Meta-analyses were conducted on 14 separate risk factors for posttraumatic stress disorder (PTSD), and the moderating effects of various sample and study characteristics, including civilian/military status, were examined. Three categories of risk factor emerged: Factors such as gender, age at trauma, and race that predicted PTSD in some populations but not in others; factors such as education, previous trauma, and general childhood adversity that predicted PTSD more consistently but to a varying extent according to the populations studied and the methods used; and factors such as psychiatric history, reported childhood abuse, and family psychiatric history that had more uniform predictive effects. Individually, the effect size of all the risk factors was modest, but factors operating during or after the trauma, such as trauma severity, lack of social support, and additional life stress, had somewhat stronger effects than pretrauma factors.

Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults.

A review of 2,647 studies of posttraumatic stress disorder (PTSD) yielded 476 potential candidates for a meta-analysis of predictors of PTSD or of its symptoms. From these, 68 studies met criteria for inclusion in a meta-analysis of 7 predictors: (a) prior trauma, (b) prior psychological adjustment, (c) family history of psychopathology, (d) perceived life threat during the trauma, (e) posttrauma social support, (f) peritraumatic emotional responses, and (g) peritraumatic dissociation. All yielded significant effect sizes, with family history, prior trauma, and prior adjustment the smallest (weighted r = .17) and peritraumatic dissociation the largest (weighted r = .35). The results suggest that peritraumatic psychological processes, not prior characteristics, are the strongest predictors of PTSD.

Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis.

Meta-analyses of studies yielding sex-specific risk of potentially traumatic events (PTEs) and posttraumatic stress disorder (PTSD) indicated that female participants were more likely than male participants to meet criteria for PTSD, although they were less likely to experience PTEs. Female participants were more likely than male participants to experience sexual assault and child sexual abuse, but less likely to experience accidents, nonsexual assaults, witnessing death or injury, disaster or fire, and combat or war. Among victims of specific PTEs (excluding sexual assault or abuse), female participants exhibited greater PTSD. Thus, sex differences in risk of exposure to particular types of PTE can only partially account for the differential PTSD risk in male and female participants.

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Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research.

Context Uncertainties continue about the roles that methodological factors and key risk factors, particularly torture and other potentially traumatic events (PTEs), play in the variation of reported prevalence rates of posttraumatic stress disorder (PTSD) and depression across epidemiologic surveys among postconflict populations worldwide. Objective To undertake a systematic review and meta-regression of the prevalence rates of PTSD and depression in the refugee and postconflict mental health field. Data Sources An initial pool of 5904 articles, identified through MEDLINE, PsycINFO and PILOTS, of surveys involving refugee, conflict-affected populations, or both, published in English-language journals between 1980 and May 2009. Study Selection Surveys were limited to those of adult populations (n ≥ 50) reporting PTSD prevalence, depression prevalence, or both. Excluded surveys comprised patients, war veterans, and civilian populations (nonrefugees/asylum seekers) from high-income countries exposed to terrorist attacks or involved in distal conflicts (≥25 years). Data Extraction Methodological factors (response rate, sample size and design, diagnostic method) and substantive factors (sociodemographics, place of survey, torture and other PTEs, Political Terror Scale score, residency status, time since conflict). Data Synthesis A total of 161 articles reporting results of 181 surveys comprising 81 866 refugees and other conflict-affected persons from 40 countries were identified. Rates of reported PTSD and depression showed large intersurvey variability (0%-99% and 3%-85.5%, respectively). The unadjusted weighted prevalence rate reported across all surveys for PTSD was 30.6% (95% CI, 26.3%-35.2%) and for depression was 30.8% (95% CI, 26.3%-35.6%). Methodological factors accounted for 12.9% and 27.7% PTSD and depression, respectively. Nonrandom sampling, small sample sizes, and self-report questionnaires were associated with higher rates of mental disorder. Adjusting for methodological factors, reported torture (Δ total R 2 between base methodological model and base model + substantive factor [ΔR 2 ] = 23.6%; OR, 2.01; 95% CI, 1.52-2.65) emerged as the strongest factor associated with PTSD, followed by cumulative exposure to PTEs (ΔR 2  = 10.8%; OR, 1.52; 95% CI, 1.21-1.91), time since conflict (ΔR 2  = 10%; OR, 0.77; 95% CI, 0.66-0.91), and assessed level of political terror (ΔR 2  = 3.5%; OR, 1.60; 95% CI, 1.03-2.50). For depression, significant factors were number of PTEs (ΔR 2  = 22.0%; OR, 1.64; 95% CI, 1.39-1.93), time since conflict (ΔR 2  = 21.9%; OR, 0.80; 95% CI, 0.69-0.93), reported torture (ΔR 2  = 11.4%; OR, 1.48; 95% CI, 1.07-2.04), and residency status (ΔR 2  = 5.0%; OR, 1.30; 95% CI, 1.07-1.57). Conclusion Methodological factors and substantive population risk factors, such as exposure to torture and other PTEs, after adjusting for methodological factors account for higher rates of reported prevalence of PTSD and depression.

Association of Torture and Other Potentially Traumatic Events With Mental Health Outcomes Among Populations Exposed to Mass Conflict and Displacement: A Systematic Review and Meta-analysis

Stressors have a major influence upon mood, our sense of well-being, behavior, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the long-term effects of stressors can damage health. The relationship between psychosocial stressors and disease is affected by the nature, number, and persistence of the stressors as well as by the individual's biological vulnerability (i.e., genetics, constitutional factors), psychosocial resources, and learned patterns of coping. Psychosocial interventions have proven useful for treating stress-related disorders and may influence the course of chronic diseases.

Stress and Health: Psychological, Behavioral, and Biological Determinants

BACKGROUND: Although much research has focused on mechanisms of traumatization and factors related to post-trauma psychological functioning in survivors of trauma, there have been few studies of survivors of torture despite the widespread practice of torture in the world. The aim of this study was to examine the role of 'psychological preparedness' for trauma in post-traumatic stress responses in survivors of torture. METHOD: Thirty-four torture survivors who had no history of political activity, commitment to a political cause or group, or expectations of arrest and torture were compared with 55 tortured political activists, using structured interviews and measures of anxiety, depression, and post-traumatic stress disorder. RESULTS: Compared with tortured political activists, tortured non-activists were subject to relatively less severe torture but showed higher levels of psychopathology. Less psychological preparedness related to greater perceived distress during torture and more severe psychological problems, explaining 4% of the variance in general psychopathology and 9% of the variance in post-traumatic stress disorder symptoms. CONCLUSIONS: The study findings lend support to the role of prior immunization to traumatic stress and to unpredictability and uncontrollability of stressors in the effects of traumatization. Further research aimed at identifying the behavioural and cognitive components of psychological preparedness that play a role in traumatization may provide useful insights into effective treatment strategies for survivors of torture. Language: en

Psychological preparedness for trauma as a protective factor in survivors of torture

Objective: The aim ofthe study was to investigate the long-term effects oftorture in a group of former political prisoners. Method: The study was carried out in Istanbul, Turkey, where 55 Turkish political activists who had been tortured were compared with a closely matched group of 55 activists who had not been tortured. The Structured Clinical Interview for DSMIII-R, the Semistructured Interview for Survivors of Torture, and other self-rated and assessor-rated measures of anxiety, depression, and posttraumatic stress disorder (PTSD) were used. The tortured and the nontortured activists were similar in age, sex, marital and socioeconomic status, political ideology, political involvement, stressful life events other than torture, and other features. Results: The torture survivors reported an average of291 exposures to a mean of23 forms oftorture. The mean length oftheir imprisonment was 47 months. The survivors of torture had significantly more symptoms of PTSD and anxiety/depression than the nontortured comparison subjects, although their PTSD symptoms were only moderately severe and their general mood was normal. Despite the severity of their torture experiences, the survivors had only a moderate level ofpsychopathology. Conclusions: The results suggest that torture has long-term psychological effects independent of those related to uprooting, refugee status, and other traumatic life events in a politically repressive environment. Prior knowledge of and preparedness for torture, strong commitment to a cause, immunization against traumatic stress as a result of repeated exposure, and strong social supports appear to have protective value against PTSD in survivors of torture.

Psychological Effects of Torture: A Comparison of Tortured With Nontortured Political Activists in Turkey

Objective. —To examine factors related to long-term psychological functioning in political ex-prisoners who had been subjected to systematic torture. Design. —The psychological status of 55 tortured political activists, 55 nontortured political activists, and 55 subjects with no history of torture or political activism was assessed using Structured Clinical Interview for DSM-III for psychiatric assessment, Semi-structured Interview for Survivors of Torture, and other self-rated and assessor-rated measures of anxiety, depression, and posttraumatic stress disorder (PTSD). Correlational and multiple regression analyses were used to assess the independent effects of precaptivity, captivity, and postcaptivity variables as predictors of long-term psychological status among the torture survivors. Setting. —Istanbul, Turkey. Main Outcome Measures. —Number of lifetime and current PTSD symptoms, and scores on the Beck Depression Inventory, Hamilton Depression Rating, Hamilton Anxiety Scale, and State-Trait Anxiety Inventory. Results. —Effect of captivity experience on various life areas (eg, family and social, economic, and employment status) and other postcaptivity psychosocial stressors were associated with PTSD symptoms, anxiety, and depression. Perceived severity of torture was related to PTSD symptoms but not to anxiety or depression. Lack of social support predicted anxiety and depression but not PTSD. Family history of psychiatric illness correlated with higher scores on most measures. Impact of captivity experience on family was the strongest predictor of PTSD symptoms. Conclusions. —These findings point to three types of stressors related to different aspects of psychopathology in survivors of torture: perceived severity of torture, secondary effects of captivity experience on various life areas, and general psychosocial stressors following captivity. Different interventions may be needed for three components of survivors' traumatic experience: cognitive and behavioral strategies for treatment of PTSD symptoms, marital or family strategies for minimizing the impact of the trauma on the family, and strategies for enhancing social support to minimize postcaptivity depression and anxiety. ( JAMA . 1994;272:357-363)

