A R T I C L ESOCIAL REACTIONS TO SEXUALASSAULT DISCLOSUR.docx

A R T I C L E
SOCIAL REACTIONS TO SEXUAL
ASSAULT DISCLOSURE, COPING,
PERCEIVED CONTROL, AND PTSD
SYMPTOMS IN SEXUAL ASSAULT
VICTIMS
Sarah E. Ullman and Liana Peter-Hagene
University of Illinois at Chicago
The social reactions that sexual assault victims receive when
they disclose
their assault have been found to relate to posttraumatic stress
disorder
(PTSD) symptoms. Using path analysis and a large sample of
sexual
assault survivors (N = 1863), we tested whether perceived
control,
maladaptive coping, and social and individual adaptive coping
strategies
mediated the relationships between social reactions to
disclosure and PTSD
symptoms. We found that positive social reactions to assault
disclosure
predicted greater perceived control over recovery, which in turn
was related
to less PTSD symptoms. Positive social reactions to assault
disclosure were
also associated with more adaptive social and individual coping;
however,
only adaptive social coping predicted PTSD symptoms.
Negative social

reactions to assault disclosure were related to greater PTSD
symptoms both
directly and indirectly through maladaptive coping and
marginally
through lower perceived control over recovery. C© 2014 Wiley
Periodicals,
Inc.
Social reactions to sexual assault disclosure can have a
significant effect on victims’ recov-
ery after the assault, and can either help or hinder the recovery
process. Although the
relationships between positive and negative social reactions and
posttraumatic stress dis-
order (PTSD) symptoms have been investigated before, there is
still much to learn about
We thank Cynthia Najdowski, Mark Relyea, Meghna Bhat,
Amanda Vasquez, Saloni Shah, Susan Zimmerman,
Rene Bayley, Farnaz Mohammad-Ali, and Gabriela Lopez for
assistance with data collection. This research was
supported by NIAAA Grant No. AA17429 to Sarah E. Ullman.
Please address correspondence to: Sarah E. Ullman,
Criminology, Law and Justice Department, University of
Illinois at Chicago, 1007 W. Harrison St., Chicago, IL 60607.
E-mail: [email protected]
JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 42, No. 4,
495–508 (2014)
Published online in Wiley Online Library
(wileyonlinelibrary.com/journal/jcop).
C© 2014 Wiley Periodicals, Inc. DOI: 10.1002/jcop.21624
496 � Journal of Community Psychology, M ay 2014

the many psychological mechanisms that can mediate these
relationships. We know, for
example, that negative social reactions to disclosure are related
to maladaptive coping
strategies and, in turn, to PTSD symptoms (Ullman, Townsend,
Filipas, & Starzynski,
2007). We know less, however, about the different effect social
reactions can have on
adaptive coping strategies that involve others (i.e., social
coping) and more solitary forms
of coping (i.e., individual coping, Orchowski, Untied, &
Gidycz, in press) because most
studies combine all forms of adaptive coping into one single
measure.
Further, most research on coping strategies as predictors of
PTSD has only compared
maladaptive versus adaptive forms of coping (Littleton,
Horsley, John, & Nelson, 2007)
and has failed to distinguish between social and individual
coping. Finally, perceived
control over recovery has emerged as the only protective
psychosocial factor against
PTSD symptoms (Ullman, Filipas, Townsend, & Starzynski,
2007), and thus deserves
further exploration as a mediator between social reactions to
sexual assault disclosure and
PTSD symptoms (Peter-Hagene & Ullman, in press). We
investigated maladaptive coping,
individual and social adaptive coping strategies, and perceived
control over recovery as
potential mechanisms through which negative and positive
social reactions relate to PTSD
symptomatology.

Social Reactions to Assault Disclosure
As many as 92% of sexual assault survivors disclose the assault
to at least one person
(Ahrens, Campbell, Ternier-Thames, Wasco, & Sefl, 2007;
Starzynski, Ullman, Filipas,
& Townsend, 2005; Ullman & Filipas, 2001), and most of them
receive a mixture of
positive and negative social reactions in response to their sexual
assault disclosure (Filipas
& Ullman, 2001; Starzynski et al., 2005). Common negative
social reactions to assault
disclosure include blaming the victim, treating the victim
differently (i.e., as if she were
damaged in some manner), attempting to control the victim’s
actions (i.e., force victim to
tell others or go to the police), or focusing on one’s own
feelings rather than the victim’s.
Positive social reactions to assault disclosure include providing
emotional (i.e., listening)
and practical (i.e., seeking and reaching resources) support and
telling the victim it was
not her fault (Ullman, 2000). Both these types of social
reactions to disclosure have
significant effects on victims’ recovery after the assault,
although the deleterious effects of
negative reactions to disclosure tend to be stronger than the
protective effects of positive
reactions to assault disclosure.
Negative social reactions to sexual assault disclosure have
robust negative effects on
recovery (Davis, Brickman, & Baker, 1991; Ullman, 1996;
Campbell, Wasco, Ahrens, Sefl,
& Barnes, 2001) and seem to play a crucial role in the
development of PTSD symptoms

(Ullman, Filipas et al., 2007; Ullman, Townsend et al., 2007).
There are several possible
psychological mechanisms that drive this effect. First,
unsupportive responses to victims
can lower victims’ perceived control over recovery (Frazier et
al., 2011) or attributions
about their own capacity to take charge of their recovery
process and control their feelings
and thoughts in the aftermath of the assault (e.g., Frazier,
2003). Perceived control over
recovery is indeed related to less social withdrawal and distress
in sexual assault survivors
(Frazier, Mortensen, & Steward, 2005). Blaming the victim or
attempting to control her
actions and feelings after sexual assault may reinforce the loss
of control experienced
during assault and translate into perceptions of poor control
over recovery (Peter-Hagene
& Ullman, in press).
Second, negative social reactions to assault disclosure might
lead survivors to dis-
engage from seeking support from others, and to rely on
potentially maladaptive and
Journal of Community Psychology DOI: 10.1002/jcop
Social Reactions and PTSD � 497
avoidant coping strategies instead (Ullman, Townsend et al.,
2007). If victims feel their
social networks are betraying them by responding negatively to
their assault disclosure,
they may engage in greater maladaptive coping to escape

feelings of anger, sadness, or
anxiety. Negative social reactions to assault disclosure might
also negatively affect positive
social coping, by discouraging victims’ attempts to seek help
from friends or talk to others
about feelings related to the assault.
Negative reactions, however, might not necessarily impair
individual forms of adaptive
coping (e.g., meditation, planning, cognitive restructuring),
especially for victims who do
not rely entirely on others for support during recovery. In fact,
Orchowski et al. (in
press) found that social reactions of victim blaming were
associated with greater problem-
solving coping. It is possible, therefore, that negative social
reactions to assault disclosure
can encourage women to not only adopt maladaptive coping
strategies but also engage
in positive individual strategies when they cannot rely on others
for support.
Although the effect of negative social reactions to assault
disclosure on recovery is
robust, positive reactions do not seem to provide a similarly
powerful protective effect
against negative outcomes (Ullman, 1999; Ullman, 2010). There
are, however, reasons
to believe that positive social reactions to assault disclosure
could affect both perceived
control over recovery and positive social coping, and perhaps in
turn help reduce PTSD
symptoms. Health psychology research shows that social
support increases feelings of
self-efficacy, which in turn improves health outcomes (e.g.,
Chlebowy & Garvin, 2006). In

the context of sexual assault, support such as spending time
with the survivor, giving her
somewhere to stay, or providing resources after an assault can
increase victims’ perceived
control over their recovery process (that is, their perceived self-
efficacy for coping with
the assault). Positive reactions to assault disclosure may also
lead victims to feel better
and therefore engage in more adaptive forms of coping and
fewer maladaptive forms of
coping (Ullman, Townsend et al., 2007). It is also possible that
positive social reactions
to assault disclosure are more strongly related to social forms of
adaptive coping, rather
than to individual forms of adaptive coping. Thus, it is
important to separate the effects
of social reactions to assault disclosure on these different types
of coping, because social
reactions might affect one form of coping and not another.
Finally, positive social reactions to sexual assault disclosure
may lead to more PTSD
symptoms, even though research shows that general measures of
social support (not
specific to assault) are related to less PTSD symptoms in sexual
assault survivors (Ullman,
1999, 2010). Perhaps this surprising positive relation exists
because victims who disclose
to more people typically get a mix of both positive and negative
reactions from others to
disclosure (Ullman, 2010), and perhaps victims of more severe
trauma are more likely to
both disclose to more people and to develop PTSD symptoms,
not because of a causal
link between positive reactions to assault disclosure and PTSD
symptoms.

