PTSD research paper

http://tandfonline.com/ijmh ISSN: 0963-8237 (print), 1360-0567 (electronic)

J Ment Health, 2017; 26(3): 257–263 ! 2017 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2016.1276531

O R I G I N A L A R T I C L E

Effect of directness of exposure and trauma type on Mental Health Literacy of PTSD

Cheuk Yan Lee1, Adrian Furnham1,2, and Christopher Merritt3

1Research Department of Clinical, Educational and Health Psychology, University College London, London, UK, 2Norwegian Business School (BI),

Nydalveien, Olso, Norway and 3Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Abstract

Background: Research has demonstrated that Post-Traumatic Stress Disorder (PTSD) is one of the most widely recognized mental disorders, but recognition is affected by trauma type. Aims: The current study investigated the effect of direct versus indirect exposure to traumatic event and trauma types on Mental Health Literacy (MHL) of PTSD. Methods: Two hundred and thirty-three participants were asked to identify the mental health problem after presentation of an unlabeled vignette describing a character experiencing PTSD symptoms. The six vignettes described the same symptoms but differed in directness (direct/ indirect exposure) and trauma type (rape, military combat or man-made disaster). It was hypothesized that (1) recognition rate would be higher in direct than indirect conditions, and (2) higher in military combat, followed by man-made disaster, and lowest in rape condition. Results: Overall, correct recognition of PTSD was 42.5%. Recognition in direct exposure vignettes was significantly higher than indirect, supporting the first hypothesis. The second hypothesis was only partly supported. While PTSD recognition in rape vignettes was significantly lower than the other two scenarios, no difference was found between combat and man-made disaster trauma types. Conclusions: Our findings implied under-recognition of PTSD, with lack of awareness of different causes of PTSD and of PTSD from indirect trauma exposure. The latter finding is important in the light of DSM-V revisions to diagnostic criteria for PTSD.

Keywords

Post-Traumatic Stress Disorder (PTSD), Mental Health Literacy, trauma, indirect exposure

History

Received 17 May 2016 Revised 20 September 2016 Accepted 30 November 2016 Published online 12 January 2017

Introduction

Mental Health Literacy (MHL) is defined as ‘‘knowledge and

beliefs about mental disorders which aid their recognition,

management or prevention’’ (Jorm et al., 1997, p. 182).

People able to identify mental disorders correctly are more

likely to seek help from professionals (Jorm, 2000). It is

suggested that correct labeling of mental illness acts as a cue

to activate schema about appropriate action (Wright et al.,

2007). Most MHL studies employ vignette methodology.

Participants are presented with a vignette describing a

character with symptoms of a specific mental disorder, and

are asked to identify it.

Different mental health disorders have different rates of

correct recognition. Depression is the most widely recognized

mental disorder among the general population, at around 75%

correct (e.g. Wang et al., 2007). Schizophrenia is also

accurately identified, with Furnham et al. (2009) recording a

recognition rate of 61%. Research into MHL of anxiety

disorders (ADs) found that type of AD affected correct

identification (Furnham & Lousley, 2013), where recognition

rate was high for Obsessive-Compulsive Disorder (64.7%),

but very low for Panic Disorder (1.3%) and Generalized

Anxiety Disorder (2.8%). However, MHL and subsequent

help seeking were also susceptible to cultural difference. For

example, mental illness was heavily stigmatized in Chinese

culture, therefore, Chinese participants were less likely to

perceive a person as having mental illness, leading to low

MHL and reluctance to discuss mental illness with family or

friends (Wong et al., 2012).

MHL of PTSD and military stereotyping

PTSD was first introduced as an AD in DSM-III 1

(APA,

1980), mainly in response to Vietnam War veteran trauma

cases in the USA. Since then, the diagnosis of PTSD has

become synonymous with military conflict (Wessely, 2006).

MHL of PTSD has received limited attention, perhaps due to

its relatively low lifetime prevalence (estimated at 6.8% in the

USA) compared to disorders such as depression (Kessler

et al., 2005).

Correspondence: Adrian Furnham, Research Department of Clinical, Educational and Health Psychology, University College London, 26 Bedford Way, London WC1H0AP, UK and Norwegian Business School (BI), Nydalveien, Olso, Norway. E-mail: [email protected]

1 PTSD has been re-classified as a ‘‘trauma-and-stress-related disorder’’

in DSM-V (APA, 2013), comprising four symptom clusters: intrusion, arousal, avoidance, and negative cognition and mood.

Due to its strong association with military experience, most

MHL studies of PTSD based their vignettes on military

combat and had relatively high recognition rates in the

general population: 41.6% in the UK (Furnham & Lousley,

2013) and 37.5% in the USA (Reavley & Jorm, 2011).

Though these figures place PTSD amongst the most widely-

recognized mental health conditions, its recognition rate was

still under 50%.

PTSD was also found to be under-recognized among

clinicians, implying sub-optimal intervention recommenda-

tions. Magruder et al. (2005) found that among 86 US veterans

meeting PTSD criteria in a research survey, only 34.4% were

diagnosed with PTSD by their treating clinicians. Similar

under-recognition of PTSD by UK health professionals was

observed by Ehlers et al. (2009), and among clinicians

treating patients with psychosis where PTSD rates are

higher than community norms (Mueser et al., 1998).

One possible explanation for why recognition rates are not

higher among general population or clinician samples could

be the common association of PTSD with military personnel.

The stereotype of veterans experiencing PTSD-like symptoms

has persisted since the early twentieth century ‘‘Shell Shock’’

diagnosis (Wessely, 2006). In fact, PTSD prevalence in the

military is low relative to trauma exposure; Iversen et al.

(2009) found that only 4.7% of a UK military sample had

PTSD, comparable to community norms. However, PTSD can

arise from a range of traumas, such as sexual or physical

abuse, natural disaster, man-made disaster and road traffic

accidents (Brewin, 2003).

PTSD prevalence from other trauma sources is much

higher. For example, the lifetime prevalence of PTSD among

women with history of rape was 32% (Resnick et al., 1993). A

meta-analysis by Galea et al. (2005) found PTSD prevalence

rates of 30–60% following man-made/technological disaster,

and 5–60% following natural disaster. Merritt et al. (2014)

found a significant difference in recognition rate for PTSD by

trauma type among a general population sample in the UK

and Ireland, with 82.4% of participants correctly identifying

PTSD from a vignette about a soldier, versus just 68.6% and

49.4% of participants shown vignettes describing identical

PTSD symptoms from industrial accident and rape, respect-

ively. These findings supported the common popular associ-

ation of PTSD with military combat.

DSM-V revisions to PTSD and directness of trauma exposure

DSM-V (APA, 2013) acknowledged that PTSD could be the

result of either direct or indirect exposure toward traumatic

events. Direct exposure is experience of the event in person

and carries a greater risk of developing PTSD (May & Wisco,

2016). However, indirect exposure could also cause PTSD

through ‘‘repeated or extreme exposure to aversive details of

event(s), usually in the course of professional duties’’ (APA,

2013, p. 272). There is increasing evidence that professionals

involved in helping those who experienced trauma are

vulnerable to developing PTSD through indirect exposure.

For example, Zimering et al. (2006) found that 4.6% of relief

workers (e.g. social workers, psychologists) developed PTSD

from exposure to survivors’ accounts of the 9–11 terrorist

attacks in the USA. Similarly, Bride (2007) found 15% of a

US sample of social workers exposed indirectly to trauma

through their work developed PTSD; more than twice the

lifetime prevalence rate of general population (6.8%). These

social workers were not aware of the risk of indirect exposure

causing PTSD.

With the increasing evidence to suggest that PTSD could

also result from indirect exposure to traumatic events, it is

important for the general population and professionals to

develop a wider understanding of PTSD. Improving MHL of

PTSD would benefit public wellbeing and facilitate help-

seeking behaviors. Although Bride (2007) found that most

social workers were not aware of indirect-exposure PTSD,

this phenomenon was not formally tested.

Study aims and hypotheses

This study aimed to investigate how directness of trauma

exposure affected recognition of PTSD. In addition, given the

‘‘military combat’’ stereotype and difference in prevalence

rate among various PTSD causes, this study aimed to

investigate how MHL of PTSD varied by three trauma

types: military, man-made accident and rape.

Given the higher prevalence rate of PTSD among direct

than indirect exposure, we hypothesized that (1) recognition

rate would be higher in direct than indirect conditions.

Second, we hypothesized that trauma type would affect

recognition rate, specifically that (2) recognition would be the

highest in a military combat condition due to stereotyping,

followed by man-made disaster, and lowest in rape condition.

We also examined demographic differences in recognition

rate and beliefs about help seeking, though this was explora-

tory and did not therefore have specific hypotheses.

Additionally, we looked at participants’ experience of

mental illnesses to determine how this impacted on

recognition.

Method

Participants

Opportunistic sampling was used for participant selection.

The first two authors contacted various individuals and

groups with which they had worked in the past to complete

the questionnaire. Two hundred and thirty-three participants

took part, 60 males and 173 females. Mean age was 23.2 years

(SD¼9.1; range 18–57). 46.8% gave their ethnicity as Chinese, 25.8% White British, 12.9% Other European.

Because of the demography of the authors, a large group of

British Chinese people were contacted and agreed to take

part. The remaining 14.5% comprised American, Australian,

Canadian and other ethnicities. Over half reported their

highest education as university-level (39.1% Bachelor’s;

17.6% Master’s), 42.9% A-levels or equivalent and 0.4%

GCSE only (or equivalent). 2

54.1% of participants indicated

2 For subsequent analyses, a binary variable was created indicating

university level education or not. Participants’ age was divided into three categories, 18–29, 30–39 and 40+, and participants nationality was divided into three categories, Chinese (n¼109), Europeans including British (n¼83) and other nationalities (n¼41).

258 C. Y. Lee et al. J Ment Health, 2017; 26(3): 257–263

that they had studied psychology, of which 11.6% were

university psychology students.

Design and procedure

The study was run online using Qualtrics. A 2�3 between- subject factorial design was employed. Participants were

randomly allocated one of six vignettes, differing only in

directness (direct or indirect exposure to traumatic event) and

trauma type (rape, military combat or man-made disaster).

Each vignette described a character, Alex, who was

experiencing symptoms of PTSD. These are reproduced in

the appendix. Participants were asked to identify the mental

disorder described. They were asked whether or not they think

‘‘Alex’’ has a mental health problem (Yes/No), followed by

‘‘If so, what do you think it is?’’ where participants could

enter their response into the text box. They were also asked to

rate distress, happiness and their sympathy level regarding

‘‘Alex’s’’ situation on a seven-point Likert scale. Lastly, they

were asked what help they would suggest for ‘‘Alex’’ (12

choices were given with multiple responses permitted). These

questions were chosen as they have been used in previous

research on MHL. Independent variables were trauma direct-

ness (direct/indirect) and type (combat, man-made disaster or

rape). The dependent variable was correct PTSD recognition.

Participants were also asked if they had experience of

mental health difficulties, either personal or someone they

knew, to assess the impact of this on recognition.

Results

In all, 8.6% of participants reported having been diagnosed

with mental disorder and 71.7% indicated that they knew

someone diagnosed with mental disorder. Table 1 shows

participants’ allocation into different conditions.

Classification as having a mental health problem

Overall, 82.8% (n¼193) responded ‘‘Yes’’ to ‘‘Do you think Alex has a mental disorder?’’, while 17.2% (N¼40) responded ‘‘No’’ (Table 2). Two-way ANOVA was conducted

to test the effect of directness and type on classification rate.

No significant main effect of directness (F(1, 227)¼3.73, p40.05, �2¼1.6%) and type (F(2, 227)¼2.40, p40.05, �2¼2.1%) on classification rate was found. No significant interaction between directness and type was found, F(2,

227)¼0.33, p40.05, �2¼0.3%.

Recognition of PTSD

Participants’ responses toward what mental health problem

‘‘Alex’’ had were coded as either ‘‘correct’’ (PTSD) or

‘‘incorrect’’ (other responses). Responses such as ‘‘trauma-

tized’’, ‘‘war trauma’’, ‘‘shell shock’’ were considered

‘‘incorrect’’. A second researcher external to the study

independently coded all responses to check reliability. There

was high inter-rater reliability, with disagreement in only 2 of

233 responses (Cohen’s kappa¼0.98, p50.01). Overall, 42.5% of participants correctly identified the

mental health problem as PTSD. Table 3 shows recognition

rates across all conditions. Two-way ANOVA found a

significant main effect of directness on recognition rate,

F(1, 227)¼33.07, p50.01, �2¼12.7%. There was also a significant main effect of type on recognition rate, F(2,

227)¼8.71, p50.01, �2¼7.1%. No significant interaction was found between directness and type, F(2, 227)¼1.08, p40.05, �2¼0.9%.

Recognition rate was significantly higher in direct (58.8%)

than indirect (25.4%) conditions, t(231)¼5.45, p50.01 (Figure 1).

Recognition rate was significantly higher in the military

combat than the rape condition, t(230)¼2.67, p50.01, and for man-made disaster versus rape conditions, t(230)¼3.68, p50.01. No significant difference was found between mili- tary and man-made disaster conditions, t(230)¼0.993, p40.05 (Figure 2). Due to the low recognition rate in indirect exposure to rape condition, participants’ free-text

responses were examined. Fifteen participants gave

‘‘anxiety’’ as the mental health problem; one responded

Table 2. Classification as having a mental health problem across all conditions.

Conditions Direct Indirect Total

Rape 77.5% (N¼31/40) 73% (N¼27/37) 75.3% (N¼58/77) Military combat 90.2% (N¼37/41) 80.6% (N¼29/36) 85.7% (N¼66/77) Man-made disaster 94.7% (N¼36/38) 80.5% (N¼33/41) 87.3% (N¼69/79) Total 87.4% (N¼104/119) 78.1% (N¼89/114)

Table 3. Recognition rate across all conditions.

Conditions Direct Indirect Total

Rape 45.0% (N¼18/40) 5.4% (N¼2/37) 26.0% (N¼20/77) Military combat 65.9% (N¼27/41) 25.0% (N¼9/36) 46.8% (N¼36/77) Man-made disaster 65.8% (N¼25/38) 43.9% (N¼18/41) 54.4% (N¼43/79) Total 58.8% (N¼70/119) 25.4% (N¼29/114)

Table 1. Participants’ allocation into different conditions.

Conditions (number of participants) Direct Indirect Total

Rape 40 37 77 Military combat 41 36 77 Man-made disaster 38 41 79 Total 119 114 233

DOI: 10.1080/09638237.2016.1276531 MHL of PTSD 259

‘‘depression’’; the remainder used everyday language (e.g.

‘‘not functioning well’’, ‘‘fearful’’ and ‘‘sexual fear’’).

Nationality significantly affected PTSD recognition (F(2,

230)¼4.06, p50.05). Recognition was significantly higher in Other nationalities (58.5%) than Chinese (33.9%),

t(230)¼2.75, p50.01. No difference in recognition rate was found between Chinese and Europeans (45.8%; t(230)¼1.66, p40.05) or Europeans and Other nationalities (t(230)¼1.37, p40.01). No other demographic factors significantly affected recognition rate.

Participants’ ratings

Participants’ ratings were recorded on a seven-point Likert

scale (1¼‘‘Not at all’’; 7¼‘‘Extremely’’). Regarding ‘‘Alex’s’’ distress level, a significant main effect of directness

on distress ratings was found, F(1, 227)¼10.44, p50.01, �2¼4.4%. No other effects were significant. Distress ratings was significantly higher in direct (M¼6.07, SD¼0.97) than indirect conditions (M¼5.66, SD¼0.96), t(231)¼3.24, p50.01.

A significant main effect of directness was found on

participants’ sympathy ratings toward ‘‘Alex’’, F(1,

227)¼7.78, p50.01, �2¼3.3%. No other effects were significant. Sympathy ratings were significantly higher in

direct (M¼5.97, SD¼1.10) than indirect exposure condition (M¼5.55, SD¼1.12), t(231)¼2.84, p50.01.

A significant main effect of directness on happiness ratings

was found, F(1, 227)¼7.91, p 50.01, �2¼3.4%, and of trauma type (F(2, 227)¼0.088, p40.05, �2¼0.1%). Interaction between directness and trauma type was not

significant. Happiness ratings in direct condition (M¼2.13, SD¼0.093) was significantly lower than indirect exposure (M¼2.52, SD¼1.16), t(231)¼2.85, p50.01.

Help seeking

Participants were given 12 choices for help they think ‘‘Alex’’

should seek and allowed unlimited, multiple choices. Table 4

shows participants’ help-seeking responses for all conditions,

and columns: p(directness), and p(type), show significance

levels for conditions.

The most popular choice of help for ‘‘Alex’’ was ‘‘see a

psychologist/counselor’’ suggested by 92.7% of participants.

63.9% suggested talking to family and/or friends, while 50.2%

recommended ‘‘talk to a trusted person outside family and

friends’’. Far fewer respondents suggested seeing a medical

professional and taking medication.

The number of participants suggesting a psychologist was

significantly lower in the rape condition (85.7%) than combat

(96.1%; t(230)¼2.51, p50.05) and man-made disaster con- dition (96.2%; t(230)¼2.55, p50.05). No significant differ- ence was found between combat and man-made disaster

(t(230)¼0.024, p40.05). Practical recommendations were chosen significantly more

in direct (27.7%) than indirect conditions (3.5%), F(1,

231)¼28.48, p50.01. The number of recommendations was

Table 4. Help seeking suggestions for all conditions.

What help, if any, do you think Alex should seek? Frequency % of all participants (N¼233) p (directness) p (type)

See a psychologist/counselor 216 92.7 n.s. 50.05 See a medical professional 56 24.0 n.s. n.s. Take medication 58 24.9 n.s. n.s. Talk to a trusted person outside of family and friends 117 50.2 n.s. n.s. Talk to family and/or friends 149 63.9 n.s. n.s. See a non-health worker (e.g. support charity) 28 12.0 n.s. n.s. Practical steps (e.g. justice, legal assistance, compensation) 37 15.9 50.01 50.01 General lay advice (e.g. ‘‘move on’’, ‘‘be strong’’) 20 8.6 n.s. n.s. Alternative interventions (e.g. hypnosis, holistic treatment, exercise) 63 27.0 n.s. n.s. Don’t know/not qualified to say 17 7.3 n.s. n.s. Other 5 2.1 n.s. n.s. No suggestion for help 0 0 n.s. n.s.

R ec

og ni

ti on

R at

e (%

)

Conditions

Figure 1. Recognition rate across direct and indirect conditions.

R ec

og ni

ti on

R at

e (%

)

Conditions

Figure 2. Recognition rate across type of PTSD.

260 C. Y. Lee et al. J Ment Health, 2017; 26(3): 257–263

higher in the rape condition (36.4%) than both combat (6.5%;

t(230)¼5.48, p50.01) and man-made disaster (5.1%; t(230)¼5.78, p50.01). The number of recommendations did not differ significantly between combat and man-made

disaster (t(230)¼0.26, p40.05).

Discussion

This study aimed to examine the effect of directness and

trauma type on MHL of PTSD. The result obtained partly

supported our hypotheses. Recognition rate was higher in

direct than indirect conditions, which supported our first

hypothesis. When comparing trauma types, PTSD recognition

rate was lowest in the rape condition; significantly lower than

both military combat and man-made disaster conditions.

However, no significant difference was found between

military combat and man-made disaster conditions. Hence,

our second hypothesis that recognition rate would be higher in

military combat, followed by man-made disaster and lowest in

rape condition was only partly supported. Overall, the

recognition rate of PTSD was found to be 42.5%. This

implies limitations within public understanding of PTSD.

