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The 1996 Detroit Area Survey of Trauma

Naomi Breslau, PhD; Ronald C. Kessler, PhD; Howard D. Chilcoat, ScD; Lonni R. Schultz, PhD; Glenn C. Davis, MD; Patricia Andreski, MA

Arch Gen Psychiatry. 1998;55:626-632.

ABSTRACT
Background  The study estimates the relative importance of specific types of traumas experienced in the community in terms of their prevalence and risk of leading to posttraumatic stress disorder (PTSD).

Methods  A representative sample of 2181 persons in the Detroit area aged 18 to 45 years were interviewed by telephone to assess the lifetime history of traumatic events and PTSD, according to DSM-IV . Posttraumatic stress disorder was assessed with respect to a randomly selected trauma from the list of traumas reported by each respondent, using a modified version of the Diagnostic Interview Schedule, Version IV, and the World Health Organization Composite International Diagnostic Interview.

Results  The conditional risk of PTSD following exposure to trauma was 9.2%. The highest risk of PTSD was associated with assaultive violence (20.9%). The trauma most often reported as the precipitating event among persons with PTSD (31% of all PTSD cases) was sudden unexpected death of a loved one, an event experienced by 60% of the sample, and with a moderate risk of PTSD (14.3%). Women were at higher risk of PTSD than men, controlling for type of trauma.

Conclusions  The risk of PTSD associated with a representative sample of traumas is less than previously estimated. Previous studies have overestimated the conditional risk of PTSD by focusing on the worst events the respondents had ever experienced. Although recent research has focused on combat, rape, and other assaultive violence as causes of PTSD, sudden unexpected death of a loved one is a far more important cause of PTSD in the community, accounting for nearly one third of PTSD cases.

INTRODUCTION

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ALTHOUGH posttraumatic stress disorder (PTSD) has been closely identified with Vietnam war veterans, there has been a growing interest in the disorder as it applies to a wide range of traumas experienced by individuals in the community.^1-8 The core features of PTSD consist of (1) the "stressor criterion" that defines the etiologic event in PTSD; and (2) the set of symptoms that defines the characteristic PTSD syndrome, ie, (a) reexperiencing the trauma, (b) numbing of responsiveness or avoidance of thoughts or acts related to the trauma, and (c) excess arousal.⁹ Recent surveys in the general population have estimated that approximately 1 adult in 12 has experienced PTSD at any time in life, roughly 15% to 24% of those exposed to traumatic events.^{3, 8}

Previous epidemiological studies have focused on traumas nominated by respondents as the worst or most upsetting events they had ever experienced. The purpose has been to measure the lifetime prevalence of PTSD in the population, assuming that the worst trauma experienced by each respondent is the one most likely to cause PTSD. Evidence supporting this assumption has been reported.⁴ However, data on the worst trauma also have been used to estimate the conditional risk of PTSD across types of trauma (ie, the probability of PTSD among those exposed to trauma). The focus on the worst traumas has probably overstated the conditional risk of PTSD given exposure, because these traumas represent the extreme end of the distribution of experiences regarded as potential causes of PTSD, in terms of their objective features or the psychological distress in the aftermath.⁸ It is reasonable to assume that traumas resulting in marked psychological distress would be more likely to be selected as the worst. A contamination of the selection of events by their psychological sequelae would result in a spuriously strong association between trauma and PTSD. An unbiased estimate of the conditional risk of PTSD can be obtained by eliciting complete accounts of all the traumas experienced by each respondent and assessing PTSD for a trauma randomly selected from each respondent's list.⁸ To our knowlwedge, no survey of this type has yet been reported.

The present study examines traumatic events and PTSD in a representative sample of 2181 persons in the Detroit area. An important advance in this study is the collection of a complete history of traumatic events and information on PTSD linked to a randomly selected trauma from the list of all traumas reported by each respondent. We focus on PTSD as defined in the DSM IV.⁹ Although the syndrome of PTSD has changed little from earlier DSM editions,^10-11 the stressor criterion that defines the etiologic event in PTSD changed materially. The new definition broadens the range of "qualifying" events beyond the core category that had initially been used to define PTSD, ie, military combat, war, disaster, and criminal violence. The revised definition also includes a subjective component, requiring that the "person's response involved intense fear, helplessness, or horror."⁹ The revision aligns the stressor criterion with ongoing clinical practice, which is guided by the principle that people may perceive and respond differently to outwardly similar events.¹²

MATERIALS AND METHODS

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SAMPLE

The 1996 Detroit Area Survey of Trauma is a representative sample of 2181 persons 18 to 45 years of age in the Detroit primary metropolitan statistical area (PMSA). The cutoff age of 45 years was selected based on evidence that the onset of PTSD occurs primarily in early adulthood.⁴ The Detroit PMSA is a 6-county area that contained 4266654 residents at the time of the 1990 census and 1922173 in the 18-to-45 age range.¹³ A random-digit dialing method was used to select the sample.^14-15 A total of 6110 households were contacted. Screening for age eligibility was completed in 76.2% of households, of which 64.1% contained an age-eligible respondent. In households with more than 1 age-eligible respondent, a random respondent was selected. An intensive recruitment effort with a financial incentive ($50) was made in a randomly selected subsample of initial nonrespondents (both those in which screening was not completed and in which eligibility was established but the predesignated respondent refused to participate). A 30% cooperation rate was obtained. These initial nonrespondents (n=295) were added to the final sample with a weight to adjust for their underrepresentation. Cooperation rate in eligible households was 86.8%. Additional weights were used to adjust for differences in number of age-eligible persons in the household, for oversampling of men (in anticipation of lower cooperation among men than women¹⁶), and for differences in the probability of completing the interview.¹⁷ Finally, to approximate the sample distribution to the population, poststratification weights were applied based on the joint distribution of age, sex, race, income, and education in the geographic area in the 1990 US census.¹³

Table 1, which presents the characteristics of the sample and the population of comparable age range in the Detroit PMSA in the 1990 census, suggests that we succeeded in getting a representative sample with respect to key characteristics.