Coping Strategies
Coping is the process of attempting to manage the demands
created by stressful events that
are appraised as taxing or exceeding a person’s resources
(Lazarus & Folkman, 1984). A
common response to stressful life events such as rape is
engagement in effortful attempts
to avoid or reduce negative affect (Littleton et al., 2007).
Unfortunately, such strategies
can be ineffective and even maladaptive. Maladaptive coping
strategies such as denial,
disengagement, substance use to cope, and social withdrawal
can protect women from the
immediate reality of trauma, but in the long run may thwart
recovery, because recovery
requires dealing with the trauma and its effects. In fact,
avoidant coping strategies are
related to more PTSD symptoms (Ullman, Filipas et al., 2007).
For example, Gutner, Rizvi,
Monson, and Resick (2006) interviewed female rape and
physical assault victims within
1 month postassault and then 3 months later. Increased
maladaptive coping strategies
(e.g., wishful thinking, social withdrawal) over time were
related to increased PTSD
symptoms.

Few studies have examined distinct forms of adaptive coping,
successful strategies
such as cognitive restructuring (i.e., identification and rebuttal
of automatic, maladap-
tive cognitions about the assault such as self-blame), expressing
one’s emotions, and
seeking social support. These coping strategies lead to better
recovery and decreased
PTSD symptoms over time (e.g., Gutner et al., 2006), Thus,
there are reasons to believe
that adaptive coping strategies might serve as protective factors
against PTSD symptoms.
Adaptive strategies, however, generally have a weaker influence
on PTSD symptoms than
maladaptive coping (Ullman, Filipas et al., 2007).
As discussed earlier, social reactions to assault disclosure are
related to coping, espe-
cially when it comes to negative reactions and maladaptive
coping (Ullman et al., 2007).
Only two studies have examined how adaptive coping strategies
are affected by positive
social reactions to assault disclosure (Orchowski et al., in press;
Ullman & Najdowski,
2011). Both these studies fail to distinguish between social and
individual coping strate-
gies, although it would be reasonable to expect these two forms
of coping to (a) be
differentially affected by social reactions and (b) to
differentially affect PTSD symptoms.
Specifically, social coping strategies should act as mediators of
positive social reactions to
assault disclosure effects on PTSD symptoms, whereas
individual coping strategies might
not. For example, Orchowski and colleagues (in press) found
that social reactions to

assault disclosure that provided emotional support to college
women survivors of sexual
assault were associated with increased coping by seeking
emotional support–a construct
that is included in our conceptualization of social forms of
adaptive coping. Prosocial
coping is generally related to positive outcomes, although social
forms of coping are also
likely to be more sensitive to other interpersonal factors such as
disclosure, and thus may result in more negative outcomes (see
Folkman & Moskowitz,
2004). Perhaps disaggregating positive forms of coping may
also show distinct effects on
recovery in sexual assault victims.
Perceived Control Over Recovery
Rape is traumatic because it entails a significant loss of control
over one’s body during
the assault, and can lead to a shattering of women’s beliefs
about their own safety in
the world, increased feelings of vulnerability, and lower
perceived control over recovery
and self efficacy (Janoff-Bulman, 1992; Perloff, 1983; Schepple
& Bart, 1983). Although
attributions of past and future control do not seem to enhance
sexual assault survivors’
recovery (Frazier, 2003; Frazier, Steward, & Mortensen, 2004;
Ullman, Filipas et al., 2007),
there is consistent evidence that attributions of present control,
specifically perceived
control over the recovery process, are associated with fewer
PTSD symptoms in sexual
assault survivors (Frazier, 2003; Ullman, Filipas et al., 2007).
In one sample of sexual

assault survivors, present control (control over the recovery
process) was associated with
less distress partly because it was associated with less social
withdrawal (a maladaptive
form of coping) and more cognitive restructuring (an adaptive
form of coping) in sexual
assault survivors (Frazier et al., 2004). Perceived control over
recovery also negatively
predicts PTSD symptoms and binge drinking (Frazier, 2003;
Frazier et al., 2011; Ullman
et al., 2007). In addition, unsupportive social reactions are
negatively related to perceived
control (Frazier et al., 2011). Thus, we wanted to explore the
role of perceived control over
recovery as a mediator between social reactions to assault
disclosure and PTSD symptoms.
Present Study
The present study tested a mediational model of social reactions
to assault disclosure and
PTSD symptoms in a large sample of sexual assault survivors.
Several direct effects were
hypothesized based on the theory and past literature discussed
above. We expected nega-
tive social reactions to assault disclosure to relate to greater
PTSD symptoms directly and
through maladaptive coping and perceived control over the
recovery process. Theoreti-

cally, we expected that victims who receive more negative
reactions to assault disclosure of
blame, control, and stigma from others would feel further
disempowered, and that such
responses would reinforce the loss of control women have
already experienced in the as-
sault and result in lower perceived control over recovery. We
expected positive reactions
to assault disclosure to relate to more adaptive forms of social
coping and less PTSD symp-
toms, because positive, validating responses to disclosure may
lead victims to use more
adaptive forms of coping such as seeking support and taking
better care of themselves.
We did not make specific predictions about the effect of
positive social reactions to assault
disclosure on positive individual coping; these forms of coping
in particular might be less
sensitive to social reactions to assault disclosure than are
maladaptive and social forms of
coping.
METHOD
Sample
A volunteer sample of women (N = 1863) from the Chicagoland
area, ranging in age
from 18 to 71 years (mean [M] = 31.1, standard deviation [SD]
= 12.2), completed
a mail survey. The sample was racially/ethnically diverse (45%
African American, 35%
White, 2% Asian, 8.1% other; 14% Hispanic, assessed
separately). Overall, the sample was
well educated, with 34.6% having a college degree or higher,
43.5% having some college

education, and 21.9% having a high school education or less.
Just under half of the sample
(46.8%) was currently employed, although income levels were
relatively low, with 68% of
women having household incomes of less than $30,000. The
response rate was 85% which
was the percentage of eligible women sent mail surveys who
returned completed surveys.
Procedure
We recruited adult women from the Chicagoland area via
weekly advertisements in lo-
cal newspapers, on Craigslist, and through university mass mail.
In addition, we posted
fliers in the community, at other Chicago colleges and
universities, as well as at agencies
that cater to community members in general and victims of
violence against women in
particular (e.g., community centers, cultural centers, substance
abuse clinics, domestic
violence, and rape crisis centers). Interested women called the
research office and were
screened for eligibility using the following criteria: (a) had an
unwanted sexual experi-
ence at the age of 14 or older, (b) were 18 years of age or older
at the time of participation,
and (c) had previously told someone about their unwanted
sexual experience. We sent
eligible participants packets containing the survey, an informed
consent sheet, a list of

community resources for dealing with victimization, and a
stamped return envelope for
the completed survey. The survey had questions about current
social contact and social
support, psychological symptoms, alcohol/drug use and
treatment seeking, stressful life
experiences, unwanted sexual experiences, PTSD symptoms,
and various postassault fac-
tors, such as attributions of blame, coping, assault disclosure,
help seeking, and social
reactions to assault disclosure. We mailed participants $25
money orders for their partici-
pation upon receipt of their completed surveys. The university’s
institutional review board
approved all study procedures and documents as complying with
federal regulations for
the ethical conduct of human subjects’ research.
Measures
Sexual assault. Sexual victimization in both childhood (prior to
14 years of age) and
adulthood (at 14 years of age or older) was measured using a
modified version of the
Sexual Experiences Survey (SES; Koss, Gidycz, & Wisniewski,
1987) that assesses various
forms of sexual assault including unwanted sexual contact,
verbally coerced intercourse,
attempted rape, and rape resulting from force or incapacitation
(e.g., from alcohol or
drugs). Testa, VanZile-Tamsen, Livingston, and Koss (2004)
reported their revised 11-item
SES measure had good reliability (α = .73); similar reliability
was found in this sample

(α = .77).
Social reactions to assault disclosures. Women completed the
Social Reactions Questionnaire
(SRQ; Ullman, 2000), reporting how often they received 48
different social reactions from
any support provider they told since the assault on a scale
ranging from 0 (never) to 4
(always). Responses were averaged to create subscales assessing
the frequency with which
participants received positive reactions to assault disclosure
(e.g., emotionally or informa-
tionally supportive reactions such as “Held you or told you that
you are loved” or “Helped
you get information of any kind about coping with the
experience”) and negative reac-
tions to assault disclosure (e.g., blaming or stigmatizing the
victim reactions such as “Told
you that you could have done more to prevent this experience
from occurring” or “Said
he/she feels you’re tainted by this experience”). On average,
women reported “rarely”
receiving negative reactions to assault disclosure (M = .96, SD
= .80) and “sometimes”
receiving positive reactions to assault disclosure (M = 2.22, SD
= .95). The SRQ has good
test-retest reliability (rs = .68 to .77) and evidence of several
forms of validity as reported
by Ullman (2000). The subscales were also reliable in this
sample with Cronbach’s α =
.93 for negative reactions to assault disclosure and .92 for
positive reactions to assault
disclosure.
Perceived control over recovery. Perceived control over
recovery from assault was assessed

using seven items from the Rape Attribution Questionnaire
(RAQ) to assess present
control (Frazier, 2003). On a scale ranging from 1 (strongly
disagree) to 5 (strongly agree),
women were asked specifically to rate their perceptions of
control over recovery from their
sexual assault in the past year (M = 3.71, SD = .71). Frazier
(2003) reported an average
alpha of .75 for present control over recovery from assault
across four time periods in one
year. The scale was also reliable in our sample (Cronbach’s α =
.70; M = 3.60; SD =.78).
Maladaptive coping. Participants completed the Brief COPE, a
28-item self-report scale of
coping strategies (Carver, 1997). Strategies used in the past 12
months to cope with the
assault were assessed on a scale ranging from 1 (I didn’t do this
at all) to 4 (I did this a lot).
Maladaptive coping was computed based on a factor analysis as
the average of responses to
eight items comprising the behavioral disengagement, denial,
self-blame, and substance
use subscales (M = 16.35, SD = 5.78, α = .81).
Adaptive coping. In past research, approach and/or adaptive
forms of coping had weaker
relationships with PTSD symptoms (Littleton et al., 2007;
Ullman, Filipas et al., 2007).

