Reading of the Week: PTSD – More Common in High-Income Countries? The New BJP Open Paper; Also, the Trauma of 911 & Torrey on His Sister

From the Editor

Is there more PTSD in countries like Norway and Canada?

The question seems odd since we typically don’t associate major mental illness with affluence (though, of course, not everyone in an affluent society is affluent). Yet there is a literature suggesting that high-income countries may have more PTSD.

This week, we look at a new paper on the topic. The University of Oslo’s Trond Heir and co-authors consider PTSD in Norway. Drawing on a survey, they find significant rates of PTSD, higher than found in low-income countries. “A possible explanation may be that high expectations for a risk-free life or a happy life can lead to a low threshold for perceiving adverse events as life-threatening or as violating integrity.”

norway-aurlands-fjordenNorway: High incomes, universal health care, many fiords, and more PTSD?

In the next selection and continuing on the topic of PTSD, New York Times reporter James Barron writes about the other victims of September 11 – those who survived, but have struggled with PTSD. As a Long Island clinician notes: “So many suffer in silence. It’s 18 years later, and to some it’s pretty new.”

And in the third selection, Dr. E. Fuller Torrey, a psychiatrist and accomplished researcher, considers his career. He notes that his sister’s psychosis pushed him to choose psychiatry, though he had originally planned to be a family doc.



Selection 1: “Serious life events and post-traumatic stress disorder in the Norwegian population”

Trond Heir, Tore Bonsaksen, Tine Grimholt, Øivind Ekeberg, Laila Skogstad, Anners Lerdal and Inger Schou-Bredal

British Journal of Psychiatry Open, 11 September 2019  Online First


Post-traumatic stress disorder (PTSD) may develop after exposure to exceptionally threatening or horrifying events. It can arise after a single traumatic event or from prolonged exposure to trauma. The symptom course is characterised by re-experiences of the traumatic events in the form of intrusive memories, flashbacks or nightmares; avoidance of stimuli associated with the traumatic events; negative alterations in cognition and mood and marked alterations in arousal and reactivity.

PTSD rates vary widely across countries, with lifetime prevalence in general populations ranging from 0% to 7%. As expected, countries with higher exposure to trauma have a higher prevalence of PTSD. More surprisingly, in the context of high trauma exposure, countries with more resources and better healthcare services have populations with a higher risk of developing PTSD than other countries. 

So begins a paper by Trond Heir et al.

Here’s what they did:

  • They aimed to “examine lifetime trauma exposure and the point prevalence of current PTSD in the general Norwegian population.”
  • They randomly selected 5 500 people “from a public registry of the Norwegian adult population, stratified by age, gender and region of residence.” These individuals were then mailed a survey.
  • Questions asked about serious life events (using a Life Event Checklist for DSM-5, the LEC-5) and PTSD symptoms (using the PTSD Checklist for DSM-5, the PCL-5).
  • Statistical analyses were done.

Here’s what they found:

  • “1 792 individuals participated in the study, for a response rate of 36.0%.”
  • Demographically, there were more women than men (945 vs 834). The mean age was 55.7 for women and 51.0 for men. Most were employed (62.4% vs 59.2%).
  • “At least one serious lifetime event was reported by 85% of men and 86% of women.”
  • “The prevalence of current PTSD was 3.8% for men and 8.5% for women (P < 0.001). The most common events causing PTSD were sexual assaults, physical assaults, life-threatening illness or injury, and sudden violent deaths. Sexual assaults caused PTSD more often in women than in men.”

The authors write:

The high PTSD rate in the Norwegian population supports the ‘vulnerability paradox’ in which those living in countries with more resources have higher, rather than lower, PTSD risk. Essential for PTSD is the exposure to actual or threatened death, serious injury or sexual violence. The subjective perception of life threat, however, can play a key role in the development and maintenance of PTSD regardless of the objectively estimated threat of the actual exposure.

This is a good study, and the conclusion is very interesting. It should be noted the survey focused on Norway; the response rate was good but not great; the comparison with PTSD rates in low-income countries was not done directly (i.e., the authors only surveyed people in Norway, and drew non-Norwegian data from other papers). Maybe it’s not surprising that this paper has appeared in a solid but not major journal.

