Can Sudden, Severe Emotional Loss Be a Traumatic Stressor?

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1 Journal of Trauma & Dissociation, 14: , 2013 ISSN: print/ online DOI: / Can Sudden, Severe Emotional Loss Be a Traumatic Stressor? EVE B. CARLSON, PhD National Center for Posttraumatic Stress Disorder, VA Palo Alto Health Care System, Menlo Park, California, USA STEVE R. SMITH, PhD Department of Counseling, Clinical, and School Psychology, University of California at Santa Barbara, Santa Barbara, California, USA CONSTANCE J. DALENBERG, PhD Trauma Research Institute and California School of Professional Psychology, Alliant International University, San Diego, California, USA Aspects of the stressor criterion for posttraumatic stress disorder (PTSD) have been controversial since its inception, and the theoretical or empirical reasons for decisions about it have not been clear. To investigate whether sudden events involving severe emotional loss have the potential to precipitate PTSD, we assessed exposure to Criterion A stressors, sudden abandonment, sudden move or loss of home, and symptoms of PTSD and dissociation in a community sample of 427 adults. In regression analyses, models that included a severe emotional loss stressor accounted for a significant amount of additional variance in PTSD and dissociation symptoms beyond that accounted for by a model including only Criterion A stressors. The findings suggest that limiting Criterion A1 to events involving actual or threatened death or injury may be overly restrictive. Future research is needed to replicate these findings in a clinical sample and to prospectively examine the conditional probability of PTSD following these events. KEYWORDS traumatic stress, posttraumatic stress, trauma, traumatic stressors, PTSD, diagnostic criteria, stressor criterion This article is not subject to U.S. copyright law. Received 17 August 2011; accepted 30 January Address correspondence to Eve B. Carlson, PhD, National Center for PTSD (NC-PTSD- 334), 795 Willow Road, Menlo Park, CA eve.carlson@va.gov 519

2 520 E. B. Carlson et al. CLINICAL UTILITY OF THE POSTTRAUMATIC STRESS DISORDER (PTSD) STRESSOR CRITERION The stressor criterion for PTSD has been controversial ever since the disorder was added to the diagnostic system in 1980 (Davidson & Foa, 1991; Lindy, Green, & Grace, 1987; Weathers & Keane, 2007). In the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III), the criterion was existence of a recognizable stressor that would evoke significant symptoms of distress in almost everyone (American Psychiatric Association, 1980, p. 238). Version 10 of the International Classification of Diseases (ICD- 10) has a very similar definition of the stressor: Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone (World Health Organization, 1993, p. 120). A stipulation was added in DSM IV to restrict Criterion A events to those involving actual or threatened death or serious injury (American Psychiatric Association, 2000). A theoretical or empirical basis for this restricted definition of Criterion A1 was not provided. That is, we know of no theory of traumatic stress or empirical evidence to support the premise that such events are the only types of events that can cause overwhelming distress or be associated with the development of PTSD. Shalev and Ursano (2003) have described a number of elements of stressors that are traumatizing but do not involve threat of injury or death. Sudden separation, relocation, surrender, loss, isolation, dehumanization, uncertainty during traumatic events, incongruity of extreme experiences, and exposure to the grotesque can all cause extreme psychological pain (Shalev & Ursano, 2003). The mechanism of traumatization in such events has been hypothesized to be sudden and uncontrollable threatened or actual severe emotional or psychological pain (Carlson & Dalenberg, 2000). Threat of psychological harm due to emotional loss seems to be the traumatizing element in events involving threat of or actual injury or death of a loved one, which are already included in the current Criterion A. Given that such a threat could be associated with other extreme stressors, it is unclear why such stressors are not included in Criterion A. As the criteria for PTSD in DSM 5 were developed, the restrictiveness of Criterion A1 was widely discussed. One author voiced concern that including noncatastrophic events in Criterion A would produce a kind of conceptual bracket creep whereby increasingly trivial events are awarded causal significance as triggering PTSD (McNally, 2005, p. 97). Others expressed concern that Criterion A is overly restrictive (Brewin, Lanius, Novac, Schnyder, & Galea, 2009; Kilpatrick, Resnick, & Acierno, 2009). Several past studies have investigated whether events that do not meet Criterion A1 are associated with PTSD symptoms. In two large epidemiological samples, Kilpatrick and colleagues (1998, 2009) found that the diagnosis of PTSD was affected very little by whether the event in question met various

