Influence of Multiple Traumatic Event Types on Mental Health Outcomes: Does Count Matter?
The experience of potentially traumatizing events (PTEs) may be associated with conflicting outcomes: individuals may experience greater psychological distress (dose-response theory), or individuals may become more resilient against repeated PTEs (stress-inoculation theory). With limited empirical data comparing these theories, we examined the relationships between the count of lifetime PTE types and psychological outcomes [posttraumatic stress disorder (PTSD), depression, impaired distress tolerance] using linear and quadratic regressions. A linear relationship would support the dose-response theory, and a quadratic relationship would support the stress-inoculation theory. We also explored whether there was a threshold number of PTE types fostering resiliency before an increase of distressing outcomes. The sample included 123 (68.30% female) treatment-seeking patients at a community mental health center participating in a larger study (Contractor et al. in Psychiatry Research, 252, 252215–252222, 2017). Linear regression results indicated number of PTE types significantly predicted increasing PTSD and depression severity and distress tolerance difficulties. Quadratic regression model results were not significant. ROC analyses indicated exposure to at least 3.5 PTE types predicted PTSD with moderate accuracy. In conclusion, the dose-response theory was supported, with results indicating there may be a threshold count of lifetime PTE types (> 3) influencing traumatic stress outcomes.
KeywordsLifetime traumatic experiences PTSD Depression Distress tolerance Dose-response theory Stress-inoculation theory
Dr. Frankfurt’s work is supported by the Department of Veterans Affairs Office of Research and Development Rehabilitation Research and Development Service Career Development Award - 1 (#IK1RX00304-01-A1). Since Dr. Frankfurt is an employee of the U.S. Government and contributed to this manuscript as part of her official duties, the work is not subject to US copyright.
Compliance with Ethical Standards
Conflict of Interest
Monica Gerber, Sheila B. Frankfurt, Ateka A. Contractor, Kelsey Oudshoorn, Paula Dranger, and Lily Brown declare that they have no conflict of interest.
This study was approved by a Midwestern university’s Institutional Review Board. The present study is a secondary analysis of this larger dataset (see Contractor et al. 2017 for full study details). Participants were recruited from waiting rooms at a Midwest community mental health center. All paricipants completed informed consent and compensation for participation was not offered.
- Agorastos, A., Pittman, J. O., Angkaw, A. C., Nievergelt, C. M., Hansen, C. J., Aversa, L. H., Parisi S.A., Barkauskas D.A., Marine Resiliency Study Team., Baker D.G. (2014). The cumulative effect of different childhood trauma types on self-reported symptoms of adult male depression and PTSD, substance abuse and health-related quality of life in a large active-duty military cohort. Journal of Psychiatric Research, 58, 46–54. https://doi.org/10.1016/j.jpsychires.2014.07.014.
- Anestis, M. D., Tull, M. T., Bagge, C. L., & Gratz, K. L. (2012). The moderating role of distress tolerance in the relationship between posttraumatic stress disorder symptom clusters and suicidal behavior among trauma exposed substance users in residential treatment. Archives of Suicide Research, 16(3), 198–211. https://doi.org/10.1080/13811118.2012.695269.CrossRefPubMedPubMedCentralGoogle Scholar
- Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254.CrossRefPubMedGoogle Scholar
- Briere, J., & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA, US: Sage Publications, Inc..Google Scholar
- Campbell, D. G., Felker, B. L., Liu, C., Yano, E. M., Kirchner, J. E., Chan, D., et al. (2007). Prevalence of depression–PTSD comorbidity: Implications for clinical practice guidelines and primary care-based interventions. Journal of General Internal Medicine, 22(6), 711–718. https://doi.org/10.1007/s11606-006-0101-4.CrossRefPubMedPubMedCentralGoogle Scholar
- Cicerone, K. D., & Fraser, R. T. (1999). Counseling interactions for clients with traumatic brain injury. In R. T. Fraser & D. C. Clemmons (Eds.), Traumatic brain injury rehabilitation: Practical vocational, neuropsychological, and psychotherapy interventions (pp. 95–127). New York: CRC Press.Google Scholar
- Contractor, A. A., Caldas, S., Fletcher, S., Shea, M. T., & Armour, C. (2018). Empirically-derived lifespan polytraumatization typologies: A systematic review. Journal of Clinical Psychology, 1–23. https://doi.org/10.1002/jclp.22586.
