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Differences

in

prevalence

rates

of

PTSD

in

various

European

countries

explained

by

war

exposure

other

trauma

and

cultural

value

orientation

Andrea

Burri

and

Andreas

Maercker

Author

information

Article

notes

Copyright

and

License

information

This

article

has

been

cited

by

other

articles

in

PMC

Go

to

Abstract

Background

Guided

by

previous

explorations

of

historical

and

cultural

influences

on

the

occurrence

of

PTSD

the

aim

of

the

present

study

was

to

investigate

the

contributions

of

war

victimisation

in

particular

World

War

II

and

other

civil

trauma

on

the

prevalence

of

PTSD

as

mediated

by

cultural

value

orientation

Secondary

data

analysis

was

performed

for

European

countries

using

data

including

PTSD

prevalence

and

number

of

war

victims

crime

victims

and

natural

disaster

victims

from

different

sources

Ten

single

value

orientations

as

well

as

value

aggregates

for

traditional

and

modern

factors

were

investigated

Results

Whilst

differences

in

PTSD

prevalence

were

strongly

associated

with

war

victim

rates

associations

albeit

weaker

were

also

found

between

crime

victims

and

PTSD

When

cultural

value

orientations

such

as

stimulation

and

conformity

as

representatives

of

modern

and

traditional

values

were

included

in

the

multivariate

predictions

of

PTSD

prevalence

an

average

of

approximately

of

PTSD

variance

could

be

explained

by

the

model

independent

of

the

type

of

trauma

exposure

Conclusion

The

results

suggest

that

the

aftermath

of

war

contributes

to

current

PTSD

prevalence

which

may

be

explained

by

the

high

proportion

of

the

older

population

who

directly

or

indirectly

experienced

traumatic

war

experiences

Additional

findings

for

other

types

of

civil

trauma

point

towards

an

interaction

between

value

orientation

and

countryspecific

trauma

rates

Particularly

being

personally

oriented

towards

stimulation

appears

to

interact

with

differences

in

trauma

prevalence

Thus

cultural

value

orientation

might

be

viewed

not

only

as

an

individual

intrinsic

process

but

also

as

a

compensatory

strategy

after

trauma

exposure

Keywords

Cultural

values

Mental

disorder

Posttraumatic

stress

disorder

PTSD

War

trauma

World

War

II

Societies

Crosscultural

assessment

Go

to

Background

Estimates

of

the

lifetime

prevalence

of

posttraumatic

stress

disorder

PTSD

have

been

shown

to

vary

considerably

between

countries

Data

collection

for

a

recent

study

on

the

size

and

burden

of

mental

disorders

in

Europe

for

example

revealed

differences

in

PTSD

prevalence

that

ranged

from

to

in

the

general

population

with

one

outlier

country

reporting

a

tenfold

higher

prevalence

Countries

with

the

highest

prevalence

of

PTSD

were

the

Netherlands

the

UK

France

and

Germany

Countries

with

the

lowest

prevalence

of

PTSD

were

Spain

and

Switzerland

The

outlier

country

was

Croatia

Interpreting

these

differences

in

the

prevalence

of

psychopathological

syndromes

across

cultures

remains

a

difficult

task

In

addition

to

methodological

variations

eg

assessment

instruments

and

sample

characteristics

some

of

the

difference

in

PTSD

prevalence

estimates

across

nations

can

be

ascribed

to

differing

levels

of

trauma

exposure

Other

factors

that

may

account

for

estimate

variability

within

and

across

cohorts

are

independent

of

trauma

exposure

diversity

and

often

remain

unidentified

There

is

however

an

increasing

appreciation

for

the

historical

societal

and

cultural

influences

on

mental

disorders

thus

helping

to

explain

PTSD

prevalence

presentation

and

progression

profiles

PTSD

has

been

discussed

as

being

a

culturally

constructed

syndrome

itself

present

predominately

in

industrialised

countries

of

the

century

In

previous

studies

we

have

proposed

that

value

orientations

in

a

given

society

or

nation

could

serve

as

an

independent

explanatory

factor

for

differences

in

PTSD

presentation

and

prevalence

The

debate

about

the

role

and

significance

of

value

orientation

in

the

development

and

expression

of

mental

illness

is

not

new

or

recent

Two

conceptually

and

theoretically

different

perspectives

prevail

cultural

relativists

claim

that

mental

illness

can

not

be

separated

from

an

individuals

cultural

context

whereas

universalists

argue

that

biological

similarity

suppresses

cultural

influences

Both

perspectives

however

agree

that

cultural

factors

play

a

role

in

the

development

and

perception

of

mental

disorders

The

main

cultural

factors

are

value

orientations

According

to

an

extensively

empirically

validated

theory

of

value

orientations

ten

motivationally

distinct

individual

values

can

be

summarised

into

two

universally

accepted

dichotomous

dimensions

of

related

motivations

one

dimension

contrasts

openness

to

change

and

conservation

values

and

the

other

dimension

contrasts

selfenhancement

and

selftranscendence

values

Figure

As

such

the

theory

goes

beyond

the

simple

identification

of

specific

values

and

also

explicates

the

structure

of

dynamic

relations

among

the

values

common

to

culturally

diverse

groups

Conservation

and

selftranscendence

can

be

regarded

as

traditional

values

whereas

openness

to

change

and

selfenhancement

reflect

modern

values

Traditional

values

mostly

represent

the

value

orientations

of

lessdeveloped

societies

and

countries

whereas

modern

values

correspond

with

and

evolve

alongside

the

achievements

of

modern

developed

countries

with

postindustrial

economies

A

description

of

the

ten

individual

values

can

be

found

in

Table

Figure

Model

illustrating

the

relations

among

the

ten

motivational

types

of

value

as

proposed

by

Schwartz

Illustration

taken

from

Schwartz

Basic

Human

Values

Theory

Measurement

and

Applications

with

permission

from

the

author

Table

Description

of

the

ten

motivationally

distinct

value

orientations

as

described

by

Schwartz

Until

quite

recently

scholars

from

the

social

sciences

and

humanities

postulated

that

traditional

value

orientations

were

associated

with

less

morbidity

whilst

modern

value

orientations

increased

risk

especially

for

mental

disorders

However

in

the

case

of

PTSD

and

other

stress

response

syndromes

eg

adjustment

disorders

several

lines

of

evidence

indicate

just

the

opposite

With

similar

levels

of

trauma

exposure

traditional

value

orientations

were

associated

with

greater

PTSD

symptom

severity

whereas

modern

value

orientations

were

associated

with

lower

PTSD

symptom

severity

The

level

of

traumatic

stress

exposure

predicted

only

a

very

small

proportion

of

the

symptom

variance

particularly

as

shown

in

studies

of

combatexposed

war

veterans

Assuming

that

variation

in

the

level

of

trauma

exposure

and

differences

in

cultural

value

orientations

determine

or

at

least

influence

PTSD

development

and

symptom

severity

the

question

arises

as

to

whether

interactions

between

societal

levels

of

trauma

exposure

and

value

orientations

exist

and

to

what

extent

such

potential

interactions

contribute

to

the

variability

in

PTSD

expression

and

perception

AIM

The

present

study

focuses

on

European

countries

Although

Europe

has

not

been

involved

in

any

continental

wars

since

a

number

of

PTSD

studies

have

suggested

the

presence

of

longterm

emotional

and

psychological

impact

ie

up

to

years

after

the

war

experiences

of

the

Second

World

War

WWII

on

the

population

even

on

second

and

third

generations

The

first

aim

of

this

study

was

to

explain

the

variability

in

PTSD

prevalence

reported

across

a

number

of

European

nations

by

the

effects

of

trauma

and

value

orientations

As

primary

predictors

four

main

types

of

trauma

exposure

were

examined

war

fatalities

crime

victimisation

natural

disasters

and

road

fatalities

Because

only

a

fraction

of

the

variability

in

PTSD

prevalence

can

be

attributed

to

different

levels

of

trauma

exposure

the

second

aim

of

the

present

study

was

to

explore

value

orientations

as

determinants

of

PTSD

prevalence

disparity

beyond

the

level

of

trauma

exposure

More

specifically

based

on

findings

from

our

own

In

this

context

an

antecedent

note

of

caution

is

appropriate

the

primary

determinants

included

in

this

study

are

estimates

originating

from

various

sources

which

have

been

jointly

investigated

in

these

secondary

analyses

Although

all

sources

are

valid

and

representative

and

all

estimates

or

proxies

of

trauma

exposure

have

been

assessed

using

solid

methodologies

the

unknown

error

variance

of

each

parameter

needs

to

be

considered

when

interpreting

the

results

Therefore

the

explorative

character

of

this

study

has

to

be

considered

Go

to

Methods

Samples

For

this

study

we

used

data

from

the

European

Size

and

Burden

of

Disorders

of

the

Brain

study

organised

by

the

European

Brain

Council

EBC

see

Table

and

supplemented

by

World

Mental

Health

Survey

data

Data

analysis

was

conducted

only

for

countries

that

had

data

available

for

populationbased

representative

PTSD

estimates

information

on

value

orientation

and

estimates

of

accidental

versus

interpersonal

trauma

exposure

These

criteria

resulted

in

a

total

of

European

countries

Each

data

source

relied

on

different

sample

sizes

Table

Descriptives

for

PTSD

and

traumatic

events

for

countries

included

in

the

study

Measures

PTSD

Prevalence

In

the

European

Research

Council

ERC

and

the

European

College

of

Neuropsychopharmacology

ECNP

launched

a

Europewide

interdisciplinary

project

aimed

at

assessing

the

economic

burden

of

neurological

and

mental

disorders

In

an

updated

and

improved

program

was

launched

This

program

provided

consolidated

estimates

for

the

prevalence

of

mental

disorders

including

PTSD

for

all

EU

countries

For

our

analysis

of

the

relationship

between

PTSD

and

rough

estimates

of

trauma

prevalences

of

PTSD

from

the

following

studied

countries

were

included

Belgium

France

Italy

Spain

Germany

Switzerland

the

UK

the

Netherlands

Bulgaria

Romania

and

Croatia

Note

that

in

the

original

EBC

publication

the

Croatian

prevalence

of

PTSD

was

reported

as

a

proxy

for

the

neighbouring

EUcountry

Slovenia

Value

orientation

Data

on

value

orientation

were

taken

from

the

European

Social

Survey

ESS

a

biennial

crosssectional

survey

initiated

in

which

was

designed

to

chart

attitudes

beliefs

and

behaviour

patterns

of

Europes

diverse

populations

The

survey

includes

questions

based

on

Schwartzs

original

portrait

values

questionnaire

PVQ

which

was

developed

to

assess

value

orientations

Schwartzs

value

typology

is

grouped

into

ten

value

types

security

conformity

tradition

benevolence

universalism

power

selfdirection

stimulation

hedonism

and

achievement

The

value

structure

is

defined

by

two

different

sets

of

values

individual

interest

power

achievement

hedonism

stimulation

and

selfdirection

and

collective

interest

benevolence

tradition

conformity

universalism

and

tradition

As

mentioned

before

the

ten

motivationally

distinct

values

can

be

summarised

into

four

dimensions

openness

to

change

conservation

selfenhancement

and

selftranscendence

values

The

four

dimensions

also

called

higherorder

values

express

a

broad

motivational

goal

that

is

shared

by

the

basic

values

that

compose

it

In

the

selfenhancement

vs

selftranscendence

dimension

values

of

Each

value

type

was

assessed

with

two

questions

except

for

universalism

which

was

assessed

with

three

questions

due

to

its

broad

content

Respondents

were

asked

to

rate

the

extent

to

which

the

description

of

a

fictitious

person

corresponded

to

their

own

attitudes

and

behaviours

Response

options

were

on

a

sixpoint

Likerttype

scale

ranging

from

very

much

like

me

to

not

like

me

at

all

Evidence

for

the

validity

of

the

theoretical

and

contentrelated

structure

of

Schwartzs

typology

has

been

demonstrated

previously

in

samples

from

nations

and

recently

in

data

from

countries

Data

collected

in

the

ESS

can

be

freely

accessed

from

their

webpage

httpwwweuropeansocialsurveyorg

which

includes

a

brief

description

of

score

computation

for

the

Human

Value

Scale

For

more

information

on

the

assessment

of

value

orientation

within

the

context

of

the

ESS

see

Davidov

Level

of

trauma

exposure

Potentially

traumatic

events

can

be

divided

into

two

basic

groups

intentional

or

interpersonal

and

accidental

The

intentional

or

interpersonal

group

includes

war

abuse

and

violence

The

accidental

group

includes

earthquakes

hurricanes

floods

fires

and

technical

catastrophes

To

assess

the

degree

of

exposure

to

traumatic

events

estimates

of

various

types

of

intentional

events

and

natural

disasters

were

included

in

this

study

The

number

of

war

deaths

during

WWII

for

each

of

the

eleven

countries

included

in

this

study

was

taken

from

Preger

and

Mourik

For

each

country

we

then

calculated

a

proportion

measure

representing

the

number

of

war

victims

per

million

inhabitants

based

on

population

estimates

for

For

Croatia

the

war

deaths

were

calculated

using

the

Yugoslavian

WWII

data

proportion

of

Croatians

out

of

the

Yugoslavian

total

population

plus

the

war

deaths

from

the

Balkan

wars

in

the

early

resulting

in

million

deaths

during

WWII

and

during

Yugoslavian

wars

Information

on

the

number

of

crime

victims

was

taken

from

Eurostat

a

directorategeneral

of

the

European

Commission

which

provides

statistical

information

on

the

Institutions

of

the

European

Union

for

a

wide

range

of

variables

The

figures

used

in

this

study

represent

the

estimates

of

crime

victims

per

million

inhabitants

for

the

year

The

category

crime

victims

includes

homicide

violent

crime

robbery

and

domestic

burglary

For

accidental

trauma

exposure

rates

for

natural

disasters

were

taken

from

the

WHO

World

Mental

Health

Survey

WMH

survey

n

which

is

a

series

of

epidemiologic

surveys

carried

out

in

a

number

of

countries

throughout

the

world

to

allow

comparison

of

prevalences

and

correlates

of

mental

disorders

Of

the

original

countries

that

completed

the

WMH

surveys

we

selected

the

eleven

countries

that

had

data

available

for

PTSD

prevalence

In

these

surveys

exposure

to

natural

disasters

was

assessed

using

the

PTSD

section

of

the

WHO

Composite

International

Diagnostic

Interview

Version

CIDI

For

more

information

on

the

WMH

survey

and

data

assessment

see

Kessler

and

Üstün

The

number

of

road

fatalities

was

based

on

the

WHO

Global

Status

Report

on

Road

Safety

from

which

represents

the

estimates

of

road

fatalities

per

million

inhabitants

for

the

year

Statistical

analysis

Statistical

methods

appropriate

for

small

data

sets

were

chosen

First

simple

correlations

were

calculated

between

PTSD

prevalence

and

estimates

of

accidental

and

intentionalinterpersonal

disasters

and

value

orientation

For

correlation

analyses

Spearmans

rank

correlation

coefficients

rS

were

used

Spearman

correlations

were

also

calculated

to

investigate

the

relationship

between

PTSD

and

the

four

trauma

exposure

levels

and

value

orientations

The

advantages

of

using

Spearmans

rank

correlations

rather

than

the

more

common

product

moment

correlations

are

that

Spearmans

rank

correlation

is

unaffected

by

the

distribution

of

the

population

and

can

be

used

with

very

small

sample

sizes

All

analyses

were

carried

out

separately

on

the

ten

individual

values

the

four

dimensions

and

the

two

main

factors

Because

the

small

sample

size

restricted

significance

testing

correlations

were

considered

statistically

significant

when

p

and

were

referred

to

as

substantial

when

rS

even

if

p

Multiple

linear

regression

analyses

were

carried

out

to

investigate

the

moderating

effect

of

value

orientations

as

independent

variables

on

the

relationship

between

PTSD

prevalence

and

the

four

categories

of

trauma

exposure

level

In

model

the

main

effect

of

the

two

main

aggregate

factors

traditional

values

and

modern

values

was

investigated

Model

included

the

main

effect

as

well

as

the

interaction

effect

of

the

two

aggregate

factors

In

model

two

specific

individual

values

conformity

and

stimulation

and

their

interaction

with

trauma

exposure

were

included

These

two

values

were

chosen

because

of

their

high

correlation

with

PTSD

prevalence

and

Multiple

linear

regression

modelling

assumes

a

normal

distribution

for

the

error

terms

which

was

granted

in

our

dataset

Beta

values

represent

standardised

betas

indicating

how

many

standard

deviations

SDs

the

dependent

variable

PTSD

prevalence

will

change

per

SD

increase

in

the

predictor

variables

Given

our

small

sample

size

of

only

twelve

observations

ie

countries

conventional

significance

levels

may

largely

be

ignored

when

interpreting

the

data

and

instead

attention

given

to

the

relative

magnitude

of

the

obtained

betas

where

indicated

This

approach

is

recommended

for

research

relying

on

small

samples

The

missing

prevalence

data

for

natural

disasters

for

Croatia

was

imputed

using

multiple

imputation

which

is

a

simulationbased

approach

that

replaces

missing

values

with

multiple

sets

of

simulated

values

This

method

further

adjusts

the

obtained

parameter

estimate

for

missingdata

uncertainty

Because

Croatia

was

a

statistical

outlier

in

terms

of

PTSD

prevalence

and

was

also

more

likely

to

report

aftermath

effects

of

the

Balkan

war

rather

than

WWII

analyses

were

conducted

both

with

and

without

Croatia

All

data

handling

and

descriptive

analyses

were

completed

using

STATA

StataCorp

Stata

Statistical

Software

Release

College

Station

TX

StataCorp

LP

Go

to

Results

PTSD

prevalence

and

trauma

exposure

rates

PTSD

prevalence

and

trauma

exposure

rates

for

the

twelve

nations

are

reported

in

Table

Strong

statistically

significant

associations

were

observed

between

PTSD

prevalence

and

war

victim

rate

rS

p

and

between

PTSD

prevalence

and

crime

victim

rate

rS

p

Table

No

statistically

significant

associations

were

found

between

PTSD

prevalence

and

accidental

trauma

events

including

natural

disasters

and

road

fatalities

Associations

between

PTSD

prevalence

value

orientation

and

trauma

exposure

In

the

first

step

correlations

between

PTSD

and

the

individual

values

were

calculated

and

in

the

second

step

correlations

between

PTSD

and

the

two

aggregate

factors

described

in

the

methods

section

ie

the

two

factors

related

to

tradition

and

modern

value

orientation

were

calculated

Table

For

the

association

of

the

individual

values

with

PTSD

the

highest

correlation

was

found

between

the

modern

value

stimulation

and

PTSD

prevalence

rS

and

the

lowest

correlation

was

found

between

the

modern

value

benevolence

and

PTSD

prevalence

rS

For

the

aggregate

factors

the

factor

reflecting

a

modern

value

orientation

correlated

substantially

stronger

with

PTSD

prevalence

compared

with

the

factor

reflecting

a

traditional

value

orientation

rS

vs

rS

Overall

the

proxies

of

trauma

exposure

correlated

highest

with

the

individual

values

that

represent

a

modern

value

orientation

with

significant

correlations

found

between

war

victims

and

stimulation

rS

Table

Correlations

between

PTSD

prevalence

and

prevalence

estimates

of

intentional

and

accidental

traumatic

events

and

value

orientations

The

strongest

positive

correlations

were

between

the

individual

value

stimulation

and

the

exposure

types

war

victims

and

crime

victims

rS

p

and

rS

p

respectively

Table

The

strongest

negative

correlations

were

between

the

individual

value

selfdirection

and

road

fatalities

r

p

and

between

universalism

and

power

and

all

trauma

exposure

types

except

natural

disasters

rSs

ranging

from

to

Overall

consistent

patterns

of

negative

correlations

were

observed

for

conformity

universalism

selfdirection

achievement

and

power

with

all

trauma

exposure

types

whereas

consistent

positive

correlations

were

only

observed

for

stimulation

hedonism