The result that recognition rate was lower in indirect than

direct conditions suggested that participants were not aware

that PTSD could result from indirect exposure to traumatic

events. This is in line with Bride’s (2007) findings that social

workers were not aware of their vulnerability to acquiring

PTSD. A likely explanation for this lower recognition was that

evidence of the link between indirect trauma exposure and

PTSD emerged only recently, with indirect exposure included

as one criterion for PTSD with DSM-V in 2013. This recent

acknowledgement of indirect exposure on PTSD might

explain why participants were less familiar, and hence, were

less able to identify PTSD in indirect conditions.

Bride (2007) also provided evidence that social workers

and first responders were two of the high-risk groups in

acquiring PTSD. The inability of participants to identify

PTSD from the indirect vignettes might imply that such cases

of PTSD could go unrecognized and untreated in ‘‘real

world’’ situations. The limitation in MHL of indirect PTSD

indicates lack of awareness toward PTSD and specifically to

the revision of DSM-V criteria for PTSD resulting from

indirect exposure.

Our result was consistent with Merritt et al.’s (2014)

findings, which showed higher MHL in military combat

vignette than rape vignette. This might be because PTSD was

commonly known to be a diagnosis for veterans, so more

participants in the present study (46.8%) were able to identify

it from the combat vignette. Conversely, the low recognition

rate in rape condition (26.0%) might suggest that people were

not aware that rape could result in PTSD. However, a high

proportion (75.3%) of participants in the rape condition

selected ‘‘yes’’ when asked if Alex had a mental health

problem. Therefore, the low MHL in rape condition might be

the result of incorrect identification of mental health problem

as something other than PTSD.

Though recognition rate was higher in the man-made

disaster than the military combat condition, this difference

was not statistically significant. Since the study was run

around the time of the Paris terrorist attacks in November

2015, this might have increased participants’ awareness and

knowledge of PTSD from man-made disaster, specifically

terrorist attacks. There are further indications that PTSD

to terrorist attacks is increasingly recognized, for example the

establishment of a new UK-government funded scheme to

assist British victims of terror attacks worldwide with

screening and treatment for PTSD. 3

The overall recognition rate for PTSD in this study was

42.5%, which was lower than the 67% reported by Merritt

et al. (2014). In Merritt et al.’s study, a proportion of the

sample worked in mental health, so might have been more

familiar with PTSD, while in the present study a higher

proportion of participants were students. This difference may

also have been affected by participant nationality. 46.8% of

participants in the present study were Chinese, and Chinese

participants had lower recognition of PTSD than other

nationalities. While the present study did not aim to examine

cultural differences in MHL, future research could consider

investigating this with PTSD. In China, for example, a

different diagnostic system to DSM-V is commonly used, and

PTSD symptoms may be represented differently in Chinese

communities. Though beyond the scope of the present study,

this could be an avenue of future research.

The majority of the participants (92.7%) recommended

‘‘seeing a psychologist/counselor’’, which was the most

popular choice of help. However, this recommendation was

affected by trauma type. Significantly more participants

recommended a psychologist if they read combat or man-

made disaster vignettes, compared to rape. This could suggest

that participants view both veterans and survivors of man-

made disaster as more likely to experience mental disorders

than sexual assault victims.

Nonetheless, the number of participants recommending a

psychologist in rape condition remained high (85.7%). Even

though not all participants were able to correctly identify

PTSD from the vignette, this suggests that correct labeling of

the mental condition was not necessary for subsequent help-

seeking recommendations, contrary to the findings of Wright

et al. (2007). It is possible that merely believing there was a

mental health issue for ‘‘Alex’’, regardless of what the mental

illness was, was sufficient to drive people’s help-seeking

recommendation. If this was the case, then being able to

notice a possible mental health problem was the cue to

activate the schema of help-seeking action, rather than correct

labeling of the problem as PTSD.

