A soldier and a sex worker walk into a therapist’s office. Who's more likely to have PTSD?

When we think about post-traumatic stress disorder (PTSD), we most often think of soldiers traumatised by their experiences of war. But the statistics tell another story.

While about 5-12% of Australian military personnel who have experienced active service have PTSD at any one time, this is about the same (10%) as rates for police, ambulance personnel, firefighters and other rescue workers.

And while these rates are significant, they are not vastly different to rates in the general Australian population (8% of women and 5% of men).

PTSD is actually most common in populations with a high exposure to forms of complex trauma. This involves multiple, chronic and deliberately inflicted interpersonal traumas (physical and sexual abuse and assaults, emotional abuse, neglect, persecution and torture).

Sex workers, women fleeing domestic violence, survivors of childhood abuse and Indigenous Australians are far more likely to have experienced this complex trauma. In these groups, between 40% and 55% are affected by PTSD.

So, how and why does their complex trauma differ from the PTSD we most commonly associate with the military?

PTSD vs complex PTSD

Complex trauma leads to a specific type of PTSD, known as complex PTSD, which will be listed in the 2018 edition of International Classification of Diseases for the first time.

Complex PTSD applies to responses to extremely threatening or horrific events that are extreme, prolonged or repetitive, from which a person finds it difficult or impossible to escape. Examples include repeated childhood sexual or physical abuse, and prolonged domestic violence.

Generally, PTSD involves persistent mental and emotional stress as a result of injury or severe psychological shock. It typically involves disturbed sleep, traumatic flashbacks and dulled responses to others and the outside world.

But people with complex PTSD also have problems regulating their emotions, believe they are worthless, have deep feelings of shame, guilt or failure, and have ongoing difficulties sustaining relationships and feeling close to others.

Early trauma

Complex PTSD is linked to early trauma, such as childhood physical and sexual abuse. And given girls are two to three times more likely to be sexually abused than boys, this might partly explain why, by the time girls reach adolescence, they are three and a half times more likely than boys to be diagnosed with PTSD. Girls’ nervous systems may also be more vulnerable to developing PTSD.

Complex trauma as a child also increases the risk of trauma as an adult. Other studies confirm a link between early trauma and being a victim of domestic violence.

An occupational hazard

People with certain occupations are also at high risk of PTSD. A study of street-based sex workers in Sydney found nearly half would have met the criteria for a PTSD diagnosis at some point during their lives, making this the highest occupational risk for PTSD in Australia. Their high rates of PTSD are attributed to multiple traumas, including childhood sexual abuse and violent physical or sexual assaults while working.

People with histories of complex trauma are also more likely to find work where trauma is an occupational hazard, like the military or police, with the potential to compound their trauma further.

People with histories of childhood abuse and other adverse childhood experiences are also more likely to develop PTSD in the line of duty.

Other groups at risk

Women fleeing domestic violence are at particular risk of PTSD, with an Australian study finding 42% of women in a women’s refuge suffering from it.

While domestic violence is a form of complex trauma in itself, it is far more likely to be experienced by women who, as children, experienced sexual abuse, severe beatings by parents, and who were also raised in homes with domestic violence. These experiences of complex trauma in childhood and adulthood significantly increase the risk of having complex PTSD in adulthood.

Another of the most at-risk groups is Indigenous Australians, with a study in a remote community finding 97% had experienced traumatic events and 55% met the criteria for PTSD at some point in their lives.

Indigenous Australians have high rates of interpersonal trauma that frequently begin early in life and are characterised as severe, chronic and perpetrated by multiple people, often those in authority and well known to the individual. These complex traumas are further compounded by the pervasive transgenerational impacts of colonisation.

Stigma remains

PTSD in the military, police and emergency services in the line of duty has less stigma attached to it than PTSD associated with domestic violence situations and sex workers, partly because some people think this last group created the problem themselves.

Such misconceptions reflect a lack of awareness about the impact of complex trauma on a person’s self-worth, coping skills and ability to gauge danger then effectively respond to it.

Survivors of complex trauma are less likely to be treated for their PTSD despite their symptoms being more pervasive.

This may not be surprising given survivors of complex trauma are often faced with societal, community and family pressure to remain silent, and have a legitimate fear of being accused of fantasising, lying, seeking attention or seeking revenge.

And without adequate professional support, many survivors of complex trauma self-medicate with drugs and alcohol.

Engaging with the health care system

There are pitfalls for people with complex PTSD who engage with the mental health care system. This is because the standard treatment for PTSD, exposure therapy, which involves talking about their experience and their reaction to it, can be potentially retraumatising and destabalising. Health care professionals might also miss the underlying trauma if the focus is on more visible symptoms, like substance abuse, depression or anxiety.

But the new diagnostic category of complex PTSD provides an opportunity to screen high-risk populations that would be unlikely to seek treatment.

The new diagnostic category also allows treatments to sensitively address standard PTSD symptoms as well as the emotional dysregulation, negative self-perceptions and relationship disturbances that come with it.

If this article has raised concerns for you or someone you know, please call:

Blue Knot Helpline for adults survivors of trauma and abuse (1300 657 380)

National Sexual Assault, Domestic and Family Violence Counselling Service (1800 737 732)

SANE Australia for information, guidance, and referrals to manage mental health concerns (1800 187 263).

Mary-Anne Kate receives funding from the Department of Education and Training (Australian Postgraduate Award) and is a member of the International Society for the Study of Trauma and Dissociation

Graham Jamieson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.