (whose risk for PTSD is gener
sion (Galea et al., 2002), hand calculations of
ally lower than that of female trauma victims)
respond to traumatic experiences by abusing
reported numbers reveal that the prevalence of
major depression in persons with PTSD was alcohol or drugs. Such susceptibility would
49%, and in those without PTSD, it was only result in an increased risk for alcohol and drug
6.5%. The latter figure is not far from what use disorders in trauma-exposed men without
could be expected for past-30-day major depres PTSD, relative to unexposed men. rrhe data are
sion in the general population. inconsistent with this expectation.
With respect to the relationship of substance
use disorders to trauma exposure and PTSD,RESEARCH
a ON RISK FACTORS
recent report shows an increased risk for the
subsequent onset of nicotine dependence and Studies of risk factors examined lists of vari
ables that included sociodemographic factors
drug abuse or dependence in trauma victims

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 Breslau / TRAUMA, PTSD, AND OTHER POSTTRAUMA DISORDERS 205

together with personality traits and biographi studies and retrospective reports, a limitation
cal events. The NVVRS included race, familythat is generally acknowledged in the litera
religion, family SES (socioeconomic status), ture. A major limitation that has been over
educational attainment, marital status, child looked is the failure to assess how persons had
abuse, childhood behavior problems, family responded to the prior trauma, specifically,
mental health problems, and history of mental whether or not they had developed PTSD in
health problems. A meta-analysis of a long list response to the prior trauma. Consequently, it
of risk factors for PTSD discovered heterogene is unclear whether prior trauma per se, or
ity between civilian and veteran studies and instead prior PTSD, predict an elevated risk for
across methods (Brewin, Andrews, & Valentine, PTSD following a subsequent trauma. Evidence
2000). However, three risk factors were uniform that previously exposed persons are at increased
across populations and methods: psychiatricrisk for PTSD only if their prior trauma resulted
history, family psychiatric history, and early in PTSD would not support the hypothesis that
adversity (Brewin et al., 2000). Although the exposure to traumatic events increases the risk
effect of each individual risk factor examined in for (sensitizes to) the PTSD effects of a subse
the meta-analysis is relatively small, their sum quent trauma, transforming persons with "nor
might outweigh the impact of trauma severity mal" reactions to stressors into persons susceptible
(Brewin et al., 2000, p. 756). Another meta to PTSD. Instead, it might suggest the possibil
analysis of risk factors for PTSD (or PTSD ity that trauma precipitates PTSD in persons
symptoms) concluded that 'peritraumatic'with preexisting susceptibility (that had already
responses (e.g., dissociation as the immediate been present before the prior trauma occurred).
response to the stressor) count the most (Ozer, A predisposition to pathological response to
Best, Lipsey, & Weiss, 2003). There is a concep stressors might account for the PTSD response
tual problem in this analysis (and similar stud to the prior trauma as well as to the subsequent
ies concerning negative appraisal as risk factor) trauma. Evidence that personal vulnerabilities,
in that peritraumatic responses and appraisalchiefly neuroticism, history of major depression
might themselves be aspects of the outcome and anxiety disorders, and family history of
we wish to explain. Dissociations, negativepsychiatric disorders increase the risk for PTSD
appraisal, and PTSD are likely to be manifes has been consistently reported. There also is
tation of the same psychological process or evidence that personal vulnerabilities might be
consequences of a common vulnerability. stronger predictors of psychiatric response to
traumatic events than trauma severity, espe
PRIOR TRAUMA AS RISK FACTOR cially in civilian samples.
This question was examined recently in a
A frequently replicated epidemiologic findlongitudinal epidemiologic study of young
ing is the enhanced probability of PTSD in adults (Breslau, Peterson, & Schultz, 2008). At
exposed persons who had experienced prior baseline and at three reassessments over the
traumatic events. Studies of Vietnam veterans following 10 years, respondents were asked
and general population samples have reportedabout the occurrence of traumatic events and
higher rates of prior trauma (including childPTSD. Data from one or more follow-up assess
hood maltreatment) among exposed personsment were available on 990 respondents (98.3%
who succumbed to PTSD than among exposedof the initial panel). Exposure to trauma and
persons who did not (Bremner, Southwick, PTSD measured at baseline and at the 5-year
Johnson, Yehuda, & Charney, 1993; Breslau,follow-up were used to predict new exposure
Chilcoat, Kessler, & Davis, 1999; Galea et al.,and PTSD during the respective subsequent
2002). The finding has been interpreted as sup periods: from baseline to the 5-year assess
porting a 'sensitization' process, that is, greaterment and from the baseline and 5-year assess
responsiveness to subsequent stressors (Post & ment to the 10-year assessment. Preexisting major
Weiss, 1998). The evidence on prior trauma depression and any anxiety disorder were
comes almost exclusively from cross-sectional included as covariates to control for their effects.

