Lifetime Traumas and Mental Health: The Significance of Cumulative Adversity Author(s): R. Jay Turner and Donald A. Lloyd Source: Journal of Health and Social Behavior, Vol. 36, No. 4 (Dec., 1995), pp. 360-376 Published by: American Sociological Association Stable URL: http://www.jstor.org/stable/2137325 . Accessed: 18/10/2011 15:29 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. American Sociological Association is collaborating with JSTOR to digitize, preserve and extend access to Journal of Health and Social Behavior. http://www.jstor.org

Lifetime Traumas and Mental Health: The Significance of Cumulative Adversity* R. JAY TURNER University of Miami DONALD A. LLOYD University of Toronto Journal of Health and Social Behavior 1995, Vol. 36 (December):360-376 This paper reports the community prevalence of 20 life traumas and considers their individual relevance as risk factors for psychiatric disorder. Also presented is the first evidence on the mental health significance of cumulative adversity as indexed by a count of lifetime exposure to a wide array of potentially traumatic events. The question of the importance of considering such events within efforts to assess variations in life stress is also examined. Our results demonstrate clear relationships between many traumatic events and, especially, accumulated lifetime trauma experience and both psychological distress and psychiatric disorder. That these relationships persist with temporal priority controlled-and net of the effects of parental psychopathology-suggests the causal relevance of major lifetime events and the conclusion that they represent an important dimension of increased mental health risk. From these findings and from evidence for the significance of traumas in disorder recurrence, it is contended thatfailure to take account of such events has resulted in the systematic underestimation of the role of stress exposure in accounting for variations in emotional distress and disorder. INTRODUCTION A very substantial body of evidence has accumulated over the past several decades supporting the conclusion that the nature of the social environment is consequential for emotional health and well-being. This evi- dence has consistently linked risk for mental health problems with various social statuses * This is a revision of a paper presented at the 5th International Conference on Social Stress Research, Honolulu, May 1994. This study was supported by a research grant from the National Health Research and Development Program (NHRDP) of Health and Welfare Canada, by a National Health Scientist Award to R. Jay Turner, and by a Social Sciences and Humanities Research Council of Canada Doctoral Fellowship to Donald A. Lloyd. Direct correspondence to: R. Jay Turner, Department of Sociology, Research Cen- ter, University of Miami, 5665 Ponce de Leon Blvd., Coral Gables, FL 33124-0719, e-mail JTURNER@umiami.ir.miami.edu. that are thought to embody characteristic differences in social experience (Aneshensel 1992). As House and Mortimer (1990) have noted, the primary focus of research attention has now turned to the question of how these factors come to influence individual health and under what circumstances such effects are made more or less intense. Clearly, the factor receiving the most attention has been social stress as measured by life event checklists. A monumental outpouring of research following the publica- tion of the Social Readjustment Rating Scale (Holmes and Rahe 1967) established a clear connection between mental health status and scores on event checklists (Dohrenwend and Dohrenwend 1974 Jenkins 1976). This con- nection, in turn, suggested the appealing hypothesis that the elevated levels of psycho- logical distress and disorder observed among disadvantaged subgroups may be at least partially attributable to greater exposure to stressful circumstances (Dohrenwend and Dohrenwend 1969 Kohn 1972). However, 360

LIFETIME TRAUMAS AND MENTAL HEALTH 361 cumulative evidence from event checklist studies (Rabkin and Struening 1976 Kessler 1979 Kessler and Cleary 1980 Thoits 1983, 1987) has diminished enthusiasm for this hypothesis and generated the widespread habit of thought that social stress is of only minimal significance for understanding varia- tions in psychological distress and disorder. In counterpoint to this perception, we have elsewhere argued that the hypothesis that level of social stress is an important determi- nant of mental health status has never been effectively tested because we have yet to adequately measure social stress (Turner, Wheaton, and Lloyd 1995). Evidence rele- vant to this argument was reported based on a more comprehensive effort to estimate varia- tions in life stress than has been typical. This effort combined data from an index of major childhood and lifetime traumas, a measure of chronic stress developed by Wheaton (1991), and an inventory of recent life events that allowed consideration of the enduring nature of many reported events (Avison and Turner 1988 Turner and Avison 1992). Our findings indicated that differences in stress exposure account for substantially more variability in depression than previous reports have tended to suggest. This was so for both major depressive disorder and depressive symptom- atology, but was especially clear in relation to symptomatology, where the variance ac- counted for was about two and one half times the upper range of reports from previous research. In addition, we found that differ- ences in stress exposure account for between 23 and 50 percent of observed sex, marital status, and SES differences in mental health (Turner et al. 1995). These findings provided rather compelling support for the hypothesis that level of experienced social stress may be a considerably more powerful determinant of health and well-being than is generally assumed. Whatever advance may have been involved in this more elaborate effort to measure life stress, it seems clear that fully adequate estimates of stress exposure remain to be achieved. At a minimum, however, these results encourage continued efforts to identify relevant domains and dimensions of life stress and to develop reliable means for their assessment. Only when the range of poten- tially stressful experiences has been approxi- mated and reliably measured will it be possible to meaningfully estimate the health significance of social stress. One domain of potentially relevant life stress that has re- ceived little consideration in terms of its contribution to the stress burden of individu- als or groups is that of major traumatic experiences. This paper reports the lifetime prevalence of 20 major events or traumas and considers their individual relevance as risk factors for psychiatric disorders. It also presents the first evidence on the mental health significance of cumulative adversity where such adversity is indexed by a wide array of potentially traumatic events. Finally, the question of the importance of considering such traumas within efforts to assess variations in stress exposure is examined. BACKGROUND It is, of course, hardly novel to suggest that traumatic experiences can have significant adverse mental health consequences. Such experiences have represented prominent ex- planatory factors at least from the early days of psychoanalytic theory (Freud 1920), and numerous clinical descriptive and case control studies have reported elevated rates of traumatic experiences among both psychiatric inpatients and outpatients (Coyne and Downey 1991 Kessler and Magee 1993). A considerable body of research has accumu- lated suggesting the relevance for adult mental health of specific forms of early trauma. Principal among these are sexual abuse (Browne and Finkelhor 1986 Burnam et al. 1988 Green 1993 Stein et al. 1988 Yama, Tovey, and Fogas 1993), physical violence and abuse (Bryer, Miller, and Krol 1987 Holmes and Robins 1988), parental deaths and parental divorces (Brown and Harris 1978 Brown, Harris, and Bifulco 1986 Barnes and Prosen 1985 McLeod 1991), and parental psychopathology and substance abuse (West and Prinz 1987). While there is evidence suggesting that various mediating factors are implicated in some of these established connections with mental health outcomes (Harris et al. 1986 Harris, Brown, and Bifulco 1990 Kessler and Magee 1994 McLeod 1991), the hypothesis is clearly tenable that major adverse experi- ences have long-term psychiatric signifi- cance. If this is accepted, it follows that an adequate assessment of differences in expo- sure to life stress requires consideration of