Significantly more participants chose practical help

options if they were in direct rather than indirect condition,

and in rape condition compared to combat and man-made

disaster conditions. It was likely that participants viewed

‘‘Alex’’ as having suffered an attack from an offender in

direct exposure to rape condition, therefore requiring legal

help in order to convict the offender. Conversely, veterans and

survivors of disaster had less need for legal help. Half of the

sample chose ‘‘talk to a trusted person outside family and

friends’’, which was the third most popular option. The reason

for this figure not being higher might be the large number of

Chinese participants in the present study. As Wong et al.

3 See, for example: https://www.gov.uk/government/publications/terror-

ist-attacks-in-paris-support-for-people-affected.

DOI: 10.1080/09638237.2016.1276531 MHL of PTSD 261

(2012) suggested, due to stigmatization Chinese participants

were more reluctant to talk about mental illness with family

and friends.

Participants’ ratings of distress, sympathy and happiness

level varied as a function of directness but not trauma type.

Individuals’ ratings might be affected by their perceived

seriousness of different causes of PTSD, where they viewed

direct exposure as a more serious problem than indirect

exposure. This is consistent with Zimering et al.’s (2006)

findings, where direct exposure resulted in a higher preva-

lence rate of PTSD (6.4%) than indirect exposure (4.6%).

Another possible reason for this might be because all

characters in indirect conditions were professional.

Participants might think that professionals were better at

dealing with stress and helping patients to cope as a routine

part of their work. The similarity in ratings between trauma

types might means participants’ perception of seriousness

between them were similar, where all traumas were seen as

equally serious and devastating to a person’s life.

Our results overall suggest that people had limited

knowledge regarding various causes of PTSD. This might

imply an inability for people to recognize PTSD if a traumatic

event happened to their family members, friends or even

themselves. As a result, people might not seek help and access

appropriate treatment. The difference in recognition rate

across conditions further implied that this sample of the

general population was not aware that professionals and rape

victims were at risk at developing PTSD. Given the high

prevalence of PTSD among rape victims (32%) and social

workers (15%), the low recognition rate would potentially

mean thousands of PTSD cases resulting from indirect

exposure to traumas, particularly rape, would go undetected

and untreated. Nevertheless, results also suggested that

correct labeling was not necessary for subsequent help-

seeking recommendations to see a mental health professional.

Applying this result to real life situations, this could mean that

so long as people noticed there was a mental health problem,

even if they could not correctly identify it, they would still

seek help from psychologist. Given the relatively low

recognition rate revealed in the present study, there is still a

need for raising awareness and increasing education around

PTSD, especially among students and younger adults.

A limitation of the present study was the small sample size

(N¼233) relative to other MHL studies with N41000. Many participants were students and younger adults, meaning that

results obtained might only apply to this cohort. Future

research is needed to assess whether the findings generalize to

a wider population, particularly older adults.

The current study investigated only three trauma types.

Future research could include further trauma sources, such as

natural disaster, mugging and physical abuse. If similar results

were found, this would further point toward the importance of

increasing education around the occurrence of PTSD from

different trauma types. Additionally, future research could

also replicate this study among mental health care profes-

sionals and GPs, given their roles in diagnosis and treatment.

Higher MHL among health professionals would indicate more

likelihood of appropriate treatment being offered. Lastly, the

present study showed a cultural difference in MHL of PTSD.

Researchers could consider comparing MHL of PTSD more

systematically between different countries and/or cultural

groups in the future.

Declaration of interest

There is no conflict of interest in this paper.

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Appendix A

Vignette 1 – Direct exposure, rape

Alex was attacked by a group of men on the way home from school, they took turns raping her. For months after this horrifying event, these images still haunted her. Alex was unable to keep these memories out of her mind. Alex noticed that at night, she had difficulties relaxing and falling asleep. Scenes from the attack would run repeatedly through her mind and disrupt her focus at school. This also affected Alex’s day-to- day life, for example, when Alex walked back from school, which took her past the site of the attack, this immediately rekindled certain horrific memories. So, Alex would have to go the long way home. She felt as though her emotions were numbed, and as though she had no real future. At home she was anxious, tense, and easily startled. She found herself avoiding social interactions, and became very fearful of being out in public.