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206 TRAUMA, VIOLENCE, & ABUSE / July 2009

To estimate prospectively the risk for PTSD anxiety disorders, and conduct problems in
associated with prior trauma, the study used childhood influence the risk for PTSD and
multinomial logistic regression, applying gen exposure to traumatic events. The association
eralized estimating equations (GEE). between intelligence and the risk for PTSD has
The relative risk for PTSD following expo been examined in samples of Vietnam War vet
sure to traumatic events in subsequent periods erans in case-control designs, using contempo
was significantly higher among trauma victims raneous measurement of PTSD and IQ and
with PTSD in the preceding periods, but not archival data on IQ tests given at the time of
among trauma victims who had not succumbed enlistment before deployment(Macklin et al.
to PTSD. Odds ratio was 2.68 (95% Confidence 1998). These studies reported that combat vet
Interval [CI] = 1.33,5.41) and 1.22 (95% CI = 0.64, erans with PTSD had lower test scores than
2.34), respectively, adjusted for sex, race, edu veterans without PTSD.
cation, preexisting major depression and anxi Elevated rates of anxiety disorders and major
ety disorders and time of assessment. The depression in persons diagnosed with PTSD
authors concluded that there was no support in have been reported in Vietnam -veterans and
their data for the idea that traumatic events civilian samples (Green, Grace, Lindy, Gleser, &
Leonard, 1990; Kessler et al, 1995; Kulka, 1990).
experienced in the past lurk inside, waiting
The lifetime association has been explained in
to shape reactions to future traumatic events.
part by preexisting anxiety and depressive dis
The findings suggest the possibility that preexi
sting susceptibility to pathological responseorders,
to increasing victims' susceptibility to the
PTSD
stressors account for the PTSD response to the effects of traumatic events. There also is
prior trauma and the subsequent trauma. evidence
Of that preexisting anxiety and depres
interest is the finding of higher PTSD risk
sion increase the risk of exposure to traumatic
events, as they do to ordinary stressful life
among females, given that prior PTSD expo
events
sure/no PTSD and preexisting major depres (Breslau et al, 2000; Kendler et al., 1993).
sive disorder were controlled. Childhood conduct problems, antecedents to a
A 1987 Israeli study of acute combat stresswide range of psychiatric disorders in adult
reaction (CSR; PTSD was not examined) among hood, were reported in cross-sectional studies
soldiers in the 1982 Lebanon war had reported to be more frequent among Vietnam veterans
the same pattern (Solomon, Mikulincer, &with PTSD than among those without PTSD
Jakob, 1987). The authors reported that CSR(Kulka, 1990).
occurred more frequently among soldiers of Our goal in this prospective study is to pro
the Lebanon war who had experienced CSR invide a strong test of the hypothesis that intelli
a previous war, but not among soldiers whogence, conduct problems, and anxiety disorders
had fought in a previous war but had not expein early childhood influence the risk for experi
rienced CSR, compared to new recruits who encing traumatic events and developing
had not fought in a previous war. The authors PTSD after exposure. Data on childhood factors
concluded that knowledge of the outcome ofwere gathered at age 6 years. Data on exposure
prior combat was essential for predicting solto traumatic events and PTSD were gathered
diers' response to subsequent combat. Soldiers at age 17 years and cover the participant's
who suffered CSR in a previous war might cumulative experience up to the time of the
have had preexisting vulnerability that alsointerview.
accounted for their increased risk of CSR during The study was described in previous publica
the subsequent war. tions (Breslau, Paneth, & Lucia, 2004). Briefly,
data are from randomly selected sample of all
1983-1985 low-birth-weight and normal-birth
EARLY ANTECEDENTS: RESULTS
weight newborn discharges of two major hospi
FROM A PROSPECTIVE STUDY.
tals in southeast Michigan, representing a
In a prospective study from age 6 to 17 years,disadvantaged urban community and a sub
we examine the extent to which intelligence,urban middle-class community. In the analysis,

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 Breslau / TRAUMA, PTSD, AND OTHER POSTTRAUMA DISORDERS 207

