The Junior Eysenck Personality Inventory ratings of traumatized youth with and without PTSD

Personality and Individual Differences 101 (2016) 16–21

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The Junior Eysenck Personality Inventory ratings of traumatized youth with and without PTSD Philip A. Saigh a,⁎, Dusty Hackler a, Anastasia E. Yasik b, Leah A. McGuire a, Alessandro Bellantuono a, Constance Dekis a, Katherine Durham a, Phill V. Halamandaris c, Richard A. Oberfield d a

Teachers College, Columbia University, United States Pace University, United States Riverside County Department of Mental Health, United States d New York University School of Medicine, United States b c

a r t i c l e

i n f o

Article history: Received 25 October 2015 Received in revised form 28 April 2016 Accepted 6 May 2016 Available online 26 May 2016 Keywords: PTSD Personality Child Adolescent

a b s t r a c t The Junior Eysenck Personality Inventory (JEPI) scores of traumatized youth with or without PTSD were compared to the scores of a non-traumatized control group. It was observed that the PTSD group had significantly higher JEPI Neuroticism scores relative to the comparison groups. The JEPI Neuroticism scores of the traumatized group without PTSD and the non-traumatized controls were not significantly different. Nonsignificant differences were also evidenced between groups on the JEPI Extraversion and Lie scales. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction Neuroticism is an important personality construct that has been positively associated with posttraumatic stress disorder (PTSD) symptoms (Casella & Motta, 1990; Hyer et al., 1994; McFarlane, 1988). To date, a number of prospective investigations have reported that neuroticism was positively associated with the frequency of PTSD symptoms among adults (Alexander & Wells, 1991; Breslau & Schultz, 2013; Parslow, Jorm, & Christensen, 2006). Given the need to facilitate our understanding about the way that trauma may influence personality and the need to identify non-diagnostic measures that reflect the expression of PTSD, several studies have administered different versions of the Eysenck Personality Inventory (e.g., Eysenck & Eysenck, 1964) to traumatized samples. Breslau, Davis, Andreski, and Peterson (1991) conducted a longitudinal study that involved 1007 young, American adults. Breslau and colleagues administered the Eysenck Personality Questionnaire-Revised (EPQ-R; Eysenck, Eysenck, & Barrett, 1985) and the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R; American Psychiatric Association, APA, 1987) form of the Diagnostic Interview Schedule (DIS; Robins, Helzer, Cottler, & Golding, 1989) PTSD module to the study sample. The authors observed that EPQ-R Neuroticism was strongly associated with PTSD (Breslau et al., 1991). On the

⁎ Corresponding author.

http://dx.doi.org/10.1016/j.paid.2016.05.013 0191-8869/© 2016 Elsevier Ltd. All rights reserved.

other hand, EPQ-R Extraversion was not a significant predictor of PTSD. Breslau and Schultz (2013) went on to conduct a 10-year follow-up investigation involving 990 of the 1007 participants that Breslau et al. (1991) had initially examined. Interestingly, baseline EPQ-R Neuroticism scores significantly predicted PTSD 10 years later. In a similar vein, Mulder, Fergusson, and Horwood (2013) administered the Eysenck Personality Inventory (EPI; Eysenck & Eysenck, 1964) and the DSM-IV (American Psychiatric Association, APA, 1994) version of the DIS PTSD module (Robins, Cottler, Bucholz, & Compton, 1995) to 987 adults from Australia and New Zealand as part of a 30-year longitudinal study. Mulder et al. (2013) reported that EPI Neuroticism scores were significantly associated with lifetime PTSD diagnoses. Perrin et al. (2014) administered a French translation of the Eysenck Personality Questionnaire (EPQ; Eysenck et al., 1980) and a French translation of the DSM-IV (APA, 1994) Schedule for Affective Disorders and Schizophrenia-Lifetime and Anxiety Disorder PTSD module (SADS-LA; Endicott & Spitzer, 1978) to 3691 Swiss adults. Perrin et al. (2014) observed that EPQ Neuroticism scores were significantly associated with PTSD diagnoses. While these studies consistently represented that neuroticism was correlated with PTSD, procedural and theoretical concerns are apparent. Initially, it is not known if PTSD was associated with neuroticism or if trauma exposure without the onset of PTSD was associated with neuroticism. Moreover, all of the reports that were considered employed correlational designs that did not allow comparisons of individuals with PTSD to traumatized cases without PTSD and non-traumatized