Therefore, we performed a factor analysis of the COPE items to
disaggregate adaptive
coping into two forms: individual and social coping. Adaptive
individual coping includes
12 items assessing adaptive, active forms of individual coping
(M = 29.19, SD = 7.81, α =
.83), such as “I thought hard about what steps to take.”
Adaptive social coping includes four
items assessing active, adaptive interpersonal forms of coping
(M = 9.07, SD = 3.72, α =
.87), such as “I tried to get advice or help from other people
about what to do.” All items
referred to participants’ coping in the past 12 months.
PTSD symptoms. PTSD symptoms were assessed with the
Posttraumatic Stress Diagnostic
Scale (PDS; Foa, 1995), a standardized 17-item instrument
based on the Diagnostic and
Statistical Manual of Mental Disorders Fourth Edition (DSM-
IV) criteria (American Psychi-
atric Association, 2000). On a scale ranging from 0 (not at all)
to 3 (almost always), women
rated how often each symptom (i.e., reexperiencing/intrusion,
avoidance/numbing, hy-
perarousal) bothered them in relation to the assault during the
past 12 months. The PDS
has acceptable test–retest reliability for a PTSD diagnosis in
assault survivors over 2 weeks
(κ = .74; Foa, Cashman, Jaycox, & Perry, 1997). The 17 items
were summed to assess the
extent of posttraumatic symptomatology (M = 20.75, SD =
12.76, α = .93 in this sample).
RESULTS
Bivariate correlations revealed that both negative and positive

disclosure were positively related to PTSD symptoms, but the
relation was stronger for neg-
ative reactions (Table 1). In fact, all predictors were positively
related to PTSD symptoms,
except for perceived control over recovery, which was
negatively related to PTSD symp-
toms (confirming its role as a unique protective factor). In
addition, negative reactions to
assault disclosure were not related to perceived control over
recovery, but were positively
related to all coping strategies. Positive reactions to assault
disclosure were related to
adaptive coping strategies and perceived control, but unrelated
to maladaptive coping.
Thus, we found encouraging support for our meditational paths
hypotheses. As for the
Table 1. Bivariate Correlations Between Social Reactions,
Coping, Perceived Control, and Symptoms
1. 2. 3. 4. 5. 6. 7.
1. Negative social reactions — .18* .42* .27* .12* −.05 .44*
2. Positive social reactions — .07 .30* .43* .32* .37*
3. Maladaptive coping — .18* .05 −.22* .55*
4. Adaptive individual coping — .57* .36* .20*
5. Adaptive social coping — .23* .10*
6. Perceived control over recovery — −.18*
7. PTSD —
Note. PTSD = posttraumatic stress disorder. All Ns range from
1486–1781.

*p ≤ .001.
mediators, maladaptive coping was unrelated to adaptive social
coping, but positively re-
lated to individual coping. Maladaptive coping was also
negatively related to perceived
control over recovery.
To test our hypotheses, we used a path analysis model (i.e.,
observed variables struc-
tural equation model) with maximum likelihood estimation
(AMOS 19, Arbuckle, 2010).
All measures were univariate normal with skew less than 3 and
kurtosis less than 4 (Kline,
1998). We used the untransformed variables, given that with
larger samples, effects of
violations of normality assumptions regarding kurtosis are
minimal (Tabachnick & Fidell,
2001).
The main purpose of our model was to test individual paths and
direct and indirect
effects of social reactions to assault disclosure on coping,
perceived control over recovery,
and PTSD symptoms. Our model, however, also had a good fit
with comparative fit
index (CFI) of .99, Tucker-Lewis index (TLI) of .99, and root
mean square error of
approximation (RSMEA) of .057; χ2 (3, N = 1865) = 14.28, p =
.001. Although the

model chi-square was significant, it was relatively low
considering the very high power
of this large sample. Fit indices exceed the recommendation of
0.95 and the RMSEA is
lower than 0.06, indicating good fit (Hu & Bentler, 1999). Thus,
although we did not
set out to test explanatory models of PTSD symptoms, the
mediation paths suggested by
previous theory and research and defined in the present model
show good fit to our data.
To clarify, path analysis was used instead of (or rather, in
addition to) regression because
it allows for the inclusion of multiple predictors and mediators
in the same model and
allows us to calculate direct, indirect, and total effects for all
predictors and mediators
as a part of the same analysis. Thus, although path analysis is
often used to assess the fit
of a theoretical model to the empirical data, it can also be a
useful tool in testing more
complex mediation models and revealing the complex
relationships between multiple
predictors and mediators that could not be gleaned from
traditional regression analyses.
As predicted, negative social reactions to assault disclosure
were related to greater
PTSD symptoms directly and indirectly through maladaptive
coping (see Figure 1 for
standardized coefficients). Unexpectedly, negative reactions to
assault disclosure also
related to survivors’ greater reliance on adaptive individual
coping, but adaptive individual
coping was only weakly related to PTSD symptoms and did not
mediate the effect of
negative social reactions to assault disclosure on PTSD

symptoms.
Positive social reactions to assault disclosure were weakly but
positively related to
PTSD symptoms, a counterintuitive effect that is somewhat
surprising, but that has been
established before (Ullman, Filipas et al., 2007). Although
positive reactions to assault dis-
closure were related to greater use of both positive individual
and social forms of adaptive
coping, as predicted, neither strategy mediated the relation
between social reactions to
assault disclosure and PTSD symptoms. Positive social
reactions to assault disclosure were
unrelated to maladaptive coping, but were related to better
perceived control over recov-
ery, which in turn was associated with less PTSD symptoms.
Thus, perceived control over
recovery emerged as the only protective factor against PTSD
symptoms, and mediated the
relation between social reactions to assault disclosure and PTSD
symptoms.
To assess the individual role of each mediator in more detail
(rather than infer it
from significance tests of each path), we also employed the
bootstrapping techniques rec-
ommended by Preacher and Hayes (2008) for testing multiple
mediators simultaneously.
The disadvantage, however, was that although we could test all
mediators together, we
could only test the indirect effects of social reactions separately
(i.e., these techniques
only allow one exogenous variable at a time). Thus, these
analyses were meant to sup-
plement the structural paths conducted in AMOS that tested all

variables in one model.
Figure 1. Structural model of the relations of social reactions,
coping, perceived control, and PTSD symptoms.
We confirmed that the direct effects of positive reactions to
assault disclosure (B = 1.65,
standard error [SE] = .33, p < .001) and negative reactions to
assault disclosure (B =
3.94, SE = .39, p < .001) on PTSD symptoms were positive and
significant. Furthermore,
the effects of both positive and negative reactions to assault
disclosure were partially me-
diated by maladaptive coping and adaptive individual coping,
and perceived control over
recovery mediated only the relation between positive reactions
to assault disclosure and
PTSD symptoms (see Table 2).
Table 2. Indirect Effects of Social Reactions on PTSD Mediated
by Perceived Control and Coping
Positive social reactions Negative social reactions
Point
estimate SE
BCa CI
Lower

