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Section 9
Factors Influencing the Severity of PTSD

Question 9 | Test | Table of Contents

Resilience
The impact of traumatic events also depends to some degree on the resilience of the affected person. While studies of combat veterans in the Second World War have shown that every man had his “breaking point,” some “broke” more easily than others. Only a small minority of exceptional people appear to be relatively invulnerable in extreme situations. Studies of diverse populations have reached similar conclusions: stress-resistant individuals appear to be those with high sociability, a thoughtful and active coping style, and a strong perception of their ability to control their destiny. For example, when a large group of children were followed from birth until adulthood, roughly one child in ten showed an unusual capacity to withstand an adverse early environment. These children were characterized by an alert, active temperament, unusual sociability and skill in communicating with others, and a strong sense of being able to affect their own destiny, which psychologists call “internal locus of control.” Similar capacities have been found in people who show particular resistance to illness or hardiness in the face of ordinary life stresses.

During stressful events, highly resilient people are able to make use of any opportunity for purposeful action in concert with others, while ordinary people are more easily paralyzed or isolated by terror. The capacity to preserve social connection and active coping strategies, even in the face of extremity, seems to protect people to some degree against the later development of post-traumatic syndromes. For example, among survivors of a disaster at sea, the men who had managed to escape by cooperating with others showed relatively little evidence of post-traumatic stress disorder afterward. By contrast, those who had “frozen” and dissociated tended to become more symptomatic later. Highly symptomatic as well were the “Rambos,” men who had plunged into impulsive, isolated action and had not affiliated with others.

A study of ten Vietnam veterans who did not develop post-traumatic stress disorder, in spite of heavy combat exposure, showed once again the characteristic triad of active, task-oriented coping strategies, strong sociability, and internal locus of control. These extraordinary men had consciously focused on preserving their calm, their judgment, their connection with others, their moral values, and their sense of meaning, even in the most chaotic battlefield conditions. They approached the war as “a dangerous challenge to be met effectively while trying to stay alive,” rather than as an opportunity to prove their manhood or a situation of helpless victimization. They struggled to construct some reasonable purpose for the actions in which they were engaged and to communicate this understanding to others. They showed a high degree of responsibility for the protection of others as well as themselves, avoiding unnecessary risks and on occasion challenging orders that they believed to be ill-advised. They accepted fear in themselves and others, but strove to overcome it by preparing themselves for danger as well as they could. They also avoided giving in to rage, which they viewed as dangerous to survival. In a demoralized army that fostered atrocities, none of these men expressed hatred or vengefulness toward the enemy, and none engaged in rape, torture, murder of civilians or prisoners, or mutilation of the dead.

The experiences of women who have encountered a rapist suggest that the same resilient characteristics are protective to some degree. The women who remained calm, used many active strategies, and fought to the best of their ability were not only more likely to be successful in thwarting the rape attempt but also less likely to suffer severe distress symptoms even if their efforts ultimately failed. By contrast, the women -who were immobilized by terror and submitted without a struggle were more likely not only to be raped but also to be highly self-critical and depressed in the aftermath. Women’s generally high sociability, however, was often a liability rather than an asset during a rape attempt. Many women tried to appeal to the humanity of the rapist or to establish some form of empathic connection with him. These efforts were almost universally futile.

Though highly resilient people have the best chance of surviving relatively unscathed, no personal attribute of the victim is sufficient in itself to offer reliable protection. The most important factor universally cited by survivors is good luck. Many are keenly aware that the traumatic event could have been far worse and that they might well have “broken” if fate had not spared them. Sometimes survivors attribute their survival to the image of a connection that they managed to preserve, even in extremity, though they are well aware that this connection was fragile and could easily have been destroyed. A young man who survived attempted murder describes the role of such a connection:

“I was lucky in a lot of ways. At least they didn’t rape me. I don’t think I could have lived through that. After they stabbed me and left me for dead, I suddenly had a very powerful image of my father. I realized I couldn’t die yet because it would cause him too much grief. I had to reconcile my relationship with him. Once I resolved to live, an amazing thing happened. I actually visualized the knot around my wrists, even though my hands were tied behind my back. I untied myself and crawled into the hallway. The neighbors found me just in time. A few minutes more and it would have been too late. I felt that I had been given a second chance at life.”
- Herman M.D., Judith Lewis, “Trauma and Recover”, Basic Books: New York, 1992.

