R ISK AND R ESILIENCE F ACTORS IN PTSD

Extensive research is conducted on risk and resilience factors concerning PTSD. The stud-ies find a broad range of risk and resilience factors. However, some results are inconsistent.

Emily Ozer and colleagues (2003) conducted a meta-analysis on n = 68 studies on predic-tive factors for PTSD in the general population. In support of the results of others (Birmes et al., 2003; Breslau, 2002; Brewin, Andrews, & Valentine, 2000) they conclude that PTSD symptoms are not a coincidental reaction to traumatic experiences. As described above (see 5.2.1) the lifetime prevalence of traumatic experiences is high compared to the lifetime preva-lence of PTSD following such an experience. The aforementioned studies found two classes of predictors: (a) characteristics of the individual or his/her life history that were more distal to the traumatic event and produced average coefficients smaller than .20 (i.e., gender, age, edu-cation, socioeconomic status, IQ, and race in Brewin et al., 2000; prior adjustment, prior his-tory of trauma, and family hishis-tory of psychopathology in Ozer et al., 2003); and (b) stronger predictive factors yielding coefficients greater than .20 that were more proximal to the trau-matic event (i.e. intercurrent life stress in Brewin et al., 2000; perceived life threat, perceived support, peritraumatic emotionality, and peritraumatic dissociation in Ozer et al., 2003). Mod-erating factors were found to be “time elapsed since the event” and “method of assessment”. In addition, Brewin and colleagues (2000) report that only factors during or after the trauma, such as trauma severity, lack of social support, and additional life stress, had somewhat stronger effects than pretrauma factors.

The studies included in the meta-analysis by Ozer and others (2003) covered a great vari-ety of traumatic experiences (natural disaster vs. man made; accident vs. purpose; rape, war etc.). Also the samples, the individual amount (number and severity), as well as the individual compensating characteristics (age at traumatic experience, recurrent experiences, time relapsed since event, support, and environment etc.) vary across the studies.

The majority of studies focus on certain aspects in relation to a traumatic experience and PTSD, respectively.

5.4.1 Risk Factors

A prospective study on fire fighters report that the personality traits hostility and low level of self-efficacy at baseline accounted for 42% of the variance in PTSD after 2 years (Heinrichs, Wagner, Schoch, Soravia, Hellhammer, & Ehlert, 2005). Also pretrauma catastrophic thinking was found to be a risk factor in fire fighters, accounting for 24% of variance (Bryant &

Guthrie, 2005). In a prospective, longitudinal epidemiological study of adolescents and young adults Perkonigg and others (2005) found that respondents with a chronic course were more likely to experience new traumatic event(s) during follow-up, to have higher rates of avoidance symptoms at baseline, and to report more help seeking behavior, compared to respondents with remission. Rates of incident somatoform disorder and other anxiety disorders were also signifi-cantly associated with a chronic course.

The severity of the traumatic event is repeatedly named as predictive factor for PTSD (Engdahl et al., 1997; Lie, 2002; Silove, Steel, McGorry, Miles, & Drobny, 2002), also in stud-ies on the longitudinal course of trauma (Gold, Engdahl, Eberly, Blake, Page, & Frueh, 2000;

Steel, Silove, Phan, & Bauman, 2002). Age at capture was also found to be predictive for PTSD (Engdahl et al., 1997).

