Predicting posttraumatic stress symptoms from pretraumatic risk factors: a 2-year prospective follow-up study in firefighters.

OBJECTIVE Most studies focusing on risk factors for posttraumatic stress disorder (PTSD) have used retrospective study designs. Only a small number of studies have prospectively examined risk factors in the immediate aftermath of trauma exposure in predicting PTSD symptoms. The purpose of this study was to identify predictive risk factors for posttraumatic stress symptoms and comorbid psychopathological symptoms present during the time before exposure to traumatic stress in a high-risk population. METHOD Forty-three professional firefighters were assessed immediately after basic training (baseline) and at 6, 9, 12, and 24 months after entry into firefighter service. Subjects were screened for psychopathological symptoms, including symptoms of PTSD, depression, and anxiety. Subjects were also characterized with regard to personality traits such as self-efficacy, hostility, and alexithymia. Neuroendocrine activity was assessed by examination of awakening and diurnal salivary cortisol profiles and 24-hour urinary catecholamine excretion. Multiple linear regression analysis was used to analyze posttraumatic stress symptoms at 24-month follow-up as a function of pretraumatic characteristics. RESULTS A high level of hostility and a low level of self-efficacy at baseline accounted for 42% of the variance in posttraumatic stress symptoms after 2 years. Subjects who had both risk factors at baseline showed a significant increase in measures of PTSD symptoms, depression, anxiety, general psychological morbidity, global symptom severity, and alexithymia during the 2-year period. Biological characteristics were not predictive of the development of psychopathological symptoms. CONCLUSIONS These results suggest that specific personality traits may constitute markers of vulnerability to the development of psychopathological symptoms after trauma exposure. Early identification of preexisting risk factors is needed to provide effective prevention and intervention for individuals who are at risk of developing trauma-related disorders.

[1]  S. Joseph,et al.  Incident-Related Stressors, Locus of Control, Coping, and Psychological Distress Among Firefighters in Northern Ireland , 2002, Journal of traumatic stress.

[2]  R. McNally,et al.  Psychological mechanisms in acute response to trauma , 2003, Biological Psychiatry.

[3]  B. Frueh,et al.  Relationship between scores on anger measures and PTSD symptomatology, employment, and compensation-seeking status in combat veterans. , 1997, Journal of clinical psychology.

[4]  C. Kirschbaum,et al.  Salivary cortisol in psychoneuroendocrine research: Recent developments and applications , 1994, Psychoneuroendocrinology.

[5]  C. Kirschbaum,et al.  Increasing correlations between personality traits and cortisol stress responses obtained by data aggregation , 1997, Psychoneuroendocrinology.

[6]  A. Maercker,et al.  Anger in former East German political prisoners: relationship to posttraumatic stress reactions and social support. , 2000, The Journal of nervous and mental disease.

[7]  N. Schneiderman,et al.  Coping self-efficacy buffers psychological and physiological disturbances in HIV-infected men following a natural disaster. , 1997, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[8]  J W Mason,et al.  Urinary Free-Cortisol Levels in Posttraumatic Stress Disorder Patients , 1986, The Journal of nervous and mental disease.

[9]  R. Rosenheck,et al.  Social support and psychopathology in the war zone. , 1997, The Journal of nervous and mental disease.

[10]  J. Stellman,et al.  Risk factors for course of posttraumatic stress disorder among Vietnam veterans: a 14-year follow-up of American Legionnaires. , 2003, Journal of consulting and clinical psychology.

[11]  A. Harvey,et al.  Posttraumatic Stress in Volunteer Firefighters: Predictors of Distress , 1995, The Journal of nervous and mental disease.

[12]  S. Orr,et al.  A prospective study of heart rate response following trauma and the subsequent development of posttraumatic stress disorder. , 1998, Archives of general psychiatry.

[13]  C. Kirschbaum,et al.  Salivary cortisol in psychobiological research: an overview. , 1989, Neuropsychobiology.

[14]  R. Kessler,et al.  Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. , 1998, Archives of general psychiatry.