View this table: [in this window] [in a new window] Table 1. The Detroit Area Survey of Trauma: Comparisons With Data on the Area in the 1990 US Census

ASSESSMENT OF EXPOSURE TO TRAUMATIC EVENTS

Trained interviewers administered a computer-assisted telephone interview, averaging 30 minutes. The interview began with a complete enumeration of traumatic events, using a list of 19 types of traumatic events, which operationalized the DSM-IV definition as explicated in its accompanying text (Table 2). An endorsement of an event type was followed by questions on the number of times an event of that type had occurred and the respondent's age at each time. A special data collection strategy was developed to ensure that events occurring at the same age were distinct and that linked traumas occurring on the same occasion were not counted as multiple traumas.

View this table: [in this window] [in a new window] Table 2. Lifetime Prevalence of Specific Traumatic Events (N=2181)

ASSESSMENT OF PTSD

A computer-assembled list of all the distinct events reported by the respondent was read by the interviewer and the respondent was asked to identify the 1 event that was most upsetting, the worst trauma. First, PTSD was evaluated in connection with this event, using the PTSD section of the Diagnostic Interview Schedule, Version IV (DIS-IV), and the World Health Organization Composite International Diagnostic Interview (CIDI), Version 2.1. The DIS-IV and the CIDI, which is modeled on the DIS-IV, are fully structured diagnostic interviews designed to be administered by experienced interviewers without clinical training.¹⁸ Second, a computer-selected random event from the complete list of distinct events reported by each respondent was then evaluated with respect to PTSD. Finally, PTSD was evaluated a third time for the earliest event reported by each respondent. In cases where respondents reported fewer than 3 lifetime events or where the randomly selected and/or earliest events were also the events nominated as most upsetting, fewer than 3 events were assessed. The responses were used to diagnose PTSD based on DSM-IV criteria.⁹ Although the DIS-IV or CIDI version for DSM-IV PTSD diagnosis has not yet been validated, a validation of the DIS for DSM-III-R PTSD, which contained symptom questions similar to those used here, found good agreement between the DIS and independent clinical reinterviews.⁸

DATA ANALYSIS

Analysis of exposure to trauma was conducted on weighted data, as described above. In addition, analysis of the randomly selected traumas took into account the number of traumas reported by each respondent. Each randomly selected event from each respondent's list of events was weighted by the number of events reported by the respondent. The weighting adjusts for the variation in the selection probabilities of events due to differences in the number of events across respondents. As a result, the sample of randomly selected events is representative of the total pool of events reported by the respondents.

Data are presented on 19 specific types of events, as well as 4 classes of events into which they were grouped (Table 2). Direct personal traumas were divided into 2 classes, separating events that involved intentional violence, referred to as "assaultive violence," from other types of directly experienced traumas, referred to as "other injury or shocking experience." The third category covers traumas involving "learning about traumatic events experienced by others." "Learning about the sudden unexpected death of a family member or a close friend" was separated from the third category because of its high prevalence in the population.

We used a series of univariate analyses to depict the distributions of exposure to traumatic events and estimate the associations of classes of traumas with key sociodemographic factors. Adjusted odds ratios, estimated in multiple logistic regressions, reflect the odds of exposure for persons in a given category relative to a reference group, adjusted for other factors. Based on respondents' reports of their lifetime history of events, including the age at each event, we estimated the rates of exposure from the first decade to age 45 years, using standard life table methods.^19-20 At each age interval, the estimated rate represents the risk of exposure, using as a denominator total person-years at that interval. It is not the hazard rate of first exposure, which would be based on person-years at each specific age interval contributed only by those who had not been previously exposed. Commercially available software (SUDAAN, Research Triangle Park, NC) was used to take into account the sample weights and obtain SEs for estimates based on weighted data. Similar analyses were conducted to describe the risk of PTSD after exposure and estimate the associations with sociodemographic factors, using data on the randomly selected traumas.

RESULTS

Jump to Section  • Top  • Introduction  • Materials and methods  • Results  • Comment  • Author information  • References

EXPOSURE TO TRAUMATIC EVENTS

The lifetime prevalence of exposure to trauma varied widely across traumatic events, with some occurring in less than 2% of the population (ie, held captive/tortured/kidnapped, military combat) and others in more than 25% (eg, mugged, serious car crash) (Table 2). Sudden unexpected death of a close relative or friend was the most prevalent, with 60% of the sample having experienced an event of this type. The lifetime prevalence of exposure to any trauma was 89.6% (SE=0.8). The mean number of distinct traumatic events reported by persons exposed to any trauma was 4.8 (SE=0.1), and was significantly higher in men than in women, 5.3 vs 4.3, respectively (Student t=5.6, P<.001).

