capstone final paper - finish

Running Head: UNTREATED PTSD & NON-VETERAN POPULATIONS 1

Untreated PTSD in Non-Veteran Populations

Rory Wise

May 8, 2015

Honor Code:

I have neither given nor received any unauthorized aid on this piece of work nor have I

knowingly tolerated any violation of the Honor Code. – Rory Barnes Wise Jr.

UNTREATED PTSD & NON-VETERAN POPULATIONS 2

Abstract

War veterans over represent the population diagnosed with Posttraumatic stress disorder (PTSD)

(Lawford, 2014). As a result, non-veteran civilians who experience other traumatic events may

not receive the attention they need and may develop other depressive or anxiety disorders.

Therefore, possible non-veteran populations at risk for PTSD were examined, finding that

victims of intentional traumas are more likely to develop PTSD. Moreover, perceived life threat

is positively correlated to the prevalence of PTSD. High comorbidity was found with patients

diagnosed with PTSD and generalized anxiety disorder (GAD), major depressive disorder

(MDD), obsessive-compulsive disorder (OCD). This implies that PTSD may be a risk factor for

the previously stated disorders. More aid should be provided to the suggested at risk civilian

populations for PTSD.


Untreated PTSD in Non-Veteran Populations

Posttraumatic stress disorder (PTSD) has been highly associated with war veterans, which

may have caused an under-representation of other population groups diagnosed with PTSD. 11%

to 20% of the soldiers fighting in the “Operations Iraqi Freedom and Enduring Freedom” have

been diagnosed with PTSD; however, soldiers and veterans account for only a small portion of

the 5.2 million adults diagnosed with PTSD each year (Gradus, 2014). The DSM-V states that

the trigger for PTSD derives from exposure to actual or threatened death, serious injury, or

sexual violation (American Psychiatric Association, [APA], 2015). Thus, there are many other

populations that are at risk for PTSD, but possibly under-represented.

The possibility arises that war veterans and soldiers may over represent the 5.2 million

diagnosed with PTSD because other populations may have not been examined. In fact, there is

no epidemiological study completed to assess the number of children and adolescences

diagnosed with PTSD (Gradus, 2014). Therefore, adolescents and children are not represented by

the 5.2 million diagnosed with PTSD; nevertheless, studies have shown that children and

adolescents may be at a higher risk of developing PTSD than the general population (Gradus,

2014). As a result, children and adolescents also may not receive the support they need to treat

their PTSD.

Furthermore, according to the criteria defined by the DSM-V, there are the 4 criteria of

exposure based scenarios that trigger PTSD: the individual directly experiences the traumatic

event, witnesses the traumatic event in person, learns that the event occurred to a close family

member or friend, or experiences first-hand repeated or extreme exposure to aversive details of

the traumatic event (APA, 2015). Thus, PTSD may be much more common than previously

expected. It is possible that those who experience traumatic events in under-represented


populations may be unaware of the possibility for them to develop PTSD; they may be

uneducated about the symptoms or fear being stigmatized. For example, one study found that

soldiers avoided seeking treatment for their posttraumatic stress symptoms (PTSS) because they

feared being stigmatized as crazy, mentally ill, or dangerous (Mittal et al., 2013). Furthermore,

people may be unaware that simply receiving the news that a close friend or family member

experienced a traumatic event may trigger PTSD. Studies have shown that simply receiving news

of the death of a family member or close friend was associated with the occurrence of PTSD

(Stewart, 1999).

Furthermore, according to the National Highway Transportation Safety Administration

(NHTSA), between 1990 and 1996, there were 289,928 people that died from car crashes in the

US. If only receiving the news of a family member’s or close friend’s death is associated with

developing PTSD, then at least 289,928 people were at risk for developing PTSD between 1990

and 1996. Therefore, it is imperative to examine the other possible at-risk populations for PTSD

to determine which populations are at a high risk and should receive aid. Thus, it is hypothesized

that civilians who experienced traumatic events may not receive the attention they need as a

result of veterans over representing the population diagnosed with PTSD (Lawford, 2014).

Moreover, these civilians not seeking the proper professional attention may develop severe

PTSD, major depressive disorder (MDD), acute stress disorder (ASD), obsessive-compulsive

disorder (OCD), or generalized anxiety disorder (GAD).