Still, the results are in keeping with other work in the area. Is PTSD more common in higher-income nations? The authors seem to think so. Of course, we can wonder about other factors, like stigma. We can also wonder if there are limits to our system of diagnosing disorders based on symptom clusters (as opposed to biomarkers).


Selection 2: “She Fled the 68th Floor. She’s Finally Dealing With 9/11 Trauma”

James Barron

The New York Times, 11 September 2019  


Kayla Bergeron can still describe that morning in matter-of-fact detail: She was dutifully working at her desk on the 68th floor when the building lurched. Someone ran in and said that a plane had hit – a small plane, she assumed. She realized it must not have been just a Cessna.

Then came a harrowing descent in a stairwell that was dark and wet because pipes had burst as the twin towers collapsed.

She can also describe her life since, including the loss of a new job, the foreclosure of her condominium, the two convictions for drunken driving and, just last year, the diagnosis from a court-ordered alcohol treatment program: post-traumatic stress disorder stemming from Sept. 11, 2001.

This New York Times story discusses PTSD in those who survived September 11. It focuses on Bergeron. Once a high-ranking government official who worked in the north tower, she has struggled: she has moved several times, quit her work in New York and lost her job in Florida, and experienced a foreclosure of her condo. She works now in a low-paying fast food job.

“PTSD never occurred to me,” she notes. “We weren’t first responders. We weren’t cops or firefighters whose job was to go into the building. People told us, ‘Be happy to be alive.’ We minimized ourselves afterward, and it all built up over the years.”

The article discusses her problem drinking, culminating in two convictions for driving while intoxicated.

The article discusses how common PTSD is among survivors, drawing data from a health plan that covers those affected by September 11:

  • The health program has nearly 25,000 emergency responders with about 30% having PTSD.
  • The health program also has people who fled the towers. 12.3% have PTSD; others have anxiety disorders and depression.

This is a well-written article, and well describes Bergeron. Much is still written about September 11 – people remembering the day, writers commenting on the geopolitical implications, etc. It’s good to see a major article in a major newspaper talk about the psychiatric consequences.


Selection 3: “What Shaped My Career”

Fuller Torrey

Psychiatric Services, 24 July 2019  Online First


It is difficult to be certain what shapes our lives and careers. If we were born again with just one thing changed, such as our parents or birthplace, then we could determine the essential factors. Alas, we are each living a unique social experiment with an N of one.

My best guess is that my life and career were largely shaped by four seminal experiences. The first was my younger sister’s psychotic breakdown in 1957, at age 18. Rhoda had serious schizophrenia with anosognosia as well as treatment resistance. At one time she was suicidal and homicidal. She was hospitalized continuously in a New York State hospital for 25 years and spent the rest of her life in group homes and nursing homes. I was a third-year premed student in college when she got sick, and I envisioned myself practicing family medicine. Because my father had died when we were young, I accompanied my mother and sister as they sought a definitive diagnosis and treatment at psychiatric centers recommended by friends – Columbia, Massachusetts General, Silver Hill, the Brattleboro Retreat, Baldpate, etc.

So begins an autobiographical essay by Dr. Torrey.

Dr. Torrey focuses on several “seminal experiences.” The illness of his sister is clearly profound in its influence on him.

Dr. Torrey notes his surprise and then disappointment when people attributed his sister’s mental disorder to the death of their father.

That made no sense to me whatsoever because my older sister and I had shared all of Rhoda’s childhood experiences and we seemed to be pretty normal – other than the time she broke a dinner plate over my head because I had called her a bad name. My mother, who had had only a high school education, was baffled by my sister’s ordeal and the lack of available information. These events certainly influenced my decision many years later, when I was working with patients at St. Elizabeth’s Hospital, to write Surviving Schizophrenia (1983) for their families.

Dr. Torrey has had a very big career – as a physician and a researcher, as an educator of families who have been touched by schizophrenia, and as an advocate. Even now in the twilight of his career, he is known to work incredibly long hours. This paper helps explain why.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.

1 Comment

  1. It’s heartening to see attention brought to the outstanding contributions of Dr. E. Fuller Torrey. There are so many useful resources, especially on anosognosia, on the website of the Treatment Advocacy Center, the very valuable organization he started:

    I mention, in my recent article on “Advocacy as a Coping Strategy”, the enormous impact that Fuller Torrey’s writings had on my decision to undertake various advocacy projects: