**10. Conclusion**

examined in future studies.

In conclusion, although numerous studies have been published on sex or gender differences in PTSD, most have focused on establishing and explaining sex differences in PTSD prevalence. There is general consensus that females are approximately twice as likely as males to be diagnosed with PTSD following a wide range of trauma types, although sex differences in the prevalence of PTSD following some trauma types (e.g. rape, CSA, combat) have not been fully established. Sex differences in the types of trauma that males and females are exposed to and in the risk factors associated with PTSD appear to account for at least some of the increased PTSD prevalence in females compared to males. However, more research is needed to establish the degree to which sex differences in PTSD prevalence and severity is mediated by trauma type and risk factors, which are more prevalent in females.

In this chapter we have gone beyond simply focusing on sex differences in the prevalence of PTSD and have examined how sex differences in the acute response to trauma may cause males and females to follow different pathways to PTSD. There is some evidence that whereas males tend to react to trauma with the well-known fight-or-flight response, females may be more prone to react with a tend-and-befriend response. These two distinct responses to stress are associated with marked physiological differences in SNS, PNS, and HPA activity. Dysregulation of these systems may lead to sensitisation of the fight-or-flight response in males and the tend-and-befriend response in females. This may result in males and females following separate pathways to PTSD. There is some support for the existence of such pathways, as preliminary findings suggest that sex may serve as a moderator on the relationship between certain risk factors and PTSD. In this chapter we have reviewed some support for the hypothesis that physiological arousal and possibly anxiety may be more closely associated with the development of PTSD in males compared to females. In contrast, some studies have found that social support and dissociation are more closely linked to the development of PTSD in females. Sex differences in the relationship between coping and PTSD may exist but are less well documented.

Despite sex differences in the initial response to trauma and risk factors associated with PTSD, there do not appear to be major differences in the core symptomatology of PTSD in treatment seeking males and females. However, there is some evidence that males may experience more physiological arousal and anger, whereas females report more dissociation and somatisation. Although the combined impact of multiple variables on the reactivity of the HPA axis makes it theoretically possible for males and females to primarily follow different pathways to PTSD, the end result appears to be similar, although sex differences in

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survey of trauma. *Archives of General Psychiatry, 55*, 626-632.

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signs and PTSD in a treatment, seeking sample of motor vehicle accident survivors.

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stress disorder: Findings from the National Comorbidity Survey. *American Journal* 

stress disorder and posttraumatic stress disorder following motor vehicle accidents.

psychophysiological arousal, acute stress disorder, and posttraumatic stress

effectiveness, in *Gender and PTSD*, Kimerling, R., Ouimette, P., & Wolfe, J., pp. 305-

PTSD in women, in *Gender and PTSD*, Kimerling, R., Ouimette, P., & Wolfe, J., pp.

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posttraumatic symptomatology need to be studied further. Such research is particularly needed for symptomatology not covered by the PTSD diagnosis.

Finally, although different risk factors associated with PTSD as well as minor differences in symptoms such as anger and somatisation may call for different therapeutic approaches, sex differences in the efficacy of different PTSD treatments remain to be studied. However, the HPA axis appears to be influenced by multiple factors of both biological and social origin. This suggests that the core disturbances in PTSD may be treated through either biological, psychotherapeutic, or social interventions, regardless of the different pathways which may have caused it.

It is difficult to discern whether sex differences in PTSD are best accounted for by sex or by gender-based theories. We believe it to be most likely, that sex and gender differences work together to account for the increased prevalence and severity of PTSD in females compared to males, as well as the other sex differences in PTSD. It is therefore unlikely that scientists will ever be able to fully account for the unique influence of either. Many gender differences in society are likely to build on pre-existing sex differences related to differences in brain structure and functioning, physiological response to stress, and the influence of sex hormones on the different areas of human functioning. In contrast, the extent to which sex differences come to affect the actual behaviour of males and females may be affected by cultural factors, such as gender role expectancies, which can explain why the extent of sex differences in PTSD appear to vary between cultures (Norris et al., 2001).

As stated in a report by the Institute of Medicine on the biological contributions to human health: "sex matters and until the question of sex is routinely asked and the results - positive or negative - are routinely reported, many opportunities to obtain a better understanding of the pathogenesis of disease and to advance human health will surely be missed (Wizemann & Pardue, 2001).

#### **11. References**


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**7** 

*Taiwan* 

**Risk Factors and Hypothesis for** 

**(PTSD) in Post Disaster Survivors** 

*2Department of Nursing, I-Shou University, Kaohsiung City,* 

*1Department of Community Psychiatry, Kai-Suan Psychiatric Hospital, Kaohsiung,* 

Disasters, both natural and man-made, affect millions of people around the world every year. Natural disasters (e.g., earthquakes and hurricanes) and man-made disasters (e.g., traffic accidents, acts of terrorism and wars) can cause mental trauma with long-lasting consequences (Chou et al., 2005; Chou et al., 2007). The impact of a mass disaster or man-made trauma on the individual is a composite of two major elements: the catastrophic event itself and the vulnerability of those people affected by the event. To this end, post-disaster survivors need

**2. The relationship between disasters and Posttraumatic Stress Disorder** 

Breslau et al. (1991) estimated that 6% to 7% of the US population is exposed to disaster or trauma every year, while Wang et al. (2000) showed that natural disasters affect an average of approximately 200 million people in China every year, several thousand of whom do not survive. In the aftermath of these catastrophic events, PTSD is one of the most common

The prevalence of PTSD ranged from 3.0% to 34.3% in Taiwan after the 1999 earthquake (Chou et al., 2004a,b), it was approximately 25% in Turkey after the 1999 earthquake (Tural et al., 2004), and it was reported as 74% in Armenia after the 1988 earthquake (Armen, 1993). In a systemic review of the literature, Andrews, Brewin, Philpott, & Stewart (2007) found that delayed-onset PTSD in the absence of any prior symptoms was rare, whereas delayed onset that represented exacerbations or reactivations of prior symptoms accounted for, on average, 38.2% and 15.3% of military and civilian cases of PTSD, respectively. Generally, the lifetime and current prevalence rates for psychiatric disorders range anywhere from 1% to 74% (Breslau, Davis, Andreski, & Peterson, 1991; Carr et al., 1995; Chang et al., 2003; Chou et al., 2003; Tainaka et al., 1998), with women twice as likely as men to be affected. Furthermore, women report more symptoms of anxiety and depression than men (Chou et

specific, systemic evaluation and management (Sapir, 1993).

psychiatric diseases suffered by post-disaster survivors.

**1. Introduction** 

**(PTSD)** 

al., 2003; Chang et al., 2003).

**Posttraumatic Stress Disorder** 

Frank Huang-Chih Chou1 and Chao-Yueh Su2

