Capstone final Paper - finish

Running Head: UNTREATED PTSD & NON-VETERAN POPULATIONS 1
Untreated PTSD in Non-Veteran Populations
Rory Wise
May 8, 2015
Honor Code:
I have neither given nor received any unauthorized aid on this piece of work nor have I
knowingly tolerated any violation of the Honor Code. – Rory Barnes Wise Jr.

UNTREATED PTSD & NON-VETERAN POPULATIONS 2
Abstract
War veterans over represent the population diagnosed with Posttraumatic stress disorder (PTSD)
(Lawford, 2014). As a result, non-veteran civilians who experience other traumatic events may
not receive the attention they need and may develop other depressive or anxiety disorders.
Therefore, possible non-veteran populations at risk for PTSD were examined, finding that
victims of intentional traumas are more likely to develop PTSD. Moreover, perceived life threat
is positively correlated to the prevalence of PTSD. High comorbidity was found with patients
diagnosed with PTSD and generalized anxiety disorder (GAD), major depressive disorder
(MDD), obsessive-compulsive disorder (OCD). This implies that PTSD may be a risk factor for
the previously stated disorders. More aid should be provided to the suggested at risk civilian
populations for PTSD.

Untreated PTSD in Non-Veteran Populations
Posttraumatic stress disorder (PTSD) has been highly associated with war veterans, which
may have caused an under-representation of other population groups diagnosed with PTSD. 11%
to 20% of the soldiers fighting in the “Operations Iraqi Freedom and Enduring Freedom” have
been diagnosed with PTSD; however, soldiers and veterans account for only a small portion of
the 5.2 million adults diagnosed with PTSD each year (Gradus, 2014). The DSM-V states that
the trigger for PTSD derives from exposure to actual or threatened death, serious injury, or
sexual violation (American Psychiatric Association, [APA], 2015). Thus, there are many other
populations that are at risk for PTSD, but possibly under-represented.
The possibility arises that war veterans and soldiers may over represent the 5.2 million
diagnosed with PTSD because other populations may have not been examined. In fact, there is
no epidemiological study completed to assess the number of children and adolescences
diagnosed with PTSD (Gradus, 2014). Therefore, adolescents and children are not represented by
the 5.2 million diagnosed with PTSD; nevertheless, studies have shown that children and
adolescents may be at a higher risk of developing PTSD than the general population (Gradus,
2014). As a result, children and adolescents also may not receive the support they need to treat
their PTSD.
Furthermore, according to the criteria defined by the DSM-V, there are the 4 criteria of
exposure based scenarios that trigger PTSD: the individual directly experiences the traumatic
event, witnesses the traumatic event in person, learns that the event occurred to a close family
member or friend, or experiences first-hand repeated or extreme exposure to aversive details of
the traumatic event (APA, 2015). Thus, PTSD may be much more common than previously
expected. It is possible that those who experience traumatic events in under-represented

populations may be unaware of the possibility for them to develop PTSD; they may be
uneducated about the symptoms or fear being stigmatized. For example, one study found that
soldiers avoided seeking treatment for their posttraumatic stress symptoms (PTSS) because they
feared being stigmatized as crazy, mentally ill, or dangerous (Mittal et al., 2013). Furthermore,
people may be unaware that simply receiving the news that a close friend or family member
experienced a traumatic event may trigger PTSD. Studies have shown that simply receiving news
of the death of a family member or close friend was associated with the occurrence of PTSD
(Stewart, 1999).
Furthermore, according to the National Highway Transportation Safety Administration
(NHTSA), between 1990 and 1996, there were 289,928 people that died from car crashes in the
US. If only receiving the news of a family member’s or close friend’s death is associated with
developing PTSD, then at least 289,928 people were at risk for developing PTSD between 1990
and 1996. Therefore, it is imperative to examine the other possible at-risk populations for PTSD
to determine which populations are at a high risk and should receive aid. Thus, it is hypothesized
that civilians who experienced traumatic events may not receive the attention they need as a
result of veterans over representing the population diagnosed with PTSD (Lawford, 2014).
Moreover, these civilians not seeking the proper professional attention may develop severe
PTSD, major depressive disorder (MDD), acute stress disorder (ASD), obsessive-compulsive
disorder (OCD), or generalized anxiety disorder (GAD).
At Risk Populations
There have been many studies that looked at the prevalence rates of different at risk
populations for PTSD. Studies examined categorized these populations by their type of trauma:
intentional or unintentional (Santiago et al., 2013). Intentional traumas are due to actions that