At Risk Populations

There have been many studies that looked at the prevalence rates of different at risk

populations for PTSD. Studies examined categorized these populations by their type of trauma:

intentional or unintentional (Santiago et al., 2013). Intentional traumas are due to actions that


deliberately inflict harm on another person (Santiago et al., 2013). Therefore, civilians who

experienced an intentional trauma include rape victims, physical assault victims, and child abuse

victims. Unintentional traumas are those not aimed to cause harm to another person (Santiago et

al., 2013). Examples of unintentional traumas are car crashes or natural disasters. This

categorization allows examination of the differences between the two groups, in which some

studies have found that experiencing intentional traumatic events was more associated with

worse health outcomes in comparison to those exposed to unintentional traumas (Santiago et al.,

2013). Further support for this finding may be found when the aftermath of experiencing rape is

examined.

Intentional traumas.

Rape victims. Victims of rape are examined frequently to assess their association with PTSD.

Studies have found that rape victims developed PTSD more frequently when victims perceived

the experience to be life threatening (Tiihonen Moller, Backstrom, Sondergaard, & Helstrom,

2014). The same results were found when there was moderate to severe violence during the

assault (Tiihonen Moller et al., 2014). Therefore, research has demonstrated that violence and

perceived life threat is positively correlated to the likelihood of developing PTSD. Furthermore,

the same study has found that 1 in 3 women are diagnosed with PTSD following an assault

(Tiihonen Moller et al., 2014). An epidemiological study utilizing a national probability sample

of women in the United States found 18% of these women have been forcible rape at least once

(Kilpatrick, Resnick, Ruggiero, Conoscenti, & McCauley, 2007). According to the 2005 US

Census data, using the 18% of raped women, studies suggest that 20.2 million women have been

raped (Kilpatrick et al., 2007). Therefore, the prevalence rate and risk level of female rape


victims is very substantial since every 1 of 3 women may develop PTSD and 20 million women

are raped solely in one year.

Many studies focus on the prevalence rates and the effect of experiencing rape on women; as

a result, women may also over–represent rape victims. On the other hand, there have not been

many studies focusing on the outcome of experiencing rape in men. On the contrary, a study has

shown that 7.2% of a sample of 1480 homosexual men in Los Angeles reports being sexually

assaulted since the age of 16 (Sorenson, Stein, Siegel, Golding, & Burnham, 1987). Furthermore,

another study found that 27.6% of their sample, composed of homosexual men, was sexually

assaulted (Hickson et al., 1994). Thus, research has demonstrated that men are frequent victims

of rape as well as women and the prevalence rate of men raped should be assessed. This

population may also be underrepresented in the 5.2 million adults diagnosed with PTSD. This

suggestion is possible in which studies have shown that males raped by other males may develop

posttraumatic stress symptoms (PTSS); however, the sample size was small making the findings

weak (Myers, 1989).

Additionally, males raped by other males may be another population at risk for developing

PTSD, but males sexually assaulted by women may not be an at-risk population for PTSD. There

have not been many studies focusing on the effects of sexual assault on males by females.

However, Coxell and Kingm (2010) suggested that males sexually assaulted by women are less

likely to develop PTSD due to the lack of violence during the assault. This suggestion may be

accurate in which the more perceived life threat and more violence during an attack have been

highly associated with higher prevalence of PTSD. However, due to cultural stigma placed on

males raped by females (i.e.: men raped by females are less of a man or weak), it may be

possible that these victims may be unlikely to report the assault (Garnets, Herek, & Levy, 1993).


If one does not report a sexual assault, one might not express their emotions. Furthermore, not

identifying and describing one’s emotions (alexithymia) have been associated with symptoms of

PTSD (Halpern, Maunder, Schwartz, & Gurevich, 2012). Thus, this contradicts previous

evidence by Coxell and Kingm (2010), that males raped by females may not develop PTSD.

Nevertheless, research has suggested that male victims of rape may also be an at-risk population

for PTSD.

Physically assaulted victims. Physically assaulted victims are also a possible at risk

population for developing PTSD. One study looked at the correlation between experiencing a

physical assault and PTSD prevalence. Three months after the initial physical assault, 29% of the

remaining sample met the criteria for PTSD (Johansen, Eilertsen, Nordanger, & Weisaeth, 2013).

29% of the sample is a substantial number; suggesting that those physically assaulted are at a

moderate risk for developing PTSD. On the contrary, the study’s sample was 80% male, lacking

representative statistics for women and making the results ungeneralizable to the general

population. Thus, from this study, the findings may suggest that only men physically attacked are

at a moderate risk for developing PTSD (Johansen et al., 2013).

