The role of social threat and threat to life in the development of post-traumatic stress disorder and social anxiety disorder

The definition of traumatic stressors capable of leading to post-traumatic stress disorder (PTSD) has been debated for forty years. The emphasis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) has been on objective definitions of traumatic events (Criterion A). However, many non-Criterion A stressors can result in PTSD symptoms (PTSS). In this study, we propose moving the debate forward by reconceptualizing trauma as perceived threat; threat to life and/or social threat, the latter involving rejection and/or humiliation. We explored threat rates among 113 trauma-exposed Icelandic women, and examined the relationship between threat types and PTSS. We also compared women with PTSS and social anxiety disorder (SAD) to women with PTSS but without SAD. The results showed that everyone in the PTSS group reported some type of high threat while 43% of the control group reported no threat to self. Fascinatingly, 95.6% of PTSS women reported high social threat, compared to 46.2% of the control group. Only two PTSS women reported primarily life threat (4.3%) compared to 10.4% of the control group. In the PTSS group, reporting both types of threat was most common and these women had more severe clinical symptoms than those who reported a single threat (life or social). However, it was only intensity of social threat that predicted an increase in PTSS symptoms when controlling for empirically validated treatment of PTSD. Social threat was also the only predictor of increase in SAD symptom severity, indicating that it may be the bridge between PTSD and SAD. Almost half of the PTSS group also met criteria for SAD, reporting higher impairment in functioning, less quality of life and greater depression symptoms. These findings suggest that there may be a large group of individuals who develop PTSD and SAD as one integrated condition rather than two separate disorders. We conclude that trauma is primarily about social threat. These findings have implications for theoretical models of both PTSD and SAD, and for the assessment and treatment of those disorders