and

security

Predicting

prevalence

differences

by

aggregate

andor

individual

value

orientations

Multiple

linear

regression

of

PTSD

prevalence

indicated

that

a

model

including

war

victims

and

both

aggregate

factors

of

modern

and

traditional

value

orientation

best

explained

the

variance

in

PTSD

prevalence

compared

with

regression

models

based

on

the

three

other

trauma

exposure

proxies

R

of

vs

R

s

of

and

respectively

Table

When

including

specific

exposure

type

x

aggregate

factor

interactions

in

the

models

variance

in

PTSD

prevalence

explained

by

the

war

victim

model

was

even

higher

reaching

R

of

Similarly

a

significant

increase

in

variance

explanation

was

observed

for

the

models

based

on

crime

victims

and

road

fatalities

whereas

no

such

drastic

increase

was

observed

for

the

natural

disaster

model

To

further

interpret

these

relationships

and

interactions

posthoc

visual

examinations

were

conducted

These

visual

examinations

revealed

that

lower

crime

rates

and

lower

modern

values

predicted

lower

PTSD

prevalence

whereas

lower

crime

rates

and

higher

modern

value

orientation

predicted

higher

PTSD

prevalence

beta

p

Table

Regression

analyses

of

PTSD

prevalence

proxys

of

trauma

exposure

and

value

orientation

using

different

models

Because

the

possibility

of

codependency

of

values

within

the

aggregate

factors

could

not

be

excluded

a

second

step

that

replaced

the

aggregate

factors

with

two

individual

values

most

representative

of

modern

and

traditional

value

orientations

ie

stimulation

and

conformity

was

included

in

the

model

A

model

including

specific

exposure

type

conformity

as

representative

of

traditional

value

orientation

stimulation

as

representative

of

modern

value

orientation

and

the

interaction

terms

showed

the

highest

variance

explanation

across

all

four

types

of

trauma

exposure

proxies

Table

However

in

contrast

to

stimulation

conformity

did

not

significantly

contribute

either

as

a

main

or

as

an

interaction

effect

to

the

prediction

of

PTSD

When

analysing

the

data

including

crime

victims

a

picture

similar

to

the

aggregated

modern

values

emerged

Figure

Further

inspection

of

the

regression

including

road

fatalities

revealed

that

higher

road

fatalities

and

lower

stimulation

orientation

predicted

lower

PTSD

prevalence

Figure

AB

Interaction

effects

in

predicting

PTSD

A

Interaction

effects

between

crime

rates

and

the

individual

value

of

stimulation

B

Interaction

effects

between

road

fatality

rates

and

the

individual

value

of

stimulation

As

previously

mentioned

all

analyses

were

additionally

conducted

excluding

Croatia

However

no

significant

deviations

from

the

initial

results

were

detected

Therefore

only

results

from

the

full

dataset

are

presented

and

discussed

Go

to

Discussion

Overall

our

findings

revealed

a

significant

predictive

effect

of

value

orientation

on

PTSD

prevalence

in

a

sample

of

European

countries

In

particular

low

crime

rates

and

high

modern

value

orientation

ie

aggregate

factor

predicted

higher

PTSD

prevalence

This

result

was

supported

by

the

model

that

substituted

stimulation

for

the

aggregate

factor

as

representative

of

modern

value

orientation

which

excluded

the

possibility

of

codependency

of

values

within

the

aggregate

factor

In

this

model

the

main

effect

and

interaction

effect

of

stimulation

accounted

for

the

highest

variance

in

PTSD

prevalence

compared

with

the

individual

value

conformity

as

representative

of

traditional

values

Whilst

much

research

effort

has

been

invested

in

identifying

and

analysing

the

relationship

of

numerous

biological

and

psychological

factors

and

their

interplay

with

PTSD

the

variability

of

PTSD

prevalence

in

relation

to

diverse

cultural

and

societal

influences

has

so

far

been

under

researched

To

fill

this

gap

the

aim

of

the

current

study

was

to

explore

these

potential

societal

influences

including

historical

and

cultural

factors

using

value

orientations

Supported

by

findings

from

previous

research

by

our

group

we

hypothesised

that

disparities

in

PTSD

prevalence

across

European

countries

are

related

to

differences

in

value

orientations

and

in

trauma

exposure

rates

Our

main

finding

showed

a

strong

association

between

war

fatalities

and

PTSD

prevalence

rates

across

the

European

countries

included

in

this

study

This

association

remained

stable

in

subsequent

multivariate

analyses

even

after

including

value

orientations

For

most

countries

the

war

death

rates

taken

as

a

proxy

for

trauma

exposure

were

based

on

WWII

victims

A

number

of

previous

studies

have

shown

that

affected

people

still

suffer

from

PTSD

or

present

with

severe

PTSD

symptoms

years

post

WWII

the

original

studies

on

PTSD

in

the

different

countries

were

conducted

between

and

Living

through

WWII

and

its

aftermath

The

latter

effect

is

known

and

discussed

as

a

secondary

or

tertiary

traumatisation

effect

With

regard

to

aggregate

