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Risk Factors for PTSD

Obstacles to the Study of Risk Factors

for Posttraumatic Stress Disorder

Richard J. McNallya

Invited ms for Strides

Submitted July 19, 2010

Department of Psychology, Harvard University, 1230 William

James Hall, 33 Kirkland Street, Cambridge, MA 02138 USA.

electronic mail: rjm@wjh.harvard.edu

Risk Factors for PTSD

People vary dramatically in their susceptibility for

developing medical illnesses, including psychiatric ones.
Yet for many years, studying risk factors for posttraumatic
stress disorder (PTSD) was taboo.

Psychiatric advocates for

troubled Vietnam veterans argued that the war itself, not

preexisting psychological problems or vulnerabilities
explained why many veterans experienced delayed stress
reactions after their return home.

They aimed to banish

discourse on vulnerability lest it provide an excuse for the

federal government to skirt its responsibility to provide
veterans with psychiatric treatment and disability
compensation (McNally, in press).

As Blank (1985) put it,

discussing vulnerability for PTSD amounts to blaming the

victim (p. 83).

Of course, identifying predictors of PTSD

among people exposed to trauma involves statistical discourse

regarding effect sizes, not moral discourse about blame.
Nevertheless, fear of blaming victims for their plight
impeded the study of risk factors for PTSD for many years.
However, now that the PTSD diagnosis is secure within
our diagnostic system (Shephard, 2004), traumatologists are
increasingly willing to investigate why victims of trauma
vary in their likelihood for developing the disorder (Yehuda,
1999).

Indeed, our field must confront risk factors because

Risk Factors for PTSD

the vast majority of people exposed to PTSD-qualifying

stressors do not develop the disorder (e.g., Breslau, Davis,
Andreski, & Peterson, 1991).
There are two reasons why most trauma victims do not
succumb to PTSD. First, victims vary in their
vulnerabilities. Just as not everyone who smokes cigarettes
is equally likely to develop heart disease or lung cancer,
not everyone exposed to a traumatic stressor is equally
likely to develop PTSD.
Second, our concept of trauma has dramatically expanded
since PTSD first appeared in the third edition of the
Diagnostic and statistical manual of mental disorders (DSMIII; American Psychiatric Association [APA], 1980).

To

qualify as trauma-exposed, people no longer need be survivors

of rape, combat, natural disasters, or other catastrophic,
life-threatening events.

Thanks to a conceptual bracket

creep in the definition of trauma (McNally, 2003a), vastly

more people are eligible for the PTSD diagnosis than in the
past (Breslau & Kessler, 2001).

In fact, DSM-IV-TR (APA,

2000) does not even require that a person be physically

present at the scene of the trauma to qualify as a trauma
survivor.

A person who feels helpless when learning about

threats to the safety of other people now qualifies as a

Risk Factors for PTSD

trauma survivor just as much as those whose lives were in

danger (McNally, 2009; McNally & Breslau, 2008).

For

example, Schlenger et al. (2002) reported that the terrorist

attacks of September 11, 2001 triggered apparent PTSD in 4%
of Americans who lived very far from the scenes of the
attacks. Evidently, televised coverage of the violence caused
the disorder.

Although preexisting vulnerability factors

affect the probability of psychiatric breakdown even in

response to the incontestable trauma of combat (Helzer,
1981), vulnerability factors will dominate the etiological
picture when people develop PTSD in response to
noncatastrophic stressors (e.g., watching televised coverage
of terrorist attacks).
Conceptual Obstacles to Understanding Risk Factors
According to the dose-response principle (March, 2003),
the more severe the stressor, the more likely PTSD will
develop. There are plenty of exceptions to this rule, and
measuring severity of trauma independently of the victims
subjective response remains challenging (For a review, see
McNally, 2003b, pp. 79-89). Yet apart from these
complexities, there is its ambiguous conceptual status.

On

the one hand, the dose-response principle implies that trauma

severity is a risk factor for PTSD.

On the other hand,

Risk Factors for PTSD

trauma is no mere risk factor.

Trauma, or more precisely,

the memory of trauma (Rubin, Berntsen, & Bohni, 2008), is

integral to the concept of PTSD. It is what ties an otherwise
disparate list of symptoms together (Young, 1995, p. 5).
Hence, discovery of unambiguous risk factors entails the
search for predictors of PTSD among people exposed to trauma.
That is, given exposure to trauma, what factors heighten risk
for PTSD?
Many people with PTSD have encountered traumatic
stressors prior to the one triggering their disorder (e.g.,
Bremner, Southwick, Johnson, Yehuda, & Charney, 1993;
Breslau, Chilcoat, Kessler, & Davis, 1999). These findings
seem to imply that exposure to trauma is a risk factor for
developing PTSD in response to a later trauma. Even when a
specific stressor does not itself incite PTSD, it may
sensitize victims, rendering them especially likely to
develop the disorder in response to subsequent stressors.
One can understand the appeal of this hypothesis to
anyone who worries that identifying risk factors blames
victims for their plight.