SOCIODEMOGRAPHIC FACTORS ASSOCIATED WITH EXPOSURE TO TRAUMA

The distributions of exposure to traumatic events and the associations between exposure and key sociodemographic factors were examined in relation to the 4 classes of traumatic events (Table 3). Women were about half as likely as men to be exposed to assaultive violence and other injury or shocking experience, adjusted for sociodemographic factors. Sex comparisons of exposure to specific traumas within the assaultive violence class showed that women were more likely than men to report rape (9.4% vs 1.1%) and other sexual assault (9.4% vs 2.8%), whereas men were more likely than women to report other types of assaultive violence, including mugging or threatened with a weapon (34.0% vs 16.4%), shot or stabbed (8.2% vs 1.8%), and badly beaten up (13.1% vs 9.8%) (data not shown in a table). The lifetime prevalence of assaultive violence was higher in nonwhites than whites, in persons with low education than college graduates, in those with low income than high income, in central-city residents than other-area residents, and in those previously married than married. The associations with place of residence and marital status disappeared when race, education, and income were controlled. The adjusted odds for assaultive violence was approximately 2-fold higher in nonwhites than whites, and in those with less than high school education and annual income of less than $25000, compared with college graduates and those with annual income of $75000 or above, respectively. In contrast with assaultive violence, other classes of trauma were only weakly or not at all associated with race and socioeconomic indicators (Table 3).

View this table: [in this window] [in a new window] Table 3. Prevalence of Exposure to 4 Classes of Trauma by Sex, Race, Education, Income, Marital Status, and Residence (N=2181)*

AGE-SPECIFIC RISK OF TRAUMA

Figure 1 depicts the occurrence rates of exposure to trauma by age, using standard life table methods. The rates of occurrence of all 4 classes of trauma peaked sharply at age 16 to 20 years. However, marked differences were observed across classes of trauma in the pattern of the rates over the life span of the respondents. The probability of assaultive violence declined precipitously after age 20 years, continued to decline in the third and fourth decades of life, and remained low up to age 45 years. In contrast, the probabilities of other classes of trauma, which also declined after age 20 years, did not continue to decline in the subsequent years. Sudden unexpected death of a loved one was the only trauma to remain at the high level it reached at the 16-to-20 age interval until age 40 years and to climax between 41 and 45 years of age.

View larger version (21K): [in this window] [in a new window] Figure 1. Age-specific occurrence rates of 4 classes of traumatic events. At each age interval, the occurrence rate is estimated from the number of exposures divided by the number of person-years at that interval.

THE CONDITIONAL RISK OF PTSD

The conditional probability of PTSD was estimated on the randomly selected traumatic events (Table 4). Overall, the probability of PTSD after exposure was 9.2% (SE=1.0)—13.0% (SE=1.6) in women and 6.2% (SE=1.2) in men. Assaultive violence had the highest probability of PTSD (20.9%). Learning about traumatic events experienced by others had the lowest probability of PTSD (2.2%). However, learning about the sudden unexpected death of a loved one was associated with a moderate probability of PTSD (14.3%).

View this table: [in this window] [in a new window] Table 4. Posttraumatic Stress Disorder (PTSD) Risk Associated With Specific Traumas and the Proportion of PTSD Cases Resulting From Various Types of Traumas*

PROPORTIONS OF PTSD CASES RESULTING FROM SPECIFIC TYPES OF TRAUMAS

As shown in the third part of Table 4, the single most important trauma as cause of PTSD was sudden unexpected death of a loved one, with 31.1% of all PTSD cases attributable to an event of this type. The prominence of unexpected death of a loved one reflects its high prevalence in the community and the moderate risk of PTSD associated with it. Assaultive violence as a category accounted for 39.5% of PTSD cases. However, each specific type of trauma subsumed under it accounted for a small proportion of PTSD cases.

DURATION OF PTSD

Kaplan-Meier survival methods²¹ were used to estimate the time to remission of PTSD in persons who met criteria for the disorder (Figure 2). Approximately 26% of PTSD cases remitted by 6 months, and 40% by 12 months. From that point on, remission tapered off. The median time to remission was 24.9 months, and in more than one third of cases PTSD persisted for more than 60 months. Posttraumatic stress disorder persisted longer in women than men (log-rank ²₁=10.568, P=.002), with median duration of 48.1 months in women vs 12.0 months in men. Posttraumatic stress disorder persisted longer in cases resulting from traumas experienced directly, compared with learning about traumas to a loved one or a sudden unexpected death of a loved one (log-rank ²₁=6.534, P=.01) with median duration of 48.1 months vs 12.1 months, respectively. Using Cox proportional hazards model, no interaction was detected between sex and trauma type (²₁=.001, P=.99).²² Hazards ratios for remission in women vs men was 0.53 (95% confidence interval [CI], 0.36-0.90), and for directly experienced trauma vs other trauma, 0.61 (95% CI, 0.41-0.90), with each variable adjusted for the effect of the other.

View larger version (20K): [in this window] [in a new window] Figure 2. Remission of posttraumatic stress disorder (PTSD) by sex and trauma type.

