The truth is that even though we are all exposed to high levels of stress, including some of us who have been exposed to war, combat, and related stressors that would be defined as traumatic stressors, research has continued to show that most individuals exposed to stressors that would meet the definition of a traumatic stressor fail to develop PTSD, much like the citizens of Israel and Palestine. According to Breslau, Andreski, Federman, and Anthony (1998) only 9 percent of those exposed to traumatic stressors develop PTSD. It was once widely held that a direct linear relationship between the intensity of a stressor and symptom development existed. That is, if you were exposed to a traumatic stressor, you would develop PTSD. This is referred to as the dose-response model; the more intense a stressor, the more likely PTSD will develop. Research has not supported this strict direct correlation (McNally, 2003). From this we can conclude that a traumatic stressor alone is necessary but not sufficient for PTSD to develop. Before we get into the other necessary components, let's take a closer look at this traumatic stressor issue.
The following are the most common types of traumatic stressors related to PTSD (DSM-III-R; National Center for PTSD):
Threats to one's life or physical integrity
A serious threat or harm to one's children, spouse, relative, or close friend
Sudden destruction of one's home or community
Seeing another person injured or killed due to physical violence
For Men: For Women:
Combat exposure Rape
Rape Sexual molestation
Childhood neglect Physical attack
Childhood physical abuse Being threatened with a weapon
Defining a traumatic stressor is tricky. Certainly not all severe stressors are traumatic. The DSM-IV-TR defines a traumatic stressor in its diagnostic Criteria A for PSTD as "an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others" (p. 467).
Criterion A indicates that an individual can experience, witness, or be confronted with such a stressor in order to meet this criterion. Criteria A accounts for the subjective element of definition of a traumatic stressor. Criteria A states that in order for a stressor to qualify for traumatic status, it not only needs to fit with the previous criteria but must also involve "[a] person's response [that] involved fear, helplessness, or horror" (p. 467).
Researchers have also found that in addition to these characteristics, stressors that are very sudden, very intense, very dangerous, and perceived as uncontrollable and unpredictable are likely to be experienced as traumatic.
Eve Carlson and Constance Dalenberg (2000) propose three defining features that classify a stressor as traumatic: negative valence, lack of controllability, and suddenness. Carlson and Dalenberg propose that restricting the definition of a traumatic stressor to only those events that involve injury or death excludes other traumatic stressors, such as losing one's home due to a flood, which may not necessarily lead to fears of death or injury but is nonetheless traumatic. In order to capture the traumatizing nature of the traumatic stressor, it is vital to get inside the mind and experience of a traumatized individual. How did he or she psychologically experience the event in question?
An event with negative valence is an event that has negative consequences. Events with severe negative consequences can result in death or serious injury, and events with less negative valence can involve lesser degrees of pain or discomfort. Carlson and Dalenberg (2000) propose that the negative valence of an event can be the result of physical pain, emotional pain, or because of the perception that an event is likely to cause physical pain, injury, or emotional pain or death. It is important to point out their inclusion of emotionally painful events in their work. Emotional pain can produce extreme fear and activate issues related to one's sense of self or psychic integrity. A man who has always known himself to be a physically fit professional athlete could be traumatized by news that he may never walk again after a car accident. Carlson and Dalenberg state it best: "the perception of the event is more important that the actual danger associated with the event" (p. 8).
Oftentimes following a traumatic event, we find ourselves thinking or saying, "If only I had done . . ." or "I should have done. . . ." This is an excellent example of how important the perceived controllability of an event is in determining our reaction and eventual adjustment. These sorts of questions represent post hoc attempts to control an event, at least psychologically, and to give both a sense of controllability in the aftermath and in potential future events of the same nature. In essence, the more uncontrollable an event is experienced as, the more likely it will be experienced as traumatic. Ultimately, control over one's life and limb is a critical component to the perception of trauma.
Finally, the time frame of a stressor plays a key role in the perception of trauma. Events that are more imminent are more stressful. This is in part because the amount of time one may need to muster an effective response is smaller, and thus the negative valence of the event is higher as a consequence (Carlson & Dalenberg, 2000). If you know that a stressor is coming, you can prepare for it, you can experience it in smaller doses if you will. This is one of the key components of stress inoculation therapy (SIT; for more on SIT, see Chapter 12). One can see that the negativity, controllability, and suddenness of an event are all interrelated and work together to either produce a traumatic experience or not.
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