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controls. This is problematic because trauma exposure may not induce PTSD (Alisic et al., 2014; Copeland, Keeler, Angold, & Costello, 2006; Saigh, Yasik, Sack, & Koplewicz, 1999; Schnyder et al., 2015) and because there is a theoretical and clinical need to know if traumatized individuals without PTSD have increased neuroticism. The latter point is especially relevant as population based surveys have indicated that most of the people in the United States experience a traumatic event by the time that they are 45 years old and because approximately 25% of the American population are exposed to trauma by the time they enter early adulthood (Norris & Slone, 2013). It is also of concern to note that none of the studies that were reviewed ruled out major comorbid diagnoses. This omission makes data interpretation rather challenging because individuals with PTSD often also have mood disorders, anxiety disorders, conduct disorder, attention-deficit hyperactivity disorder, and substance dependence (Alisic et al., 2014; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Saigh et al., 1999) and because these disorders have been marked by increased neuroticism (Cheng & Furnham, 2003; Gabrys et al., 1988; Grekin, Sher, & Wood, 2006; Miller, Miller, Newcorn, & Halperin, 2008; Richman, Sallee, & Folley, 1996). Finally, comparative information regarding personality, as measured by a version of the Eysenck Personality Inventory (e.g., Eysenck & Eysenck, 1964) of youth with clearly diagnosed PTSD relative to traumatized youth who did not have PTSD and controls has not been reported. In light of these concerns, this report sought to establish if the Junior Eysenck Personality Inventory (JEPI; Eysenck, 1965) Neuroticism and Extraversion scores of traumatized youth with or without PTSD and non-traumatized controls significantly differed following the exclusion of cases with possibly confounding comorbid disorders. Given that prospective investigations have reported that neuroticism was positively associated with the frequency of PTSD symptoms (Alexander & Wells, 1991; Breslau & Schultz, 2013; Parslow et al., 2006), it was hypothesized that JEPI Neuroticism scores of youth with PTSD would be significantly greater than the scores of traumatized youth without PTSD and controls. It was also expected that the JEPI Extraversion scores of the comparison groups would not significantly differ as earlier reports determined that extraversion was not a predictor of PTSD symptoms (Breslau et al., 1991; Breslau & Schultz, 2013; Mulder et al., 2013; Perrin et al., 2014).

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diagnostic status of every examinee. If diagnostic discordance was evidenced, case conferences were conducted and case designation was formulated through consensual agreement. 2.2. Participant inclusion criteria 2.2.1. PTSD group participation criteria Youth who were assigned to this group satisfied the criteria for PTSD as reflected by two clinical interviews that were based on the DSM-IV criteria. Staff psychiatrists and staff psychologists performed the interviews. The youth in this group also met criteria for PTSD as determined by separate administrations of a DSM-IV-based structured interview (i.e., the Children's PTSD Inventory; Saigh, 2003a, 2003b). Doctoral school psychology students were trained to administer the Children's PTSD Inventory and administered the inventory according to the standardized format that is designated in the test manual. 2.2.2. Traumatized group without PTSD participation criteria Youth who were assigned to this group experienced trauma as indicated by the DSM-IV PTSD Criterion A1 definition. The DSM-IV PTSD Criterion A1 defines trauma as “experience[ing], witness[ing], or [being] confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (APA, 1994, p. 424). Accordingly, the youth in this group had one or more Criterion A1 trauma exposures and did not meet the minimum criteria for a PTSD diagnosis. Psychiatrists or psychologists examined cases using the DSM-IV PTSD criteria and independently determined that they were exposed to one or more traumas as per the Criterion A1 definition and did not meet criteria for the disorder. Youth in this group must have also indicated that they were exposed to one or more Criterion A1 events during two administrations of the Children's PTSD Inventory (Saigh, 2003a, 2003b) and not met criteria for PTSD. 2.2.3. Non-traumatized control group participation criteria Youth in this group must have represented that they had not had a traumatic experience as reflected by the DSM-IV PTSD Criterion A1 during two unstructured clinical interviews as well as two separate administrations of the Children's PTSD Inventory (Saigh, 2003a, 2003b).

