Social Support in PTSD: An Analysis of Gender, Race, and Trauma Type

Introduction

Posttraumatic stress disorder (PTSD) is a mental disorder that millions of people are diagnosed with each year (Kessler, 2005). Prevalence rates indicate that approximately 3.5% (or 7.7 million people) of Americans age 18 and older currently have PTSD (Kessler, 2005). According to figures collected in 2000 by the National Comorbity Survey (NCS), 56% of Americans experience trauma in their lifetime, and 8% go on to develop PTSD from that trauma (Perkonigg et al., 2000). According to the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV-TR) criteria for PTSD includes a “stressor” (or a traumatic event); intrusive recollection of the trauma that can include dreams or flashbacks; persistent avoidance of stimuli (like thoughts or activities) that may be related to the trauma; hyper arousal, which includes difficulty sleeping, hyper-vigilance, or exaggerated startle response; and the duration of the disturbance must be longer than one month (American Psychological Association, 2000).

Risk

Though PTSD is one of the most common difficulties among those who experience trauma, most trauma victims do not develop PTSD (Charney, 2004). Risk factors for PTSD are varied. Several meta-analyses concluded that prior trauma, perceived life-threat during trauma, trauma severity, additional life-stress, and adverse childhood events were all predictors of a person developing PTSD after experiencing trauma. (Brewin, Andrews & Valentine, 2000; Ozer et. al, 2003). The largest risk factor, however, was lack of social support (Brewin et al., 2000). Conversely, the presence of social support is seen as one of the best protective factors against developing PTSD (Lazarus & Folkman, 1984) as well as a predictor of better treatment outcomes (Thrasher et al., 2010). Because of the importance of the factor, social support, in the development and treatment of PTSD, many studies have examined its impact.

Social Support

The impact of social support on treatment outcome can be significant. One study (Thrasher et al., 2010) examined the role of social support in treatment utilizing exposure therapy, cognitive restructuring, a combination of both, or a relaxation control. This randomized, controlled trial assessed 87 men and women with chronic PTSD for their level of intensity in diagnostic symptoms on a Clinician Administered PTSD Scale (CAPS). The same sample was also administered the Significant Others Scale (SOS) to assess their level of social support. This study found that social support predicted greater symptom improvement on the CAPS test, after treatment, more than any other variable, including trauma severity, age, trauma duration, and number of life events preand post-trauma. They also found that, although all types of treatment were effective, those who reported less social support received less therapeutic benefit than those who reported greater social support. In essence, social support was a contributing factor in treatment outcome.

Another study (Yuan et al., 2011) examined the kinds of protective factors that were exhibited in a cohort of police officers. A sample of 233 police officers were assessed for PTSD symptoms during their training in the police academy and again after 2 years of service. They found that a number of variables acted as protective factors against developing PTSD, including race (Caucasian), less exposure to trauma prior to service, and greater selfworth. They found, however that greater social adjustment (or socialization) was a protective factor both prior to service as well as after 2 years of service.

Many studies have shown that low levels of social support are met with negative health outcomes (Berkman & Syme, 1979; Cohen & Wills, 1985; House, Landis & Umberson, 1988). In one study, specifically, a sample of over 1000 New Yorkers were evaluated on their levels of social support post-9/11. Those who reported high levels of social support were much less likely to develop PTSD and depression than those with low levels of social support (Galea et al, 2002). Based on the protective factor of social support, as well as the increased efficacy of treatment that occurs when a patient has high levels of social support, we can conclude that social support is a significant variable to discuss in the realm of mental health. Social support, as a whole, has been proven to be significant, but is all social support positive?