[15]  S. Orr,et al.  Lower precombat intelligence is a risk factor for posttraumatic stress disorder. , 1998, Journal of consulting and clinical psychology.

[16]  R F Vining,et al.  Salivary Cortisol: A Better Measure of Adrenal Cortical Function than Serum Cortisol , 1983, Annals of clinical biochemistry.

[17]  C. Brewin,et al.  Gender, Social Support, and PTSD in Victims of Violent Crime , 2003, Journal of Traumatic Stress.

[18]  W. Corneil,et al.  Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries. , 1999, Journal of occupational health psychology.

[19]  P. Ferren.  Comparing Perceived Self-Efficacy Among Adolescent Bosnian and Croatian Refugees with and Without Posttraumatic Stress Disorder , 1999, Journal of traumatic stress.

[20]  T. Freeman,et al.  Gun use, attitudes toward violence, and aggression among combat veterans with chronic posttraumatic stress disorder. , 2001, The Journal of nervous and mental disease.

[21]  Barbara O. Rothbaum,et al.  Reliability and validity of a brief instrument for assessing post-traumatic stress disorder , 1993 .

[22]  J. Beckham,et al.  Posttraumatic stress disorder, hostility, and health in women: A review of current research , 2002, Annals of behavioral medicine : a publication of the Society of Behavioral Medicine.

[23]  R. Yehuda.  Current status of cortisol findings in post-traumatic stress disorder. , 2002, The Psychiatric clinics of North America.

[24]  C. A. Morgan,et al.  Neurotransmitter alterations in PTSD: catecholamines and serotonin. , 1999, Seminars in clinical neuropsychiatry.

[25]  P. Schnurr,et al.  Premilitary MMPI scores as predictors of combat-related PTSD symptoms. , 1993, The American journal of psychiatry.

[26]  W. Corneil,et al.  Exposure to Duty-Related Incident Stressors in Urban Firefighters and Paramedics , 1998, Journal of traumatic stress.

[27]  J Hill,et al.  Individual predictors of traumatic reactions in firefighters. , 2000, The Journal of nervous and mental disease.

[28]  A. Taylor,et al.  Psychophysiology of posttraumatic stress disorder related to motor vehicle accidents: replication and extension. , 1996, Journal of consulting and clinical psychology.

[29]  I. Iancu,et al.  Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. , 2001, The Journal of nervous and mental disease.

[30]  C. Forneris,et al.  Hostility and Functional Health Status in Women Veterans With and Without Posttraumatic Stress Disorder: A Preliminary Study , 2000, Journal of traumatic stress.

[31]  A. Bandura.  Self-Efficacy: The Exercise of Control , 1997, Journal of Cognitive Psychotherapy.

[32]  E. Foa,et al.  Anger, Dissociation, and Posttraumatic Stress Disorder Among Female Assault Victims , 2000, Journal of traumatic stress.

[33]  Douglas R. Glasnapp.  Change Scores and Regression Suppressor Conditions , 1984 .

[34]  C. Kirschbaum,et al.  The cortisol response to awakening in relation to different challenge tests and a 12-hour cortisol rhythm. , 1999, Life sciences.

[35]  H. Kraemer,et al.  How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. , 2001, The American journal of psychiatry.

[36]  Z. Solomon,et al.  Coping, locus of control, social support, and combat-related posttraumatic stress disorder: a prospective study. , 1988, Journal of personality and social psychology.

[37]  R. Yehuda,et al.  Predicting the development of posttraumatic stress disorder from the acute response to a traumatic event , 1998, Biological Psychiatry.

[38]  A. Anderson,et al.  Self-Efficacy and Externality in Adolescence: Theoretical Conceptions and Measurement in New Zealand and German Secondary School Students , 2001 .

[39]  A. Shalev,et al.  Posttraumatic stress disorder as a result of mass trauma. , 2004, The Journal of clinical psychiatry.

[40]  R. Yehuda,et al.  Effect of previous trauma on acute plasma cortisol level following rape. , 1995, The American journal of psychiatry.

[41]  S. Orr,et al.  Aggression and its correlates in Vietnam veterans with and without chronic posttraumatic stress disorder. , 1994, Comprehensive psychiatry.

