Sloan - Twice Removed (Deluxe Edition) (2012)
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Providing a comprehensive literature review on trauma, traumatic stress, trauma-informed care (TIC), and trauma-related interventions is a daunting task when considering the quantity and prolific production of research in this area in the past 20 years. To manage the volume of information, this literature review mainly focuses on reviews and meta-analyses rather than seminal work to address many of the most relevant topics.
The NCS also found that it was not uncommon for individuals to have experienced multiple traumatic events (Kessler, 2000). Among men in the total sample, 14.5 percent reported two traumatic events, 9.5 percent reported three, 10.2 percent reported four or more, and 26.5 percent reported only one such event. Among women, 13.5 percent of the total sample reported two traumatic events, 5 percent reported three, 6.4 percent reported four or more, and 26.3 percent reported only one.
The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is another large national survey of behavioral health, but it only assessed posttraumatic stress disorder (PTSD) and trauma exposure in its second wave of interviews, in which 34,653 of the original 43,093 respondents were reinterviewed (Pietrzak, Goldstein, Southwick, & Grant, 2011a). In the Wave 2 interview, respondents were asked about 27 different types of potentially traumatic events; the most commonly reported traumatic events were serious illness or injury to someone close (affecting 48.4 percent of those who did not have PTSD symptoms and 66.6 percent of those with PTSD), unexpected death of someone close (affecting 42.2 percent of those without PTSD and 65.9 percent of those with PTSD), and seeing someone badly injured or killed (affecting 24 percent of those without PTSD and 43.1 percent of those with PTSD; Pietrzak, Goldstein, Southwick, & Grant, 2011a). According to the same data, 71.6 percent of the sample witnessed trauma, 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent experienced a trauma that was purely psychological in nature (e.g., being threatened with a weapon; El-Gabalawy, 2011).
NESARC also found that exposure to specific traumatic events varied considerably according to race, ethnicity, or cultural group. The survey found that 83.7 percent of non-Latino White Americans reported a traumatic event, compared with 76.4 percent of African Americans, 68.2 percent of Latinos, and 66.4 of percent of Asian Americans, Native Hawaiians, or Pacific Islanders (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Exposure to specific traumas also varied considerably. White Americans were more likely to report an unexpected death of someone they knew (44.7 percent did) than were African Americans (39.9 percent), Latinos (29.6 percent), and Asian Americans, Native Hawaiians, or Pacific Islanders (25.8 percent) as well as being more likely to report having a close friend/relative who experienced a life-threatening injury. On the other hand, African Americans were the most likely to report being the victim of assaultive violence (29.7 percent), followed by White Americans (26.1 percent), Latinos (25.6 percent), and Asian Americans, Native Hawaiians, or Pacific Islanders (16.3 percent). In terms of combat trauma, White Americans and African Americans were about as likely to have been combatants (10 percent of each group reported combat trauma), and more likely than Asian Americans, Native Hawaiians, or Pacific Islanders (5.4 percent) or Latinos (4.4 percent). However, Asian Americans, Native Hawaiians, or Pacific Islanders were the most likely to have been unarmed civilians in a war zone (7.5 percent), followed by Latinos (3.8 percent), White Americans (2 percent), and African Americans (1.9 percent).
Across the world, according to data from the World Health Organization (WHO) surveys, which includes the NCS and NCS replication (NCS-R) and surveys from 20 other countries, the most commonly reported traumas are the death of a loved one (30.5 percent), witnessing violence to others (21.8 percent), and experiencing interpersonal violence (18.8 percent; Stein et al., 2010). As Kessler (2000) noted, trauma from assaultive violence in the United States is likely to be more common than in most other developed countries in general. However, trauma related to other traumatic events (e.g., automobile accidents, natural disasters) appear to be quite similar throughout developed countries.