Other studies point out, that trauma-related persistent dissociation, peritraumatic dissocia-tion and acute stress would predict PTSD (Birmes et al., 2003; Briere, Scott, & Weathers, 2005). Since Briere and colleagues (2005) found that peritraumatic dissociation ceased to pre-dict PTSD at a multivariate level, they conclude that it is less what happens at the time of a trauma (e.g., disrupted encoding) that predicts PTSD than what occurs thereafter (i.e., persis-tent avoidance). In contrast, Richard Bryant (2005) concludes in a review that whereas acute dissociation is an important factor in the acute stress response, many people develop PTSD in the absence of dissociative symptoms. Accordingly, the evidence suggests that dissociation needs to be considered in the context of other factors in the aftermath of trauma if optimal identification of high-risk individuals is to be achieved. In an earlier paper, Bryant (2003) al-ready proposed that there may be greater utility in focusing on the interaction between symp-toms, biological responses, and cognitive factors on predicting who will develop PTSD, than solely focusing on a diagnostic category or constellation of symptoms as a marker of acutely traumatized people who are at risk of developing PTSD. However, North and colleagues (2004) report, that co-morbidity with Major Depression determined whether the PTSD would have remitted by 1 year later.

A study concerning cognitive factors as predictors of PTSD in survivors of physical or sexual assault found the following variables which predicted PTSD severity significantly: cog-nitive processing style during assault (mental defeat, mental confusion, detachment); appraisal of assault sequelae (appraisal of symptoms, perceived negative responses of others, permanent change); negative beliefs about self and world; and maladaptive control strategies (avoid-ance/safety seeking) (Dunmore, Clark, & Ehlers, 2001). Ehlers and others (1998) report that survivors of rape rather suffer from chronic PTSD and benefit less from exposure therapy if they experienced mental defeat, an overall feeling of alienation and a feeling of permanent change, respectively, as compared to survivors who have not experienced these feelings. Per-manent change in terms of objectively and subjectively perceived consequences can function as continuous reminders of the traumatic experience and thereby hinder it to become a concluded part of one’s past so that they are a source of chronic strain. A factor analysis on retrospec-tively collected data by Basoglu and colleagues (2005) revealed a factor called fear and loss of control associated with perceived threat from those held responsible for trauma which was most strongly associated with PTSD and depression.

Cheung (1994) found in Cambodian refugees a significant association between PTSD and amount of traumatic experiences, coping strategies as well as post-migration stressors. With regard to refugees living in exile, Silove et al. (1997) report that a diagnosis of PTSD was as-sociated with greater exposure to pre-migration trauma, delays in processing refugee applica-tions, difficulties dealing with immigration officials, obstacles to employment, racial discrimi-nation, and loneliness and boredom. Others found, that a greater number of war traumas and a greater number of resettlements lead to an increased risk for PTSD and Major Depression, and that financial distress leads to an increased risk of Major Depression (Blair, 2000).

Further factors associated with pre and post migration stressors and their influence on psy-chiatric morbidity as well as quality of life are discussed in chapter 6 (see below).

5.4.2 Resilience Factors

A number of protective factors are discussed. Surveys concerning protective factors in refugees and survivors of organized violence come up with different results. Basoglu et al.

(1994b) state, that prior knowledge of and preparedness for torture, strong commitment to a cause, immunization against traumatic stress as a result of repeated exposure, and strong social supports appear to have protective value against PTSD in survivors of torture. They conse-quently discuss, whether the resistance found towards the development of PTSD could be

ex-plained by a lack of beliefs concerning safety, trust and justice (Basoglu et al., 1996), since the politically active respondents were found to score lower as compared to not politically active people. A subsequent survey supported this hypothesis (Basoglu, Mineka, Paker, Aker, Li-vanou, & Gok, 1997). The authors found that tortured, but not politically active people under-went less severe maltreatment in comparison to politically active persons, however the former were found to have more psychopathology, i.e. anxiety, depression, and PTSD. They conclude, that less psychological preparedness towards torture is associated with higher rates of per-ceived stress during torture and therefore leads to more severe psychiatric pathology. Less psy-chological preparedness accounted for 4% of the variance with regard to general psychopa-thology and 9% of the variance concerning PTSD symptoms. Holtz and colleagues (1998) also conclude that political commitment and prior knowledge of and preparedness for confinement and torture can be protective factors. Bichescu and others (2003) found that former political detainees with political commitment were found to have significantly more remitted than cur-rent PTSD as compared to detainees with less political commitment, suggesting that political commitment might also influence recovery. In addition, deeply held belief systems affecting life-views may impart significant resilience to developing stress-related problems, even under extreme conditions (Kaplan, Matar, Kamin, Sadan, & Cohen, 2005). The later further con-clude, that religiousness combined with common ideological convictions and social cohesion was associated with substantial resilience as compared to a secular metropolitan urban popula-tion. Religious belief as protective factors has repeatedly been reported (Allden, Poole, Chan-tavanich, Ohmar, Aung, & Mollica, 1996; Holtz, 1998; Shrestha et al., 1998). A firm belief system – either religious or political – was also found to be a predictor for a better therapy out-come (Brune, Haasen, Krausz, Yagdiran, Bustos, & Eisenman, 2002).