or

individual

value

orientations

correlational

findings

between

number

of

war

victims

and

value

orientation

essentially

confirm

previous

study

findings

that

reported

modern

values

especially

stimulation

were

positively

associated

with

PTSD

and

even

more

so

with

trauma

exposure

rates

Stimulation

as

a

modern

value

orientation

is

distinguished

by

seeking

excitement

novelty

and

challenge

in

life

by

daring

and

by

living

a

varied

and

exciting

life

In

our

study

the

expression

of

this

value

was

stronger

in

nations

who

reported

a

higher

number

of

traumatic

events

and

increased

PTSD

rates

To

the

best

of

our

knowledge

no

socialpsychological

or

sociological

explanation

exists

for

this

association

between

populationlevel

value

orientation

and

PTSD

prevalence

However

on

an

individual

level

the

relationship

between

trauma

exposure

andor

PTSD

and

the

personality

trait

of

sensation

seeking

has

been

debated

and

substantiated

for

its

pathological

effect

Sensation

seeking

describes

an

urge

to

pursue

novel

intense

and

complex

sensations

and

experiences

and

the

willingness

to

take

risks

for

the

sake

of

such

experience

As

such

it

is

comparable

to

the

populationlevel

value

of

stimulation

Research

evidence

has

suggested

an

association

between

sensation

seeking

and

PTSD

although

not

in

the

direction

previously

predicted

from

the

compulsive

exposure

hypothesis

ie

high

sensation

seeking

is

associated

with

PTSD

In

a

study

conducted

by

Joseph

et

al

the

investigators

explored

the

association

between

PTSD

and

impulsivity

parameterised

as

consisting

of

the

two

components

impulsiveness

and

venturesomeness

The

authors

found

no

relationship

Further

interesting

results

were

observed

related

to

the

other

exposure

types

crime

natural

disasters

and

road

fatalities

investigated

in

this

study

Crime

and

road

fatality

related

trauma

exposure

and

PTSD

was

predicted

not

only

by

the

exposure

rates

themselves

but

also

by

the

cascades

of

main

and

interaction

effects

of

value

orientation

x

trauma

exposure

For

the

trauma

proxy

of

crime

victims

a

modern

value

orientation

in

society

predicted

the

development

of

PTSD

When

taking

the

interaction

effect

between

modern

values

and

trauma

exposure

into

account

an

additional

increase

in

PTSD

rates

was

observed

In

terms

of

the

modern

value

A

tentatively

significant

but

reverse

finding

was

found

for

road

fatalities

in

which

stimulation

as

a

modern

value

predicted

lower

PTSD

rates

and

in

which

lower

crime

exposure

combined

with

lower

stimulation

values

predicted

higher

PTSD

The

UK

the

Netherlands

and

Germany

showed

comparably

low

rates

of

road

fatalities

and

citizens

with

low

modern

stimulation

orientation

were

consistently

more

prone

to

develop

PTSD

when

exposed

to

road

accidents

compared

with

citizens

with

traditional

value

orientations

eg

conformity

To

interpret

the

differential

findings

described

in

the

preceding

two

paragraphs

a

simple

distinction

may

help

war

and

crimerelated

victimisation

belong

to

the

category

of

interpersonal

traumatic

exposure

These

traumas

are

considered

to

be

especially

anomalous

and

aberrant

by

the

victims

who

subsequently

look

for

culprits

and

perceive

the

world

as

meaningless

and

incomprehensible

and

consequently

change

their

worldviews

In

contrast

accidental

trauma

such

as

natural

disasters

or

road

fatalities

is

perceived

as

inevitable

and

predestined

and

provokes

fear

and

caution

Because

of

this

interpersonal

trauma

is

more

likely

to

negatively

interact

with

modern

values

such

as

stimulation

compared

with

accidental

trauma

that

will

correlate

positively

In

other

words

individuals

living

in

countries

where

modern

value

orientations

predominate

are

more

likely

to

suffer

traumatic

stress

due

to

interpersonal

trauma

exposure

whereas

in

countries

with

traditional

value

orientations

accidental

or

coincidental

trauma

might

lead

to

substantial

stress

When

interpreting

the

influence

of

cultural

values

on

trauma

and

trauma

consequences

additional

aspects

such

as

whether

and

how

trauma

exposure

itself

might

shape

cultural

orientation

need

to

be

considered

Research

on

changes

in

prosocial

attitudes

after

traumatic

events

eg

natural

disasters

and

terroristic

attacks

does

suggest

such

effects

Furthermore

our

results

suggest

that

the

effects

of

traumatic

events

can

last

more

than

years

further

highlighting

the

potential

intergenerational

effect

of

trauma

sequelae

and

how

such

stressrelated

consequences

can

be

present

in

offspring

of

war

combat

participants

Importantly

the

results

of

this

study

need

to

be

interpreted

in

view

of

certain

study

limitations

First

because

information

on

value

orientation

and

corresponding

PTSD

prevalence

was

not

available

for

all

European

countries

resulting

in

countries

included

in

this

study

restricted

power

in

statistical

testing

needs

to

be

addressed

To

address

this

issue

