Howard Liu1, Maria V Petukhova2, Nancy A Sampson2, Sergio Aguilar-Gaxiola3, Jordi Alonso4, Laura Helena Andrade5, Evelyn J Bromet6, Giovanni de Girolamo7, Josep Maria Haro8, Hristo Hinkov9, Norito Kawakami10, Karestan C Koenen11, Viviane Kovess-Masfety12, Sing Lee13, Maria Elena Medina-Mora14, Fernando Navarro-Mateu15, Siobhan O'Neill16, Marina Piazza17, José Posada-Villa18, Kate M Scott19, Victoria Shahly2, Dan J Stein20, Margreet Ten Have21, Yolanda Torres22, Oye Gureje23, Alan M Zaslavsky2, Ronald C Kessler2. 1. Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts2Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts. 2. Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts. 3. Center for Reducing Health Disparities, University of California, Davis, Health System, Sacramento. 4. Hospital del Mar Research Institute, Parc de Salut Mar, Pompeu Fabra University, Barcelona, Spain5Group 9/Program 06-Evaluation of Health Services of Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain. 5. Section of Psychiatric Epidemiology-Laboratórios de Investigação Médica No. 23, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil. 6. Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York. 7. Istituto di Ricovero e Cura a Carattere Scientifico, Fatebenefratelli, Brescia, Italy. 8. Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, Centro de Investigación Biomédica en Red de Salud Mental, Universitat de Barcelona, Barcelona, Spain. 9. National Center for Public Health and Analyses, Ministry of Health, Sofia, Bulgaria. 10. Department of Mental Health, School of Public Health, University of Tokyo, Tokyo, Japan. 11. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts. 12. Ecole des Hautes Etudes en Santé Publique, EA 4057, Paris Descartes University, Paris, France. 13. Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong, China. 14. Dirección de Investigaciones Epidemiológicas y Psicosociales, National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico. 15. Servicio Murciano de Investigación y Formación en Salud Mental, Subdirección General de Planificación, Innovación y Cronicidad, Servicio Murciano de Salud, Instituto Murciano de Investigación Biosanitaria-Arrixaca, CIBERESP, Murcia, Spain. 16. School of Psychology, Ulster University, Londonderry, Northern Ireland. 17. Facultad de Salud Pública y Administración, Universidad Cayetano Heredia, Lima, Peru18National Institute of Health, Lima, Peru. 18. Faculty of Social Sciences, Colegio Mayor de Cundinamarca University, Bogota, Colombia. 19. Department of Psychological Medicine, University of Otago, Dunedin, New Zealand. 20. Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, Republic of South Africa. 21. Trimbos-Instituut, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands. 22. Center for Excellence on Research in Mental Health, CES University, Medellin, Colombia. 23. Department of Psychiatry, University College Hospital, Ibadan, Nigeria.
Abstract
Importance: Previous research has documented significant variation in the prevalence of posttraumatic stress disorder (PTSD) depending on the type of traumatic experience (TE) and history of TE exposure, but the relatively small sample sizes in these studies resulted in a number of unresolved basic questions. Objective: To examine disaggregated associations of type of TE history with PTSD in a large cross-national community epidemiologic data set. Design, Setting, and Participants: The World Health Organization World Mental Health surveys assessed 29 TE types (lifetime exposure, age at first exposure) with DSM-IV PTSD that was associated with 1 randomly selected TE exposure (the random TE) for each respondent. Surveys were administered in 20 countries (n = 34 676 respondents) from 2001 to 2012. Data were analyzed from October 1, 2015, to September 1, 2016. Main Outcomes and Measures: Prevalence of PTSD assessed with the Composite International Diagnostic Interview. Results: Among the 34 676 respondents (55.4% [SE, 0.6%] men and 44.6% [SE, 0.6%] women; mean [SE] age, 43.7 [0.2] years), lifetime TE exposure was reported by a weighted 70.3% of respondents (mean [SE] number of exposures, 4.5 [0.04] among respondents with any TE). Weighted (by TE frequency) prevalence of PTSD associated with random TEs was 4.0%. Odds ratios (ORs) of PTSD were elevated for TEs involving sexual violence (2.7; 95% CI, 2.0-3.8) and