SOCIODEMOGRAPHIC FACTORS ASSOCIATED WITH THE RISK FOR PTSD AFTER EXPOSURE

Sex emerged as a significant risk factor for PTSD when other sociodemographic factors were controlled, with women's rate being 2-fold higher than men's (Table 5). The sex difference remained nearly the same when trauma type was controlled in a conditional regression in which respondents were grouped into risk sets based on specific trauma types. A considerable race difference was observed in the PTSD rate, a difference that was no longer significant when adjusted for other variables. Note that when central city was dropped from the model, the adjusted odds ratio for PTSD in nonwhites vs whites was 1.80 (95% CI, 1.11-2.94). A higher PTSD rate was observed also in the formerly married than the married, a difference that disappeared when race and socioeconomic factors were controlled.

View this table: [in this window] [in a new window] Table 5. Conditional Risk for Posttraumatic Stress Disorder (PTSD) by Sex, Race, Education, Income, Marital Status, and Residence*

ADDITIONAL ANALYSIS: PTSD FROM THE WORST EVENTS

The availability of data on traumas nominated by the respondents as the worst offers a direct comparison of the unbiased estimate of the conditional risk of PTSD based on the randomly selected traumas with the estimation approach used in previous studies. The probability of PTSD associated with the worst events was 13.6% (SE=0.9), 17.7% (SE=1.5) in women and 9.5% (SE=1.1) in men.

COMMENT

Jump to Section  • Top  • Introduction  • Materials and methods  • Results  • Comment  • Author information  • References

Key findings from this study are as follows: (1) The lifetime prevalence of exposure to 1 or more traumatic events defined according to DSM-IV was 89.6%; the most prevalent trauma was sudden unexpected death of a close relative or friend (60%). (2) Assaultive violence was higher in men, nonwhites, and persons with low socioeconomic status; other classes of trauma showed weak or no relationship with race and socioeconomic status. (3) The conditional probability of PTSD after exposure to a representative sample of traumas experienced by the respondents was 9.2%; it was 2-fold higher in women than in men, controlling for type of trauma. (4) Assaultive violence had the highest risk of PTSD. (5) Sudden unexpected death of a loved one contributed a large proportion of PTSD cases (31%), because of its high rate in the population and a moderate risk of PTSD. (6) In most cases (74%), PTSD persisted for more than 6 months; the duration of PTSD was longer in women than in men and in cases resulting from trauma experienced directly than learning about trauma or sudden death of a loved one.

The lifetime prevalence of exposure to 1 or more traumatic events in this study was higher than in previous community surveys that have used the narrower definition of trauma. However, estimates from the National Comorbidity Survey of the prevalence of specific types of trauma with similar definition to those in this study, ie, rape, natural disaster, and witnessing a killing or serious injury, are close to the estimates in this study.⁸ The prevalence of sudden unexpected death of a loved one, which was found to be higher than any other trauma, had not been estimated previously.

We found that the period of high risk of exposure to assaultive violence is limited to late adolescence and early adulthood. In addition, while other classes of trauma were unrelated to race and social class, assaultive violence was more likely to occur in nonwhites and in persons in lower social classes. Inequality in the risk of assaultive violence was observed also in relation to central-city residence, although the relationship disappeared when race was controlled. As in many metropolitan areas in the United States, the subset of the sample with central-city residence was predominately nonwhite (78.4%), whereas the subset in the remaining PMSA was predominately white (87%). The finding that assaultive violence had a stronger link to race than to central-city residence might reflect the fact that, even within the central city, whites and nonwhites reside in separate neighborhoods that vary with respect to characteristics that correlate with assaultive violence.^23-25 Furthermore, nonwhites who resided outside the central city at the time of the interview might have lived in the central city in the past; their lifetime risk for exposure to violence would reflect that experience. Similar findings on race, social class, sex, and age differences have been reported for exposure to criminal victimization.^26-28

This analysis confirms the suspicions that previous studies, by focusing on the worst traumas, overestimated the conditional risk of PTSD. The conditional risk of PTSD based on the representative sample of traumas was approximately one third lower than that based on the worst traumas. The analysis indicates that sudden unexpected death of a loved one is a common experience and accounts for approximately one third of PTSD cases in the community. Its relative importance as cause of PTSD might be particularly prominent after young adulthood. Our findings suggest that the profile of PTSD in the community, in terms of the etiologic events that precipitate the disorder as well as its course, might vary with age. Posttraumatic stress disorder in late adolescence and young adulthood might be more likely than in later years to result from experiencing assaultive violence and be of longer duration. In later years, PTSD might more often result from experiencing a sudden unexpected death of a loved one and be of much shorter duration.

Women's risk of PTSD following exposure to trauma was approximately 2-fold higher than that of men, a finding consistent with previous reports.^{3, 5, 8, 29-30} The sex difference cannot be explained by differences in the type or number of traumas experienced by men and women and suggests a greater vulnerability to the PTSD effects of trauma in women. A similar conclusion was reached in the National Comorbidity Survey, in which the female-to-male relative risk, adjusted for trauma type, was 4.0.⁸ Our analysis also revealed a sex difference in the chronicity of PTSD, with a considerably longer duration in women than men, independent of the type of trauma that gave rise to PTSD.

Recent research has focused on combat, rape, and sexual or physical assault as causes of PTSD. The evidence that the highest risk of PTSD is linked to these types of trauma underscores the importance of this focus in future research. However, our finding that sudden unexpected death of a loved one, despite a lower risk of PTSD, accounts for a large proportion of PTSD cases in the community has not been reported previously. It suggests the need for further research on this heterogeneous category of trauma.