A longitudinal survey from New Zealand also provides useful data on trauma exposure. In this survey, a cohort of subjects from a single town was interviewed at age 26 and again at age 32 in order to evaluate what constituted the worst trauma those individuals had experienced (Koenen, Moffitt et al., 2008). The types of worst experiences reported before age 26 were:
As noted earlier, Wave 1 of NESARC did not evaluate PTSD, but Wave 2 found that 6.4 percent of the population (8.6 percent of women and 4.1 percent of men) had PTSD at some point during their lives (Pietrzak et al., 2011a). NESARC researchers also evaluated lifetime prevalence of partial PTSD (defined as including at least one symptom under Criteria B, C, and D, with symptom duration of at least 1 month) and found that 6.6 percent of the total population (8.6 percent of women and 4.5 percent of men) met criteria for partial but not full PTSD at some point during their lives. It should be noted, however, that most large behavioral health surveys, such as the NCS and NESARC, rely on retrospective evaluation of symptoms, and some research indicates that they underestimate behavioral health disorders compared with prospective longitudinal studies (Moffitt et al., 2009). Differences in prevalence estimates may also be related both to changes in PTSD diagnostic criteria and to a variety of methodological differences in the research (e.g., different diagnostic instruments, procedures) on which these estimates were based (Kessler, 2000; Kessler, Chiu et al., 2005; Kessler et al., 1995; Narrow, Rae, Robins, & Regier, 2002).
It is also worth noting that delayed PTSD may account for a considerable percentage of PTSD cases. A meta-analytic review that included studies in which individuals were assessed 1 to 6 months after trauma exposure and again at least 6 months later found that 24.8 percent of PTSD cases involved delayed trauma (Smid, Mooren, van der Mast, Gersons, & Kleber, 2009). Studies included in the review found between 3.8 and 83.3 percent of their samples had delayed PTSD. Factors that were associated with significantly greater odds of having delayed rather than nondelayed PTSD included a Western (as opposed to non-Western) cultural background and military combat exposure.
An individual has been exposed to complex trauma when he or she has either experienced repeated instances of the same type of trauma over a period of time or experienced multiple types of trauma (van der Kolk, McFarlane, & Weisaeth, 1996). Expert consensus is that people who have complex trauma will typically require more intensive and extensive treatment as well as possible adaptations to standard treatment (see the expert clinician survey in Cloitre et al., 2011).
Acute stress disorder (ASD), according to the DSM-5, involves a traumatic stress reaction that occurs within 1 month of trauma exposure and includes at least nine symptoms from any of the five categories (intrusion, negative mood, dissociation, avoidance, and arousal; APA, 2013). To receive this diagnosis, the individual also has to display a reaction that causes significant distress or impairment in social, occupational, or other important areas of functioning. ASD can occur at the time of the trauma exposure or any time within 4 weeks of that event As Roberts, Kitchiner, Kendardy, and Bisson (2010) observed, there is a large degree of overlap between ASD and PTSD symptoms, but what distinguishes them is the timing of those symptoms relative to trauma exposure. Cardea and Carlson (2011) provided a history of the ASD diagnosis and discussed the validity of the diagnostic criteria. ASD can develop into PTSD if the symptoms extend beyond 1 month.
PTSD is a traumatic stress reaction that develops in response to a significant trauma. It is a mental disorder, and for behavioral health providers in the United States, the currently accepted diagnostic criteria for the disorder are those provided by the DSM-5 (APA, 2013). For professionals in the field of behavioral health, the definition of psychological trauma is historically and clinically tied to the diagnostic criteria for PTSD, which made their first appearance in the DSM-III (APA, 1980). However, over the years, the diagnostic criteria have undergone some significant changes. These changes are important factors to consider when reading, evaluating, and especially comparing research.
Criterion A concerns the type of trauma involved; Criterion B describes symptoms of intrusion; Criterion C includes the presence of persistent avoidance of stimuli associated with the trauma; Criterion D highlights symptoms of negative alterations in cognitions and mood associated with the traumatic event(s); Criterion E includes marked alterations in arousal and reactivity as it relates to the trauma; Criterion F addresses the duration of the symptoms; and Criterion G includes clinical distress or impairment in important areas of functioning (e.g., occupational). The presenting symptoms cannot be attributable to the physiological effects of a substance, including alcohol or medications.
Turnbull (1998) describes the historical development of the idea of PTSD up to its inclusion in the International Statistical Classification of Diseases and Related Health Problems, 9th Revision (1979) and the DSM-III-R. The DSM-5 recognizes certain specifiers that may further characterize PTSD (APA, 2013). For example, a specific case of PTSD may be with delayed expression (full criteria are not met until at least 6 months have passed since the trauma exposure, although the onset of symptoms may immediately follow the trauma; APA, 2000; 2013).
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