deliberately inflict harm on another person (Santiago et al., 2013). Therefore, civilians who
experienced an intentional trauma include rape victims, physical assault victims, and child abuse
victims. Unintentional traumas are those not aimed to cause harm to another person (Santiago et
al., 2013). Examples of unintentional traumas are car crashes or natural disasters. This
categorization allows examination of the differences between the two groups, in which some
studies have found that experiencing intentional traumatic events was more associated with
worse health outcomes in comparison to those exposed to unintentional traumas (Santiago et al.,
2013). Further support for this finding may be found when the aftermath of experiencing rape is
examined.
Intentional traumas.
Rape victims. Victims of rape are examined frequently to assess their association with PTSD.
Studies have found that rape victims developed PTSD more frequently when victims perceived
the experience to be life threatening (Tiihonen Moller, Backstrom, Sondergaard, & Helstrom,
2014). The same results were found when there was moderate to severe violence during the
assault (Tiihonen Moller et al., 2014). Therefore, research has demonstrated that violence and
perceived life threat is positively correlated to the likelihood of developing PTSD. Furthermore,
the same study has found that 1 in 3 women are diagnosed with PTSD following an assault
(Tiihonen Moller et al., 2014). An epidemiological study utilizing a national probability sample
of women in the United States found 18% of these women have been forcible rape at least once
(Kilpatrick, Resnick, Ruggiero, Conoscenti, & McCauley, 2007). According to the 2005 US
Census data, using the 18% of raped women, studies suggest that 20.2 million women have been
raped (Kilpatrick et al., 2007). Therefore, the prevalence rate and risk level of female rape

victims is very substantial since every 1 of 3 women may develop PTSD and 20 million women
are raped solely in one year.
Many studies focus on the prevalence rates and the effect of experiencing rape on women; as
a result, women may also over–represent rape victims. On the other hand, there have not been
many studies focusing on the outcome of experiencing rape in men. On the contrary, a study has
shown that 7.2% of a sample of 1480 homosexual men in Los Angeles reports being sexually
assaulted since the age of 16 (Sorenson, Stein, Siegel, Golding, & Burnham, 1987). Furthermore,
another study found that 27.6% of their sample, composed of homosexual men, was sexually
assaulted (Hickson et al., 1994). Thus, research has demonstrated that men are frequent victims
of rape as well as women and the prevalence rate of men raped should be assessed. This
population may also be underrepresented in the 5.2 million adults diagnosed with PTSD. This
suggestion is possible in which studies have shown that males raped by other males may develop
posttraumatic stress symptoms (PTSS); however, the sample size was small making the findings
weak (Myers, 1989).
Additionally, males raped by other males may be another population at risk for developing
PTSD, but males sexually assaulted by women may not be an at-risk population for PTSD. There
have not been many studies focusing on the effects of sexual assault on males by females.
However, Coxell and Kingm (2010) suggested that males sexually assaulted by women are less
likely to develop PTSD due to the lack of violence during the assault. This suggestion may be
accurate in which the more perceived life threat and more violence during an attack have been
highly associated with higher prevalence of PTSD. However, due to cultural stigma placed on
males raped by females (i.e.: men raped by females are less of a man or weak), it may be
possible that these victims may be unlikely to report the assault (Garnets, Herek, & Levy, 1993).

If one does not report a sexual assault, one might not express their emotions. Furthermore, not
identifying and describing one’s emotions (alexithymia) have been associated with symptoms of
PTSD (Halpern, Maunder, Schwartz, & Gurevich, 2012). Thus, this contradicts previous
evidence by Coxell and Kingm (2010), that males raped by females may not develop PTSD.
Nevertheless, research has suggested that male victims of rape may also be an at-risk population
for PTSD.
Physically assaulted victims. Physically assaulted victims are also a possible at risk
population for developing PTSD. One study looked at the correlation between experiencing a
physical assault and PTSD prevalence. Three months after the initial physical assault, 29% of the
remaining sample met the criteria for PTSD (Johansen, Eilertsen, Nordanger, & Weisaeth, 2013).
29% of the sample is a substantial number; suggesting that those physically assaulted are at a
moderate risk for developing PTSD. On the contrary, the study’s sample was 80% male, lacking
representative statistics for women and making the results ungeneralizable to the general
population. Thus, from this study, the findings may suggest that only men physically attacked are
at a moderate risk for developing PTSD (Johansen et al., 2013).
On the other hand, another study provided more useful evidence on the comorbidity of PTSD
with female victims of domestic violence. Another study on females domestically assaulted
found that women who reported their attack as less severe were less likely to meet the criteria for
PTSD (Hellmuth, Jaquier, Swan, & Sullivan, 2014). On the contrary, 1 in 2 women met the
criteria for PTSD when they reported their attack experience as moderately severe (Hellmuth et
al., 2014). Furthermore, 4 in 5 women met the criteria of PTSD when they reported that their
attack severity was high (Hellmuth et al., 2014). These findings suggest that the more severe the