The principal goal in this study was to provide an unbiased estimate of the conditional risk of PTSD in the general population and to describe the distribution of trauma and PTSD across subgroups of the population. Other suspected risk factors for exposure and PTSD, primarily preexisting psychiatric disorders shown previously to be associated with these phenomena,^{3-4,8, 30} have not been examined in this study. In view of our finding that the risk of PTSD following trauma is even lower than in recent studies that focused on the worst trauma, the continued investigation of vulnerability factors is essential for understanding why some of those who experience trauma develop PTSD.

AUTHOR INFORMATION

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Accepted for publication February 12, 1998.

Supported in part by grant MH 48802 from the National Institute of Mental Health, Bethesda, Md.

Reprints: Naomi Breslau, PhD, Director of Research, Department of Psychiatry, Henry Ford Health Sciences Center, One Ford Place, Department 3A, Detroit, MI 48202-3450 (e-mail: nbresla1{at}hfhs.org).

From the Departments of Psychiatry (Drs Breslau, Chilcoat, and Davis and Ms Andreski) and Biostatistics/Research Epidemiology (Drs Breslau, Chilcoat, and Schultz), Henry Ford Health System, Detroit, Mich; and the Department of Health Care Policy, Harvard Medical School, Boston, Mass (Dr Kessler).

REFERENCES

Jump to Section  • Top  • Introduction  • Materials and methods  • Results  • Comment  • Author information  • References

1. Helzer J, Robins L, McEvoy L. Post-traumatic stress disorder in the general population: findings of the Epidemiologic Catchment Area Survey. N Engl J Med. 1987;317:1630-1634. ABSTRACT 2. Davidson JRT, Hughes D, Blazer DG. Post-traumatic stress disorder in the community: an epidemiological study. Psychol Med. 1991;21:713-721. WEB OF SCIENCE | PUBMED 3. Breslau N, Davis GC, Andreski P, Peterson EL. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry. 1991;48:216-222. FREE FULL TEXT 4. Breslau N, Davis GC, Peterson E, Schultz L. Psychiatric sequelae of posttraumatic stress disorder in women. Arch Gen Psychiatry. 1997;54:81-87. FREE FULL TEXT 5. Norris FH. Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol. 1992;60:409-418. FULL TEXT | WEB OF SCIENCE | PUBMED 6. Resnick HS, Kilpatrick DG, Dansky BS, Saunders BE, Best CL. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol. 1993;61:984-991. FULL TEXT | WEB OF SCIENCE | PUBMED 7. March JS. What constitutes a stressor? the "Criterion A" issue. In: Davidson JRT, Foa EB, eds. Posttraumatic Stress Disorder, DSM-IV and Beyond. Washington, DC: American Psychiatric Press; 1993:37-54. 8. Kessler RC, Sonnega A, Bromet E, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060. FREE FULL TEXT 9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Press; 1994. 10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, DC: American Psychiatric Press; 1987. 11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC: American Psychiatric Press; 1980. 12. Young A. The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press; 1995. 13. US Bureau of the Census. Census of Population and Housing, 1990 (United States): Public Use Microdata Sample: 1% Sample. Washington, DC: US Dept of Commerce, Bureau of the Census; 1990. 14. Survey Sampling Inc. Random Digit Telephone Sampling Methodology. Fairfield, Conn: Survey Sampling Inc; 1996. 15. Potthoff RF. Telephone sampling in epidemiologic research: to reap the benefits, avoid the pitfalls. Am J Epidemiol. 1994;10:967-978. 16. Groves RM. Survey Errors and Survey Costs. New York, NY: John Wiley & Sons; 1989:207. 17. Kessler RC, Little RJA, Groves RM. Advances in strategies for minimizing and adjusting for survey nonresponse. Epidemiol Rev. 1995;17:192-204. FREE FULL TEXT 18. World Health Organization. Composite International Diagnostic Interview (CIDI, Version 2.1). Geneva, Switzerland: World Health Organization; 1997. 19. Lawless JF. Statistical Models and Methods for Lifetime Data. New York, NY: John Wiley & Sons; 1982. 20. Crowley J. Some Extensions of Log Rank Test. University of Wisconsin–Madison, Departments of Human Oncology and Statistics; 1980. Technical Report 10. 21. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457-481. FULL TEXT | WEB OF SCIENCE 22. Kay R. Proportional hazards regression models and the analysis of censored survival data. Appl Stat. 1977;26:227-237. FULL TEXT 23. Lillie-Blanton M, Anthony JC, Schuster CR. Probing the meaning of racial/ethnic group comparisons in crack-cocaine smoking. JAMA. 1993;269:993-997. FREE FULL TEXT 24. Crum RM, Lillie-Blanton M, Anthony JC. Neighborhood environment and opportunity to use cocaine in late childhood and early adolescence. Drug Alcohol Depend. 1996;43:155-161. FULL TEXT | WEB OF SCIENCE | PUBMED 25. Chilcoat HD, Schütz CG. Racial/ethnic and age differences in crack use within neighborhoods. Addict Res. 1995;3:103-111. 26. Cohen LE, Felson M. Social change and crime rate trends: a routine activity approach. Am Soc Rev. 1979;44:588-607. FULL TEXT 27. Gottfredson M. On the etiology of criminal victimization. J Criminal Law Criminol. 1981;72:714-726. FULL TEXT | WEB OF SCIENCE 28. Langan PA, Innes CA. The Risk of Violent Crime. Washington, DC: Bureau of Justice Statistics; 1985. Special Report, publication NCJ-97119. 29. Green BL. Psychosocial research in traumatic stress: an update. J Trauma Stress. 1994;7:341-362. FULL TEXT | WEB OF SCIENCE | PUBMED 30. Breslau N, Davis GC, Andreski P, Peterson EL, Schultz LR. Sex differences in posttraumatic stress disorder. Arch Gen Psychiatry. 1997;54:1044-1048. FREE FULL TEXT