[42]  R. Yehuda,et al.  Increased pituitary activation following metyrapone administration in post-traumatic stress disorder , 1996, Psychoneuroendocrinology.

[43]  H. M. van der Ploeg,et al.  Predeployment personality traits and exposure to trauma as predictors of posttraumatic stress symptoms: a prospective study of former peacekeepers. , 2000, The American journal of psychiatry.

[44]  M. Raskind,et al.  Multidimensional assessment of anger in Vietnam veterans with posttraumatic stress disorder. , 1999, Comprehensive psychiatry.

[45]  A. Harvey,et al.  A prospective study of psychophysiological arousal, acute stress disorder, and posttraumatic stress disorder. , 2000, Journal of abnormal psychology.

[46]  W. Zung.  A SELF-RATING DEPRESSION SCALE. , 1965, Archives of general psychiatry.

[47]  C. Fullerton,et al.  Longitudinal Assessment of Posttraumatic Stress Disorder and Depression after Exposure to Traumatic Death , 1995, The Journal of nervous and mental disease.

[48]  W. Riley,et al.  Anger and Hostility in Depression , 1989, The Journal of nervous and mental disease.

[49]  D. Charney,et al.  Psychobiological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress. , 2004, The American journal of psychiatry.

[50]  R. Yehuda,et al.  The Acute Stress Response Following Motor Vehicle Accidents and Its Relation to PTSD , 1997, Annals of the New York Academy of Sciences.

[51]  S. Wang.  Traumatic stress and attachment. , 1997, Acta physiologica Scandinavica. Supplementum.

[52]  D. Goldberg,et al.  A scaled version of the General Health Questionnaire , 1979, Psychological Medicine.

[53]  R. Bagby,et al.  The twenty-item Toronto Alexithymia Scale--I. Item selection and cross-validation of the factor structure. , 1994, Journal of psychosomatic research.

[54]  G J Taylor,et al.  The Twenty-item Toronto Alexithymia Scale--II. Convergent, discriminant, and concurrent validity. , 1994, Journal of psychosomatic research.

[55]  S Rose,et al.  Predicting PTSD symptoms in victims of violent crime: the role of shame, anger, and childhood abuse. , 2000, Journal of abnormal psychology.

[56]  C. Classen,et al.  Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley, Calif., firestorm. , 1994, The American journal of psychiatry.

[57]  C. Kirschbaum,et al.  Synthesis of a cortisol-biotin conjugate and evaluation as a tracer in an immunoassay for salivary cortisol measurement , 1992, The Journal of Steroid Biochemistry and Molecular Biology.

[58]  B I O'Toole,et al.  Risk Factors for Posttraumatic Stress Disorder in Australian Vietnam Veterans , 1998, The Australian and New Zealand journal of psychiatry.

[59]  W. Zung.  Zung Self-Rating Depression Scale and Depression Status Inventory , 1986 .

[60]  C. Benight,et al.  Coping Self-Efficacy Perceptions as a Mediator Between Acute Stress Response and Long-Term Distress Following Natural Disasters , 2002, Journal of traumatic stress.

[61]  B. Zimmerman,et al.  Self-efficacy expectations among traumatized adolescents. , 1995, Behaviour research and therapy.

[62]  R. Bryant.  Early predictors of posttraumatic stress disorder , 2003, Biological Psychiatry.

[63]  A. Harvey,et al.  Posttraumatic stress reactions in volunteer firefighters. , 1996, Journal of traumatic stress.

[64]  R. Novaco,et al.  Anger and Combat-Related Posttraumatic Stress Disorder , 2002, Journal of traumatic stress.

[65]  H. Veiel,et al.  The meaning and measurement of social support , 1992 .

[66]  J. Fairbank,et al.  Interpersonal and self-reported hostility among combat veterans with and without posttraumatic stress disorder , 1996, Journal of traumatic stress.

[67]  Elizabeth M. Smith,et al.  Psychiatric disorders in rescue workers after the Oklahoma City bombing. , 2002, The American journal of psychiatry.