attack, the more likely a person may develop PTSD due to the higher perceive life threat. Thus,
victims of severe physical attacks may be an at-risk population for developing PTSD.
Child abuse victims. The suggestion that victims of physical attacks may be another at risk
population for developing PTSD can be debatable, due to the lack of strong evidence; however,
studies already have found strong evidence suggesting that children and adolescents may be at a
higher risk for developing PTSD than the general population (Gradus, 2014). There is also
evidence determining which childhood abuse is more correlated with PTSD, but this evidence is
not widely known. A study comparing the effects of child sexual and physical abuse and its
relation to PTSD was examined, in which child sexual abuse was associated with greater PTSS
in comparison to a child that was physically abused (Wilson & Scarpa, 2014). It may be the case
that sexual abuse has a stronger negative effect on a person because it is more traumatizing,
exemplifying why childhood sexual abuse has a greater association with PTSD than physical
abuse. Moreover, perceived family and friend support may not be beneficial with children
sexually abused (Wilson & Scarpa, 2014). This further supports that the effects of sexual abuse
may be more traumatizing than the effects of physical abuse.
Furthermore, there was a meta-analysis examined that assessed the prevalence of PTSD
between genders (Walker, Carey, Mohr, Stein, & Seedat, 2004). This meta-analysis found no
significant difference in childhood PTSD prevalence between genders, contrary to other studies
that suggest girls may be at a greater risk for PTSD than boys (Walker et al., 2004). Thus, both
boys and girls affected by childhood abuse may be equally, highly at risk for developing PTSD,
contrary to previous findings.

Unintentional traumas.
Car crash victims. Previously in the introduction, the findings from the National Highway
Transportation Safety Administration or NHTSA demonstrated that has found that there may
have been at least about 290,000 people potentially at risk for developing PTSD. The briefly
mentioned study by Stewart (1999) supported this possibility in which the study found a
correlation between learning about a family member’s death in a car crash and the prevalence of
PTSD (Stewart, 1999). Moreover, the risk for developing PTSD in car crash victims is not only
applicable to adults, but also to children. A study on the longitudinal effects of a car crash on
children found that children that were in a bus crash had high levels of posttraumatic distress
(PTS) nine months later after the event (Arnberg, Rydelius, & Lundin, 2011). Furthermore, after
20 years, these same children had a higher prevalence rate of PTS, than those students in the
same class but not in the car crash – or the indirectly affected participants (Arnberg et al., 2011).
These findings suggest that experiencing a car crash may lead to the development of PTSD.
Natural disasters. Natural disasters may not occur as frequently as car crashes; however,
some natural disasters affect more people than car crashes in a year. A prodigious amount of
people may be at a great risk for developing PTSD, resulting in the hypothesis that there should
also be a large number of survivors that may develop PTSD. There has been a study on the
effects of Hurricane Ike and Katrina on PTSD long term (Cerda et al., 2013). In this study, only
6.1% of the sample met the criteria for PTSD after 2-5 months, in which these levels dropped
significantly after the first months after the hurricane (Cerda et al., 2013). Cerda et al. (2013)
suggested that since the problems that the hurricane caused were alleviated, this aided the mental
health of the survivors, causing the drop in PTSS in survivors/sample (Cerda et al., 2013). It
could be possible that due to the lack of severity and destruction from the hurricanes, perceived

