Academic journal article European Journal of Psychotraumatology

A New Perspective on PTSD Symptoms after Traumatic vs Stressful Life Events and the Role of Gender

Academic journal article European Journal of Psychotraumatology

A New Perspective on PTSD Symptoms after Traumatic vs Stressful Life Events and the Role of Gender

Article excerpt

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1. Background

Post-Traumatic Stress Disorder (PTSD) is one of only a few disorders in the DSM (American Psychiatric Association, 2013) that require an aetiological factor (a traumatic event) for its diagnosis. In the DSM-IV-TR this so-called A1 criterion involved experiencing, witnessing or being confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others (American Psychiatric Association, 2000). In the DSM-5, the A1 criterion has been narrowed to 'exposure to actual or threatened death, serious injury or sexual violence' (American Psychiatric Association, 2013). This means that events such as the unexpected death of a family member or a close friend due to natural causes do not meet the A1 criterion of PTSD anymore. During the last decades there has been an ongoing debate about the validity and clinical usefulness of the A1 criterion. One of the first critiques is that other (non-A1) stressful life events can also cause PTSD (Breslau & Davis, 1987). Since this influential paper, several studies have reported that stressful non-A1 events are associated with similar or even higher rates of PTSD symptoms than A1 events (e.g. Anders, Frazier, & Frankfurt, 2011; Cameron, Palm, & Follette, 2010; Gold, Marx, Soler-Baillo, & Sloan, 2005; Long et al., 2008; Mol et al., 2005; Roberts et al., 2012; Robinson & Larson, 2010), questioning the constricted definition of traumatic A1 events. In this regard, in contrast to the DSM-5, the ICD-11 will differentiate less between effects of formal DSM traumatic (A1) events and other (non-A1) stressful life events (World Health Organization), and diagnosis of PTSD will mainly be based on PTSD symptom presentation (Maercker et al., 2013; World Health Organization; Vermetten, Baker, Jetly, & McFarlane, 2016). Hence, this calls for a renewed discussion on the role ofstressful life events in the development of PTSD.

Furthermore, women are approximately twice as likely to meet criteria for PTSD than men, even though women are less likely to experience an A1 event (Olff, Langeland, Draijer, & Gersons, 2007; Tolin & Foa, 2008). Men and women tend to experience different types of A1 events but, even after controlling for type of experienced A1 event, the gender differences in PTSD prevalence remain (Christiansen & Hansen, 2015; Moser, Hajcak, Simons, & Foa, 2007; Tolin & Foa, 2008). It is still unknown whether the increased vulnerability in women to develop PTSD after experiencing A1 events also extends to the experience of non-A1 events. Earlier studies that examined the association between A1 versus non-A1 events and PTSD symptom severity only investigated women (e.g. Anders et al., 2011; Cameron et al., 2010; Roberts et al., 2012) or did not investigate gender differences (e.g. Gold et al., 2005).

Little is known about the mechanisms behind gender differences in PTSD development. A possible explanation may be that women experience (A1 and non-A1) stressful events as more anxiety provoking. Anxiety sensitivity predicts PTSD symptom severity and it is suggested that this association is stronger for women (Feldner, Zvolensky, Schmidt, & Smith, 2008; Marshall, Miles, & Steward, 2010). Such peri-traumatic processes, including appraisal processes concerning the trauma, play an important role in the development of PTSD after trauma (Ozer, Best, Lipsey, & Weiss, 2003). Subjective measures of distress or impact of experienced events are often even better in predicting PTSD symptoms than objective measures of danger during events (McNally, 2003). Some studies indeed suggest that these initial responses to trauma may account for gender differences in PTSD (e.g. Irish et al., 2011), but a review by Olff et al. (2007) emphasizes that there is a serious lack of evidence on gender specific appraisal processes of trauma. …

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