[68]  A. Shalev,et al.  Predicting PTSD in trauma survivors: prospective evaluation of self-report and clinician-administered instruments , 1997, British Journal of Psychiatry.

[69]  Lr Derogatis,et al.  SCL-90-R, Administration, Scoring, and Procedures Manual-II for the R(evised) Version and Other Instruments of the Psychopathology Rating Scale Series , 1983 .

[70]  C. Brewin,et al.  Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. , 2000, Journal of consulting and clinical psychology.

[71]  Jacob Cohen,et al.  Applied multiple regression/correlation analysis for the behavioral sciences , 1979 .

[72]  S. Southwick,et al.  Low Urinary Cortisol Excretion in Patients with Posttraumatic Stress Disorder , 1990, The Journal of nervous and mental disease.

[73]  E. Giller,et al.  Low urinary cortisol excretion in holocaust survivors with posttraumatic stress disorder , 1994, Biological Psychiatry.

[74]  A. Holm,et al.  Salivary cortisol and serum prolactin in relation to stress rating scales in a group of rescue workers , 1999, Biological Psychiatry.

[75]  U. Ehlert,et al.  Psychoneuroendocrinological contributions to the etiology of depression, posttraumatic stress disorder, and stress-related bodily disorders: the role of the hypothalamus–pituitary–adrenal axis , 2001, Biological Psychology.

[76]  A. Gino,et al.  Relationship of cynical hostility and PTSD among vietnam veterans , 1994, Journal of traumatic stress.

[77]  D. Weiss,et al.  Predicting symptomatic distress in emergency services personnel. , 1995, Journal of consulting and clinical psychology.

[78]  Prior interpersonal trauma: the contribution to current PTSD symptoms in female rape victims. , 2000, Journal of abnormal psychology.

[79]  E. Foa,et al.  Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. , 1995, Journal of consulting and clinical psychology.

[80]  R. Lev-Wiesel,et al.  Time Does Not Heal All Wounds: Quality of Life and Psychological Distress of People Who Survived the Holocaust as Children 55 Years Later , 2003, Journal of traumatic stress.

[81]  R. Bryant,et al.  Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques. , 1999, The American journal of psychiatry.

[82]  C. Kirschbaum,et al.  Social support and oxytocin interact to suppress cortisol and subjective responses to psychosocial stress , 2003, Biological Psychiatry.

[83]  R. Kessler,et al.  Risk factors for DSM-III-R posttraumatic stress disorder: findings from the National Comorbidity Survey. , 1998, American journal of epidemiology.

[84]  U. Ehlert,et al.  Prevalence of symptoms of posttraumatic stress disorder in German professional firefighters. , 1998, The American journal of psychiatry.

[85]  D. Delahanty,et al.  Initial posttraumatic urinary cortisol levels predict subsequent PTSD symptoms in motor vehicle accident victims , 2000, Biological Psychiatry.

[86]  D. Hellhammer,et al.  Self-Reported Depressive Symptoms and Stress Levels in Healthy Young Men: Associations With the Cortisol Response to Awakening , 2003, Psychosomatic medicine.

[87]  M. Shenton,et al.  Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma , 2002, Nature Neuroscience.

[88]  Thomas R. Kosten,et al.  Sustained urinary norepinephrine and epinephrine elevation in post-traumatic stress disorder , 1987, Psychoneuroendocrinology.

[89]  Ralf Schwarzer,et al.  Self-Efficacy : Thought Control Of Action , 1992 .

[90]  H. Wittchen,et al.  Traumatic events and post‐traumatic stress disorder in the community: prevalence,risk factors and comorbidity , 2000, Acta psychiatrica Scandinavica.

[91]  A. Harvey,et al.  Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. , 1998, Journal of consulting and clinical psychology.

[92]  J. Boscarino.  Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: findings and clinical implications. , 1996, Journal of consulting and clinical psychology.

[93]  E. Foa,et al.  Evaluation of the German Version of the PTSD Symptom Scale (PSS) , 2001, Psychopathology.

[94]  R. Kessler,et al.  Posttraumatic stress disorder in the National Comorbidity Survey. , 1995, Archives of general psychiatry.