TABLE 4: Multivariable Model of Childhood Predictors of

we take into account the sampling design by
PTSD Following
lowing Ex| Exposure
incorporating the stratification variables (low
birth weight vs. normal birth weight; and urban Characteristic Adjusted OR3 (95% CI)

vs. suburban) in the statistical models. Children Urban 1.35 (0.65-2.82)

were assessed at ages 6,11, and 17 years. Low birth weight 1.56 (0.78-3.12)
Male 0.50 (0.25-0.97)b
Adjusted OR for exposure to assaultive vio Full-scale IQC
lence (but not for other trauma types) was asso 101-115 0.62 (0.30-1.26)
ciated with teachers' ratings of externalizing >115 0.21 (0.05-0.94)"
problems above the normal range. IQ scores High externalizing problems'1 1.86 (0.94-3.71 )e
Any anxiety disorder1 2.08 (1.01-4.32)"
greater than 115 were associated with a marked
decrease in the risk for exposure to assaultive NOTE: n = 541. Ci = confidence interval; OR = odds ratio; PTSD =
posttraumatic stress disorder.
violence, independent of other variables in the a. Adjusted from multiple logistic regression.
model. IQs greater than 115 were associated b. p <. 05
c. Measured by the Wechsler Intelligence Scale for Children
with a lower risk for exposure to other trauma Revised at age 6 years. An IQ less than 100 points is reference.
types, but the association was weaker than with d. Defined by a t score of 60 or greater on the Teacher Report
Form at age 6 years.
assaultive violence. Adjusted ORs for assaultive
e. p= .08.
violence associated with urban residence was f. Diagnostic and Statistical Manual of Mental Disorders (Rev. 3rd
significantly higher than for other trauma types ed., American Psychiatric Association, 1987) generalized anxiety
disorder, overanxious disorder, separation anxiety, or simple pho
(3.58 vs. 2.21, x2 - 4.72, p = .03 for the difference
bia assessed by the parent version of the diagnostic interview
between the two estimates). schedule for children at age 6 years.

Adjusted estimates for PTSD among persons

exposed to trauma based on a multiple logistic
at the age of 6 years predicted increased risk
for PTSD; and (d) youth with an IQ score
model appear in Table 4. Children with high
ratings of externalizing problems at the agegreater
of than 115 at the age of 6 years were at a
6 years had an increased risk for PTSD, control
far lower risk for PTSD than youth at or below
ling for other variables in the model, as the
did population mean. We observed in these
children with anxiety disorders at the age of 6 the sex-related pattern reported in previous
data
years. In each case, the increase was approxi
studies, with males more likely to be exposed to
mately twofold. Children with IQ scores of 1
trauma, and females more likely to experience
SD above the population mean or higher hadPTSD
a following exposure.
markedly lower risk for PTSD than children The ways in which high IQ might protect
with an IQ score of 100 or less (OR = 0.21; 95%
from the PTSD effects of traumatic exposure
CI - 0.05-0.94). are unclear. An exploratory analysis suggested
The key findings from this prospective study that the advantage associated with high IQ
indicate that (a) youth who have been rated by might be in distinguishing those who experi
their teachers as being above the normal range ence minor or moderate disturbance from
of externalizing problems at the age of 6 years those who develop PTSD, that is, pervasive
were at increased risk for exposure to assault disturbance associated with impairment or dis
ive violence, but not to other trauma types, tress. The findings underscore the importance
controlling for other risk factors for exposure; of investigating cognitive processes in a per
(b) youth with an IQ higher than 115 at the age son's responses to challenging and potentially
of 6 years were at lower risk for exposure to traumatic experiences and the involvement of
both assaultive violence and other trauma types; general intelligence in shaping them.
the association with assaultive violence was
significantly stronger; (c) given trauma expo
CONCLUSIONS
sure, Diagnostic and Statistical Manual of Mental
Disorders' revised third edition (DSM III-R; rev. Epidemiologic studies have consistently
3rd ed.; American Psychiatric Association, reported that only a small subset of trauma vic
1987) anxiety disorders and teachers' ratings oftims succumbs to PTSD; most trauma victims do
externalizing problems above the cutoff pointnot. Recent studies indicate that trauma victims

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208 TRAUMA, VIOLENCE, & ABUSE / July 2009

who do not develop PTSD (i.e., most victims) the type of traumatic events, specifically, the
are not at a markedly elevated risk for the sub higher occurrence of sexual assault and rape
sequent first onset of other psychiatric disorders, among females than males, are not responsible
compared with unexposed persons. The excess for the higher conditional risk of PTSD (Tolin &
incidence of the first onset of other disorders fol Foa, 2006). Second, prior traumatic experiences
lowing trauma exposure is concentrated primar do not account for the sex difference in vulner
ily in the small subset of trauma victims with ability. The sex differential remains when prior
PTSD. These observations suggest that PTSD traumas are adjusted for. Third, preexisting
identifies a subset of trauma victims at consider depression or anxiety disorder, which predict an
able risk for a range of disorders. The extent to increased PTSD risk in both sexes, are unlikely
which the increased risk for these other disor causes of the excess occurrence of PTSD in
ders represents shared diatheses versus complifemales. Fourth, the sex difference in PTSD is
cations of PTSD may vary across disorders. unlikely to be attributable to sex-related bias in
Female victims of traumatic events are at reporting as a recent analysis of measurement
higher risk for PTSD than male victims. invariance
The has demonstrated (Chun g & Breslau,
explanation for females' higher vulnerability 2008).
to Findings on sex differences in anxiety,
PTSD is unclear. Direct evidence on the causes of neuroticism, and the depression-inducing effects
the sex difference is unavailable. However, the of stressful experiences might provide a theo
available evidence suggests that some potential retical context for further inquiry inlo the greater
causes can be ruled out. First, sex differences in vulnerability of females to PTSD.