Other studies found characteristics such as hardiness towards stressors (Waysman, Schwarzwald, & Solomon, 2001), and camaraderie (Allden et al., 1996) in survivors of state sponsored violence, which were less likely to develop PTSD. Social support as protective fac-tor in PTSD has repeatedly been reported (Engdahl et al., 1997; Gerritsen et al., 2005; Holtz, 1998). Furthermore an autonomous frame of mind during imprisonment is associated with re-silience (Boos, Ehlers, Maercker, & Schuetzwohl, 1998). A persistent factor with regard to resilience to PTSD is social support, with the lack of social support increasing the risk of PTSD (e.g., Marmar et al., 2006). However, traumatic experiences such as war, persecution, and natu-ral disasters often lead to relocation of people, who in turn lose their social networks which could help in overcoming the traumatic event(s) (see e.g., Kilic et al., 2006).

5.4.3 Dose Effect

The extent of the contribution of risk and resilience factors towards the development of PTSD seems to be mediated by the number of traumatic experiences. The phenomenon of in-creased risk and severity of PTSD in association with an increasing number of traumatic events is called “dose-effect”, “dose-response”, or “building block” and repeatedly been found in various studies (Al-Saffar et al., 2003; Eytan et al., 2004; Gold et al., 2000; B. L. Green et al., 2000; Mollica et al., 1998a; Mollica et al., 1998b; Silove et al., 1997; Smith Fawzi, Murphy, Pham, Lin, Poole, & Mollica, 1997). Accordingly, refugees with more than 3 traumatic events in their past are at higher risk concerning psychiatric morbidity even after 10 years, compared to refugees with less than three or no traumatic events in their past (12% vs. 3%)(Steel et al., 2002). Neuner and colleagues (2004a) report, that 23% of refugees who survived one to three traumatic experiences fulfill the DSM criteria for PTSD, whereas all refugees do so, after sur-viving 28 or more traumatic events.

In view of the cumulative effect of potentially traumatizing experiences concerning the development of chronic PTSD, the relevance of predictive and protective factors in survivors of organized violence is limited, since this group of people is repeatedly and over longer peri-ods of time exposed to traumatic stressors. However, knowledge of risk and resilience factors is needed when planning treatment for survivors of organized violence suffering from PTSD.

For example, the cognitions of defeat and helplessness in the traumatic situation predict the course of psychiatric symptoms. If a person continues to perceive helplessness in the time after the traumatic experience, a chronification of the condition might be fostered. Treatment should accordingly focus on decreasing the perceived helplessness in the patient. Another aspect is self-esteem, defined as firm belief system or autonomous frame of mind, which can prevent enduring chronification and is also needed in the recovery process. Also the social network is a crucial aspect in therapeutic work. Yet, the social support system is often disrupted in asylum seekers who had to flee their home country. Many of them had to travel alone; others, who left their country with their families, often cannot rely on their support since also the family mem-bers are impaired by traumatic experiences. Accordingly, the social support system and coping with a restricted network needs to be taken care of in the context of PTSD treatment. These different factors are interrelated and need to be emphasized in treatment with individuals.

Cognitive-behavioral programs already try to integrate these aspects into treatment (see chapter 7).