Environmental. These include lower socioeconomic status; lower education; exposure to prior trauma (especially during childhood); childhood adversity (e.g., economic depriva- tion, family dysfunction, parental separation or death); cultural characteristics (e.g., fatal- and a family psychiatric history. Social support prior to event exposure is protective.
Genetic and physiological. These include female gender and younger age at the time of trauma exposure (for adults). Certain genotypes may either be protective or increase risk of PTSD after exposure to traumatic events.
Environmental. These include severity (dose) of the trauma (the greater the magnitude of trauma, the greater the likelihood of PTSD), perceived life threat, personal injury, in- nessed threat to a caregiver in children), and, for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy. Finally, dissociation that occurs during the trauma and persists afterward is a risk factor.
Temperamental. These include negative appraisals, inappropriate coping strategies, and development of acute stress disorder.
Environmental. These include subsequent exposure to repeated upsetting reminders, subse— quent adverse life events, and financial or other trauma-related losses. Social support (includ- ing family stability, for children) is a protective factor that moderates outcome after trauma.
The risk of onset and severity of PTSD may differ across cultural groups as a result of vari- ation in the type of traumatic exposure (e.g., genocide), the impact on disorder severity of the meaning attributed to the traumatic event (e.g., inability to perform funerary rites after a mass killing), the ongoing sociocultural context (e.g., residing among unpunished per- petrators in postconﬂict settings), and other cultural factors (e.g., acculturative stress in immigrants). The relative risk for PTSD of particular exposures (e.g., religious persecu- tion) may vary across cultural groups. The clinical expression of the symptoms or symp- tom clusters of PTSD may vary culturally, particularly with respect to avoidance and numbing symptoms, distressing dreams, and somatic symptoms (e.g., dizziness, short- ness of breath, heat sensations).
Cultural syndromes and idioms of distress inﬂuence the expression of PTSD and the range of comorbid disorders in different cultures by providing behavioral and cognitive templates that link traumatic exposures to specific symptoms. For example, panic attack symptoms may be salient in PTSD among Cambodians and Latin Americans because of the association of traumatic exposure with panic-like khytil attacks and atuque de nervios.
Comprehensive evaluation of local expressions of PTSD should include assessment of cul- tural concepts of distress (see the chapter "Cultural Formulation" in Section III).
PTSD is more prevalent among females than among males across the lifespan. Females in the general population experience PTSD for a longer duration than do males. At least some of the increased risk for PTSD in females appears to be attributable to a greater likelihood of exposure to traumatic events, such as rape, and other forms of interpersonal violence.
Within populations exposed specifically to such stressors, gender differences in risk for
PTSD are attenuated or nonsignificant.
Traumatic events such as childhood abuse increase a person’s suicide risk. PTSD is associated with suicidal ideation and suicide attempts, and presence of the disorder may indicate which individuals with ideation eventually make a suicide plan or actually attempt suicide.
PTSD is associated with high levels of social, occupational, and physical disability, as well as considerable economic costs and high levels of medical utilization. Impaired function- ing is exhibited across social, interpersonal, developmental, educational, physical health, and occupational domains. In community and veteran samples, PTSD is associated with poor social and family relationships, absenteeism from work, lower income, and lower ed- ucational and occupational success.