BCa CI
Upper
Point
estimate SE
BCa CI
Lower
BCa CI
Upper
Total .54 .28 .0079 1.1056 3.51 .30 2.9621 4.1179
Perceived control over recovery −.36 .09 −.5638 −.2019 .09 .06
−.0159 .2314
Maladaptive coping .59 .20 .1987 .9671 3.03 .26 2.5137 3.5877
Adaptive individual coping .58 .13 .3547 .8367 .38 .13 .1363
.6607
Adaptive social coping −.27 .17 −.6149 .0783 .01 .06 −.1076
.1298
Note. SE = standard error; CI = confidence interval. Significant
indirect effects are indicated by CIs that do not include
0. BCa – bias corrected and accelerated; Bootstrap samples =
1000.
Overall, our results revealed that perceived control over
recovery and coping medi-
ated the relation between social reactions to assault disclosure
and PTSD symptoms. In
addition, these analyses demonstrate the importance of

considering the effects of nega-
tive and positive social reactions to assault disclosure together
in the same model. When
the two exogenous variables were analyzed separately, they
appeared to operate through
similar mediating paths; when they were analyzed together with
the path model, they each
affected PTSD symptoms through different mediators
(maladaptive coping and perceived
control over recovery, respectively).
DISCUSSION
The present study builds on and extends past research by testing
a theoretical model of
predictors of PTSD symptoms in a large, diverse sample of
adult sexual assault victims. We
used path analyses to examine the relation between social
reactions to assault disclosure,
coping strategies, perceived control over recovery, and current
PTSD symptoms. Our
results revealed that perceived control over recovery and
maladaptive coping mediated the
effects of positive and negative social reactions to assault
disclosure on PTSD symptoms.
As predicted, negative social reactions to assault disclosure
were positively related to
PTSD symptoms, and maladaptive coping mediated this effect.
Thus, in line with previous
research (Ullman, 1996; Ullman, Townsend et al., 2007), we
found that social reactions
of control, blame, treating the victim differently, and other
negative reactions to assault
disclosure, are related to avoidant forms of coping, perhaps
because they increase victims’

feelings of self blame and helplessness and decrease their trust
in others. In turn, although
maladaptive coping strategies alleviate negative affect in the
short term, they result in long-
term negative outcomes because survivors do not actively
engage in trying to recover but
instead avoid dealing with the trauma. In time, this could
negatively affect recovery from
PTSD symptoms and result in increased symptomatology.
A seemingly counterintuitive finding was that negative social
reactions to disclosure
were related to greater use of individual adaptive coping
strategies (Ullman, 1996; Ullman
& Najdowski, 2011). Our study, in line with Orchowski and
colleagues (in press), indicates
that this may only be true for social forms of adaptive coping,
but not for individual forms.
Combining all forms of adaptive coping into one single
measure, therefore, can result in
an inaccurate picture of the complex relationships between
social reactions and coping.
As expected, negative social reactions do little to help with
social adaptive coping. When
recipients of assault disclosures blame, control, or dismiss
victims, it is no surprise that
victims do not rely on seeking their emotional support to help
recover, as these reactions
are perceived as harmful. In turn, victims might turn to
meditation, cognitive restructuring
efforts, and active planning. These findings raise an interesting
question: What are some
of the individual traits and contextual variables that affect
victims’ responses to negative
reactions? In other words, why do some victims engage in
maladaptive coping, while

others resort to adaptive individual coping strategies, when
attempts at seeking support
are thwarted? Future studies could perhaps rely on this three-
category model of coping
strategies to investigate such potential moderators.
In line with previous research that has shown weaker effects of
positive social reactions
to disclosure on PTSD symptoms (Ullman, Filipas et al., 2007),
we also found a weak but
positive relation between these variables. Because our model is
largely correlational, the
causal relationships are difficult to establish, and we rely on
previous research and theory
to infer them. In this case, perhaps survivors of more severe
traumas tend to both disclose
more and receive more positive social reactions as a result and
develop more severe PTSD
symptoms (Littleton, 2010; Ullman & Filipas, 2001). Thus, we
doubt that positive social
reactions to assault disclosure can cause more severe PTSD
symptoms.
As predicted, positive social reactions to assault disclosure
were related to greater
use of both adaptive individual and especially adaptive social
forms of coping. These
paths suggest that supportive responses from others may
promote survivors’ use of more

adaptive coping strategies, especially social forms coping.
Positive social reactions to
assault disclosure were also related to better perceived control
over recovery, which was
associated with less PTSD symptoms. Supportive responses to
assault disclosure seem to
promote survivors’ efforts to regain control after assault over
what they can influence–
their recovery process. Although we are the first to show
evidence that such reactions to
assault disclosure may enhance perceived control over recovery
in sexual assault victims
specifically (Peter-Hagene & Ullman, in press), Frazier and
colleagues (2011) also found
that unsupportive interactions may relate to poorer perceived
control over recovery in
other trauma survivors.
Negative social reactions to assault disclosure were associated
with less perceived
control over recovery, and positive social reactions to assault
disclosure were associated
with more perceived control over recovery. Thus, we built on
past work showing that
perceived control over recovery is related to less PTSD
symptoms in rape and sexual
assault victims (Frazier, 2003; Ullman, Filipas et al., 2007) by
identifying possible precursor
variables that may influence this protective mediating factor.
Our findings suggest that if
we can teach people how to respond more positively to
survivors’ disclosures, then we can
indirectly increase women’s perceived control over recovery
and adaptive social coping,
and in turn potentially reduce PTSD symptoms. Given that most
victims get a mixture of

both positive and negative social reactions to assault disclosure
from others, due to telling
multiple people about the assault (Ullman, 2010), interventions
should encourage social
reactions to assault disclosure that are helpful to victims’
recovery process and discourage
those that are not (Foynes & Freyd, in press). Such an approach
fits in with recent calls
for social network-oriented treatment and prevention approaches
in the area of violence
against women (Goodman & Smyth, 2011; Ullman, 2010).
Although the sample size was suitably large for the demands of
structural equation
modeling, the generalizability of our findings is limited by the
cross-sectional design and
nonrepresentative sample of the study. In addition, although our
path model had good
fit, good fit can also result when (a) the model is equivalent to
an alternative model that
reflects reality, (b) the model fits data from a nonrepresentative
sample but does not fit
the population, or (c) the number of parameters is so great that
it cannot have poor
fit (Kline, 1998). Thus, as noted before, we do not draw
extensively on the good fit of
our model, but rather focus on the interpretation of individual
path coefficients and the
relation between our variables based on past theory and
empirical research in this area.
The longitudinal data that are currently being collected from
this sample may also help
clarify the direction of effects.
Unlike past studies of PTSD symptoms in sexual assault victims
(Frazier, 2003, Frazier

et al., 2005; Ullman, Townsend et al., 2007), this study had a
larger, racially/ethnically
and socioeconomically diverse sample and examined social
reactions to assault disclosure,
coping, control, and PTSD symptoms as part of the same model.
Therefore, the model
tested here is more comprehensive than past models of the link
between social reactions
to assault disclosure and PTSD symptoms and is theoretically
grounded. We chose to
present a multiple mediators model instead of a series of
alternate models given our
interest in understanding how various cognitive and emotional
responses to assault may
simultaneously mediate the social reactions to assault
disclosure–PTSD symptoms associ-
ations. This is a more conservative and comprehensive
approach. This and other possible
models should be evaluated with longitudinal data in sexual
assault survivors from a vari-
ety of subpopulations (e.g., college, treatment, community), so
that mediational pathways
can be evaluated and appropriate inferences can be drawn for
treatment and intervention
with a variety of sexual assault population subgroups.
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The impact of different diagnostic
criteria on PTSD prevalence
A comparison of PTSD prevalence using the
DSM-IV and ICD-10 PTSD-criteria on a
population of 242 Danish social work students
MAJA O’CONNOR Department of Psychology
MATHIAS LASGAARD University of Aarhus
HELLE SPINDLER
ASK ELKLIT
The diagnostic criteria for PTSD have undergone several
changes in the last two decades. This
may in part explain the great variance in PTSD prevalence
found in existing research. The
objective of this study is to investigate the influence of
different diagnostic criteria and different
combinations of criteria on PTSD prevalence. A sample of 242
Danish social work students
(M =29.2 years) completed a list of potentially traumatizing
events, major life events and the
Harvard Trauma Questionnaire. A considerable difference in
PTSD prevalence as a result of
different diagnostic criteria of PTSD was found. Future meta-

analyses and reviews of PTSD
prevalence must take into account the impact of changing
criteria on prevalence. Clinicians
also need to address this issue when assessing PTSD.
Key words: Traumatic events, diagnostic criteria of PTSD,
PTSD prevalence, DSM-IV, ICD-10.
Correspondence: Maja O’Connor, Department of Psychology,
University of Aarhus, Jens Chr.
Skous Vej 4, 8000 Aarhus C, Denmark. Tel.: +45 8942 4926,
Fax: +45 8942 4901. E-mail:
[email protected]
The experience of a traumatic event involving actual or
threatened death, or
serious injury may lead to the development of PTSD. In turn,
receiving a PTSD
diagnosis may provide a client with the option of psychological
or medical care,
and compensation. However, the same person may be diagnosed
differently
depending on which general diagnostic criteria of PTSD is used
and which
specific criteria, from for example DSM-IV, has been selected.
Clinicians and
researchers studying psychological trauma need to be aware of
the potential vari-
ance in diagnostic outcome as a product of the diagnostic
criteria used.
Prevalence of PTSD
Many studies have aimed to establish the prevalence and risk of
PTSD for
specific traumatic events, e.g. violence (e.g. Boney-Mccoy &
Finkelhor, 1995;
ARTICLENordic Psychology, 2007, 59 (4) 317-331