Vignette 2 – Direct exposure, military combat

Alex saw a good deal of active combat during his time in the military. Some incidents in particular had never left his mind – like the horrifying sight of Gary, a close comrade and friend, being blown-up by a land- mine. For months after he returned to civilian life, these images still haunted him. Alex was unable to keep the memories of combat out of his mind. Alex noticed that at night, he had difficulties relaxing and falling asleep. Scenes from battle would run repeatedly through his mind and disrupt his focus on work. This also affected Alex’s day-to-day life, for example, when Alex was filing up at the gas station, the smell of diesel immediately rekindled certain horrific memories. He felt as though his emotions were numbed, and as though he had no real future. At home, he was anxious, tense, and easily startled. He found himself avoiding social interactions, and became very fearful of being out in public.

Vignette 3 – Direct exposure, man-made disaster

Alex is an auto mechanic who was working three blocks from the World Trade Center on 9/11. Alex witnessed both towers falling. For months after the 9/11 terrorist attacks, these images still haunted Alex. Alex was unable to keep the memories of the attack out of his mind. Alex noticed that at night, he had difficulties relaxing and falling asleep. Scenes from the tower falling would run repeatedly through his mind and disrupt his focus on work. This also affected Alex’s day-to-day life, for example, when he crossed the Brooklyn Bridge into Manhattan, he started sweating and trembling, as this immediately rekindled certain horrific memories. He felt as though his emotions were numbed, and as though he had no real future. At home, he was anxious, tense and easily startled.

He found himself avoiding social interactions, and became very fearful of being out in public.

Vignette 4 – Indirect exposure, rape

Alex is a sex offender therapist working at a State prison. Alex has listened to many stories from the sex offenders, and was haunted by what she heard at work. What distresses her the most is having to listen to offenders’ sexual fantasies and their sadistic sexual behaviours. Alex was unable to keep these memories out of her mind. Alex noticed that at night, she had difficulties relaxing and falling asleep. Scenes of rape would run repeatedly through her mind and disrupt her focus at work. This also affected Alex’s day-to-day life, for example, when Alex was being intimate with her husband, these images of sexual fantasies pop up in her mind. She felt as though her emotions were numbed, and as though she had no real future. At home she was anxious, tense and easily startled. She found herself avoiding social interactions, and became very fearful of being out in public.

Vignette 5 – Indirect exposure, military combat

Alex is a nurse working on a palliative care unit in a US Veteran’s Hospital. Alex has seen many veterans die, and was haunted by what she saw at work. What distressed her the most was that while she witnessed the actual dying process, she experienced their trauma from combat through their eyes. Alex was unable to keep these memories out of her mind. Alex noticed that at night, she had difficulties relaxing and falling asleep. Scenes from the veterans’ combat would run repeatedly through her mind and disrupt her focus at work. This also affected Alex’s day-to- day life, for example, whenever Alex encountered scenes of battlefield on the TV, this immediately rekindled certain horrific memories. She felt as though her emotions were numbed, and as though she had no real future. At home she was anxious, tense, and easily startled. She found herself avoiding social interactions, and became very fearful of being out in public.

Vignette 6 – Indirect exposure, man-made disaster

Alex was a social worker when the 9/11/01 terrorist attack on the World Trade Center in New York City occurred. Alex has listened to many family members and survivors, and was haunted by what he heard at work. What distressed her the most are the intense emotions that she was exposed to at work. Alex was unable to keep the memories of attack out of her mind. Alex noticed that at night, she had difficulties relaxing and falling asleep. Scenes from the tower falling would run repeatedly through her mind and disrupt her focus on work. This also affected Alex’s day-to-day life, for example, when she went near the World Trade Center, she started sweating and trembling, as this immediately rekindled certain horrific memories. She felt as though her emotions were numbed, and as though she had no real future. At home, she was anxious, tense and easily startled. She found himself avoiding social interactions, and became very fearful of being out in public.

DOI: 10.1080/09638237.2016.1276531 MHL of PTSD 263

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