On the other hand, another study provided more useful evidence on the comorbidity of PTSD

with female victims of domestic violence. Another study on females domestically assaulted

found that women who reported their attack as less severe were less likely to meet the criteria for

PTSD (Hellmuth, Jaquier, Swan, & Sullivan, 2014). On the contrary, 1 in 2 women met the

criteria for PTSD when they reported their attack experience as moderately severe (Hellmuth et

al., 2014). Furthermore, 4 in 5 women met the criteria of PTSD when they reported that their

attack severity was high (Hellmuth et al., 2014). These findings suggest that the more severe the


attack, the more likely a person may develop PTSD due to the higher perceive life threat. Thus,

victims of severe physical attacks may be an at-risk population for developing PTSD.

Child abuse victims. The suggestion that victims of physical attacks may be another at risk

population for developing PTSD can be debatable, due to the lack of strong evidence; however,

studies already have found strong evidence suggesting that children and adolescents may be at a

higher risk for developing PTSD than the general population (Gradus, 2014). There is also

evidence determining which childhood abuse is more correlated with PTSD, but this evidence is

not widely known. A study comparing the effects of child sexual and physical abuse and its

relation to PTSD was examined, in which child sexual abuse was associated with greater PTSS

in comparison to a child that was physically abused (Wilson & Scarpa, 2014). It may be the case

that sexual abuse has a stronger negative effect on a person because it is more traumatizing,

exemplifying why childhood sexual abuse has a greater association with PTSD than physical

abuse. Moreover, perceived family and friend support may not be beneficial with children

sexually abused (Wilson & Scarpa, 2014). This further supports that the effects of sexual abuse

may be more traumatizing than the effects of physical abuse.

Furthermore, there was a meta-analysis examined that assessed the prevalence of PTSD

between genders (Walker, Carey, Mohr, Stein, & Seedat, 2004). This meta-analysis found no

significant difference in childhood PTSD prevalence between genders, contrary to other studies

that suggest girls may be at a greater risk for PTSD than boys (Walker et al., 2004). Thus, both

boys and girls affected by childhood abuse may be equally, highly at risk for developing PTSD,

contrary to previous findings.


Unintentional traumas.

Car crash victims. Previously in the introduction, the findings from the National Highway

Transportation Safety Administration or NHTSA demonstrated that has found that there may

have been at least about 290,000 people potentially at risk for developing PTSD. The briefly

mentioned study by Stewart (1999) supported this possibility in which the study found a

correlation between learning about a family member’s death in a car crash and the prevalence of

PTSD (Stewart, 1999). Moreover, the risk for developing PTSD in car crash victims is not only

applicable to adults, but also to children. A study on the longitudinal effects of a car crash on

children found that children that were in a bus crash had high levels of posttraumatic distress

(PTS) nine months later after the event (Arnberg, Rydelius, & Lundin, 2011). Furthermore, after

20 years, these same children had a higher prevalence rate of PTS, than those students in the

same class but not in the car crash – or the indirectly affected participants (Arnberg et al., 2011).

These findings suggest that experiencing a car crash may lead to the development of PTSD.

Natural disasters. Natural disasters may not occur as frequently as car crashes; however,

some natural disasters affect more people than car crashes in a year. A prodigious amount of

people may be at a great risk for developing PTSD, resulting in the hypothesis that there should

also be a large number of survivors that may develop PTSD. There has been a study on the

effects of Hurricane Ike and Katrina on PTSD long term (Cerda et al., 2013). In this study, only

6.1% of the sample met the criteria for PTSD after 2-5 months, in which these levels dropped

significantly after the first months after the hurricane (Cerda et al., 2013). Cerda et al. (2013)

suggested that since the problems that the hurricane caused were alleviated, this aided the mental

health of the survivors, causing the drop in PTSS in survivors/sample (Cerda et al., 2013). It

could be possible that due to the lack of severity and destruction from the hurricanes, perceived


life threat was not substantial enough to lead to PTSD. As a result, PTSD development was not

correlated to the effects of the hurricanes.

On the other hand, the Tsunami that hit the Kanyakumari district, the second most affected

district out of all the worse hit districts in India according to death toll and affected population,

resulted in immense destruction (Pyari, Kutty, & Sarma, 2012). The earthquake that was

measured a 9 on the Richter scale caused a tsunami that hit Southeast Asia and left 300,000

people dead and one million homeless (Pyari et al., 2012). This natural disaster was far more

severe, destructive, and devastating in comparison to Hurricane Ike and Katrina together. This

study found specific risk factors for developing PTSD: death to relatives, injury to self or family

members, being female, suffering maximum loss, and poor socioeconomic background (Pyari et

al., 2012). Thus, this study further supports that the more devastating and deadly the disaster, the

higher the association with the development of PTSD.

