These events can be a single occurrence in a person’s lifetime or occur repeatedly, such as in the case of ongoing physical abuse or an extended or repeated tour of duty in a war zone. The severity of traumatic events and duration of exposure are critical risk factors for developing PTSD.
Proximity to a traumatic event can determine whether a person develops PTSD. For example, a person who was working in the Twin Towers of the World Trade Center on Sept. 11, 2001 has a much greater chance of developing PTSD than a person hearing about the attack on television.
The signs of the poorly integrated traumatic experience can appear unexpectedly and unpredictably. A flashback or intrusive nightmare can occur without warning, representing unprocessed memories of the traumatic event. As long as thoughts, memories and feelings associated with the trauma remain shut off from the actual event, it is difficult for people living with PTSD to access their inner experiences because the normal flow of emotion remains deeply affected by the traumatic event. For decades, trauma survivors have described being under-responsive (hypoarousal) or over-responsive (hyperarousal) to all types of events—even if they are unrelated.
However, because PTSD is the result of a traumatic event that occurs during the life of an individual, genetic predisposition does not play as a predominant role as it does in mental illnesses such as schizophrenia and ADHD. This is not to say that certain individuals are not inclined to react to traumatic events that may produce negative outcomes, but there is not a gene that “gives you” PTSD.
Combat Veterans and Trauma
Extreme psychological responses to combat have been mentioned throughout history, from Homer's writing in 800 B.C. to writings from the American Civil War and in every war that has followed. In wars prior to Vietnam, the disorder was referred to as “shell shock” or “battle fatigue.” As our understanding of PTSD has grown, recent reassessments of Vietnam veterans have found higher rates of PTSD than previously reported.
The return of combat veterans from Iraq and Afghanistan in recent years has highlighted the impact of psychological trauma not only for veterans but for members still in active duty. Research demonstrating that these veterans have high rates of suicide also illustrates the severity of their psychological distress. A 2007 survey of entry-level military personnel revealed that 26 percent had a history of substance abuse and nearly 16 percent reported current depressive symptoms that were “reasonable” to “severe.”
A survey of troops in Iraq and Afghanistan found a correlation between PTSD symptoms and exposure to combat experiences. Of those responses that met the criteria for diagnosis, only 38-45 percent expressed an interest in receiving help. Some common reasons for not seeking help include fear of being seen as weak or being treated differently by leaders and peers, as well as concerns about such an admission harming one’s career.
Efforts to increase screening for trauma in primary care settings and policies that encourage the identification of troops at risk for suicide are positive developments in military culture. Similarly, policies that formerly acted as disincentives to service men and women who sought mental health services are being overturned, which creates a culture more open to earlier identification and treatment.
Trauma During Childhood
Traumatic events have a very profound impact on a child’s developing brain, body and sense of self. Children can carry these negative effects of trauma well into adulthood. More than 1 million reports of abuse or neglect are substantiated by child protective agencies every year in the U.S. Children who experience chronic physical, sexual or emotional abuse struggle in many areas of life. They are still developing the ability to process ideas, emotionally and physically, and thus express PTSD symptoms in different ways from adults. Common problems include:
- difficulty regulating their emotional reactions;
- establishing and maintaining relationships;
- controlling aggression; and/or
- low self esteem and functioning in school
Adolescents who were abused as children are overrepresented in the juvenile justice and criminal justice system. They also have high rates of substance abuse and psychiatric illness. Childhood trauma increases the risk of most psychiatric conditions and is very common in borderline personality disorder, dissociative disorder and eating disorders. Children learn how to regulate their emotions and sense of self over time through caring relationships. When these relationships are the source of trauma for the child, they can cause confusion and lead to isolation and withdrawal.
Women and PTSD
Studies of the general population suggest that women experience PTSD at more than twice the rate of men. This may be due to the greater likelihood of a woman experiencing a traumatic event. In the military, women run a double risk of developing PTSD for reasons ranging from battle stress and sexual harassment to assault. In a recent study, women in the military were more than twice as likely to develop PTSD as their male counterparts.
Women, however, had been denied insurance coverage for PTSD because of a former stipulation that required combat experience to qualify for the benefit. In addition, women may take longer to recover from PTSD and are four times more likely than men to experience long-lasting PTSD. Military Sexual Trauma (MST), defined by the Department of Veterans Affairs as sexual assault or repeated threatening acts of sexual harassment, is another factor women are faced with.