B. People At-Risk For Developing Stress Symptoms After Trauma

OBJECTIVE

Identify persons at risk for developing a traumatic stress disorder (PTSD) after trauma exposure.

BACKGROUND

Although exposure to trauma is common, several risk factors for the development of PTSD have been identified. Risk factors for developing PTSD can be grouped as characteristics related to the trauma itself, pre-trauma factors and post-trauma factors.

• Trauma-related risks include the nature, severity, and duration of the trauma exposure. For example, life-threatening traumas such as physical injury or rape pose a high risk of PTSD (Kilpatrick, 1989). A prior history of trauma exposure conveys a greater risk of PTSD from subsequent trauma (Breslau et al., 1999).
• Pre-trauma risk factors include adverse childhood, younger age, female gender (not in military cohorts), minority race, and low socioeconomic or educational status.
• Post-trauma risks include poor social support and life stress (Brewin et al., 2000). A greater risk for developing PTSD may be conveyed by post-trauma factors (e.g., lack of social support and additional life stress) than pre-trauma factors.

The development of Acute Stress Disorder (ASD) at the time of the trauma is also a risk for developing PTSD (Classen et al., 1998). Similarly, dissociation at the time of the trauma appears to be an important predictor for the establishment of chronic PTSD (Murray et al., 2002).

RECOMMENDATIONS

1. Persons exposed to trauma should be assessed for known risk factors for developing PTSD – both pre-trauma risks and post trauma risks.
2. The trauma type, nature, and severity should be assessed.
3. Assessment of existing social supports and ongoing stressors is important.
4. Patients with Acute Stress Disorder (ASD) warrant careful clinical attention, as they are at high-risk for developing PTSD.
5. Patients with dissociative symptoms may also warrant careful clinical attention.

DISCUSSION

A meta-analysis of risk factors for PTSD of assessed studies of trauma-exposed adults reported that 14 different risk factors in the literature have a modest association with PTSD development (Brewin et al., 2000). Overall, factors such as gender, age at trauma, and race predicted PTSD in some populations, but not in others. Further, factors such as education, prior trauma, and childhood adversity predicted PTSD more consistently (Harvey & Bryant, 2000; Harvey & Bryant, 1998). However, this varies with the population and study methods. Prior psychiatric history, childhood abuse, and family psychiatric history have more consistent predictive effects. Factors operating during or after the trauma (e.g., trauma severity, lack of social support, and additional life stress) have somewhat stronger effects than pre-trauma factors.

This finding is consistent with other studies that suggest poor social supports and ongoing life stress to be predictors of PTSD development. This may have clinical implications as early interventions that increase social support after trauma exposure may reduce the likelihood of PTSD (Litz & ?, in press).

Numerous prospective cohort studies with various types of trauma exposure (e.g., violent assault and accidents) support that ASD is a predictor of later PTSD (Brewin et al., 1999; Bryant et al., 2000; Harvey & Bryant, 1998; Mellman et al., 2001). In these studies among persons with ASD 40 to 80 percent go on to develop PTSD. Finally, most studies suggest an increased risk of PTSD development among individuals with peritraumatic dissociation (Birmes et al., 2001; Murray et al., 2002).