3 Journal of Trauma & Dissociation, 14: , definitions of Criterion A. In other studies, compared to events that met Criterion A1, events that did not meet Criterion A1 were found to be associated with higher levels of PTSD symptoms (Gold, Marx, Soler-Baillo, & Sloan, 2005; Van Hooff, McFarlane, Baur, Abraham, & Barnes, 2009), lower levels of PTSD (Boals & Schuettler, 2009), the same levels of PTSD (Anders, Frazier, & Frankfurt, 2011; Bodkin, Pope, Detke, & Hudson, 2007), and higher levels of PTSD when assessed before Criterion A1 events (Long et al., 2008). These findings have been interpreted by some as calling into question the uniqueness of Criterion A events and as casting doubt on the core assumption that there is a distinct class of stressors that can cause traumatic stress (Rosen & Lilienfeld, 2008). Another possibility is that events that are considered nontraumatic according to the DSM definition are, in fact, traumatic. That is, if Criterion A is erroneously restricted to only a subset of events that could cause traumatization, some events that do not meet the current Criterion A may indeed be associated with high levels of PTSD symptoms. Some support for this premise is provided by detailed descriptions of events considered nontraumatic in some past studies. In Bodkin et al. (2007), two of the three examples of events considered nontraumatic involved fears about losing loved ones, and examples of equivocal events included diagnosis of a life-threatening condition, threat of gang rape, and a childhood sexual abuse experience. Similarly, in Long et al. (2008), the most prevalent nontraumatic event was breaking up with a boyfriend or girlfriend. It is also worth noting that all subjects in the Long et al. study had experienced an event that met Criterion A during the previous 5 years. This design element may have influenced the study results if participants attributed symptoms that were caused by the Criterion A event to a non-criterion A event. In the context of the validation of a measure of traumatic stress exposure, data were collected on exposure to two types of experiences of sudden threat of extreme psychological loss: experiences of sudden abandonment by a partner, a family member, or loved ones or sudden loss of home and possessions (Carlson, Smith, et al., 2011). Such experiences fit a fear model of PTSD well. In animals, loss of a mate or member of a family group, den, or burrow may well signal an increase in danger. In humans, such losses may cause psychological harm by damaging emotional security. Examples of experiences of sudden loss of a loved one that do not involve death include sudden abandonment by a spouse or the sudden absence of a parent due to imprisonment. In war-torn countries, spouses and family members may disappear or be suddenly separated with reunion uncertain. Sudden loss of home and possessions may occur when people flee war or when they experience financial problems or disasters such as fire, flood, or tornado. For children, eviction or sudden change of residence may result in the sudden loss of a familiar environment and important relationships. We hypothesized that sudden abandonment or loss of home events would be associated with

4 522 E. B. Carlson et al. PTSD and dissociation symptoms at levels comparable to those of events that meet Criterion A and that experiences of the two events would be associated with variance in posttraumatic symptoms above and beyond that accounted for by Criterion A events. We studied dissociation symptoms because they have been strongly associated with trauma exposure and PTSD (Carlson, Dalenberg, & McDade-Montez, 2012) but are not well represented in the criteria for PTSD. METHODS Participants In 2006 and 2007, participants were recruited from shopping areas located in two small West Coast cities (n = 177); other participants were students from a mid-size western university (n = 107) and a small community college located in the same town (n = 143). Some students received psychology course credit. Other students and community participants were compensated with a $5 gift card. Participants ages ranged from 18 to 73, with a mean of 24.6 (SD = 9.6), and 38.8% were male. Self-reported racial/ethnic identities were White (59.7%), Hispanic/Latino (22.2%), Asian (8.0%), other and mixed race (6.1%), and African American (4.0%). Socioeconomic status ranged from lower to upper middle class, with a mean score of 34 (SD = 8.0) on the Hollingshead Two-Factor Index (Hollingshead & Redlich, 1958) falling in the middle class. Materials and Procedures All participants completed the Trauma History Screen (THS), the Screen for Posttraumatic Stress Symptoms (SPTSS), and the Traumatic Dissociation Scale (TDS). The THS is a self-report measure of trauma exposure that has been found to have reliability and validity for assessing trauma exposure (Carlson, Smith, et al., 2011). It includes reports of frequency of exposure to 12 high magnitude stressors (HMS): transportation accidents; accidents at home or work; natural disasters; child physical assault; adult physical assault; child sexual assault; adult sexual assault; assault with a weapon; military service trauma; the sudden death of a close friend or family member; witnessing death or serious injury; and other events causing fear, helplessness, or horror. Sudden loss of home/community ( Sudden move or loss of home or possessions ) and sudden abandonment ( Sudden abandonment by spouse, partner, parent, or family ) were also assessed. Frequencies reported for the 12 Criterion A items were collapsed into categories (accidents, disasters, interpersonal violence, death, military trauma, witnessed trauma, and other). The SPTSS is a 17-item self-report measure of DSM IV PTSD symptoms during the past week that has shown good reliability and validity (Carlson,