Facets

The facets, or components, of social support have also been examined in various studies. The differences between the quality and quantity of social support were observed in several studies, noting that quantity did not denote quality when examining social support (Barrera, 1981; Sarason, Levine, Basham & Sarason, 1983). Social support is characterized in one model, the social networks model. This model describes how many people one interacts with, and how often they interact. Another way of to analyze social support is to look within the context of the quality of the relationships a person has. For example, a person may only have one close relationship, but this relationship is mutually understanding, empathetic, and rewarding for both parties. Studies (Kessler, Price & Wortman, 1985; Sarason, Shearin, Pierce, & Sarason, 1987) have compared the effectiveness of both types of support in predicting psychopathology. They found that the quality of social support was much more important in predicting protective effects of social support rather than the quantity of social contacts a client may have. Because some groups may lack sufficient quality of social support, practitioners may need to focus on certain “target” groups that are susceptible to lower levels of quality social support.

Another important factor to discuss when considering social support is whether the support is perceived as negative or positive by the patient or client. Positive support is similar to quality support in that both kinds of support have beneficial effects and are perceived by a person as “supportive.” Both positive support and quality support can include empathetic or understanding reactions, as well as offering continuing support and reassurance. However, a person may have a support system in place (quantity) but is receiving negative or hurtful feedback after a traumatic event. Despite a perceived system of support, such as a family, spouse, or Church group, negative social support or reactions can play a role in impeding recovery. (Zoellner, Foa & Bartholomew, 1999).

One study (Ullman & Fillipas, 2005) examined how social reactions to trauma differed in a sample of men and women, and also looked at how social reactions could affect PTSD symptom severity. A sample of 733 college students took a survey on sexual abuse experience, history and details of disclosure. Of this sample, 22% reported having experienced childhood sexual abuse (CSA), and 66.5% of those who experienced CSA disclosed their abuse to someone else. The study found that in both men and women, positive social reactions to disclosure were more common and related to less PTSD symptom severity, while negative social reactions were related to greater PTSD symptom severity. Women were more likely to experience greater PTSD symptom severity, and the mean number of negative reactions were nearly twice that of the men in the study. This is perhaps supportive of the idea that women may be more vulnerable, after trauma, especially CSA, to develop PTSD because of their risk of experiencing negative reactions to their trauma.

A different study by the same researchers (Ullman & Fillipas, 2001) examined how the effect of social reactions may or may not predict PTSD symptom severity, and also compared demographic variables. A sample of 323 sexual assault victims were assessed for PTSD and demographic factors like socioeconomic states, race, and gender. Social support was assessed using various methods, including the Inventory of Socially Supportive Behaviors (ISSB), Social Reactions Questionnaire (SRQ), and asking about frequency of social contact. They found that having an ethnic minority race was significantly related to receiving more negative social reactions; however, they found that there were no racial differences in PTSD symptom severity.

Disclosure of a traumatic event plays a major role in the receipt of social support. If a person does not disclose his or her traumatic event, the likelihood of him or her receiving any sort of support regarding that event is, consequently, very low. Childhood sexual assault is one type of trauma that is consistently underreported and seldom disclosed (Herman, 1981; Russell, 1983; Summit, 1983). Even when children do disclose the sexual abuse, they reported facing greater physical abuse and use of violence during abuse than those who disclosed childhood sexual assault during adulthood (Jonzon & Lindblad, 2004). More severe abuse was also related to negative reactions from a child’s social network (Jonzon & Lindblad, 2004). This may indicate that victims of childhood sexual abuse may be particularly vulnerable to the development of PTSD, as social support may not have been available at the time of the abuse.

Social support and its relation to PTSD is undeniable through the vast amount of research that has been conducted over the past few decades. However, there is a significant lack of research that discusses the demographic variables that exist within social support for those diagnosed with PTSD. Though it is clear that lack of social support plays a role in the risk of developing PTSD, we know little about how facets of social support vary among those diagnosed with PTSD. The current study seeks to evaluate a sample of chronic PTSD sufferers and to examine the demographics of those who receive social support. The study will compare men and women, minorities and non-minorities, and trauma type (specifically CSA vs. non-CSA), and examine any significant differences that exist in social support within these variables. Based on the literature reviewed, the current study hypothesizes that in a sample of people diagnosed with PTSD, minorities, women and survivors of childhood sexual assault will have less social support (or more negative social support) than that of Caucasians, men, and those who did not experience childhood sexual assault.Continued on Next Page »