- Elhai, J. D., de Francisco Carvalho, L., Miguel, F. K., Palmieri, P. A., Primi, R., & Christopher Frueh, B. (2011). Testing whether posttraumatic stress disorder and major depressive disorder are similar or unique constructs. Journal of Anxiety Disorders, 25(3), 404–410. https://doi.org/10.1016/j.janxdis.2010.11.003.CrossRefPubMedGoogle Scholar
- Fetzner, M. G., Peluso, D. L., & Asmundson, G. G. (2014). Tolerating distress after trauma: Differential associations between distress tolerance and posttraumatic stress symptoms. Journal of Psychopathology and Behavioral Assessment, 36(3), 475–484. https://doi.org/10.1007/s10862-014-9413-6.CrossRefGoogle Scholar
- Jakob, J. D., Lamp, K., Rauch, S. M., Smith, E. R., & Buchholz, K. R. (2017). The impact of trauma type or number of traumatic events on PTSD diagnosis and symptom severity in treatment seeking veterans. The Journal of Nervous and Mental Disease, 205(2), 83–86. https://doi.org/10.1097/NMD.0000000000000581.PubMedGoogle Scholar
- Karam, E. G., Friedman, M. J., Hill, E. D., Kessler, R. C., McLaughlin, K. A., Petukhova, M., Sampson, L., Shahly, V., Angermeyer, M. C., Bromet, E. J., de Girolamo, G., de Graaf, R., Demyttenaere, K., Ferry, F., Florescu, S. E., Haro, J. M., He, Y., Karam, A. N., Kawakami, N., Kovess-Masfety, V., Medina-Mora, M. E., Browne, M. A. O., Posada-Villa, J. A., Shalev, A. Y., Stein, D. J., Viana, M. C., Zarkov, Z., & Koenen, K. C. (2014). Cumulative traumas and risk thresholds: 12-month PTSD in the world mental health (WMH) surveys. Depression and Anxiety, 31, 130–142. https://doi.org/10.1002/da.22169.CrossRefPubMedGoogle Scholar
- Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National Estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547. https://doi.org/10.1002/jts.21848. CrossRefPubMedPubMedCentralGoogle Scholar
- Kolassa, I., Ertl, V., Eckart, C., Kolassa, S., Onyut, L. P., & Elbert, T. (2010). Spontaneous remission from PTSD depends on the number of traumatic event types experienced. Psychological Trauma: Theory, Research, Practice, And Policy, 2(3), 169–174. https://doi.org/10.1037/a0019362.CrossRefGoogle Scholar
- Kraemer, K. M., Luberto, C. M., & McLeish, A. C. (2013). The moderating role of distress tolerance in the association between anxiety sensitivity physical concerns and panic and PTSD-related re-experiencing symptoms. Anxiety, Stress & Coping: An International Journal, 26(3), 330–342. https://doi.org/10.1080/10615806.2012.693604.CrossRefGoogle Scholar
- Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.CrossRefPubMedPubMedCentralGoogle Scholar
- LeBouthillier, D. M., McMillan, K. A., Thibodeau, M. A., & Asmundson, G. G. (2015). Types and number of traumas associated with suicidal ideation and suicide attempts in PTSD: Findings from a U.S. nationally representative sample. Journal of Traumatic Stress, 28(3), 183–190. https://doi.org/10.1002/jts.22010.CrossRefPubMedGoogle Scholar
- Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological assessment (5th ed.). New York, NY: Oxford University Press 978-0195395525.Google Scholar
- Marshall-Berenz, E. C., Vujanovic, A. A., Bonn-Miller, M. O., Bernstein, A., & Zvolensky, M. J. (2010). Multimethod study of distress tolerance and PTSD symptom severity in a trauma-exposed community sample. Journal of Traumatic Stress, 23(5), 623–630. https://doi.org/10.1002/jts.20568.CrossRefPubMedPubMedCentralGoogle Scholar