IMPLICATIONS FOR PRACTICE, POLICY, AND RESEARCH

targeted to subpopulations with greater risk. These

• Practitioners could identify trauma victims at elevated
include
risk for PTSD by focusing on victims' psychiatric history. (a) women exposed to assaultive violence,
(b) women and men with history of psychiatric disor
Persons with a history of depression or anxiety are more
ders, and (c) persons with low education and history
likely than others to develop PTSD following exposure
to trauma. of childhood emotional problems.
• Women exposed to assaultive violence should be
• Research is needed to investigate the causes of women's
evaluated for PTSD. greater risk of PTSD.
• Efforts at prevention of PTSD and other psychiatric
disorders following exposure to trauma should be

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210 TRAUMA, VIOLENCE, & ABUSE / July 2009

Post, R. M., & Weiss, S. R. (1998). Sensitization and kin Naomi Breslau, PhD, is
dling phenomena in mood, anxiety, and obsessive professor in the Department
compulsive disorders: The role of serotonergic of Epidemiology, Michigan
mechanisms in illness progression. Biological Psychiatry,
State University College of
44,193-206.
Human Medicine. She
Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., received her ELB at Hebrew
& Best, C. L. (1993). Prevalence of civilian trauma and
University in Jerusalem, MA
posttraumatic stress disorder in a representative
national sample of women. Journal of Consulting and at New York University, and
PhD at Case Western Reserve
Clinical Psychology, 61, 984-991.
Shalev, A. Y., Freedman, S., Peri, T., Brandes, D., Sahar, University. She is a psychi
T., Orr, S. P., et al. (1998). Prospective study of atric epidemiologist and sociologist who has
posttraumatic stress disorder and depression contributed to the epidemiological study of numerous
following trauma. American Journal of Psychiatry, 155, psychiatric conditions and behavioral disturbances,
630-637.
most prominently posttraumatic stress disorder (PTSD)
Solomon, Z., Mikulincer, M., & Jakob, B. R. (1987). and tobacco dependence. She has conducted large-scale
Exposure to recurrent combat stress: Combat stress
longitudinal epidemiologic studies, including on PTSD,
reactions among Israeli soldiers in the Lebanon War.
low birth weight, and migraine headaches in relation to
Psychological Medicine, IV, 433-440.
psychiatric comorbidity. The American Association for
Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R.
the Study of Headache honored her work on the prospec
(1997). Full and partial posttraumatic stress disorder:
Findings from a community survey. American Journal tive
of relationship between major depression and migraine
Psychiatry, 154,1114-1119. with the Wolf Award. She has had continued National
Institutes of Health (NIH) grant support from 1980. In
Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma
and posttraumatic stress disorder: A quantitative addition, for a period of 10 consecutive years, from 1982
review of 25 years of research. Psychological Bulletin, to 1992, she was supported by National Institute of
132, 959-992. Mental Health (NIMH) K02 Research Scientist
van Zelst, W. H., de Beurs, E., Beekman, A. T., Deeg, D. J.,
Development. Awards. Since 1980, she has served o
& van Dyck, R. (2003). Prevalence and risk factors of numerous NIH review committees. She was a member
posttraumatic stress disorder in older adults. the NIMH Consensus Development Panel for ADHA
Psychotherapy and Psychosomatics, 72, 333-342.
the DSM-IV Work Group on GAD Mixed Anxiet
Xian, FL, Chantarujikapong, S. I., Scherrer, J. F., Eisen, S. A.,
Depression. She served on the Test Committee Behaviora
Lyons, M. J., Goldberg, J., et al. (2000). Genetic and
Science, Part I, the National Board of Medical Examiner
environmental influences on posttraumatic stress dis
order, alcohol and drug dependence in twin pairs. From 1982 to 1986, she served as coeditor of Medic
Drug and Alcohol Dependence, 61, 95-102. Care. She is currently associate editor of two scientifi
Yehuda, R., McFarlane, A. C., & Shalev, A. Y. (1998). journals, Nicotine and Tobacco Research and th
Predicting the development of posttraumatic stress International Journal of Methods in Psychiatric Researc
disorder from the acute response to a traumatic event. and is a member of the Editorial Board of Archives of
Biological Psychiatry, 44,1305-1313. General Psychiatry.

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