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Int J Soc Psychiatry 2008;54:414-424.
ABSTRACT  

Reduction of State Victim Compensation Disparities in Disadvantaged Crime Victims Through Active Outreach and Assistance: A Randomized Trial
Alvidrez et al.
AJPH 2008;98:882-888.
ABSTRACT | FULL TEXT  

A Second Look at Prior Trauma and the Posttraumatic Stress Disorder Effects of Subsequent Trauma: A Prospective Epidemiological Study
Breslau et al.
Arch Gen Psychiatry 2008;65:431-437.
ABSTRACT | FULL TEXT  

Intensive Remedial Identity Work: Responses to Workplace Bullying Trauma and Stigmatization
Lutgen-Sandvik
Organization 2008;15:97-119.
ABSTRACT  

Terrorism, Acute Stress, and Cardiovascular Health: A 3-Year National Study Following the September 11th Attacks
Holman et al.
Arch Gen Psychiatry 2008;65:73-80.
ABSTRACT | FULL TEXT  

Incidence of Drug Problems in Young Adults Exposed to Trauma and Posttraumatic Stress Disorder: Do Early Life Experiences and Predispositions Matter?
Reed et al.
Arch Gen Psychiatry 2007;64:1435-1442.
ABSTRACT | FULL TEXT  

Building Resistance, Resilience, and Recovery in the Wake of School and Workplace Violence
Nucifora et al.
dmphp 2007;1:S33-S37.
ABSTRACT | FULL TEXT  

Integrating smoking cessation into mental health care for post-traumatic stress disorder
McFall et al.
Clin Trials 2007;4:178-189.
ABSTRACT  

Parental Posttraumatic Stress Symptoms as a Moderator of Child's Acute Biological Response and Subsequent Posttraumatic Stress Symptoms in Pediatric Injury Patients
Nugent et al.
J Pediatr Psychol 2007;32:309-318.
ABSTRACT | FULL TEXT  

Post-traumatic stress disorder in childhood
Tareen et al.
EDUCATION AND PRACTICE 2007;92:ep1-ep6.
FULL TEXT  

Treatment of Acute Posttraumatic Stress Disorder With Brief Cognitive Behavioral Therapy: A Randomized Controlled Trial
Sijbrandij et al.
Am. J. Psychiatry 2007;164:82-90.
ABSTRACT | FULL TEXT  

Childhood Antecedents of Exposure to Traumatic Events and Posttraumatic Stress Disorder
Storr et al.
Am. J. Psychiatry 2007;164:119-125.
ABSTRACT | FULL TEXT  

Recent fear is resistant to extinction
Maren and Chang
Proc. Natl. Acad. Sci. USA 2006;103:18020-18025.
ABSTRACT | FULL TEXT  

Intelligence and Other Predisposing Factors in Exposure to Trauma and Posttraumatic Stress Disorder: A Follow-up Study at Age 17 Years.
Breslau et al.
Arch Gen Psychiatry 2006;63:1238-1245.
ABSTRACT | FULL TEXT  

Personality Traits, Coping Style, and Perceived Threat as Predictors of Posttraumatic Stress Disorder After Exposure to a Terrorist Attack: A Prospective Study
Gil and Caspi
Psychosom. Med. 2006;68:904-909.
ABSTRACT | FULL TEXT  

Smoking as a complex but critical covariate in neurobiological studies of posttraumatic stress disorders: a review
Rasmusson et al.
J Psychopharmacol 2006;20:693-707.
ABSTRACT  

Cognitive-Behavioral Treatment of Rape- and War-Related Posttraumatic Stress Disorder With a Female, Bosnian Refugee
Schulz et al.
Clinical Case Studies 2006;5:191-208.
ABSTRACT  

Gender Differences and Acute Stress Reactions Among Rescue Personnel 36 to 48 Hours After Exposure to Traumatic Event
Ben-Ezra et al.
Traumatology 2006;12:139-142.
ABSTRACT  

Posttraumatic Stress in Youth Experiencing Illnesses and Injuries: An Exploratory Meta-Analysis
Kahana et al.
Traumatology 2006;12:148-161.
ABSTRACT  

Symptoms of Posttraumatic Stress Disorder in a Community Sample of Low-Income Pregnant Women
Smith et al.
Am. J. Psychiatry 2006;163:881-884.
ABSTRACT | FULL TEXT  

Inconsistency in reporting potentially traumatic events
HEPP et al.
Br. J. Psychiatry 2006;188:278-283.
ABSTRACT | FULL TEXT  

Predicting Posttraumatic Stress Symptoms From Pretraumatic Risk Factors: A 2-Year Prospective Follow-Up Study in Firefighters
Heinrichs et al.
Am. J. Psychiatry 2005;162:2276-2286.
ABSTRACT | FULL TEXT  

The Structure of Posttraumatic Stress Disorder: Latent Class Analysis in 2 Community Samples
Breslau et al.
Arch Gen Psychiatry 2005;62:1343-1351.
ABSTRACT | FULL TEXT  