2. Method

2.3. Participant exclusion criteria

2.1. Recruitment process

Youth with a Wechsler Intelligence Scale for Children, Third Edition (WISC-III; Wechsler, 1991) Full Scale IQ within the significantly deficient range (i.e., ≤70), as well as participants who were taking medications that could affect performance on the WISC-III were excluded. Youth with deficient Full Scale IQs have previously evidenced problems in understanding the DSM-IV PTSD diagnostic questions (Saigh, 2003b). As youth with PTSD frequently meet criteria for additional disorders such as substance dependence, major depressive disorder, attentiondeficit/hyperactivity disorder, and conduct disorder (McGuire, 2016; Saigh et al., 1999), youth with these disorders were excluded inasmuch as their inclusion would have made it difficult to ascribe personality variations to PTSD, major comorbid disorders, or a combination thereof. Youth with a history of major head trauma and youth who did not speak English were excluded. Given that neglected and/or abused children may be distressed by foster care placement and/or court proceedings (Zona & Milan, 2011), children and adolescents who were abused by a mother, father, or legal guardian did not participate. Physical and sexual abuse was indicated as per the provisions of the New York State Family Court Act (1970).

This investigation used the identical methods and examined some of the participants that have been described in previous case-control reports that used different indices to examine the expression of PTSD among children and adolescents (e.g. Saigh, Yasik, Halamandaris, Bremner, & Oberfield, 2015; Saigh, Yasik, Oberfield, & Halamandaris, 2007; Saigh, Yasik, Oberfield, Halamandaris, & Bremner, 2006). Given IRB approval, medical personnel at Bellevue Hospital Center were provided with information about the study and asked to refer trauma-exposed child and adolescent patients. Non-trauma-exposed youth were recruited from clinics that offered medical services for children without life-threatening illnesses. As the external validity of many child PTSD studies has been compromised by the use of diagnostic tests with questionable psychometric properties (Saigh et al., 1999), a conservative approach to participant selection was used. Accordingly, all of the participants received four separate diagnostic interviews. More specifically, all participants received two separate DSM-IV-based PTSD clinical interviews that were conducted by highly experienced psychiatrists or psychologists. All participants also received two separate DSM-IV-based PTSD structured clinical interviews administered by different examiners as described below. In order to assign youth to one of the comparative groups, unanimous agreement between all four examiners must have been evident regarding the

2.4. Selected sample Health care professionals at Bellevue Hospital referred 228 traumaexposed patients. Child assent and parent or guardian consent was

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attained for 157 cases. Fifty were excluded due to head injuries (n = 24), WISC-III (Wechsler, 1991) Full Scale IQs in the deficient range (n = 16), limited English proficiency (n = 8), and documented child abuse and/or neglect (n = 2). Ten youth were excluded after receiving positive diagnoses for comorbid diagnoses as indicated by administrations of the Diagnostic Interview for Children and Adolescents, Revised (DICA-R; Reich, Leacock, & Shanfeld, 1995). Nineteen youth were excluded because they did not mark all of the tests that were in the experimental protocol. Bellevue staff from clinics that offer routine medical services referred 280 youth without a reported trauma exposure history. Child assent and parent or guardian consent was obtained for 78 youth. Five parents reported that their children had been exposed to a traumatic event and these individuals were re-assigned to the trauma-exposed group. Of the remaining 73 cases, 32 were excluded due to: limited English receptive and expressive skills (n = 15), ongoing psychopharmacological treatment (n = 8), WISC-III (Wechsler, 1991) Full Scale IQs in the deficient range (n = 7), and head injuries (n = 2). Two participants were excluded because they did not complete the test battery. None of the control cases qualified for a diagnosis of substance dependence, major depressive disorder, attention-deficit/hyperactivity disorder, or conduct disorder as measured by the DICA-R (Reich et al., 1995). None of the parents or guardians reported that their child had had a lifethreatening illness. This procedure led to the identification of 25 youth with PTSD, 58 traumatized youth without a PTSD diagnosis, and 39 non-clinical controls. Table 1 lists the characteristics of the sample. Table 2 presents a list of the traumatic experiences of the PTSD group and trauma-exposed group without PTSD.

3. Measures

Table 2 Reported traumatic experiences. PTSDa

Trauma-exposed without PTSDb

Traumas

N

%

N

%

Sexual assault Physical assault Shot Dog attack Motor vehicle accident Hand injury Smoke inhalation Other Witnessed trauma

4 7 4 1 4 1 2 1 1

16.0 28.0 16.0 4.0 16.0 4.0 8.0 4.0 4.0

0 13 5 4 14 12 2 5 3

0.0 22.4 8.6 6.9 24.1 20.7 3.4 8.6 5.2

a b

n = 25 n = 58.

3.1.2. Children's PTSD Inventory The Children's PTSD Inventory (Saigh, 2003a, 2003b) is a structured clinical interview that is composed of test items that closely correspond with the DSM-IV criteria for PTSD. With reference to reliability, Saigh (2003a, 2003b) reported a Cronbach alpha coefficient of 0.95 and a test-retest kappa coefficient of 0.91. He also reported an inter-rater intra-class coefficient of 0.98 and an inter-rater reliability kappa of 0.96. With reference to evidence regarding validity, Children's PTSD Inventory generated diagnoses were compared to clinical diagnoses that were made following administrations of the DICA-R (Reich et al., 1995) PTSD subtest and the Structured Clinical Interview for the DSM-IV (SCID; First, Gibbon, Williams, & Spitzer, 1996) PTSD subtest. Given this framework, Saigh (2003b) reported high to moderate specificity (0.93–0.98), sensitivity (0.84–0.92), positive (0.63–0.93) and negative (0.95–0.99) predictive power, and diagnostic efficiency (0.93–0.95).

3.1. Diagnostic measures 3.1.1. DSM-IV unstructured clinical interviews Unstructured clinical interviews based on the DSM-IV PTSD criteria were independently conducted by New York State licensed psychologists and by one of two board-certified child psychiatrists. Clinicians agreed on the diagnostic status of 119 of 122 cases that were examined (kappa = 0.94).

Table 1 Demographic backgrounds of participants. PTSDa

Trauma-exposed without PTSDb

Controlc

Sex (%) Male Female

60.0 40.0

67.2 32.8

41.0 59.0

Age (years) Mean SD

14.08 3.03

13.11 2.89

12.39 2.58

Race/Ethnicity (%) African American Asian Caucasian Hispanic Other

8.0 4.0 8.0 80.0 0.0

29.3 12.1 15.5 43.1 0.0

12.8 0.0 12.8 71.8 2.6

SES (%) Class I Class II Class III Class IV Class V

4.0 4.0 12.0 48.0 32.0

3.4 22.4 46.6 19.0 8.6

10.3 20.5 35.9 23.1 10.3

a b c

n = 25. n = 58. n = 39.

3.1.3. Diagnostic Interview for Children and Adolescents, Revised (DICA–R) The DICA-R (Reich et al., 1995) is a structured diagnostic interview that is congruent with the DSM-IV diagnostic criteria for multiple psychiatric disorders. Participants received administrations of the psychotic symptoms, substance dependence, major depressive disorder, attention-deficit/hyperactivity disorder, and conduct disorder modules. Reich (2000) reported test-retest kappa coefficients ranging from 0.32 to 0.59 for the attention-deficit/hyperactivity disorder module and 0.55 to 0.80 for the major depressive disorder module. Coefficients of 0.76 and 0.92 were observed for the psychotic symptoms and conduct disorder modules (Reich, 2000; Reich, personal communication, April 6, 2000). 3.2. Demographic measure 3.2.1. Hollingshead four-factor index of social status (Hollingshead, 1975) This test includes a series of questions regarding parent education, parent occupation, and marital status. Participants are assigned to social class designations with the lowest scores assigned to Class V and the highest scores assigned to Class I. Cirino et al. (2002) reported high (0.95) to moderate (0.73) inter-rater reliability coefficients for the instrument. These authors observed convergent validity correlation coefficients that ranged from 0.42 to 0.92 when Hollingshead scores were correlated with scores on the Socioeconomic Index of Occupations (Nakao & Treas, 1992). 3.3. Stressor severity measure 3.3.1. Severity of psychosocial stress scale: Children and adolescents (SPSSCA; APA, 1987) This scale measures stressor severity according to a six-point Likert index. The scale includes multiple examples to guide examiners. For

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example, the “death of both parents” (p. 27) is characterized as a catastrophic stressor and coded as a 6, while “breaking up with a boyfriend or girlfriend” (p. 27) is described as a mild stressor and coded as a 2. Failure to have had a significant stress exposure is coded as a 1 for “None” (p. 27). A licensed psychologist and a board certified child psychiatrist read the verbatim examinee responses from the Children's PTSD Inventory Criterion A1 questions and independently evaluated the responses according to the SPSS-CA guidelines. 3.4. Dependent measure 3.4.1. Junior Eysenck Personality Inventory (JEPI) The JEPI (Eysenck, 1965) is a 60-item self-report measure that assesses Neuroticism (i.e., a predisposition to experiencing negative emotions such as fear, worry, depression, and emotional diathesis) and Extraversion (i.e., a predisposition to having an outgoing and sociable personality). A Lie scale is also included. The Neuroticism and Extraversion scales each include 24 items, with scores ranging from 0 to 24. The Lie scale consists of 12 items, with scores ranging from 0 to 12. All scores are standardized relative to age and sex. Eysenck (1965) reported test-retest reliability coefficients for the JEPI that ranged from 0.53 to 0.88 for Neuroticism, 0.51 to 0.92 for Extraversion, and 0.41 to 0.89 for the Lie scale. Nias (1972) reported Cronbach alpha coefficients for the JEPI that ranged from 0.81–0.85 for Neuroticism, 0.63–0.74 for Extraversion, and 0.81–0.84 for the Lie scale. Harbinson (1970) reported correlation coefficients of 0.85, 0.83, and 0.43 when the JEPI Neuroticism, Extraversion, and Lie indices, respectively, were compared to comparable indices from the New Junior Maudsley Inventory (Furneaux & Gibson, 1966). The JEPI was developed using principal components analysis, wherein two factors, identified as neuroticism and extraversion, contributed to most of the variance (Eysenck, 1963). 4. Results An ANOVA identified a significant difference between groups on SES, F(2,119) = 8.55, p b 0.001. Bonferroni post-hoc comparisons indicated that participants with PTSD had significantly higher Hollingshead SES ratings (i.e., lower SES) than traumatized youth without PTSD, t(81) = − 0.93, p = 0.001, and non-traumatized controls, t(62) = −0.97, p = 0.001. An ANOVA indicated nonsignificant differences between groups relative to age, F(2,119) = 2.76, p b 0.05. An ANOVA determined that youth with PTSD reported a significantly greater number of traumas, M = 1.76; SD = 0.93, relative to the trauma-exposed youth without PTSD, M = 1.31, SD = 0.60, F(1, 81) = 6.98, p = 0.01. Mean stressor severity, as reflected by the SPSSCA ratings, was assessed by group and sex. An ANOVA denoted nonsignificant differences with reference to SPSS-CA stressor severity scores between the trauma exposed youth with PTSD, M = 5.85, SD = 0.31, and the youth without PTSD, M = 5.67, SD = 0.43, F(1,81) = 3.43, p = 0.07. A separate ANOVA indicated nonsignificant sex differences on the SPSS-CA stressor severity scores, males M = 5.71, SD = 0.41, females M = 5.75, SD = 0.41, F(1,81) = 0.16, p = 0.70. Univariate analyses indicated that the mean age of youth with PTSD, M = 13.39 years, SD = 3.39 years, and trauma-exposed youth without PTSD, M = 12.64 years, SD = 3.22 years, also did not significantly differ at the time of trauma exposure, F (1,80) = 0.92, p = 0.34. Similarly, univariate analyses indicated no significant differences in the average amount of time between trauma exposure and clinical assessment between youth with PTSD, M = 0.69 years, SD = 0.96 years, and trauma-exposed youth without PTSD, M = 0.47 years, SD = 0.88 years, F(1,80) = 1.02, p = 0.32. A MANCOVA controlling for group differences as indicated by the Hollingshead SES scores identified a significant difference across groups on at least one of the JEPI Index scores, Wilks' Lambda, F(6,232) = 3.35, p = 0.003. Univariate F tests identified a significant group difference relative to the JEPI Neuroticism Index scores, F(2,118) = 8.25,

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p b 0.001. There were no significant differences between groups relative to the JEPI Extraversion, F(2,118) = 0.32, p = 0.73, or Lie, F(2,118) = 0.63, p = 0.53, index scores. There were no significant differences evident across groups on the SES scores. Bonferroni post-hoc comparisons indicated that the PTSD group had significantly higher JEPI Neuroticism scores as compared to the scores of traumatized participants without PTSD, t(81) = 8.88, p = 0.001, and non-traumatized controls, t(62) = 10.04, p = 0.001. JEPI Neuroticism scores did not significantly vary between traumatized participants without PTSD and non-traumatized control subjects, t(95) = 1.16, p N 0.05. 5. Discussion In a departure from the methods used in the correlational studies that assessed the relationship between PTSD and various versions of the Eysenck Personality Inventory (Eysenck & Eysenck, 1964), this investigation used a case-control research design to assess the personality of youth with PTSD, trauma-exposed youth without PTSD and controls while excluding participants with significant comorbid disorders. As one might anticipate from a disorder that is largely indicated by multiple internalizing symptoms, the JEPI Neuroticism scores of the PTSD group exceeded the Neuroticism scores of the comparative cohorts. Whereas the JEPI Neuroticism test items reflect dimensions of withdrawn behaviors that are not closely linked to the DSM-IV (APA, 1994) diagnostic symptoms for PTSD, youth with the disorder evidenced negative emotions. It was also observed that the PTSD group had significantly higher Hollingshead SES scores (i.e., lower SES) and significantly more traumatic experiences. These observations are consistent with research indicating that lower SES and increased frequency of traumatic experiences were associated with PTSD (Fairbank, Ebert, & Zarkin, 1999; Saigh et al., 1999; McGuire, 2016.) Given the research design that was employed, the conservative diagnostic procedures that were used, and the exclusion of major comorbid disorders, trauma exposure without the development of PTSD does not appear to constitute a risk factor for increased psychiatric morbidity. The non-significant finding involving the JEPI Neuroticism scores of trauma-exposed without PTSD cohort is congruent with the previous results indicating that trauma-exposed youth without PTSD did not significantly differ from controls on indices of fear, depression, and selfconcept (Saigh, 1989a, 1989b; Saigh, Yasik, Oberfield, & Halamandaris, 2008) and on parent ratings of withdrawn child conduct (Saigh, Yasik, Oberfield, Halamandaris, & McHugh, 2002). Moreover, the results involving the observed PTSD point prevalence rate among traumatized participants attest to the resilience of the examinees as only 30.1% actually had the disorder. This finding is congruent with outcomes of earlier findings denoting that the majority of traumatized youth who have been studied did not have PTSD (Alisic et al., 2014; Giaconia et al., 1995; Saigh et al., 1999; Schnyder et al., 2015) and comparative research indicating that trauma-exposed youth without PTSD did not evidence morbidity on non-diagnostic measures of anxiety and depression (Saigh et al., 2002), scholastic performance (Saigh, Mroueh, & Bremner, 1997), and verbal intelligence (Saigh et al., 2006). Although extraversion has been associated with externalizing problems (Rothbart, Ahadi, Hershey, & Fisher, 2001; Slobodyska & Akhmetova, 2010), traumatized participants with or without PTSD did not significantly differ on the JEPI Extraversion scale. This outcome is congruent with earlier the findings of investigations that reported non-significant differences between similar comparison groups on clinical indices of externalizing problems (Saigh et al., 2002, 2015). The non-significant JEPI Extraversion differences are also congruent with the outcomes of earlier adult PTSD investigations (Breslau & Schultz, 2013; Breslau et al., 1991; Mulder et al., 2013; Perrin et al., 2014). Viewed collectively, the outcomes relative to Neuroticism and Extraversion support the decision to place PTSD within the context of anxiety disorders in the DSM-IV.

