Posttraumatic Stress Disorder: Risk Factors, Diagnosis, Culture and Resilience

By Lic. Analia Henriquez Cross, MSc Global Mental Health

Post-Traumatic Stress Disorder (PTSD) and Resilience are both possible and complex human responses after experiencing potentially traumatic events produced by avoidable and unavoidable social circumstances. These events can be difficult to avoid due to the political and social changes they require. Considering the foregoing, the role of health professionals is to identify which specific events can have the most relevant impact on Mental Health (MH), such as poverty, violence, war, migration, and disaster. Furthermore, a powerful tool for their recovery can be an early PTSD diagnosis based on the best evidence available, acknowledging global differences, and developing resilience among victims.

The adverse conditions surrounding poverty - such as food insecurity and violence- are stronger risk factors for PTSD than income. It is argued that MH and poverty have a bi-directional relationship. Das and colleagues (2007) examine two possible ways of understanding how these factors relate to each other by comparing the social causation theory and the drift hypothesis, each including mediating factors surrounding poverty nurturing this bi-directional relationship. Moreover, albeit it has been found that PTSD is prevalent in low-income urban communities (Parto, 2011), income is not the main issue concerning poverty and MH.

In that respect, the relationship between household per capita expenditure and MH was found to be inconsistent and weak (Das, 2007). The instability of living in a poor neighbourhood was identified as one of the possible causes of PTSD (Nikulina, 2011). [RM1] Furthermore, hunger is another poverty-related factor associated with PTSD (Seino, 2008). Finally, violence can also mediate this relationship. Low-income urban communities have worse mental health outcomes due to their exposure to violence (Parto, 2011; Paxton, 2004). In light of these findings, health and political authorities should focus on alleviating those factors experienced by people living in poverty to mitigate the impact of risk factors on MH, and early intervention on MH problems to prevent mental illness resulting in poverty. Notwithstanding the foregoing, another particular form of violence can especially affect women across the world. GBV is considered a crime (UN, 1981), with victims often experiencing PTSD (Goodman, 2009; Rodriguez, 2008; WHO, 2002) from different manifestations of GBV such as domestic violence, sexual assault, and Female Genital Mutilation (FGM). Jones et al. (2001) found that most female victims of domestic and sexual violence fulfilled PTSD criteria and resulted in a higher risk of PTSD if VBG resulted in homelessness or if they had lived multiple GVB experiences during their lives. Research has linked GBV with PTSD (Silove, 2017; Vazquez, 2012; Rees, 2011; Stein 2001; Golding, 1999; Street, 2001).

Another example of GBV is FGM a practice aiming to remove female genitals for cultural purposes (WHO, 2001). FGM is a widespread human rights violation in African and Eastern countries (Knipscheer, 2015). Knipscheer (2015) and Mulongo (2014) found that 20% of victims, and between 16% and 44% of FGM met PTSD criteria respectively. In contrast, Applebaum (2008) found no differences in PTSD symptoms among women after FGM compared to those who had not undergone the procedure. Knipscheer (2015) argues, considering this being a purely cultural practice, that women living within this culture develop a positive perception of FGM and are consequently less likely to develop PTSD. It has been argued that disaster and migrations - which are linked - can play a role in the development of PTSD. War can affect soldiers and communities at large. In the case of Afghanistan after migrations due to war conflicts, 42% of civilians showed PTSD (Murthy, 2006). Murthy goes onto argue that women and children are more vulnerable to developing PTSD in war settings. In this respect, 87% of children in Iraqi camps had PTSD symptoms (Ahmad, 2000). As for soldiers, McFarlane (2015) reasons that PTSD can be influenced by moral injury, and violence experienced in war.

Moreover, disasters affect vulnerable populations disproportionally (Chen, 2007). It matters where and how people live to predict the risk of psychological distress following disasters. As stated above, people living in low-income sites may develop PTSD. The consequences worsen when a disaster occurs. The displacements caused by Hurricane Katrina 2005 occurred in vulnerable populations: 50% of families reported emotional distress suffered by their children after the event, and more than 50% of adults reported clinically relevant stress (Chen, 2007). Furthermore, 79% of asylum seekers in Australia had experienced traumatic events such as assault and torture, and 37% had PTSD symptoms linked to the trauma experienced before migration (Silove, 1997).

In addition to PTSD, resilience is another normal -if not the most common response to trauma. It is popularly defined as a person’s capacity to adapt in the context of stress. Resilience can build from many factors. According to most of the available research, resilience is incited by social and cultural elements rather than by individual ones. In this context, authors like Ungar (2008) and Pooley (2010) define resilience as a multidimensional capacity, adding using social and cultural resources to sustain well-being. This means that resilience is influenced not only by individual traits but by relationships and, communities.

Davydov (2010) proposed a model of resilience including resources related to community interactions and support structures such as safety, government support, gender roles and relationships, and cultural characteristics like religion and cultural identity. These definitions have several implications for MH promotion and prevention strategies. Resilience can be a multisectoral effort providing a rich-in-resources environment can work better than promoting certain personality traits alone to build resilience. A powerful resource to promote resilience as a health strategy can be the promotion of certain environments of healthy relationships, healthy gender roles, and strong cultural identity. This intervention would be better performed if focused on the specific characteristics of each context because, with a culturally sensitive construct, promotion strategies should be culturally sensitive as well.

If resilience is understood as a socially and culturally defined construct, it may be conceived differently across the world. In that respect, Ungar (2008) considers that despite general aspects of well-being -hopefulness, attachment and self-efficacy-, each culture attributes certain relevance to each of them, and this is not registered in the literature. In consequence, there are more assumptions in the homogeneity of this construct than evidence. Another example of different conceptualization of resilience across cultures is given by Ungar (2012), where he compares having a hobby as a presentation of resilience in High-Income Countries (HICs), but in contexts of poverty, this is not only unassociated with resilience but disrespectful to expect.

PTSD faces diagnostic challenges globally regarding changes in diagnostic systems and differences in cultural manifestations. In 2013, The American Psychiatric Association (APA) relocated PTSD from Anxiety Disorders to Trauma-and Stress-or-Related Disorders. This change in classification can have a direct impact by invalidating research made using the DSM4 classification. Moreover, APA (2013) changed PTSD criteria and detailed more clearly what is a traumatic event and they included sexual assault as one. These changes help the clinical practice to better diagnose this disorder while also taking into consideration GBV victims. Cultural differences have been also discussed in the literature. E.g., avoidance symptoms are not that common in LMICs (Jayawickreme, 2013; Murthy, 2006) and -albeit APA clarified the definition of trauma-, Silva (1993) states that trauma is unequivocally related to socio-cultural background, e.g., witnessing death can be positively understood under certain religious circumstances. How society reacts to a traumatic experience is relevant for complication development, e.g., a war soldier known as a cruel killer back home (Silva, 1993). Research should now focus on understanding trauma in different risk settings and produce literature based on DSM5 new criteria. Finally, it is well known that potential traumatic events can be difficult to avoid. Under this notion, the focus for health professionals should be to early and accurately diagnose PTSD to prevent chronicity and severity, rather than to avoid this disorder.

Biomarkers have a future potential role in ensuring a reliable diagnosis of PTSD. Nonetheless, this role might be limited. The aetiology and complexity of mental disorders hinder the discovery of biological tests to determine psychiatric diagnosis, including PTSD. There are no biomarkers for PTSD yet (Lehrner, 2014; Schmidt, 2013). They can be useful in confirming symptoms when people are having trouble describing them or associating them with trauma (Lehrner, 2014). Potential biomarkers for PTSD that have been researched might target DNA to determine PTSD susceptibility, and imaging to recognize hippocampal volume loss to mark PTSD presence (Schmidt, 2013). E.g., the amygdala (Karl, 2006) and the hippocampus (Bremner, 1995) are reduced in PTSD patients. Impaired safety signals can also be a potential biomarker for PTSD because of the changes and dysregulation in fear learning and expression of trauma victims (Jovanovic, 2012). These findings are limited due to how different every traumatic event is (Schmidt, 2013). This has crucial implications for public health, such as screening in risk populations for gene expression to create programs for early intervention after trauma in these populations. The scope of PTSD biomarkers is limited because they can produce stigma, make people feel they are legitimately damaged (Lehrner, 2014) and can be reductionist (Singh, 2009).

Poverty conditions and several forms of violence such as GBV, war, migration and disaster are considered potential risks for the development of PTSD. These factors can particularly affect vulnerable populations such as women and children. PTSD, along with resilience, can be human responses following traumatic events which are both complex to define and have important cultural implications. Efforts from a multisectoral level should be the aim for global mental health professionals, politics, economics and medicine regarding trauma, resilience and wellbeing for evitable traumatic events. Also, creating health prevention, promotion and intervention strategies aimed to promote culturally sensitive mental resilience focused on environmental resources, predicting risk for PTSD in vulnerable populations and early diagnosing in the face of inevitable events, carefully using potential biomarkers.