Th
is
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A
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ch
ol
og
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A
ss
oc
ia
tio
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or
o
ne
o
f i
ts
a
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ed
p
ub
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he

rs
.
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is
a
rti
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e
is
in
te
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ed
so
le
ly
fo
r t
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p
er
so
na
l u

se
o
f t
he
in
di
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is
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to
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di
ss
em
in
at

ed
b
ro
ad
ly
.
318 Maja O'Connor et al. NP, 2007 (3)
Seedat, Nyamai, Njenga, Vythilingum & Stein, 2004), childhood
abuse (Libby,
Orton, Novis, Beals & Manson, 2005) and war (Khamis, 2005).
In contrast,
studies investigating a broad range of traumatic events and the
associated risk
of PTSD are not very common. Four national probability
samples (Kessler,
Sonnega, Bromet, Hughes & Nelson, 1995; Kessler, Berglund,
Demler, Jin,
Marikangas, et al., 2005; Perkonigg, Kessler, Storz & Wittchen,
2000; Frans,
Rimö, Åberg & Fredrikson, 2005) and two epidemiological
studies (Bernat,
Ronfeldt, Calhoun & Arias. 1998; Hepp, Gamma, Milos,
Ajdacic-Gross, et al.,
2006) have explored a broad range of traumatic events in adult
populations
(based on a September 2006 PsycInfo search using different
combinations of
search keywords such as; PTSD, prevalence, ICD 10, DSM IV,
epidemiologic

study, probability study). Similarly, one national probability
study (Elklit, 2002)
and one epidemiological study (Costello, Erkanli, Fairbank &
Angold, 2002)
have explored the prevalence of traumatic events in adolescent
populations
(based on same search as above). These studies show that the
majority of the
adults and adolescents sampled had been exposed to one or
more traumatic
events, resulting in a considerable number of PTSD cases.
The rates of prevalence found in the above studies show great
variation regard-
less of age. The number of participants reporting one or more
events ranges from
21 % to 87 % and there is large variation in the prevalence
reported for specific
events and most common event experienced. Moreover, the
prevalence of PTSD
shows great variation across studies. The lifetime risk of PTSD
ranges from 0 % to
9 %, and varies markedly across different types of trauma,
although most studies
find sexual abuse/rape to be associated with an increased risk of
PTSD. In line
with the recent findings of Foa & Tolin (2006) most studies
show that females
are more likely to suffer from PTSD, despite males reporting
more exposure to
traumatic events than females.
The reported differences in event-rates and PTSD prevalence
may be related
to methodological differences, e.g. the degree of specificity of
the measured

events, the number of events investigated, differences in data
collection methods,
demographics, and cultural and community related variables.
Furthermore, dif-
ferent problems such as the effect of the inclusion of the
emotional impact, the
A2 criterion (a subjective component of PTSD involving a
response of intense
fear, helplessness, or horror) or the diagnostic boundaries of
PTSD in DSM IV are
associated with the use of the PTSD diagnosis and have been
widely discussed
(e.g. Norman, Stein & Davidson, 2007; Brewin, 2005; Creamer,
McFarlane &
Burgess, 2005; Schützwohl & Maercker, 1999; O’Donohue &
Elliot, 1992).
Th
is
d
oc
um
en
t i
s c
op
yr
ig
ht
ed

b
y
th
e
A
m
er
ic
an
P
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ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o

ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
Th
is
a
rti
cl
e
is
in
te
nd
ed

so
le
ly
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd

is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
319The impact of different diagnostic criteria on PTSD
prevalenceNP, 2007 (3)
Development of the diagnostic criteria of PTSD
The diagnostic criteria of PTSD have developed over time. Prior
to the intro-
duction of the PTSD diagnosis in DSM-III (APA, 1980),
trauma-related symp-

tomatology was recognized in DSM-I (1952) as Gross Stress
Reaction, and in
DSM-II as Adjustment Reaction of Adult Life (Wilson, 1994).
In DSM-III different
syndromes caused by various traumatic events were finally
combined into one
diagnosis, Post Traumatic Stress Disorder. To qualify for the
diagnosis of PTSD
the existence of a stressor “that would evoke significant
symptoms of distress
in almost anyone had to be identifiable” (criteria 1). The
remaining criteria
were grouped into three symptom sections consisting of: 2) re-
experiencing
the traumatic event (recurrent and intrusive recollections of the
event, recurrent
dreams, and/or feeling as if the traumatic event is re-occurring),
3) numbing or
detachment (diminishes interest in significant activities, feeling
detachment or
estrangement from others, and/or constricted affect) and 4)
symptoms not pres-
ent before the traumatic event (hyper alertness or exaggerated
startle response,
sleep disturbance, survivor guilt, memory impairment or trouble
concentrating,
avoidance of activities that arouse recollection of the traumatic
event, and/or
intensification of symptoms when reminded of the traumatic
event). At least one
symptom from section 2 and 3 and at least two symptoms from
section 4 must
be present to qualify for the PTSD diagnosis.
The diagnostic criteria were thoroughly revised in DSM-III-R
(APA, 1987)

adding a new component (E) of duration of symptom clusters B,
C, and D, for
at least one month and with onset in the immediate aftermath of
the traumatic
event (B, C, and D were a revision of section 2, 3, and 4 in
DSM-III). Furthermore
now, the stressor criterion (A) stated that the person must have
experienced “an
event outside the range of usual human experience that would
be markedly
distressing to almost anyone”. The symptom clusters in DSM-
III-R consisted of:
(B) persistent re-experiencing the traumatic event (recurrent and
intrusive distress-
ing recollections of the event, recurrent distressing dreams of
the event, sudden
acting or feeling as if the traumatic event is reoccurring and/or
intense psycho-
logical distress when exposed to situations reminding of the
traumatic event):
(C) persistent avoidance or numbing in relation to the traumatic
event (efforts to
avoid thoughts or feelings associated with the trauma, efforts to
avoid activities
or situations evoking recollection of the trauma, inability to
recall an important
aspect of the trauma, markedly diminished interest in significant
activities, feeling
detachment or estrangement from others, restricted affect and or
a sense of fore-
shortened future), (D) persistent arousal not present before the
trauma (difficulties
falling or staying asleep, irritability or outbursts of anger,
problems concentrating,
hypervigilance, exaggerated startle response and/or physiologic
reactivity when

ed
b
ro
ad
ly
.
exposed to trauma related events). At least one symptom from
cluster B, at least
three symptoms from cluster C, and at least two symptoms from
cluster D must
be present to qualify for diagnosis (APA, 1987).
DSM-IV (APA, 1994) enlarged the definition of stressors into
two subcriteria (A1
and A2) and a functional criterion of clinically significant
distress or impairment
(F). Relatively little research on criterion (F) has yet been
published. According to
DSM-IV (APA, 1994) the diagnosis of PTSD requires the
exposure to a traumatic
event that involves: (A1) Actual or threat of death or serious
injury, or a threat to
the physical integrity of self or others, and (A2) involving a
response of intense
fear, helplessness, or horror. Moreover, the diagnosis requires
(B) persistent re-
experiencing of the traumatic event, (C) persistent avoidance of
stimuli associated

with the trauma and numbing of general responsiveness, and (D)
persistent symp-
toms of increased arousal. Finally, (E) the full symptoms must
be present for more
than 1 month, and (F) the disturbance must cause clinically
significant distress or
impairment in social, occupational, or other important areas of
functioning. At
least one symptom from cluster B, at least three symptoms from
cluster C, and at
least two symptoms from cluster D must be present to qualify
for diagnosis.
In the International Classification of Diseases 9 (ICD-9) from
1978, the World
Health Organization (WHO) recognized the possible emotional
problems follow-
ing traumatic experiences by including two diagnoses (Acute
Reaction to Stress
and Adjustment Reaction) (Joseph, Williams & Yule, 1997).
The WHO (1993) included a diagnosis of PTSD in their most
recent edition,
ICD-10, as “a reaction to severe stress and adjustment
disorders”. To diagnose the
disorder, identification of (A) a stressor that is “likely to cause
severe distress in
almost anyone” is necessary (e.g. disaster, combat, rape,
terrorism, violent death
of others). In addition the following symptoms are required: (B)
repetitive symp-
toms of re-experiencing the traumatic experience (intrusive
recollection or re-
enactment in memories, dreams, or imagery) or severe
discomfort when reminded
of the traumatic experience, (C) actual or preferred avoidance

of reminders of
the traumatic experience, (D) either (D1) partially or complete
inability to recall
important aspects of the traumatic event or (D2) two of the
following symptoms of
increased arousal (difficulty in falling or staying asleep,
irritability or outbursts of
anger, difficulty concentrating, hypervigilance, exaggerated
startle response), and
(E) the criteria B, C, and D must be met within 6 months of the
traumatic event.
Several studies and reviews have discussed differences and
similarities between
the general diagnostic criteria of PTSD in DSM-IV and ICD-10.
Empirical stud-
ies almost exclusively apply DSM-IV criteria in their research.
In contrast,
clinical diagnosis and practice in many countries is based on
ICD-10. However,
when applying evidence-based treatment of PTSD, this evidence
almost exclu-
sively builds on research using DSM-IV criteria for the
diagnosis in question.
Th
is
d
oc
um
en
t i
s c