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These comments should be viewed with the realization that a crosssectional research design was employed and that it is not certain if PTSD contributed to the increased neuroticism or if increased neuroticism was evident before trauma exposure. It is relevant to note however that these outcomes are concordant with the outcomes of retrospective studies reporting that neuroticism was a risk factor for PTSD (Casella & Motta, 1990; Hyer et al., 1994; McFarlane, 1988). The outcomes are also congruent with the prospective investigations indicating that neuroticism was positively associated with the frequency of PTSD symptoms (Alexander & Wells, 1991; Breslau & Schultz, 2013; Parslow et al., 2006). In addition, youth with major comorbid psychiatric disorders were not enrolled. Accordingly, the external validity of this investigation may be restricted to persons with comparable personal backgrounds and traumatic experiences. The results should be considered with the understanding that as 69.16% of the traumatized cases and as 27.86% of the potential controls elected to participate, a form of selection bias may have taken place. As the consent documents indicated that trauma exposure is a risk factor for psychiatric morbidity and as the document specified that participants and their families would receive free psychological evaluations, written and verbal feedback, and referrals for treatment, the traumatized participants and their parents or guardians may have valued these benefits more than the control referrals who had not been exposed to traumatic events. It is also recognized that there are different theoretical formulations regarding personality and different measures to assess personality. As such, future research may wish to investigate the personality of traumatized youth as reflected by different indices of personality. The generalizability of these findings to the DSM-5 PTSD classification (APA, 2013) is unknown as the DSM-5 PTSD criteria are at some variance with the DSM-IV PTSD criteria (APA, 1994). Given the paucity of evidence to support the validity of the new classification, a similar study using the DSM-5 PTSD diagnostic criteria should be conducted. It may be worth noting that Quay and Werry (1986) observed, “A disorder is empirically validated by determining its relationship to other variables… Of particular concern is differential validity; two putatively separate disorders ought not to be related in the same way to the same variable” (p. 37). Quay and Werry's comments are particularly pertinent at this time as the validity of the DSM-5 PTSD criteria have been questioned (Brewin, 2013) and as an alternative version of the PTSD diagnostic criteria has been proposed for the forthcoming revision of the World Health Organization's (WHO) International Classification of Diseases (ICD-11; Maerker et al., 2013). Acknowledgement The support of the Bellevue Hospital Center and the New York City Health and Hospitals Corporation is gratefully acknowledged. References Alexander, D. A., & Wells, A. (1991). Reactions of police officers to body-handling after a major disaster. A before-and-after comparison. British Journal of Psychiatry, 159, 547–555. Alisic, E., Zalta, A. K., van Wessel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K., & Smid, G. E. (2014). Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: Meta analysis. British Journal of Psychiatry, 204, 335–340. http://dx.doi. org/10.1192/bjp.bp.113.131227. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders ((3rd ed. rev. Ed.) ). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Breslau, N., & Schultz, L. (2013). Neuroticism and post-traumatic stress disorder: A prospective investigation. Psychological Medicine, 43(8), 1697–1702. http://dx.doi. org/10.1017/S0033291712002632. Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48(3), 216–222. http://dx.doi.org/10.1001/archpsyc.1991. 01810270028003.

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