statistical

methods

were

chosen

that

are

proven

to

be

highly

satisfactory

when

sample

sizes

are

small

Nevertheless

replication

of

the

study

in

other

populations

with

information

available

on

war

victimisation

in

particular

World

War

II

and

other

civil

traumas

as

well

as

on

PTSD

prevalence

and

Second

the

high

PTSD

prevalence

in

some

of

the

countries

included

in

this

study

might

not

result

from

war

deaths

alone

but

also

from

recent

war

survivors

eg

British

and

French

soldiers

that

were

involved

in

the

Gulf

War

where

most

likely

other

soldiers

from

other

countries

were

not

involved

Although

this

heterogeneity

in

sample

characteristics

of

war

victimisation

might

have

contributed

to

variation

in

PTSD

figures

we

highlight

the

fact

that

several

other

sources

of

traumatisation

road

fatalities

natural

catastrophes

and

crime

victimisation

were

included

in

the

study

thus

allowing

for

a

comprehensive

understanding

of

population

traumatisation

and

value

Third

the

fact

that

the

primary

determinants

included

in

this

study

are

estimates

originating

from

various

sources

that

have

been

jointly

investigated

in

these

secondary

analyses

should

be

considered

Although

all

sources

are

valid

and

representative

and

estimates

or

so

called

proxies

of

trauma

exposure

have

been

assessed

using

solid

methodologies

the

unknown

error

variance

of

each

parameter

needs

to

be

considered

when

interpreting

the

results

Furthermore

aggregate

data

have

a

high

risk

of

misinterpretation

as

often

described

by

Simpsons

Paradoxon

It

describes

a

case

of

probability

statistics

in

which

a

trend

that

appears

in

different

groups

of

data

disappears

Go

to

Conclusion

In

conclusion

despite

shortcomings

of

sample

size

and

secondary

inhomogeneous

data

sources

the

present

study

tentatively

suggests

that

the

currently

observed

crossnational

differences

in

PTSD

prevalence

can

be

explained

by

longterm

WWII

consequences

The

findings

further

propound

a

relationship

between

value

orientations

specifically

modern

values

such

as

stimulation

and

crossnational

rates

of

traumatisation

and

PTSD

symptomatology

The

pursuit

of

novel

intense

and

exciting

sensations

might

therefore

not

only

be

regarded

as

an

individual

intrinsic

process

or

trait

but

also

as

a

coping

strategy

for

the

terror

and

emotional

sequelae

of

repetitive

trauma

exposure

Whether

these

processes

represent

a

sustainable

additional

Go

to

Competing

interest

The

authors

report

no

conflicts

of

interest

Go

to

Authors

contribution

AB

carried

out

the

analyses

and

drafted

the

manuscript

AM

participated

in

the

design

of

the

study

helped

interpret

the

results

and

drafted

the

manuscript

Both

authors

read

and

approved

the

final

manuscript

The

corresponding

author

further

confirms

that

he

had

full

access

to

all

data

in

the

study

and

that

he

had

the

final

responsibility

for

the

decision

to

submit

the

manuscript

for

publication

Go

to

Acknowledgements

We

thank

Professor

Shalom

Schwartz

for

allowing

us

to

use

the

graph

illustrating

the

relations

among

the

ten

motivational

types

of

value

We

also

thank

Mario

Dobricki

for

the

preparation

and

provision

of

the

value

orientation

data

We

further

express

our

gratitude

to

Karestan

Koenen

and

Stefan

Priebe

for

advising

and

encouraging

us

to

conduct

this

study

Go

to

References

Wittchen

HU

Jacobi

F

Rehm

J

Gustavsson

A

Svensson

M

Jönsson

B

The

size

and

burden

of

mental

disorders

and

other

disorders

of

the

brain

in

Europe

Eur

Neuropsychopharmacol

doi

PubMed

Cross

Ref

Hinton

DE

LewisFenandez

R

The

crosscultural

validity

of

posttraumatic

stress

disorder

Depress

Anxiety

PubMed

Stein

DJ

Seedat

S

Iversen

A

Wessely

S

Posttraumatic

stress

disorder

medicine

and

politics

Lancet

doi

PubMed

Cross

Ref

Alcantara

S

Casement

MD

LewisFernandez

R

Conditional

risk

for

PTSD

among

Latinos

a

systematic

review

of

racialethnic

differences

and

sociocultural

explanations

Clin

Psychol

Rev

doi

PMC

free

article

PubMed

Cross

Ref

Jones

E

Vermaas

RH

McCartney

H

Beech

C

Palmer

I

Hyams

K

Flashbacks

and

posttraumatic

stress

disorder

the

genesis

of

a

diagnosis

Br

J

Psychiatry

doi

PubMed

Cross

Ref

Maercker

A

Mohiyeddini

C

Müller

M

Xie

W

Hui

Yang

Z

Wang

J

Traditionalversusmodernvalues

selfperceived

interpersonal

factors

and

posttraumatic

stress

in

Chinese

and

German

crime

victims

Psychol

Psychother

doi

PubMed

Cross

Ref

Müller

M

Forstmeier

S

Wagner

B

Maercker

A

Traditional

versus

modern

values

and

interpersonal

factors

predicting

stress

response

syndromes

in

a

Swiss

elderly

population

Psychol

Health

Med

doi

PubMed

Cross

Ref

AgbayaniSiewert

P

Takeuchi

DT

Pangan

RW

Mental

Illness

in

a

Multicultural

Context

Handbook

of

the

Sociology

of

Mental

Health

Handbooks

of

Sociology

and

Social

Research

Thakker

J

Ward

T

Culture

and

classification

The

crosscultural

application

of

the

DSMIV

Clin

Psychol

Rev

doi

PubMed

Cross

Ref