5 Journal of Trauma & Dissociation, 14: , ; Caspi, Carlson, & Klein, 2007). Response options are 0 = not at all, 1 = 1 or 2 times, 2 = almost every day, 3 = about once every day, 4 = more than once every day. Scores on the SPTSS range from 0 to 68. The TDS is a 24-item self-report measure of the frequency of dissociative symptoms during the past week, including experiences of depersonalization, derealization, sensory misperceptions, and gaps in awareness and memory. Response options are 0 = not at all, 1 = 1 or 2 times, 2 = almost every day, 3 = about once every day, 4 = more than once every day. Scores range from 0 to 96. The TDS has been found to have good test retest reliability over 1 2 weeks and excellent internal reliability. Higher scores in those meeting criteria for PTSD and high correlations with the Dissociative Experiences Scale and real-time reports of dissociation provided evidence of strong construct validity (Carlson, Waelde, et al., 2011). RESULTS Table 1 shows endorsement rates for each of 12 stressor type categories and for sudden abandonment and sudden loss of home. Of those endorsing any events, 9% reported exposure to a single stressor. To reduce distorting effects of outliers while retaining information about magnitude, we used Winsorization transformation to calculate total HMS events. Values above the 95th percentile were replaced by the value at the 95th percentile. The mean total frequency of HMS events endorsed was 6.4 (SD = 6.5), the median number of HMS events was 4.0, and the modal number was 0. The mean SPTSS score was 10.3 (SD = 10.1), and the mean TDS score was 8.5 (SD = 12.1). TABLE 1 Correlations Between Frequency of Trauma Types and PTSD and Dissociation Symptoms Trauma Participants endorsing 1 or more (%) PTSD Dissociation Transport and other accidents Disasters Interpersonal violence Military trauma Sudden deaths Witnessing death or injury Other trauma All Criterion A stressors Abandonment Loss of home Notes: PTSD = posttraumatic stress disorder. p <.05. p <.001. p <.0001.

6 524 E. B. Carlson et al. TABLE 2 Hierarchical Stepwise Regression with Criterion A and Sudden Abandonment Predicting PTSD and Dissociation Symptoms PTSD Predictor R 2 β Dissociation Partial correlation R 2 β Partial correlation Step Criterion A stressors Step Criterion A stressors Sudden abandonment Total R n Notes: PTSD = posttraumatic stress disorder. p <.05. p <.01. p < For statistical analyses, HMS event type frequencies were log transformed to normalize distributions skewed because of a small number of participants reporting high frequencies for one or more HMS event types. In Table 1, correlations are shown between the frequency of each event type, total HMS frequency, sudden abandonment, and sudden loss of home and symptoms of PTSD and dissociation. The correlation between frequencies of sudden abandonment and sudden loss of home was.44 (p <.001). The total frequency of Criterion A stressors was correlated.37 (p <.001) with the frequency of sudden loss of home and.34 (p <.001) with the frequency of sudden abandonment. Table 2 shows results of hierarchical multiple regressions predicting PTSD symptoms and dissociation symptoms with Criterion A stressor frequency entered in the first block and sudden abandonment entered in the second block. The models that included sudden abandonment accounted for significantly more variance in PTSD and dissociation symptoms than the models that included only Criterion A stressors. Table 3 shows the same analyses with sudden loss of home entered in the second block. The models that included sudden loss of home accounted for significantly and considerably more variance in PTSD symptoms than Criterion A stressors alone. DISCUSSION Overall, our hypotheses were confirmed that two stressors involving extreme emotional loss that do not meet Criterion A were associated with posttraumatic symptoms as strongly as Criterion A stressors and accounted for variance in posttraumatic symptoms beyond that accounted for by Criterion A stressors. These findings suggest that limiting Criterion A1 to

7 Journal of Trauma & Dissociation, 14: , TABLE 3 Hierarchical Stepwise Regression with Criterion A and Sudden Loss of Home Predicting PTSD and Dissociation Symptoms PTSD Predictor R 2 β Dissociation Partial correlation R 2 β Partial correlation Step Criterion A stressors Step Criterion A stressors Sudden loss of home Total R n Notes: PTSD = posttraumatic stress disorder. p <.01. p < events involving actual or threatened death or injury may be overly restrictive. From participants reports of persisting distress following the reported events, it appears that sudden abandonment and sudden loss of home may precipitate posttraumatic symptoms as frequently as do other extreme stressors. This does not imply that the events directly caused the symptoms, but like other extreme stressors they may precipitate disorder in individuals who are vulnerable because of prior, co-occurring, or subsequent biological, psychological, experiential, or social factors. If this is the case, excluding extreme emotional loss stressors from Criterion A may result in a failure to inquire about disabling symptoms. The additional variance accounted for by adding abandonment to the model was significant but quite small. This may be because experiences of abandonment shared variance with other traumatic stressors. Of those reporting abandonment, 98.6% also reported one or more additional types of HMS. In addition, abandonment may not be an enduring traumatic stressor for some because it is not associated with persisting psychological distress. Low associations with symptoms and endorsement of stressors that were low in severity are common for other stressors as well, such as sudden deaths, witnessing death or injury, disasters, and accidents. As with these other stressors, it seems preferable to assess severity following endorsement rather than refrain from assessing exposure. Prospective studies exploring the severity and duration of distress associated with abandonment could be illuminating. Strengths of the study are that the data were collected systematically using a validated measure of trauma exposure from a relatively large sample of adults that was ethnically and socioeconomically diverse. There are also several limitations to the study. The sample was a convenience sample and included a large proportion of younger adults, who tend to have lower levels of exposure to potentially traumatic stressors than adults who are older. As with epidemiological studies of psychiatric disorder in the

8 526 E. B. Carlson et al. general population, sampling from the community is a disadvantage in terms of generalizing findings to those seeking treatment, who have more severe symptoms and are the primary target of diagnosis. Because data on stressor exposure were cross-sectional and retrospective, it is possible that observed associations resulted from those with more symptoms recalling exposure to events more frequently than others. The relative magnitudes of the relationships with PTSD and dissociation across stressor types still seem notable. The finding that exposure to events such as sudden abandonment or loss of home was more strongly associated with both PTSD symptoms and dissociation than exposure to several other types of typical Criterion A stressors raises the question of how strongly these particular non-criterion A events are associated with PTSD compared to other types of stressors. Future research on a larger sample could examine the conditional probability of PTSD or other new anxiety or affective disorder following a single event or a most upsetting event as did Kessler, Sonnega, Bromet, Hughes, and Nelson (1995). It would also be valuable to study the differential impact of various potentially traumatic stressors when they occur at different times in life. In light of these findings and the difficulty inherent in creating an exhaustive list of stressors that may precipitate extreme emotional distress, we agree with Brewin and colleagues (2009) that in the DSM, Criterion A ought to be either eliminated or expanded to include other stressors associated with sudden, extreme emotional pain. Either change would have the advantage of bringing the DSM criteria for PTSD into closer alignment with the ICD criteria for the disorder, which is a stated goal for DSM (Andrews et al., 2009) and is of increasing importance as the United States moves toward the use of the ICD system for classifying mental disorders (Reed, 2010). REFERENCES American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Anders, S. L., Frazier, P. A., & Frankfurt, S. B. (2011). Variations in Criterion A and PTSD rates in a community sample of women. Journal of Anxiety Disorders, 25, Andrews, G., Goldberg, D., Krueger, R., Carpenter, W., Hyman, S., Sachdev, P., & Pine, D. S. (2009). Exploring the feasibility of a meta-structure for DSM-V and ICD-11: Could it improve utility and validity? Psychological Medicine, 39, Boals, A., & Schuettler, D. (2009). PTSD symptoms in response to traumatic and nontraumatic events: The role of respondent perception and A2 criterion Journal of Anxiety Disorders, 23,

9 Journal of Trauma & Dissociation, 14: , Bodkin, J. A., Pope, H. G., Detke, M. J., & Hudson, J. I. (2007). Is PTSD caused by traumatic stress? Journal of Anxiety Disorders, 21, Brewin, C. R., Lanius, R. A., Novac, A., Schnyder, U., & Galea, S. (2009). Reformulating PTSD for DSM-V: Life after Criterion A. Journal of Traumatic Stress, 22, Carlson, E. B. (2001). Psychometric study of a brief screen for PTSD: Assessing the impact of multiple traumatic events. Assessment, 8, Carlson, E. B., & Dalenberg, C. (2000). A conceptual framework for the impact of traumatic experiences. Trauma, Violence, and Abuse, 1, Carlson, E. B., Dalenberg, C. J., & McDade-Montez, E. (2012). Dissociation in posttraumatic stress disorder. Part I: Definitions and review of research. Psychological Trauma, 4, Carlson, E. B., Smith, S., Palmieri, P., Dalenberg, C., Ruzek, J. I., Kimerling, R., Spain, D. A. (2011). Development and validation of a brief self-report measure of trauma exposure: The Trauma History Screen. Psychological Assessment, 23, Carlson, E. B., Waelde, L., Palmieri, P. A., Smith, S. R., McDade-Montez, E., & Gauthier, J. (2011, November). Validation studies of the Traumatic Dissociation Scale: A measure of dissociation associated with traumatic stress. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, Baltimore, MD. Caspi, Y., Carlson, E. B., & Klein, E. (2007). Validation of a screening instrument for posttraumatic stress disorder in a community sample of Bedouin men serving in the Israeli Defense Forces. Journal of Traumatic Stress, 20, Davidson, J. R. T., & Foa, E. B. (1991). Diagnostic issues in posttraumatic stress disorder: Considerations for the DSM-IV. Journal of Abnormal Psychology, 100, Gold, S. D., Marx, B. P., Soler-Baillo, J. M., & Sloan, D. M. (2005). Is life stress more traumatic than traumatic stress? Anxiety Disorders, 19, Hollingshead, A., & Redlich, F. (1958). Social class and mental illness. NewYork, NY: Wiley. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, Kilpatrick, D. G., Resnick, H. S., & Acierno, R. (2009). Should PTSD Criterion A be retained? Journal of Traumatic Stress, 22, Kilpatrick, D. G., Resnick, H. S., Freedy, J. R., Pelcovitz, D., Resick, P., Roth, S., & van der Kolk, B. (1998). Posttraumatic stress disorder field trial: Evaluation of the PTSD construct-criteria A through E. In T. Widiger, A. Frances, H. Pincus, R. Ross, M. First, W. Davis, & M. Kline (Eds.), DSM-IV sourcebook (Vol.4,pp ). Washington, DC: American Psychiatric Press. Lindy, J. D., Green, B. L., & Grace, M. C. (1987). The stressor criterion and posttraumatic stress disorder. Journal of Nervous and Mental Disease, 175, Long, M. E., Elhai, J. D., Schweinle, A., Gray, M. J., Grubaugh, A. L., & Frueh, B. C. (2008). Differences in posttraumatic stress disorder diagnostic rates and symptom severity between Criterion A1 and non-criterion A1 stressors. Journal of Anxiety Disorders, 22,

10 528 E. B. Carlson et al. McNally, R. J. (2005). Remembering trauma. Cambridge, MA: Harvard University Press. Reed, G. M. (2010). Toward ICD-11: Improving the clinical utility of WHO s international classification of mental disorders. Professional Psychology: Research and Practice, 41, Rosen, G. M., & Lilienfeld, S. O. (2008). Posttraumatic stress disorder: An empirical evaluation of core assumptions. Clinical Psychology Review, 28, Shalev, A. Y., & Ursano, R. J. (2003). Mapping the multidimensional picture of acute responses to traumatic stress. In R. Orner & U. Schnyder (Eds.), Reconstructing early intervention after trauma (Vol , pp ). Oxford, England: Oxford University Press. Van Hooff, M., McFarlane, A. C., Baur, J., Abraham, M., & Barnes, D. J. (2009). The stressor Criterion-A1 and PTSD: A matter of opinion? Journal of Anxiety Disorders, 23, Weathers, F. W., & Keane, T. M. (2007). The Criterion A problem revisited: Controversies and challenges in defining and measuring psychological trauma. Journal of Traumatic Stress, 20, World Health Organization (1993). The ICD 10 classification of mental and behavioural disorders: Diagnostic criteria for research Geneva, Switzerland: WHO.

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