Furthermore, Pyari et al. (2012) also assessed a village in North China with little exposure to

the disaster and found that this population had a high prevalence rate of PTSD. This supports the

suggestion that simply witnessing a traumatic event is associated with the development of PTSD.

Providing counseling services to people in areas that have been substantially affected by a

natural disaster may be very effective in preventing PTSD. Moreover, this study found that

women were at a higher risk for having PTSD, a 6.35 times higher risk. On the contrary, many

studies in psychology discovered this same finding that may be due to cultural factors, in which

men have a greater restricted emotionality due to stigma causing men to limit emotional

expression and also seek treatment (Vogel, Wester, Hammer, & Downing-Matibag, 2014). This

finding may also help explain why men do not seek PTSD treatment.


Comorbidity

Examining the amount of comorbidity and time of onset between disorders may provide

the evidence to support the possibility that untreated PTSD may be a risk factor for other

depressive or anxiety disorders. Findings have found that depressive disorders can be a common

and independent condition resulting from of exposure to trauma, supporting the link of

comorbidity of PTSD and depressive disorders (Brady, Killeen, & Brewerton, 2000). Studies

suggest that PTSD is strongly correlated to the increase risk of developing comorbid depression

(Sareen, 2014). Furthermore, a study found that 54 of the 74 women that was sexually assaulted

and diagnosed with PTSD suffered from moderate or severe depression (Tiihonen Moller et al.,

2014). Thus, results suggest that since PTSD has been highly associated with depression, it is

possible that PTSD may lead to major depressive disorder (MDD).

Other studies support this suggestion in which one specifically has found that the most

common comorbid diagnosis with PTSD is depressive disorders (Brady et al., 2000). Angelakis

& Nixon (2015) suggested that PTSD might be a possible risk factor for developing MDD; thus,

MDD may be a possible reaction to PTSD. Moreover, another study found that the risk of

developing depression increases following a trauma and the diagnosis of PTSD (Breslau, Davis,

Peterson, & Schultz, 2000; Kilpatrick et al., 2003). Therefore, research has shown that PTSD

may be a risk factor or lead to MDD.

Obsessive-compulsive disorder has also been show to be highly comorbid with PTSD.

According to the DSM-V, obsessive–compulsive disorder (OCD) is characterized by intrusive

obsessive thoughts causing distress accompanied by repetitive compulsive physical or mental

acts (APA, 2015). Findings suggest that stressful life events, which this could include traumatic

experiences, has been associated with the development of OCD even with those without a family


history of the disorder (Cath, van Groothest, Willemsen, Oppen, & Boomsma, 2008). Another

study examined the proximity of onset of OCD and PTSD, in which this study found that there

might be a specific pre-traumatic OCD factor that increases the risk of developing comorbid

PTSD (Fontenelle et al., 2012). Thus, previously provided evidence suggest that OCD does have

a high prevalence rate with PTSD. Furthermore, OCD may be triggered traumatic events,

suggesting that PTSD or at least PTSS symptoms could possibly lead to OCD.

On the contrary, studies examining the comorbidity of acute stress disorder (ASD) and

PTSD in female rape victims did not support the thesis. Studies examined found that suffering

from ASD shortly after the assault may be a risk factor for developing PTSD (Tiihonen Moller et

al., 2014). Experiencing traumatic events of rape have been highly associated with the

development of ASD; however, the development of PTSD was a poor predictor for developing

ASD (Bryant, Salmon, & Sinclair, 2007).

Traumatic events or PTSD may also cause the development of generalized anxiety

disorder (GAD). GAD is defined as a “chronic, excessive, uncontrollable and pervasive worry”

(APA, 2015). Participants diagnosed with GAD reported experiencing potentially traumatic

events more frequently than participants not diagnosed with GAD (Roemer, Molina, Litz, &

Borkovec, 1996). Thus, this suggests an association between PTSD and GAD. This study further

supported this possible association in which results found a correlation between the development

or maintenance of GAD and potentially traumatizing events. Therefore, GAD may be sequela of

exposure to traumatic experiences (Roemer et al., 1996). PTSD has been strongly associated with

avoidance behavior as also functioning similarly to those with GAD (Roemer et al., 1996). The

purpose of avoidance behavior is to reduce the distress associated with trauma; however,

avoidance behavior does not allow the resolution of trauma (Roemer et al., 1996). As a result,


this exposure to traumatic event may not be solved and lead to the development of GAD. This

shows that comorbidity and the possibility that PTSD may lead to GAD.