op
yr
ig
ht
ed
b
y
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc

ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
Th
is
a
rti
cl
e

is
in
te
nd
ed
so
le
ly
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du

al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

Consequently, there is a risk that using treatment strategies
based on DSM-IV
results in lack of coherence between evidence-based clinical
practice and ICD-10
diagnosis.
General consensus holds that there are great similarities, but
also important
differences between the two systems, mainly that ICD-10 does
not emphasize
avoidance and increased arousal to the same extent as DSM-IV,
and that DSM-IV
includes criteria of more than 1 months duration (E) and
impairment of function
(F) that ICD-10 does not (Joseph et al., 1997; Peters, Slade, and
Andrew, 1999;
Andrews, Slade, and Peters, 1999; Lundin & Lofti, 1996;
Lopez-Ibor, 2002; Peters,
Issakidis, Slade & Andrews, 2005). It is noteworthy that only
two studies investi-
gating differences in identification of PTSD cases using DSM-
IV and ICD-10 have
been identified. These studies found that only 37% of cases
identified through
ICD-10 (PTSD prevalence = 7%) also fulfilled the criteria of
DSM-IV (PTSD preva-
lence = 3 %), while on the other hand 85% of cases fulfilling
DSM-IV criteria
also fulfilled ICD-10 criteria (Andrews et al., 1999; Peters et
al., 1999). Peters
and colleagues suggested that this difference appears because
DSM-IV requires
fulfillment of a functional criterion (F), and put more emphasis

on symptoms of
avoidance or numbing (C) compared to ICD-10 (Peters et al.,
1999). Moreover, a
study focusing on gender differences found twice as many cases
of PTSD using
ICD-10 compared to DSM-IV (Peters et al., 2005).
Diagnostic criteria and prevalence of PTSD
Epidemiological studies have used different diagnostic criteria
that likely influ-
ence the reported prevalence of PTSD and hence possibly
explain some of the
differences (see Table 1). The results of a cohort study (n=367)
by Hepp and
colleagues (2006) in which they found no cases at all of full
PTSD is worth
mentioning. The participants in this study reported whether or
not they, dur-
ing the last 12 months, had experienced or witnessed an event
that involved
actual or threatened death, serious injury or threat to the
physical integrity of
others - corresponding closely to the DSM-IV criteria A1.
Participants were
only asked to categorize the type of event if they answered
affirmative to this
question. The estimated prevalence of lifetime exposure to
potentially traumatic
events was 28 %, which may be explained by the very broad
formulation of
this question in terms not easily understandable to the
population investigated.
Another explanation could be that specific categories of events,
as for example
the categorizations developed by Kessler et al. (1995) are more
likely to trigger

recognition of specific, potentially traumatic events than the
broader approach
used by Hepp and colleagues (2006). This does not, however,
explain why
none of the 128 individuals fulfilling criteria A1 met all the
remaining criteria
Th
is
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um
en
t i
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op
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an
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A
ss
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ia
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n
or
o
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o
f i
ts
a
lli
ed

p
ub
lis
he
rs
.
Th
is
a
rti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r t
he
p

er
so
na
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se
o
f t
he
in
di
vi
du
al
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se
r a
nd
is
n
ot
to
b
e
di

ss
em
in
at
ed
b
ro
ad
ly
.
of PTSD (Hepp et al., 2006). One reason may be that the
participants, con-
sistent with, for example, Perkonigg and colleagues (2000), had
to meet all 6
specific diagnostic criteria (A-F) to qualify for the diagnosis of
PTSD. However,
in a Swedish probability study (n=1824) Frans and colleagues
(2005) found a
lifetime prevalence of 5.6 % using all 6 specific criteria of
PTSD and using yes/
no answers to identify symptoms, hence possibly increasing the
effect.
In comparison, the remaining studies described in Table 1 found
a lifetime
prevalence of PTSD ranging from 4-9 %. This may be explained

by the use of
less specific DSM-IV criteria for PTSD or different general
diagnostic criteria
(DSM-III-R).
Table 1
Lifetime prevalence of PTSD and general and specific criteria
in national populations
Lifetime
prevalence
(All partici-
pants)
Prevalence in exposed
participants (one or more
potentially traumatic
events reported)
General and
specific diagnostic
criteria applied
Kessler et al.,
1995
7.8 % 11.8 % DSM-III-Ra
Kessler et al.,
2005
6.8 % - DSM-IVa

Elklit,
2002
9 % 10.3% DSM-IV
A1, B, C, & D
Bernat et al.
1998
4 % 12 % DSM-IV
A1, A2, B, C, & D
Hepp et al.
2006
0 % 0 % DSM-IV
A1, A2, B, C, D, E, & F
Perkonigg et al.,
2000
1.3 % 7.8 % DSM-IV
A1, A2, B, C, D, E, & F
Frans et al.,
2005
5.6 % 6.9 % DSM-IV
A1, A2, B, C, D, E, & F
aNo information available about specific criteria used.
While trauma and PTSD in non-clinical adult populations have
been investigated
(e.g. Kessler et al., 1995; Kessler et al 2005; Perkonigg et al.,
2000; Frans et al.,

2005), few studies have investigated the effect of different
diagnostic criteria
applied to the same population. Three studies have found
significant variations in
PTSD prevalence according to the different diagnostic criteria
(Bernat et al. 1998;
Peters et al., 2005; Peters et al., 1999). Concurrently, the
prevalence of PTSD
varies widely between studies. Different diagnostic criteria and
configurations
of symptoms may partly explain variations found in studies of
PTSD prevalence,
Th
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oc
um
en
t i
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e
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A
ss
oc
ia
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n
or
o
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o
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ts
a
lli
ed
p
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lis
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rs
.
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is
a
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e
is
in
te
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ed
so
le
ly

fo
r t
he
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er
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na
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se
o
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he
in
di
vi
du
al
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to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
both in non-clinical and clinical populations, emphasizing the
relevance of
studying this issue further.
Aim of the study
The aim of the present study was to explore the impact of
different diagnostic
criteria on PTSD prevalence in an adult non-clinical population.
The hypotheses

investigated are: 1) The diagnostic tool used influences the
PTSD prevalence, 2)
Introducing additional specific DSM-IV criteria for PTSD
reduces the prevalence
rate of PTSD.
Material and methods
Participants
The sample for the current study consisted of 242 adult students
with a mean
age of 33 years (SD = 11.26; range 16-61 years). There were
209 (86 %) females
and 33 (14 %) males. Forty two percent of the students lived
alone (unmarried,
divorced or widowed), while 56 % lived together with a partner
(married or
cohabiting). 50 % of the students had children. The average
length of education
was 13 years (SD 3.1; range 7-24 years).
Procedures
The first author introduced the study to the students and was
available for
clarifying questions while the participants completed the
questionnaire in the
classroom. Participation was voluntary and the response rate
was 99%. The par-
ticipants were recruited from three different schools of
intermediate educational
level located in Aarhus, Denmark. The participants were
selected because of
their status as adult social worker students, of which the
majority had a non-
university background. A Tukey B post hoc analysis, that allow

statistically reli-
able identification of differences between two groups or more
(Pallant, 2005),
showed few differences between the three groups on parameters
of gender, age
and range of traumatic events and life events.
Measures
The first part of the questionnaire contained socio-demographic
questions about
gender, age, education and family conditions. Following that,
two types of
stressors, traumatic experiences ad modum Kessler and
colleagues (1995) and
distressing life events were investigated. Distressing life-events
were reported by
answering the following question: “Within the last year have
you experienced
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um
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ht
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P
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og
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al
A
ss
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ia
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n

or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
Th
is
a
rti
cl
e
is
in
te

nd
ed
so
le
ly
fo
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er
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na
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se
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he
in
di
vi
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r a
nd
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to
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e
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ss
em
in
at
ed
b
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ad
ly
.
major life-events/changes?”. Subsequently, the students were
asked about the
experience of different traumatic events (see Table 2).

Table 2
Trauma and Life Events According to Exposure and Prevalence
of PTSD
(fulfilling criteria A1, B, C, and D of DSM-IV)
Event
Frequency
(%)
Choice of most
distressing event
(%)
Relative risk (%)
PTSD
Sub clinical
PTSD
Traumatic events
Accident 20 38 38 32
Shock by some one close
being exposed to a traumatic
event 16 21 51 35
Threat of violence 15 18 38 34
Serious illness 13 28 50 23
Childhood abuse 14 52 75 14
Violent assault 10 24 41 28
Witness other people getting
injured or killed 9 3 38 29
Rape 2 86 100 0
Recent life events
Move of residence 17 13 54 20

Divorce/break up with a
partner 6 20 64 14
Change of employment or
education 5 6 46 8
Getting fireda 2 38 - -
a = less than 5 cases
Harvard Trauma Questionnaire-Part IV (Mollica, Capsi-Yavin,
Bollini, & Truong,
1992) was used to estimate the occurrence of PTSD. HTQ
consists of 30 items,
rated on a 4-point Likert scale (1 = not at all; 4 = very often).
Sixteen items relate
to the three core clusters in PTSD in DSM-III-R: intrusion,
avoidance, and arousal.
In the present study, participants rated the HTQ on the basis of
the most stressful
life or traumatic event experienced. Participants answered HTQ
in relation to their
reaction in the time immediately after the stressful event. Only
scale items ≥ 3 on
HTQ were considered for a PTSD diagnosis. Recognition of a
sub clinical level
of PTSD was given if the respondent met two of the three
criteria.
The Danish version of the HTQ has been found to be a reliable
and valid mea-
sure (Bach, 2003). Moreover, HTQ ratings according to the
DSM-III-R diagnostic
Th
is
d