Factors Related to Long-term Traumatic Stress Responses in Survivors of Torture in Turkey

Severity of Trauma as Predictor of long-term Psychological Status in Survivors of Torture

Sosyal Sigortalar Kurumu Hospital This study examined appraisal of self and others, as measured by semantic differential ratings of Police, State, Society, Family, Friend, Myself as a Man/Woman, and Myself as a Political Person, in 55 tortured political activists in Turkey, 55 nontortured political activists, and 55 nontortured, politically noninvolved controls. There were no remarkable differences between tortured and non- tortured political activists; both groups differed from controls in having a more negative appraisal of the police and the state and stronger perceptions of danger, mistrust, and injustice in relation to state authority. Lack of beliefs concerning a "benevolent state" may have protected the survivors from the traumatic effects of state-perpetrated torture. Further research into the possible protective role of belief systems in posttraumatic stress disorder is needed. Systematic torture has certain features that distinguishes it from other traumas. It is a deliberate attack on the physical and psychological well-being of the individual and is often extremely severe and prolonged. Accordingly, most studies have found high rates of psychopathology among concentration camp sur- vivors (Solkoff, 1992 ), former prisoners of war (Miller, 1992 ), and other survivors of torture (Mollica, Wysak, & Lavelle, 1987). In contrast to earlier studies, a recent study in Turkey by our group. (Ba§o~lu, Paker, Paker, et al., 1994; Ba~o~lu, Paker, Tasde- mir, Ozmen, & ~ahin, 1994) found relatively low levels oftrau- matization among a group of torture survivors despite severe Metin Baso~lu, Institute of Psychiatry, University of London, Lon- don, England; Murat Paker and Ozg/in Ta~emir, New School for Social Research, New York; Erdo~,an Ozmen, Ayten Ceyhanh, and Cem In- cesu, Baklrk6y Psychiatric Hospital, Istanbul, Turkey; Do,an S ahin, Department of Psychiatry, University of Istanbul, Istanbul, Turkey; Nusin Sanmurat, Sosyal Sigortalar Kurumu Hospital, Ankara, Turkey. This research was supported in part by the Bromley Trust, the Hu- man Rights Association of lstanbul, the Istanbul Chamber of Medicine, the Turkish Human Rights Association, and the Turkish Medical Asso- ciation. Thanks are also due to Chris Brewin for his helpful comments on a draft. Correspondence concerning this article should be addressed to Metin Ba~o~lu, Institute of Psychiatry, DeCrespigny Park, 99 Denmark Hill. London SE5 8AE England. torture. In the present study we attempted to find a possible explanation for this striking finding. Because our study partici- pants were different from the average person in that they were highly committed political activists with a strong belief system, their appraisal of themselves and the world might have played a protective role against the traumatic effects of torture. Because the study involved two groups of political activists (tortured and nontortured) and a third group of nontortured, nonpolitically involved individuals, we could examine how the political activists differed from the nonactivists in their ap- praisal of self and the world. Using the semantic differential method (Osgood, Suci, & Tannenbaum, 1978), we examined the participants' evaluations of personal safety, trust, and justice in relation to social environment, because posttraumatic stress disorder (PTSD) responses may be mediated by violation of previously held assumptions of invulnerability and personal safety (Foa, Zinbarg, & Rothbaum, 1992; Janoff-Bulman, 1992), inability to find an acceptable explanation for the trauma (Lifton & Olson, 1976), and violation of beliefs that the world is a just and orderly place (Lerner & Miller, 1978). Although this method did not provide direct measurements of beliefs (standardized beliefs questionnaires are not available in Turkish ), we expected the semantic meaning of these concepts to be strongly associated with beliefs about safety, trust, and justice. If violation of beliefs regarding safety, trust, and justice do indeed play a role in PTSD, then cognitive theory of trauma as 232

Murat Paker

Papers

Psychological preparedness for trauma as a protective factor in survivors of torture

Psychological Effects of Torture: A Comparison of Tortured With Nontortured Political Activists in Turkey

Factors Related to Long-term Traumatic Stress Responses in Survivors of Torture in Turkey

Severity of Trauma as Predictor of long-term Psychological Status in Survivors of Torture

Appraisal of Self, Social Environment, and State Authority as a Possible Mediator of Posttraumatic Stress Disorder in Tortured Political Activists