Does Post-Traumatic Stress Disorder Require Trauma?

Revisiting the role of trauma in PTSD

More broadly, research that psychologist George A. Bonanno of Columbia University and his colleagues reviewed in 2011 suggests that only about 5 to 10 percent of people typically develop PTSD after experiencing traumatic life events. And although the rates rise when stressors are severe or prolonged, they hardly ever exceed 30 percent. The rare exceptions may occur with repeated trauma. In another 2011 study psychologist Stevan Hobfoll of Rush Medical College and his colleagues reported that of 763 Palestinians living in areas rife with political violence, more than 70 percent exhibited moderate PTSD symptoms and about 26 percent had severe symptoms.

The finding that PTSD is not an inevitable sequela to trauma has spurred investigators to pursue factors that forecast relative immunity to the condition. Across studies, higher income and education, strong social ties and male gender tend to confer heightened resilience, although these predictors are far from perfect. People who usually experience very little anxiety, guilt, anger, alienation and other unpleasant emotions—that is, who have low “negative emotionality”—are also less likely to suffer from PTSD following trauma. Thus, in ways that researchers do not yet understand, individual characteristics must combine with trauma to produce this illness.

Emotional Triggers
Not only is trauma insufficient to trigger PTSD symptoms, it is also not necessary. Although by definition clinicians cannot diagnose PTSD in the absence of trauma, recent work suggests that the disorder’s telltale symptom pattern can emerge from stressors that do not involve bodily peril. In 2008 psychologist Gerald M. Rosen of the University of Washington and one of us (Lilienfeld) reviewed data demonstrating that significant PTSD symptoms can follow emotional upheavals resulting from divorce, significant employment difficulties or loss of a close friendship. In a 2005 study of 454 undergraduates, psychologist Sari Gold of Temple University and her colleagues revealed that students who had experienced nontraumatic stressors, such as serious illness in a loved one, divorce of their parents, relationship problems or imprisonment of someone close to them, reported even higher rates of PTSD symptoms than did students who had lived through bona fide trauma. Taken together, these findings call into question the long-standing belief that these symptoms are tied only to physical threat.

In light of these and other data, some authors have suggested that the PTSD diagnosis be extended to include anxiety reactions to events that are stressful but not terrifying. Yet such a change could lead to what Harvard University psychologist Richard J. McNally calls “criterion creep”—expanding the boundaries of the diagnosis beyond recognition. This and other controversies aside, recent results raise the possibility that PTSD is a less distinctive affliction than originally thought and that its symptoms may arise in response to a plethora of intense stressors that are part and parcel of the human condition.

This article was published in print as "When Coping Fails."

(Further Reading)
  • Posttraumatic Stress Disorder: An Empirical Evaluation of Core Assumptions. Gerald M. Rosen and Scott O. Lilienfeld in Clinical Psychology Review, Vol. 28, No. 5, pages 837–868; 2008.
  • Resilience to Loss and Potential Trauma. George A. Bonanno, Maren Westphal and Anthony D. Mancini in Annual Review of Clinical Psychology, Vol. 11, pages 511–535; April 2011.

This article was originally published with the title "When Coping Fails."

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