witnessing atrocities (4.2; 95% CI, 1.0-17.8). Prior exposure to some, but not all, same-type TEs was associated with increased vulnerability (eg, physical assault; OR, 3.2; 95% CI, 1.3-7.9) or resilience (eg, participation in sectarian violence; OR, 0.3; 95% CI, 0.1-0.9) to PTSD after the random TE. The finding of earlier studies that more general history of TE exposure was associated with increased vulnerability to PTSD across the full range of random TE types was replicated, but this generalized vulnerability was limited to prior TEs involving violence, including participation in organized violence (OR, 1.3; 95% CI, 1.0-1.6), experience of physical violence (OR, 1.4; 95% CI, 1.2-1.7), rape (OR, 2.5; 95% CI, 1.7-3.8), and other sexual assault (OR, 1.6; 95% CI, 1.1-2.3). Conclusion and Relevance: The World Mental Health survey findings advance understanding of the extent to which PTSD risk varies with the type of TE and history of TE exposure. Previous findings about the elevated PTSD risk associated with TEs involving assaultive violence was refined by showing agreement only for repeated occurrences. Some types of prior TE exposures are associated with increased resilience rather than increased vulnerability, connecting the literature on TE history with the literature on resilience after adversity. These results are valuable in providing an empirical rationale for more focused investigations of these specifications in future studies.
Importance: Previous research has documented significant variation in the prevalence of posttraumatic stress disorder (PTSD) depending on the type of traumatic experience (TE) and history of TE exposure, but the relatively small sample sizes in these studies resulted in a number of unresolved basic questions. Objective: To examine disaggregated associations of type of TE history with PTSD in a large cross-national community epidemiologic data set. Design, Setting, and Participants: The World Health Organization World Mental Health surveys assessed 29 TE types (lifetime exposure, age at first exposure) with DSM-IV PTSD that was associated with 1 randomly selected TE exposure (the random TE) for each respondent. Surveys were administered in 20 countries (n = 34 676 respondents) from 2001 to 2012. Data were analyzed from October 1, 2015, to September 1, 2016. Main Outcomes and Measures: Prevalence of PTSD assessed with the Composite International Diagnostic Interview. Results: Among the 34 676 respondents (55.4% [SE, 0.6%] men and 44.6% [SE, 0.6%] women; mean [SE] age, 43.7 [0.2] years), lifetime TE exposure was reported by a weighted 70.3% of respondents (mean [SE] number of exposures, 4.5 [0.04] among respondents with any TE). Weighted (by TE frequency) prevalence of PTSD associated with random TEs was 4.0%. Odds ratios (ORs) of PTSD were elevated for TEs involving sexual violence (2.7; 95% CI, 2.0-3.8) and witnessing atrocities (4.2; 95% CI, 1.0-17.8). Prior exposure to some, but not all, same-type TEs was associated with increased vulnerability (eg, physical assault; OR, 3.2; 95% CI, 1.3-7.9) or resilience (eg, participation in sectarian violence; OR, 0.3; 95% CI, 0.1-0.9) to PTSD after the random TE. The finding of earlier studies that more general history of TE exposure was associated with increased vulnerability to PTSD across the full range of random TE types was replicated, but this generalized vulnerability was limited to prior TEs involving violence, including participation in organized violence (OR, 1.3; 95% CI, 1.0-1.6), experience of physical violence (OR, 1.4; 95% CI, 1.2-1.7), rape (OR, 2.5; 95% CI, 1.7-3.8), and other sexual assault (OR, 1.6; 95% CI, 1.1-2.3). Conclusion and Relevance: The World Mental Health survey findings advance understanding of the extent to which PTSD risk varies with the type of TE and history of TE exposure. Previous findings about the elevated PTSD risk associated with TEs involving assaultive violence was refined by showing agreement only for repeated occurrences. Some types of prior TE exposures are associated with increased resilience rather than increased vulnerability, connecting the literature on TE history with the literature on resilience after adversity. These results are valuable in providing an empirical rationale for more focused investigations of these specifications in future studies.
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