Combat
The “bush vets” live hidden in the jungle on the island of Hawaii. PTSD counselors estimate there are several hundred of them, living in tents or makeshift “hooches,” shelters like they made for themselves during the Vietnam War.

Some simply want to be left alone. Their PTSD symptoms are so severe that they cannot live among other people. For many the war has never ended; they still carry rifles and set booby traps around their camps. Other bush vets have settled in remote and isolated areas of Washington State, Maine, and Texas. They continue to be emotional hostages of a war that ended 30 years ago.

Wars cause mental suffering to all of the people this form of violence touches. Except for prisoners of war and concentration camp survivors, combat veterans seem to be the most affected by PTSD. As a general rule, the more combat a veteran was exposed to and the more intense that combat was, the more likely the former soldier is to suffer from PTSD. One Veterans Administration psychiatrist has called PTSD an occupational hazard of war.

Several factors make wars especially traumatic to the soldiers who fight them:
• Soldiers are separated from their homes and families. Those who fight in foreign countries are faced with a different culture and language.
• For the most part, soldiers are young men who are still in the process of learning coping skills.
• During a war, especially in a battle zone, the threat of being killed or wounded is always present.
• Battlefield conditions are physically stressing. Often soldiers march for days in extreme temperatures. Food and water may be scarce, and sleep scarcer. All this marching takes place while carrying a 40-pound pack.
• Military training encourages soldiers to hate the enemy and teaches those who will fight wars to take out their anger at the enemy by trying to kill them. It discourages compassion and caring.
• War involves seeing dying and wounded people up close. Many times soldiers saw the mutilated bodies of their friends, but to survive had to stuff their anger and grief inside.
• A situation of killing another person or being killed is perhaps the most difficult one in which a moral human being can find him- or herself. Most us have been taught from childhood that killing is wrong, yet we have an urge for self-preservation.

An estimated 15 percent of the soldiers who were in Vietnam have PTSD today.
- Porterfield, Kay Marie, “Straight Talk About… Post Traumatic Stress Disorder”, Facts on File: New York, 1996

Personal Reflection Exercise #3
The preceding section contained information about factors that can influence the severity of PTSD. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
The relationship between multiple traumatic events and the severity of posttraumatic stress disorder symptoms – evidence for a cognitive link

Kube, T., Elssner, A. C., & Herzog, P. (2023). The relationship between multiple traumatic events and the severity of posttraumatic stress disorder symptoms - evidence for a cognitive link. European journal of psychotraumatology, 14(1), 2165025. https://doi.org/10.1080/20008066.2023.2165025

Peer-Reviewed Journal Article References:
Himmerich, S. J., Ellis, R. A., & Orcutt, H. K. (2020). Application of PTSD alcohol expectancy symptom clusters to the four-dimensional model of PTSD: Support from moderations of the association between symptoms of posttraumatic stress and alcohol use. Psychological Trauma: Theory, Research, Practice, and Policy, 12(4), 347–355a

Hyland, P., Karatzias, T., Shevlin, M., McElroy, E., Ben-Ezra, M., Cloitre, M., & Brewin, C. R. (2021). Does requiring trauma exposure affect rates of ICD-11 PTSD and complex PTSD? Implications for DSM–5. Psychological Trauma: Theory, Research, Practice, and Policy, 13(2), 133–141.

Palgi, Y., Karatzias, T., Hyland, P., Shevlin, M., & Ben-Ezra, M. (2021). Can subjective perceptions of trauma differentiate between ICD-11 PTSD and complex PTSD? A cross-cultural comparison of three African countries. Psychological Trauma: Theory, Research, Practice, and Policy, 13(2), 142–148.

Penney, D., El-Baalbaki, G., & Lepage, M. (2021). Exploring the factor structure of the PTSD checklist for DSM–5 in psychotic disorders. Psychological Trauma: Theory, Research, Practice, and Policy.

Sciarrino, N. A., Bartlett, B. A., Smith, L. J., Martin, C. E., & Williams, W. (2021). Factors contributing to PTSD treatment dropout in veterans returning from the wars in Iraq and Afghanistan: A systematic review. Psychological Services.

QUESTION 9
According to Porterfield, what percent of Vietnam soldiers have PTSD today? To select and enter your answer go to Test.