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um
en
t i
s c
op
yr
ig
ht
ed
b
y
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e
A
m
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an
P
sy
ch
ol
og

ic
al
A
ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
Th

is
a
rti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r t
he
p
er
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na
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se
o
f t

he
in
di
vi
du
al
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se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro

ad
ly
.
criteria of PTSD showed an 88% concordance with interview
based estimates
of PTSD (Mollica et al., 1992). The internal consistency of the
PTSD scale and
subscales in the present study was good for the HTQ (Total
score: α = .95; intru-
sion: α = .81; avoidance: α = .73; arousal: α = .73).
Furthermore, the following four single questions relating to the
chosen event
were included in the study with the purpose of establishing
whether the stressful
event selected when filling in the HTQ met the A1 and A2
criteria included in
DSM-IV-TR. 1) Were you in mortal danger while it happened?
2) Were others
in mortal danger? 3) Were you injured? 4) Did you feel helpless
or horrified?
Moreover, the participants were asked to report how much each
symptom dis-
turbed her/him during the last month to investigate present
PTSD symptoms.
Statistical Analysis
The sample used in this study was extracted from a larger study.
Prior to data

analysis, we excluded a fourth group, consisting of 86
predominantly young,
male, trainee-craftsmen, due to inadequate data quality.
To fulfill the criteria of DSM-III, the following demands had to
be met: (1) The
participant reported one or more traumatic events; the
participant reported ≥ 3
on: (2) one or more intrusion items (HTQ 1-3), (3) on one or
more numbing items
(HTQ 4, 5, 13) and (4) on two or more items of symptoms not
present before the
traumatic event (HTQ 6-8, 11, 12, 16, 20).
To fulfill the five criteria of DSM-III-R, the following was
computed: (A) The
participant reported one or more traumatic events; the
participant reported ≥ 3
on: (B) one or more intrusion items (HTQ 1-3), (C) three or
more symptoms of
persistent avoidance or numbing (HTQ 4, 5, 11-15), (D) two or
more symptoms
of persistent arousal not present before the trauma (HTQ 6-10,
16).
To fulfill the DSM-IV criteria of PTSD the participant reported
(A1) one or
more traumatic events and (A2) a sense of helplessness or
horror in relation to
the traumatic event. The participant reported one or more
traumatic events; the
participant reported ≥ 3 on (B) one or more intrusion items
(HTQ 1-3, 16) item
16 containing both the physiological and psychological stress of
being reminded
of the event; (C) three or more symptoms of persistent

avoidance or numbing
(HTQ 4, 5, 11-15) and (D) two or more symptoms of persistent
arousal not pres-
ent before the trauma (HTQ 6-10). HTQ18 “Difficulties with
carrying out work
or daily functions” was defined as the DSM-IV criterion (F)
where the disturbance
must cause clinically significant distress or impairment in
social, occupational, or
other important areas of functioning. Criterion (F) was defined
as fulfilled if the
participant reported a score ≥ 3 on this item.
Th
is
d
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um
en
t i
s c
op
yr
ig
ht
ed
b
y
th

to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
To fulfill the four first criteria of ICD-10 PTSD, the following
algorithm was
applied: (A) The participant reported one or more traumatic
events; the par-
ticipant reported ≥ 3 on (B) one or more symptoms of persisting
intrusion or
re-experiencing the traumatic event (HTQ 1-3 or 16); (C) actual
or preferred
avoidance of circumstances associated with the stressor (HTQ
11 or 15); (D)

inability to recall important aspects of the trauma (HTQ 12) or
two out of five
symptoms of increased arousal (HTQ 6-10). The last criteria (E)
where B, C, and
D must be met within 6 months of the traumatic event could not
be included in
the computation.
Frequency analysis or Chi-square analyses were computed of
the concordance
between participants identified as fulfilling the diagnostic
criteria of PTSD in
ICD-10 compared to DSM-IV and DSM-IV compared to ICD-
10. Only par-
ticipants with valid scores on both parameters were included.
All analyses were
carried out using SPSS, version 13.
Results
A total of 87 % of the students reported at least one life event
or at least one
traumatic experience (see Table 2). Eighty percent of the
students reported one
or more traumatic event (one event = 31 %, two events = 23 %,
three or more
events = 26 %). The average number of experienced traumatic
events was 1.7
(SD = 1.5), and the most common events reported were
bereavement, shock
by someone close being exposed to a traumatic event, threat of
violence, and
accident. Twenty-nine percent of the students reported one or
more distressing
life events within the last year (one event = 23 %, two events =
6 %, three or
more events = 1 %). The average number of distressing life

events per student
was 0.4 (SD = 0.6), and the most commonly reported life event
was change of
residence, and divorce/separation.
The PTSD prevalence was remarkably high in those reporting
certain major
life-events within the last year. Divorce or break-up with a
partner was the highest
ranking (64% with PTSD), followed by change of residence
(54%), and change
of employment or education (46%). The average number of
experienced events
was higher among participants with PTSD than exposed
participants without
PTSD (2.6 vs. 1.9 events).
Table 3 illustrates that the diagnostic tool used influenced the
PTSD prevalence
rate. The largest difference was found between ICD-10 with a
PTSD prevalence
of 35% and DSM-IV including criteria A1, A2, B, C, D, E, and
F with a PTSD
prevalence of 11%. Furthermore, as expected, introducing
additional DSM-IV
criteria reduced the PTSD prevalence.
Th
is
d
oc
um
en

t i
s c
op
yr
ig
ht
ed
b
y
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A

ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
Th
is
a
rti

cl
e
is
in
te
nd
ed
so
le
ly
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di

vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

Table 3
Prevalence of lifetime PTSD according to different diagnostic
criteria and different con-
figurations of specific criteria within DSM-IV
PTSD-prevalence
Sub-clinical PTSD (2 out of 3
criteria: B, C, and D)
ICD-10
A, B, C, & D
35 % (n=84) 17 % (n=42)
DSM-III-R
A, B, C, & D
30 % (n=73) 16 % (n=39)
DSM-III
1, 2, 3 & 4
29 % (n=70) 14 % (n= 33)
DSM-IV
B, C, D, & E
25 % (n=61) 17 % (n=42)
DSM-IV
A1, B, C, D, & E

22 % (n=54) 16 % (n=39)
DSM-IV
A2, B, C, D, & E
20 % (n=48) 15 % (n=35)
DSM-IV
A1, A2, B, C, D, & E
17 % (n=42) 14 % (n=33)
DSM-IV
A1, A2, B, C, D, E, & F
11 % (n=26) 4 % (n=10)
Using all 6 DSM-IV criteria of PTSD, 26 participants qualified
for the full PTSD
diagnosis. Ninety two percent of these (24 participants) also
qualified for the
ICD-10 diagnosis of PTSD using criteria A, B, C, and D. Eighty
one participants
qualified for the ICD-10 diagnosis of PTSD. Three participants
were excluded
because of missing scores in the DSM criteria. Out of the 81
participants, only
30 percent (24 participants) qualified for the full diagnosis of
PTSD according
to DSM-IV (criteria A1, A2 B, C, D, E, and F).
Discussion
In line with findings from other studies (e.g. Bernat et al.,
1998) a high num-
ber (80%) of participants in the present study reported at least

one potentially
traumatic event. PTSD prevalence was found to vary
considerably according
to which diagnostic tool was used. The PTSD prevalence
according to ICD-10
was 35% while according to DSM-IV using similar specific
criteria (A1, B, C,
D, and E) the PTSD prevalence was 22% (see Table 3). The
results indicate that
within the same population the diagnostic tool chosen may have
a strong impact
on the number of cases of PTSD identified. This may explain
why the concor-
dance between PTSD in DSM-IV versus ICD-10 was only 30%.
In addition,
Th
is
d
oc
um
en
t i
s c
op
yr
ig
ht
ed
b

y
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o
ne

o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
Th
is
a
rti
cl
e
is
in
te
nd
ed
so

le
ly
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is

n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
a lack of congruency between practice and research poses a
serious problem
in countries that use the ICD-10 in clinical work as the
empirical evidence is
based DSM PTSD. Such in-congruency may result in PTSD
losing its credibility
as a meaningful and applicable diagnosis in clinical work in