life threat was not substantial enough to lead to PTSD. As a result, PTSD development was not
correlated to the effects of the hurricanes.
On the other hand, the Tsunami that hit the Kanyakumari district, the second most affected
district out of all the worse hit districts in India according to death toll and affected population,
resulted in immense destruction (Pyari, Kutty, & Sarma, 2012). The earthquake that was
measured a 9 on the Richter scale caused a tsunami that hit Southeast Asia and left 300,000
people dead and one million homeless (Pyari et al., 2012). This natural disaster was far more
severe, destructive, and devastating in comparison to Hurricane Ike and Katrina together. This
study found specific risk factors for developing PTSD: death to relatives, injury to self or family
members, being female, suffering maximum loss, and poor socioeconomic background (Pyari et
al., 2012). Thus, this study further supports that the more devastating and deadly the disaster, the
higher the association with the development of PTSD.
Furthermore, Pyari et al. (2012) also assessed a village in North China with little exposure to
the disaster and found that this population had a high prevalence rate of PTSD. This supports the
suggestion that simply witnessing a traumatic event is associated with the development of PTSD.
Providing counseling services to people in areas that have been substantially affected by a
natural disaster may be very effective in preventing PTSD. Moreover, this study found that
women were at a higher risk for having PTSD, a 6.35 times higher risk. On the contrary, many
studies in psychology discovered this same finding that may be due to cultural factors, in which
men have a greater restricted emotionality due to stigma causing men to limit emotional
expression and also seek treatment (Vogel, Wester, Hammer, & Downing-Matibag, 2014). This
finding may also help explain why men do not seek PTSD treatment.

Comorbidity
Examining the amount of comorbidity and time of onset between disorders may provide
the evidence to support the possibility that untreated PTSD may be a risk factor for other
depressive or anxiety disorders. Findings have found that depressive disorders can be a common
and independent condition resulting from of exposure to trauma, supporting the link of
comorbidity of PTSD and depressive disorders (Brady, Killeen, & Brewerton, 2000). Studies
suggest that PTSD is strongly correlated to the increase risk of developing comorbid depression
(Sareen, 2014). Furthermore, a study found that 54 of the 74 women that was sexually assaulted
and diagnosed with PTSD suffered from moderate or severe depression (Tiihonen Moller et al.,
2014). Thus, results suggest that since PTSD has been highly associated with depression, it is
possible that PTSD may lead to major depressive disorder (MDD).
Other studies support this suggestion in which one specifically has found that the most
common comorbid diagnosis with PTSD is depressive disorders (Brady et al., 2000). Angelakis
& Nixon (2015) suggested that PTSD might be a possible risk factor for developing MDD; thus,
MDD may be a possible reaction to PTSD. Moreover, another study found that the risk of
developing depression increases following a trauma and the diagnosis of PTSD (Breslau, Davis,
Peterson, & Schultz, 2000; Kilpatrick et al., 2003). Therefore, research has shown that PTSD
may be a risk factor or lead to MDD.
Obsessive-compulsive disorder has also been show to be highly comorbid with PTSD.
According to the DSM-V, obsessive–compulsive disorder (OCD) is characterized by intrusive
obsessive thoughts causing distress accompanied by repetitive compulsive physical or mental
acts (APA, 2015). Findings suggest that stressful life events, which this could include traumatic
experiences, has been associated with the development of OCD even with those without a family

history of the disorder (Cath, van Groothest, Willemsen, Oppen, & Boomsma, 2008). Another
study examined the proximity of onset of OCD and PTSD, in which this study found that there
might be a specific pre-traumatic OCD factor that increases the risk of developing comorbid
PTSD (Fontenelle et al., 2012). Thus, previously provided evidence suggest that OCD does have
a high prevalence rate with PTSD. Furthermore, OCD may be triggered traumatic events,
suggesting that PTSD or at least PTSS symptoms could possibly lead to OCD.
On the contrary, studies examining the comorbidity of acute stress disorder (ASD) and
PTSD in female rape victims did not support the thesis. Studies examined found that suffering
from ASD shortly after the assault may be a risk factor for developing PTSD (Tiihonen Moller et
al., 2014). Experiencing traumatic events of rape have been highly associated with the
development of ASD; however, the development of PTSD was a poor predictor for developing
ASD (Bryant, Salmon, & Sinclair, 2007).
Traumatic events or PTSD may also cause the development of generalized anxiety
disorder (GAD). GAD is defined as a “chronic, excessive, uncontrollable and pervasive worry”
(APA, 2015). Participants diagnosed with GAD reported experiencing potentially traumatic
events more frequently than participants not diagnosed with GAD (Roemer, Molina, Litz, &
Borkovec, 1996). Thus, this suggests an association between PTSD and GAD. This study further
supported this possible association in which results found a correlation between the development
or maintenance of GAD and potentially traumatizing events. Therefore, GAD may be sequela of
exposure to traumatic experiences (Roemer et al., 1996). PTSD has been strongly associated with
avoidance behavior as also functioning similarly to those with GAD (Roemer et al., 1996). The
purpose of avoidance behavior is to reduce the distress associated with trauma; however,
avoidance behavior does not allow the resolution of trauma (Roemer et al., 1996). As a result,