Schwartz

S

A

Theory

of

Cultural

Value

Orientations

Explication

and

Applications

Comp

Sociol

Kleinman

A

Good

B

Culture

and

Depression

Studies

in

the

Anthropology

and

CrossCultural

Psychiatry

of

Affect

and

Disorder

Berkely

University

of

California

Press

Brewin

CR

Andrews

B

Valentine

JD

Metaanalysis

of

risk

factors

for

posttraumatic

stress

disorder

in

traumaexposed

adults

J

ConsultClinPsy

PubMed

Koenen

KC

Stellman

SD

Sommer

JE

Stellman

JM

Persisting

posttraumatic

stress

disorder

symptoms

and

their

relationship

to

functioning

in

Vietnam

Veterans

A

followup

J

Trauma

Stress

doi

PMC

free

article

PubMed

Cross

Ref

Spiro

A

Settersten

RA

LongTerm

Implications

of

Military

Service

for

LaterLife

Health

and

WellBeing

Res

Human

Develop

doi

Cross

Ref

Maercker

A

Herrle

J

Longterm

effects

of

the

Dresden

bombing

Relationships

to

control

beliefs

religious

coping

and

personal

growth

J

Trauma

Stress

PubMed

Olesen

J

Gustavsson

A

Svensson

M

Wittchen

HU

Jonsson

B

The

economic

cost

of

brain

disorders

in

Europe

Eur

J

Neurol

doi

PubMed

Cross

Ref

Kessler

RC

Üstün

TB

The

WHO

World

Mental

Health

Survey

Cambridge

MA

Cambridge

University

Press

AndlinSobocki

P

Wittchen

HU

Cost

of

affective

disorders

in

Europe

Eur

J

Neurol

doi

PubMed

Cross

Ref

Wittchen

HU

Jacobi

F

Size

and

burden

of

mental

disorders

in

Europe

a

critical

review

and

appraisal

of

studies

Eur

Neuropsychopharmacol

doi

PubMed

Cross

Ref

Schwartz

SH

Melech

G

Lehmann

A

Burgess

S

Harris

M

Extending

the

crosscultural

validity

of

the

theory

of

basic

human

values

with

a

different

method

of

measurement

J

CrossCult

Psychol

doi

Cross

Ref

Schwartz

SH

Sagiv

L

Boehnke

K

Worries

and

values

J

Personality

doi

PubMed

Cross

Ref

Fontaine

JR

In

Individuals

and

cultures

in

multilevel

analysis

van

de

Vijver

FJR

van

Hemert

DA

Poortinga

Y

editor

Mahwah

NJ

Lawrence

Erlbaum

Traditional

and

multilevel

approaches

in

crosscultural

research

An

integration

of

methodological

frameworks

Davidov

E

Testing

for

comparability

of

human

values

across

countries

and

time

with

the

third

round

of

the

European

Social

Survey

Int

J

Comp

Sociol

doi

Cross

Ref

Preger

J

van

Mourik

W

Bauer

E

Bilanz

eines

Weltkrieges

Rotterdam

Lekturama

Auflage

Research

and

Documentation

Centre

Sarajewo

European

Commission

directorate

httpeppeurostateceuropaeuportalpageportalcrimedatadatabase

Kessler

RC

AguilarGaxiola

R

Alonso

J

Chatterji

S

Lee

S

Ormel

J

The

global

burden

of

mental

disorders

an

update

from

the

WHO

World

Mental

Health

WMH

surveys

Epi

Psychi

Sociol

PMC

free

article

PubMed

Wittchen

HU

Reliability

and

validity

studies

of

the

WHOComposite

International

Diagnostic

Interview

CIDI

a

critical

review

J

Psychiatr

Res

doi

PubMed

Cross

Ref

World

Health

Organization

Global

status

report

on

road

safety

time

for

action

Geneva

WHO

Gauthier

TD

Detecting

trends

using

Spearmans

Rank

Correlation

Coefficient

Environ

Forensic

doi

Cross

Ref

Cox

DR

Wermuth

N

Multivariate

dependencies

Models

analysis

and

interpretation

Vol

Florida

CRC

Press

Rubin

DB

Multiple

imputation

after

years

J

Am

Stat

Assoc

doi

Cross

Ref

Kolassa

IT

Elbert

T

Structural

and

Functional

Neuroplasticity

in

Relation

to

Traumatic

Stress

Curr

Direct

Psychol

Sci

doi

Cross

Ref

Van

IJzendoorn

MH

BakermansKranenburg

MJ

SagiSchwartz

A

Van

IJzendoorn

MH

BakermansKranenburg

MJ

SagiSchwartz

A

Are

children

of

Holocaust

survivors

less

welladapted

No

metaanalytic

evidence

for

secondary

traumatization

J

Trauma

Stress

doi

PubMed

Cross

Ref

Joseph

S

Dalgleish

T

Thrasher

S

Yule

W

Impulsivity

and

posttraumatic

stress

Person

Individ

Diff

doi

Cross

Ref

SimmenJanevska

K

Brandstätter

V

Maercker

A

The

overlooked

relationship

between

motivational

abilities

and

posttraumatic

stress

a

review

Eur

J

Psychotraum

PMC

free

article

PubMed

Chaprazov

H

Bulgaria

and

Romania

Progress

towards

EU

integration

in

the

areas

of

judicial

reform

and

the

fight

against

corruption

and

organized

crime

Date

accessed

JanoffBulman

R

Shattered

Assumptions

Towards

a

New

Psychology

of

Trauma

NY

Free

Press

Norris

FH

Friedman

MJ

Watson

PJ

disaster

victims

speak

Part

II

Summary

and

implications

of

the

disaster

mental

health

research

Psychiatry

PubMed

Norris

FH

Baker

CK

Murphy

AD

Kaniasty

K

Social

support

mobilization

and

deterioration

after

Mexicos

flood

Effects

of

context

gender

and

time

Am

J

Community

Psychol

PubMed

Kaniasty

K

Norris

FH

Social

support

in

the

aftermath

of

disasters

catastrophes

and

acts

of

terrorism

Altruistic

overwhelmed

uncertain

antagonistic

and

patriotic

communities

Bioterrorism

Psychological

and

public

health

interventions

Pedras

S

Pereira

MG

Secondary

Traumatic

Stress

Disorder

in

War

Veterans

Adult

Offspring

Military

Behavioral

Health

doi

Cross

Ref

Articles

from

BMC

Research

Notes

are

provided

here

courtesy

of

BioMed

Central

O O O O O O O O O O O O O O O O O O O O O O O O O B I O B O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O