Although it recognizes individual

differences in vulnerability to PTSD, the hypothesis locates

the ultimate source of this vulnerability in earlier
stressors, not within the persons cognitive or genetic make-

Risk Factors for PTSD

up.

Hence, trauma serves two functions.

It functions as a

risk factor for developing PTSD in response to later trauma,

and as the direct cause of PTSD when the disorder does
emerge.
Unfortunately, researchers testing this hypothesis
failed to assess how subjects responded to the original
trauma, as Breslau, Peterson, and Schultz (2008) observed.
Revisiting their previous prospective, longitudinal data of
civilian PTSD, Breslau et al. found that previous exposure to
trauma did not increase risk for PTSD in response to later
trauma unless subjects had developed PTSD in response to the
original trauma. Hence, prior trauma per se is not a risk
factor for PTSD in response to later trauma. Rather, PTSD in
response to prior trauma predicts PTSD in response to later
trauma. In a subsequent investigation, Breslau and Peterson
(in press) found that this effect held regardless of stressor
type.

For example, exposure to assaultive violence early in

life in the absence of PTSD did not confer risk for PTSD in
response to later trauma.
Breslau et al.s (2008) findings dovetail with Koenen et
al.s (2008) prospective, longitudinal study of subjects in
Dunedin, New Zealand. Koenens research group found that
trauma victims in this civilian cohort almost never succumbed

Risk Factors for PTSD

to PTSD unless they had developed another psychiatric

disorder earlier in life.

Hence, with only very few

exceptions, PTSD never occurred in people who had not already

exhibited vulnerability for mental disorders.
Much research on risk factors for PTSD among people
exposed to trauma concerns individual difference variables
such as intelligence and neuroticism. Relative to victims
with higher intelligence, those with lower intelligence are
more likely to develop PTSD (e.g., McNally & Shin, 1995;
Macklin et al., 1998).

Relative to victims with lower

neuroticism, those with higher neuroticism are more likely to

develop PTSD (e.g., Breslau et al., 1991; McFarlane, 1989).
Research on these individual difference variables
provides clues to vulnerability. Yet constructs emerging from
psychometric studies do not directly illuminate the
mechanisms operative within a person (McNally, in press).
They are latent variables that psychologists postulate to
account for differences among people. To be sure, these
traits must somehow have their source in human psychobiology,
but none is a mechanism that can explain intraindividual
development, cognition, emotion, or behavior (Bechtel, 2008),
and thus risk for trauma.

Risk Factors for PTSD

Consider a measure of intelligence or psychometric g. It

reflects a source of interindividual differences, but it does
not correspond to any intraindividual cognitive mechanism
within the brain of a single person (Borsboom & Dolan, 2006).
The same holds for other abstract constructs, such as
neuroticism.

It alludes to a broad range of correlated

dispositions devoid of any contextual reference (Kagan,

1996).

Among its facets are self-consciousness and angry

hostility.

Yet knowing that someone is high on neuroticism

does not tell us whether we should expect a shy and selfconscious person or someone who is angry and hostile.
Indeed, it is little wonder that researchers have been unable
to identify any reliable biological correlates for such an
abstract construct as neuroticism, its high heritability
notwithstanding (Claridge & Davis, 2001).
Other scholars question the explanatory potential of
neuroticism (Ormel, Rosmalen, & Farmer, 2004). To be sure,
measures of this broad construct predict diverse negative
outcomes, including life stress, depression, unexplained
medical symptoms, and substance abuse.

Yet because

neuroticism reflects a persons average level of emotional

distress over time, the connection between neuroticism and
its predicted outcomes borders on the tautological.

People

Risk Factors for PTSD

who experience anxiety, depression, and anger at one point in

time are those mostly likely to experience these emotions in
the future. To assert that neuroticism is a shorthand marker
predicting distress tells us nothing about its
psychobiological substrate.

Hence, it does not disclose why

people high on neuroticism are vulnerable to PTSD.

Conclusion
Identifying risk factors for PTSD among people exposed
to trauma is just as important as identifying risk factors
for depression, heart disease, and cancer.

The alternative

is ignorance, and ignorance provides a poor basis for

prevention of any disorder, including PTSD.

Fortunately, the

study of risk for PTSD is no longer de factor forbidden on

ideological or political grounds.

Nevertheless, some

traumatologists still accuse risk factor researchers of

blaming victims.

For example, the clinical psychologist,

Karestan Koenen, receives these accusations for her work on

genetic variables associated with risk for PTSD (Karestan,
2009).

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Risk Factors for PTSD

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