Research published in The Lancet Psychiatry today has found that 31% of young people had a traumatic experience during childhood. Those who were exposed to trauma were twice as likely as their peers to have a range of mental health disorders. The researchers looked at participants in the E-Risk Study, funded by the Medical Research Council, which includes 2,232 children born in England and Wales in 1994-1995. Trauma exposure and PTSD symptoms were assessed at age 18 by structured interviews.

The researchers ascertained whether participants had been exposed to trauma using DSM-5 (Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition) diagnostic criteria. The DSM-5 accounts not only for direct exposure to trauma, but also witnessing trauma, learning of a close friend's or relative's exposure to trauma, and indirect exposure to trauma: usually in a professional capacity such as being a first responder or working within a child sexual abuse taskforce. 

One in four young people exposed to trauma met the criteria for PTSD. People with PTSD suffer from a range of symptoms including: re-living traumatic events through distressing memories or nightmares; avoidance of anything reminding them of their trauma; feelings of guilt, isolation or detachment; and irritability, impulsivity, or difficulty concentrating.

The risk of developing PTSD was greatest after a direct interpersonal assault or threat, with sexual assault being particularly high risk – 74% of young people experiencing sexual assault developed PTSD.

Concerningly, only a minority of young people who had developed PTSD received help from health professionals – one in three talked to their GP about their mental health in the last year, and one in five saw a mental health professional. Therefore, only a small proportion of young people with PTSD in the study could have received effective treatments. A substantial proportion of young people with PTSD do not recover without treatment and symptoms can last many years. It is unclear whether any of the participants had received a PTSD diagnosis prior to this study. 

PTSD is not the only post-traumatic reaction

This research relies upon a narrow conception of post-traumatic reactions, holding the DSM-5 criteria for PTSD as the only one. 

The study examines symptoms of PTSD, not Complex PTSD: the latter of which is yet to enter the DSM-5. Complex PTSD is characterised by prolonged exposure to trauma rather than a single traumatic incident, and the trauma is often interpersonal in nature. Whilst people who experience Complex PTSD may display symptoms of PTSD, additional symptoms include emotional flashbacks, dissociative symptoms such as feeling detached from one's body or the world, struggling with intimate relationships, and difficulty controlling emotions. It is unclear whether symptoms reflective of the dissociative sub-type of PTSD found in the DSM-5 were assessed. 

That is to say, this research may inadvertently classify participants with PTSD where Complex PTSD is more appropriate. Or, symptoms of other trauma-related disorders fail to be taken into account, so the young person's trauma history is missed, decreasing the likelihood of them accessing appropriate treatment.

Because this research uses the DSM-5 criteria of PTSD, participants whose post-traumatic reactions present as other disorders are incorrectly deemed as not having PTSD. Whilst they may not have PTSD as per the DSM-5 definition, PTSD is not the only traumagenic disorder. "Clinicians should also be aware that co-occurring psychopathology can mask the diagnosis of PTSD in trauma-exposed young people", the research says. This is not expanded upon, but perhaps it refers to experiences of dissociation in which the young person feel detached from the trauma/their symptoms, so symptoms remain unreported. Dissociative amnesia is a common reaction to trauma; some of the study's participants may have failed to report a history of trauma due to amnesia caused by the trauma itself. 

As well as Dissociative Disorders which elude the DSM-5 PTSD diagnosis, research suggests that trauma may be a precipitating factor in developing Borderline Personality Disorder. And so, symptoms of Borderline Personality Disorder - which are often similar to Complex PTSD - mean a participant's symptoms may fail to meet the DSM-5 criteria for PTSD. 

"Trauma-related disorders often go unnoticed", says Professor Andrea Danese, a Senior Researcher on the study. Maybe failing to recognise post-traumatic symptoms that differ from "standard" PTSD is part of the problem in both research and practice. 

Given these complications, perhaps even more than the reported one in 13 young people experience post-traumatic reactions before age 18: be it PTSD or not. 


Read the full report here.

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