- Meichenbaum, D. (2007). Stress-inoculation training: A preventative and treatment approach. In P. M. Lehrer, R. L. Woolfolk, W. E. Sime, P. M. Lehrer, R. L. Woolfolk, & W. E. Sime (Eds.), Principles and practice of stress management (3rd ed., pp. 497–516). New York, NY, US: Guilford Press.Google Scholar
- Miranda, J. M., Green, B. L., & Krupnick, J. (1997, December). Mental disorders in disadvantaged gynecology patients. Paper presented at the north American meeting of the Society for Psychotherapy Research. AZ: Tucson.Google Scholar
- Mustanski, B., Andrews, R., & Puckett, J. A. (2016). The effects of cumulative victimization on mental health among lesbian, gay, bisexual, and transgender adolescents and young adults. American Journal of Public Health, 106(3), 527–533. https://doi.org/10.2105/AJPH.2015.302976.CrossRefPubMedPubMedCentralGoogle Scholar
- Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from wave 2 of the National Epidemiologic Survey on alcohol and related conditions. Journal of Anxiety Disorders, 25, 456–465. https://doi.org/10.1016/j.janxdis.2010.11.010.CrossRefPubMedGoogle Scholar
- Schauer, M., Neuner, F., Karunakara, U., Klaschik, C., Robert, C., & Elbert, T. (2003). PTSD and the “building block” effect of psychological trauma among West Nile Africans. ESTSS (European Society for Traumatic Stress Studies) Bulletin, 10(2), 5–6.Google Scholar
- Suliman, S., Mkabile, S. G., Fincham, D. S., Ahmed, R., Stein, D. J., & Seedat, S. (2009). Cumulative effect of multiple trauma on symptoms of posttraumatic stress disorder, anxiety, and depression in adolescents. Comprehensive Psychiatry, 50(2), 121–127. https://doi.org/10.1016/j.comppsych.2008.06.006.CrossRefPubMedGoogle Scholar
- Thibodeau, M. A., Welch, P. G., Sareen, J., & Asmundson, G. G. (2013). Anxiety disorders are independently associated with suicide ideation and attempts: Propensity score matching in two epidemiological samples. Depression and Anxiety, 30(10), 947–954. https://doi.org/10.1002/da.22203.CrossRefPubMedGoogle Scholar
- Vujanovic, A. A., Bonn-Miller, M. O., Potter, C. M., Marshall, E. C., & Zvolensky, M. J. (2011a). An evaluation of the relation between distress tolerance and posttraumatic stress within a trauma-exposed sample. Journal of Psychopathology and Behavioral Assessment, 33(1), 129–135.CrossRefPubMedPubMedCentralGoogle Scholar
- Vujanovic, A. A., Marshall-Berenz, E. C., & Zvolensky, M. J. (2011b). Posttraumatic stress and alcohol use motives: A test of the incremental and mediating role of distress tolerance. Journal of Cognitive Psychotherapy, 25(2), 130–141. https://doi.org/10.1891/0889-8318.104.22.168.CrossRefPubMedPubMedCentralGoogle Scholar
- Vujanovic, A. A., Hart, A. S., Potter, C. M., Berenz, E. C., Niles, B., & Bernstein, A. (2013). Main and interactive effects of distress tolerance and negative affect intensity in relation to PTSD symptoms among trauma-exposed adults. Journal of Psychopathology and Behavioral Assessment, 35(2), 235–243. https://doi.org/10.1007/s10862-012-9325-2.CrossRefPubMedPubMedCentralGoogle Scholar
- Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. In Annual convention of the international society for traumatic stress studies. San Antonio: International Society for Traumatic Stress Studies.Google Scholar
- Wiederhold, B. K., & Wiederhold, M. D. (2008). Virtual reality for posttraumatic stress disorder and stress-inoculation training. Journal Of Cybertherapy And Rehabilitation, 1(1), 23–35.Google Scholar