countries using
ICD-10. In line with the findings by Peters et al. (2005) the
present study found a
much lower concordance between PTSD in ICD-10 compared to
DSM-IV (30 %
concordance) and PTSD in DSM-IV compared to ICD-10 (91%
concordance).
The DSM-IV PTSD prevalence was reduced as additional
specific diagnostic
criteria were added. This result may seem common sense, but
the fact is that
several studies only specify the general diagnostic criteria used
(e.g. ICD-10 or
DSM-IV) without specifying exactly how they operationalized
these criteria. As
mentioned, large variation has been found in PTSD prevalence
as defined by
DSM-IV criteria both in clinical and non-clinical samples. One
of the reasons for
this variability may be the fact that different specific criteria
have been applied,
but have not been clearly operationalized when reporting the
results. This poses
an obstacle when reviewing PTSD prevalence. According to the
results of this
study, it is necessary to take both the general and specific DSM
criteria applied
into consideration before comparing results from different
studies.
The main problem is that the applied specific DSM-IV criteria,
apart from A1
and A2, are rarely operationalized in studies of PTSD
prevalence. Another is that
the significant changes in all general DSM criteria variables

from 1980 to 1994
must be taken into consideration when comparing results from
studies using
different general criteria. Obviously, this makes reviewing the
literature difficult.
To avoid the risk of drawing conclusions based upon incomplete
information,
future review work on estimation of PTSD prevalence needs to
take the variance
in PTSD prevalence produced by unspecified and varying
diagnostic criteria into
account. Also existing meta-analyses and reviews should be
assessed with this in
mind (e.g. Tolin & Foa, 2006). In conclusion, when
investigating PTSD prevalence
it is crucial that researchers pay careful attention to the applied
diagnostic criteria
when performing reviews and meta-analysis. Furthermore
researchers must be
urged to specify the precise PTSD-criteria used when reporting
studies involving
PTSD prevalence.
The high PTSD prevalence in the present study (see Table 2)
might be explained
by the fact that many of the participants recently left home or
got divorced, moved
into their first own residence and started their further education
in a new field.
This type of event may cause stress, but should not lead to
PTSD, as the DSM-IV
criteria A1 is not fulfilled. Even so, in a Dutch population
including 832 adults,
Mol, Arntz, Metsemakers, Dinant, Vilters-Van, et al. (2005)
found that PTSD
scores were higher after life events than after traumatic events

from the past
30 years. In line with this, other studies have reported
significant associations
Th
is
d
oc
um
en
t i
s c
op
yr
ig
ht
ed
b
y
th
e
A
m
er
ic
an

P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub

lis
he
rs
.
Th
is
a
rti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r t
he
p
er
so

na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em

in
at
ed
b
ro
ad
ly
.
between PTSD symptoms and 1) the exposure of farmers to an
epidemic of foot
and mouth disease causing a mass cull of livestock (Olff,
Koeter, Van Haaften,
Kersten, & Gersons, 2005), 2) extreme pressure including
public humiliation in
the work setting (Ravin & Boal, 1989), 3) victims of bullying at
work (Mikkelsen
& Einarsen, 2002), and 4) parental divorce/an absent parent
(Elklit, 2002; Joseph,
Mynard & Mayall, 2000). In sum, several studies have reported
PTSD symptoma-
tology in cases lacking a DSM-IV adequate A1 stressor.
One possible reason for these findings may be that some
stressors, not including
actual or threat of death or serious injury, or a threat to the
physical integrity of

self or others, pose a threat to identity (Brewin, 2003; Mol et al.
2005). A threat
to the psychological or social integrity of a person is in some
cases comparable
to the threat of the physical integrity, included in the present
diagnostic criteria.
Another potential explanatory factor could be that accumulation
of traumatic
events experienced was related to PTSD prevalence, since the
average number
of experienced events was higher among participants with PTSD
than among
exposed participants without PTSD. In a nationally
representative sample of
Danish adolescents (Shevlin & Elklit, in press) latent class
analysis was used to
identify clusters or latent classes of events. In addition, the
relationships between
the latent classes and living arrangements and diagnosis of post-
traumatic stress
disorder (PTSD) were estimated. A three-class solution was
found to be the best
description of multiple adverse life events, and the three classes
were labelled
‘Low Risk’, ‘Intermediate Risk’, and ‘High Risk’. The High
Risk group were found
to have a relatively high likelihood of experiencing multiple
traumas and were
13 times more likely to have a PTSD diagnosis.
The results of the current study should be interpreted with
caution. Firstly, the
study is cross-sectional and retrospective. Secondly, the high
PTSD prevalence
found could be an indication of the fact that our sample was
non-representative.

On the other hand, the sample of social work students represents
a group that may
be more similar to the general population than undergraduate
university students.
Our results cannot be generalized to other populations. Despite
the limitations,
the study explores an understudied issue in the field of
traumatic stress.
To summarize, the results from this study indicate that extreme
care should
be taken regarding both the general and specific diagnostic
criteria used when
assessing PTSD prevalence. Often only the general criteria
(ICD-10 or DSM-IV)
and the A1 and A2 criteria of DSM-IV are operationalized,
making meta-analysis
and reviews on PTSD prevalence difficult to perform in a
satisfactory manner.
When reporting future research on PTSD prevalence a precise
description of
which specific DSM-IV criteria are used and operationalized is
required. In time,
this could lead to consensus on the use and operationalization of
PTSD criteria in
empirical work and clinical practice. In addition, future studies
should also con-
Th
is
d
oc
um
en

sider the possibility of alternative structures of PTSD
symptomatology including
a widening of the criteria to encompass situations that might
threaten the current
life conditions and psychological integrity of the person (see
Brewin, 2003).
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A

m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a

lli
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p
ub
lis
he
rs
.
Th
is
a
rti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r t

he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
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MAY–JUNE 2012 47
Magdalena Kaczmarek is an associate professor at Warsaw
School of Social
Psychology, Faculty of Psychology. Bogdan Zawadzki is a
professor at the Uni-
versity of Warsaw, Faculty of Psychology. Address
correspondence to Magdalena
Kaczmarek, Warsaw School of Social Psychology,
Chodakowska 19/31, 03-815
Warsaw, Poland; e-mail: [email protected]
The research was supported by Grant PL0088 “Psychological
Causes and
Consequences of Traffic Accidents,” financed by the Financial
Mechanism

Committee established by Iceland, Liechtenstein, and Norway
through the EEA
Financial Mechanism and Polish Ministry of Sciences and
Higher Education.
47
Journal of Russian and East European Psychology, vol. 50, no.
3,
May–June 2012, pp. 47–64.
© 2012 M.E. Sharpe, Inc. All rights reserved. Permissions:
www.copyright.com
ISSN 1061–0405 (print)/ISSN 1558–0415 (online)
DOI: 10.2753/RPO1061-0405500303
Magdalena KaczMareK and
Bogdan zawadzKi
Exposure to Trauma, Emotional
Reactivity, and Its Interaction as
Predictors of the Intensity of PTSD
Symptoms in the Aftermath of
Motor Vehicle Accidents
The aim of the study was to analyze the relationship between
emotional
reactivity, exposure to trauma and its interaction, and
posttraumatic
stress disorder (PTSD) symptoms in motor vehicle accident
(MVA)
survivors. Both emotional reactivity and exposure to trauma
were
expected to be significant predictors of the intensity of PTSD
symp-
toms. Exposure to trauma was considered as a total score but
also as

successive indexes, such as threat to life during an accident,
injuries
sustained in the aftermath of an accident, emotions felt during
an ac-
cident, dissociation experiences, and the amount of material
losses.
48 JOURNAL OF RUSSIAN AND EAST EUROPEAN
PSYCHOLOGY
Emotional reactivity was also expected to play the role of
moderator,
increasing the positive relationship between exposure to trauma
and
PTSD symptoms in people characterized by higher emotional
reactiv-
ity. The analyses were performed in two separate samples. The
first
sample consists of 458 MVA survivors who had a traffic
collision up
to six months before the study. The second sample (n = 674)
comprises
MVA survivors who had an accident more than six but less than
twenty-
four months before the study. The correlation and regression
analyses
revealed that, as expected, both emotional reactivity and
exposure to
trauma are significant predictors of PTSD symptoms, which
explained
about one-third of total variance of symptoms. The hierarchical
regres-
sion with interactions between emotional reactivity and
exposure to

trauma also supports the hypothesis that emotional reactivity
can be a
moderator and the MVA survivors who are more emotionally
reactive
develop more intensive PTSD symptoms when confronted with
severe
and stressful experience.
Research on trauma, and especially on disasters and accidents,
and its psychological consequences such as posttraumatic stress
disorder (PTSD) does not have a long history in Polish psychol-
ogy. It has been developed mainly in the domain of domestic
violence or—in psychiatry—as studies on World War II
veterans
and survivors of concentration camps (Lis-Turlejska, 1998). In
1997, a huge flood disaster occurred in the southern and western
part of Poland, in which fifty-five people lost their lives and
prop-
erty damages were calculated at $3.5 billon. In the aftermath,
the
Polish Ministry of Science announced a research program titled
“Man Under Disaster,” led by our research group. The aims of
this grant were to study the consequences of such experience
as well as the risk and protective factors that predict social and
psychological functioning in survivors. Being interested in indi-
vidual differences and personality processes of self-regulation,
we included personality variables, such as temperament traits,
personality traits from the “big five” model of personality, and
coping styles (see Strelau and Zawadzki, 2005).
Our studies on disaster were usually conducted using the
family research model: we carried out longitudinal studies with
two or three repeated measurements and maintained a focus on

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