this exposure to traumatic event may not be solved and lead to the development of GAD. This
shows that comorbidity and the possibility that PTSD may lead to GAD.
Limitations, Implications, & Future Direction
Some of the limitations of the research include that most of the studies utilized
overrepresented population of women and Caucasians. Therefore, men and racial minorities may
be under represented by these findings. In support of this suggestion, one study found a higher
risk for PTSD among people of Hispanic Origin (Leahy, 2011). Nevertheless, as they are under-
represented, the possible addition of this evidence may only make the prevalence rates of PTSD
even higher. Furthermore, most of the studies are retrospective; data could be skewed by this
factor. Also, the limitation of retrospective studies is that since the data is self-reported by
participants, information can be forgotten or inaccurate. This possibility is only stronger when
factoring in the effects of trauma on memory. Moreover, there is no evidence of the effects of
untreated PTSD on participants as it would be very unethical to leave PTSD untreated for
experimental purposes. Any suggestions entailing untreated PTSD are based on assumptions
with evidence based on empirical evidence from retrospective studies on PTSD. Furthermore,
survivors of traumatic events with untreated PTSD may develop other depressive and anxiety
disorders. Studies suggesting a high comorbidity rate of PTSD and GAD, OCD, and MDD
support this hypothesis; however, future studies should examine the association between PTSS
and depressive and anxiety disorders. Thus, results would further more effectively this theory.
Other limitations on this literature review include the lack of history provided by some
studies. Previous trauma exposure is a risk factor for developing PTSD (Sareen, 2014). Thus,
studies that did not control for this variable may lack internal validity, resulting in skewed and
inaccurate data. Evidence shows that there are other risk populations other than the war veterans:

female victims of sexual assault, victims of childhood abuse especially sexual abuse, victims of
severe natural disasters, and victims of severe car crashes and physical assaults. It is important
to create a way to eliminate the stigma affecting men that have been sexually assaulted or
exposed to a traumatic event, to ensure that men come forward and seek therapeutic help. The
populations high at risk for developing PTSD have many factors in common: exposed to severe
trauma, most are exposed to intentional traumas, and the trauma entailed a violent or severely
devastating experience. Another commonality is that the victim may also witness or have been
affected by the death of a family or close friend. Therefore, therapist should look out also for
these predictors also in those exposed to traumatic events to prevent the development of PTSD if
possible.
There is a correlation between the PTSD and the comorbidity of other depressive and
anxiety disorders. There are underrepresented at risk populations: child abuse victims, men
sexually assaulted by other men or by women, victims of a severe physical assault. The main
implication is that the higher the perceived threat level to life, more likely resulting in the
development of PTSD. Also, this higher perceived life threat appears to be more highly
associated with intentional traumas and severe natural disasters. More outlets and support for
those underrepresented populations seeking aid for PTSD.
An epidemiological study should also be completed on the following at risk populations of
PTSD: children, adolescents, other ethnicities besides Caucasians, the LGBT population, and
men and women resulting in separate prevalence rates. More studies should utilized adult men
and homosexual men, more specifically those on sexual assault and domestic violence. More
studies should focus on the correlation between domestic violence of both genders and PTSD.

Also, future studies should examine the comorbidity of PTSS with other depressive and anxiety
disorders.
Conclusion
Since PTSD is highly associated, it may be possible that civilians exposed to severe or
sexual traumas may not seek the proper professional attention. This may lead to the development
of severe PTSD, MDD, or GAD if PTSD if left untreated. The connection between ASD and
PTSD was not found, possibly due to limited research. Previous research suggests that the more
serious the traumatic experience, the more likely the victim will develop PTSD. Furthermore,
women and children that are victims of sexual abuse are at a high risk for developing PTSD.
Additionally, victims of intentional traumas are more likely to develop PTSD in comparison to
those that are victims of unintentional traumas (Santiago et al., 2013). Nevertheless, those
exposed to severe and traumatizing natural disaster affecting those on an immense scale are still
highly likely to develop PTSD. Most importantly, perception of life threat is the most important
findings. There are many varying at risk populations for developing PTSD; however, they all
have in common that the victims have a high level of perceived life threat. Thus, the perception
of life threat is key predictor in the prevalence of PTSD in all whose is exposed to any trauma.

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