Limitations, Implications, & Future Direction

Some of the limitations of the research include that most of the studies utilized

overrepresented population of women and Caucasians. Therefore, men and racial minorities may

be under represented by these findings. In support of this suggestion, one study found a higher

risk for PTSD among people of Hispanic Origin (Leahy, 2011). Nevertheless, as they are under-

represented, the possible addition of this evidence may only make the prevalence rates of PTSD

even higher. Furthermore, most of the studies are retrospective; data could be skewed by this

factor. Also, the limitation of retrospective studies is that since the data is self-reported by

participants, information can be forgotten or inaccurate. This possibility is only stronger when

factoring in the effects of trauma on memory. Moreover, there is no evidence of the effects of

untreated PTSD on participants as it would be very unethical to leave PTSD untreated for

experimental purposes. Any suggestions entailing untreated PTSD are based on assumptions

with evidence based on empirical evidence from retrospective studies on PTSD. Furthermore,

survivors of traumatic events with untreated PTSD may develop other depressive and anxiety

disorders. Studies suggesting a high comorbidity rate of PTSD and GAD, OCD, and MDD

support this hypothesis; however, future studies should examine the association between PTSS

and depressive and anxiety disorders. Thus, results would further more effectively this theory.

Other limitations on this literature review include the lack of history provided by some

studies. Previous trauma exposure is a risk factor for developing PTSD (Sareen, 2014). Thus,

studies that did not control for this variable may lack internal validity, resulting in skewed and

inaccurate data. Evidence shows that there are other risk populations other than the war veterans:


female victims of sexual assault, victims of childhood abuse especially sexual abuse, victims of

severe natural disasters, and victims of severe car crashes and physical assaults. It is important

to create a way to eliminate the stigma affecting men that have been sexually assaulted or

exposed to a traumatic event, to ensure that men come forward and seek therapeutic help. The

populations high at risk for developing PTSD have many factors in common: exposed to severe

trauma, most are exposed to intentional traumas, and the trauma entailed a violent or severely

devastating experience. Another commonality is that the victim may also witness or have been

affected by the death of a family or close friend. Therefore, therapist should look out also for

these predictors also in those exposed to traumatic events to prevent the development of PTSD if

possible.

There is a correlation between the PTSD and the comorbidity of other depressive and

anxiety disorders. There are underrepresented at risk populations: child abuse victims, men

sexually assaulted by other men or by women, victims of a severe physical assault. The main

implication is that the higher the perceived threat level to life, more likely resulting in the

development of PTSD. Also, this higher perceived life threat appears to be more highly

associated with intentional traumas and severe natural disasters. More outlets and support for

those underrepresented populations seeking aid for PTSD.

An epidemiological study should also be completed on the following at risk populations of

PTSD: children, adolescents, other ethnicities besides Caucasians, the LGBT population, and

men and women resulting in separate prevalence rates. More studies should utilized adult men

and homosexual men, more specifically those on sexual assault and domestic violence. More

studies should focus on the correlation between domestic violence of both genders and PTSD.


Also, future studies should examine the comorbidity of PTSS with other depressive and anxiety

disorders.

Conclusion

Since PTSD is highly associated, it may be possible that civilians exposed to severe or

sexual traumas may not seek the proper professional attention. This may lead to the development

of severe PTSD, MDD, or GAD if PTSD if left untreated. The connection between ASD and

PTSD was not found, possibly due to limited research. Previous research suggests that the more

serious the traumatic experience, the more likely the victim will develop PTSD. Furthermore,

women and children that are victims of sexual abuse are at a high risk for developing PTSD.

Additionally, victims of intentional traumas are more likely to develop PTSD in comparison to

those that are victims of unintentional traumas (Santiago et al., 2013). Nevertheless, those

exposed to severe and traumatizing natural disaster affecting those on an immense scale are still

highly likely to develop PTSD. Most importantly, perception of life threat is the most important

findings. There are many varying at risk populations for developing PTSD; however, they all

have in common that the victims have a high level of perceived life threat. Thus, the perception

of life threat is key predictor in the prevalence of PTSD in all whose is exposed to any trauma.


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