Posttraumatic Stress Disorder and Physical Comorbidity Among Female Children and Adolescents: Results From Service-Use Data
Seng et al.
Pediatrics 2005;116:e767-e776.
ABSTRACT | FULL TEXT  

Prevalence of Mental Disorders and Utilization of Mental Health Services in Two American Indian Reservation Populations: Mental Health Disparities in a National Context
Beals et al.
Am. J. Psychiatry 2005;162:1723-1732.
ABSTRACT | FULL TEXT  

Biological Underpinnings of Health Alterations in Women With PTSD: A Sex Disparity
Gill et al.
Biol Res Nurs 2005;7:44-54.
ABSTRACT  

Longitudinal Course of Posttraumatic Stress Disorder and Posttraumatic Stress Disorder Symptoms in a Community Sample of Adolescents and Young Adults
Perkonigg et al.
Am. J. Psychiatry 2005;162:1320-1327.
ABSTRACT | FULL TEXT  

The Epidemiology of Post-Traumatic Stress Disorder after Disasters
Galea et al.
Epidemiol Rev 2005;27:78-91.
FULL TEXT  

Social Epidemiology of Trauma Among 2 American Indian Reservation Populations
Manson et al.
AJPH 2005;95:851-859.
ABSTRACT | FULL TEXT  

Posttraumatic Stress Responses in Children: Awareness and Practice Among a Sample of Pediatric Emergency Care Providers
Ziegler et al.
Pediatrics 2005;115:1261-1267.
ABSTRACT | FULL TEXT  

Benefits of Combined Psychological and Medical Therapy for Treating an Individual With Generalized Anxiety Disorder and Post-Traumatic Stress Disorder
Reeder and Montgomery
Clinical Case Studies 2005;4:160-172.
ABSTRACT  

Cognitive Model of the Maintenance and Treatment of Post-traumatic Stress Disorder Applied to Children and Adolescents
Vickers
Clin Child Psychol Psychiatry 2005;10:217-234.
ABSTRACT  

The Role of Peritraumatic Dissociation and Gender in the Association Between Trauma and Mental Health in a Palestinian Community Sample
Punamaki et al.
Am. J. Psychiatry 2005;162:545-551.
ABSTRACT | FULL TEXT  

Psychological Distress of Nurses in Taiwan Who Worked During the Outbreak of SARS
Chen et al.
Psychiatr. Serv. 2005;56:76-79.
ABSTRACT | FULL TEXT  

Behavioral Interventions for Recent Trauma: Empirically Informed Practice Guidelines
Gray and Litz
Behav Modif 2005;29:189-215.
ABSTRACT  

Psychometric Properties of the Life Events Checklist
Gray et al.
Assessment 2004;11:330-341.
ABSTRACT  

Hippocampal Volume in Adult Burn Patients With and Without Posttraumatic Stress Disorder
Winter and Irle
Am. J. Psychiatry 2004;161:2194-2200.
ABSTRACT | FULL TEXT  

Posttraumatic Stress Disorder and Depression Following Trauma: Understanding Comorbidity
O'Donnell et al.
Am. J. Psychiatry 2004;161:1390-1396.
ABSTRACT | FULL TEXT  

Prevalence of Trauma, PTSD, and Dissociation in Court-Referred Adolescents
Brosky and Lally
J Interpers Violence 2004;19:801-814.
ABSTRACT  

Community Violence and PTSD in Selected South African Townships
Dinan et al.
J Interpers Violence 2004;19:727-742.
ABSTRACT  

Age of traumatisation as a predictor of post-traumatic stress disorder or major depression in young women
Maercker et al.
Br. J. Psychiatry 2004;184:482-487.
ABSTRACT | FULL TEXT  

Anxiety, Depressive, and Posttraumatic Stress Disorders Among Mothers of Pediatric Survivors of Hematopoietic Stem Cell Transplantation
Manne et al.
Pediatrics 2004;113:1700-1708.
ABSTRACT | FULL TEXT  

Sleep in Lifetime Posttraumatic Stress Disorder: A Community-Based Polysomnographic Study
Breslau et al.
Arch Gen Psychiatry 2004;61:508-516.
ABSTRACT | FULL TEXT  

Posttraumatic Stress Disorder: Acquisition, Recognition, Course, and Treatment
Davidson et al.
J. Neuropsychiatry Clin. Neurosi. 2004;16:135-147.
ABSTRACT | FULL TEXT  

Posttraumatic Stress Disorder and Trauma in Youth in Juvenile Detention
Abram et al.
Arch Gen Psychiatry 2004;61:403-410.
ABSTRACT | FULL TEXT  

Psychiatric Morbidity Following Injury
O'Donnell et al.
Am. J. Psychiatry 2004;161:507-514.
ABSTRACT | FULL TEXT  

Testimonial Psychotherapy for Adolescent Refugees: a Case Series
Lustig et al.
Transcultural Psychiatry 2004;41:31-45.
ABSTRACT  

Diagnosis and management of anxiety disorders.
Shelton
JAOA: Journal of the American Osteopathic Association 2004;104:S2-S5.
ABSTRACT | FULL TEXT  

Posttraumatic Stress Disorder in Female Veterans: Association With Self-reported Health Problems and Functional Impairment
Dobie et al.
Arch Intern Med 2004;164:394-400.
ABSTRACT | FULL TEXT  

Posttraumatic Stress Disorder and Health-Related Quality of Life in Long-Term Survivors of Acute Respiratory Distress Syndrome
Kapfhammer et al.
Am. J. Psychiatry 2004;161:45-52.
ABSTRACT | FULL TEXT  

Recognizing post-traumatic stress disorder
Sher
QJM 2004;97:1-5.
FULL TEXT  

The Relationship of Borderline Personality Disorder to Posttraumatic Stress Disorder and Traumatic Events
Golier et al.
Am. J. Psychiatry 2003;160:2018-2024.
ABSTRACT | FULL TEXT  

Good grief: a medical challenge
Klein and Alexander
Trauma 2003;5:261-271.
ABSTRACT  

Posttraumatic Stress Disorder
Connor and Butterfield
Focus 2003;1:247-262.
ABSTRACT | FULL TEXT  

Posttraumatic Stress Disorder and the Incidence of Nicotine, Alcohol, and Other Drug Disorders in Persons Who Have Experienced Trauma
Breslau et al.
Arch Gen Psychiatry 2003;60:289-294.
ABSTRACT | FULL TEXT  

Prevalence of Psychiatric Disorders Among Bereaved Survivors of a Disastrous Earthquake in Taiwan
Kuo et al.
Psychiatr. Serv. 2003;54:249-251.
ABSTRACT | FULL TEXT  

Culture and Traumatic Events
Antai-Otong
J Am Psychiatr Nurses Assoc 2002;8:203-208.
ABSTRACT  

Update in Psychiatry
Schneider and Levenson
ANN INTERN MED 2002;137:671-677.
FULL TEXT  

Genetic and Environmental Influences on Trauma Exposure and Posttraumatic Stress Disorder Symptoms: A Twin Study
Stein et al.
Am. J. Psychiatry 2002;159:1675-1681.
ABSTRACT | FULL TEXT  

A 46-Year-Old Man With Anxiety and Nightmares After a Motor Vehicle Collision
Stein
JAMA 2002;288:1513-1521.
FULL TEXT  

Nationwide Longitudinal Study of Psychological Responses to September 11
Silver et al.
JAMA 2002;288:1235-1244.
ABSTRACT | FULL TEXT  

Stress Response Syndromes and Cancer: Conceptual and Assessment Issues
Gurevich et al.
Psychosomatics 2002;43:259-281.
ABSTRACT | FULL TEXT  

Traumatic events in a general practice population: the patient's perspective
Mol et al.
Fam Pract 2002;19:390-396.
ABSTRACT | FULL TEXT  

Risk Factors for Psychosocial Dysfunction Among Enrollees in the State Children's Health Insurance Program
Brickman et al.
Psychiatr. Serv. 2002;53:614-619.
ABSTRACT | FULL TEXT  

Community Violence Exposure in University Students: A Replication and Extension
Scarpa et al.
J Interpers Violence 2002;17:253-272.
ABSTRACT  

Post-Traumatic Stress Disorder
Yehuda
NEJM 2002;346:108-114.
FULL TEXT  

A National Survey of Stress Reactions after the September 11, 2001, Terrorist Attacks
Schuster et al.
NEJM 2001;345:1507-1512.
ABSTRACT | FULL TEXT  

Lifetime Events and Posttraumatic Stress Disorder in 4 Postconflict Settings
de Jong et al.
JAMA 2001;286:555-562.
ABSTRACT | FULL TEXT  

Trauma, Symptoms of Posttraumatic Stress Disorder, and Associated Problems Among Incarcerated Veterans
Saxon et al.
Psychiatr. Serv. 2001;52:959-964.
ABSTRACT | FULL TEXT  

Incidence and Prediction of Posttraumatic Stress Disorder Symptoms in Severely Injured Accident Victims
Schnyder et al.
Am. J. Psychiatry 2001;158:594-599.
ABSTRACT | FULL TEXT  

Near drowning: self therapy in situ
Ness and Macaskill
BMJ 2000;321:1604-1606.
FULL TEXT  

Prospective Study of Posttraumatic Stress, Anxiety, and Depressive Reactions After Earthquake and Political Violence
Goenjian et al.
Am. J. Psychiatry 2000;157:911-895.
ABSTRACT | FULL TEXT  

Quality of Life in Individuals With Anxiety Disorders
Mendlowicz and Stein
Am. J. Psychiatry 2000;157:669-682.
ABSTRACT | FULL TEXT  

A Conceptual Framework for the Impact of Traumatic Experiences
CARLSON and DALENBERG
Trauma Violence Abuse 2000;1:4-28.
ABSTRACT  

Selective serotonin reuptake inhibitors in post-traumatic stress disorder
Hidalgo and Davidson
J Psychopharmacol 2000;14:70-76.
ABSTRACT  

Intrusive Traumatic Recollections and Comorbid Posttraumatic Stress Disorder in Depressed Patients
Carlier et al.
Psychosom. Med. 2000;62:26-32.
ABSTRACT | FULL TEXT  

Previous Exposure to Trauma and PTSD Effects of Subsequent Trauma: Results From the Detroit Area Survey of Trauma
Breslau et al.
Am. J. Psychiatry 1999;156:902-907.
ABSTRACT | FULL TEXT  

Short Screening Scale for DSM-IV Posttraumatic Stress Disorder
Breslau et al.
Am. J. Psychiatry 1999;156:908-911.
ABSTRACT | FULL TEXT