The Impact of Unfulfilled Dreams

The Unrecognized Grief

Grief is an often overwhelming emotion commonly associated with losing a loved one or a personal tragedy. But, what if grief arises from a dream that never materializes or when life continually falls short of expectations? Nonfinite grief occurs when one mourns for what was never realized as opposed to grieving something that has been lost.[1] In terms of duration, nonfinite grief is a continuing presence of loss that may be physical, psychological, and/or emotional.[2] In a world where life's disappointments and unfulfilled hopes can be devastating, understanding nonfinite grief can help people process and comprehend the spectrum of human emotional experiences.[3]

Assumptive World

Throughout a person's lifetime, their early experiences shape their beliefs, expectations, and assumptions about how the world operates. These foundations are influenced by various factors such as culture, people's behaviors, upbringing, and other elements, collectively called the "assumptive world".[4] Conversely, the shattered assumptions theory, introduced by Janoff-Bulman in the context of traumatic experiences, explains that individuals rely on these assumptions about the world and themselves to maintain healthy human functioning.[5] Edmondson et al. (2011) explains that without these assumptions, individuals may face a breakdown of their life narrative and a loss of self-identity, as described in the shattered assumptions theory.[6] The predictable worldview's function is to provide individuals with a sense of purpose, self-worth, and the illusion of invulnerability.[7] 

Conversely, when one’s assumptive world undergoes severe disruptions, individuals can experience nonfinite grief. This grief can manifest from different types of life experiences, as demonstrated by the following examples:

Physical: An athlete has been diligently preparing for a life-changing game. Due to a recent injury, they were rendered ineligible to participate in that pivotal game and left devastated.

Psychological: An individual tirelessly worked towards a promotion at their job. They were passed over, leaving them with a deep sense of disappointment.

Emotional: An individual longs for the day they exchange vows with their long term partner. However, as the years pass, they find themselves single and the dream of marriage seemingly slipping away.

Recognizing the Grief

Grief, when it falls outside of societal norms, can be hard to identify. The Dual Process Model for Non-Death Loss and Grief displays some of the everyday experiences of an individual oscillating between loss orientation and restoration orientation.[8] Wang et al. (2021) explains how loss orientation refers to the focus on coping with the loss itself whereas restoration orientation is a coping strategy that focuses on emotional recovery.[9]

In the Dual Process Model (as shown below) people oscillate between two types of orientation during their every day lives.[10]

In order to try to recognize one’s grief, the following three main factors separate nonfinite grief experiences from grief caused by death:[11]

1. The loss causes a persistent feeling of despair and emptiness from the reality shaped by their previous expectations with their envisioned future.

2. The loss is due to an inability to meet developmental expectations.

3. The loss is intangible, such as a loss of one’s hopes or ideals related to what the individual believes should have, could have, or would have been.

Furthermore, individuals grappling with nonfinite loss, such as erosion of long-cherished hopes and aspirations, often contend with persistent uncertainty regarding what the future holds.[12] A pervasive feeling of helplessness and powerlessness accompanies this ongoing loss, which is often met with little recognition or acknowledgment by others.[13]

Finding new meaning to life

Discovering new meaning to life can feel incredibly challenging especially when initial hopes and expectations were high. Amidst the grieving process, acceptance is more about recognizing that the new reality is permanent rather than merely adjusting.[14] Furthermore, acceptance includes taking a non-judgemental attitude towards oneself rather than labeling the grieving as a negative or positive experience.[15] When grappling with the complexities of grief, specialized therapy such as Complicated Grief Therapy (CGT) can help. This therapy is designed to address intense yearning, persistent longing, intrusive thoughts, and the acceptance of the reality of loss.[16] In addition to alleviating these specific symptoms, CGT also emphasizes the importance of personal growth, nurturing relationships as part of the healing process, and is based on attachment theory.[17] CGT with elements of cognitive-behavioral principles has been shown the most promise for individuals.[18]

An individual in CGT would cover seven core themes spanning over 16 sessions, including:[19]

1. Understanding and accepting grief

2. Managing painful emotions

3. Planning for a meaningful future

4. Strengthening ongoing relationships

5. Telling the story of the loss

6. Learning to live with reminders

7. Establishing an enduring connection with memories of the loss

Although 16 sessions is recommended, CGT is a flexible program. 

Another valuable approach for addressing grief is Acceptance and Commitment therapy (ACT).[20] Similarly to CGT, ACT uses core themes for individuals to work through their loss and life transitions including:[21]

1. Acceptance or willing to experience negative emotions or thoughts

2. Cognitive defusion

3. Contact with the present moment 

4. Self as context

5. Values

6. Committed Action
   

Malmir et al. (2017) explored the effectiveness of ACT for grieving individuals between the ages of 20 and 40 who were experiencing a range of symptoms, including anxiety, shortness of breath, illusion, and sleep disturbances.[22] The before and after outcomes were evaluated using a questionnaire designed to gauge the participant’s level of hope and anxiety.[23] The results of ACT therapy showed a significant reduction in symptoms among the eleven women and six men who received therapy compared to the ten women and seven men who did not.[24] The effectiveness of this modality in terms of healing from grief comes from increased cognitive flexibility, which is the main component of ACT.

If you or someone you know are experiencing nonfinite grief and loss that is impacting daily life and overall well-being, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Kelly Valentin

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Bruce, E. J., & Schultz, C. L. (2001). Nonfinite Loss and Grief: a psychoeducational approach. https://openlibrary.org/books/OL8601025M/Nonfinite_Loss_and_Grief

2 Neimeyer, R. A., Harris, D. L., Winokuer, H. R., & Thornton, G. (2021). Grief and bereavement in contemporary society: Bridging Research and Practice. Routledge.

3 Harris, D. L. (2011). Counting our losses: Reflecting on Change, Loss, and Transition in Everyday Life. Routledge.

4 Parkes, C. M. (1971). Psycho-social transitions: A field for study. Social Science & Medicine. https://doi.org/10.1016/0037-7856(71)90091-6

5 Edmondson, D., Chaudoir, S. R., Mills, M. A., Park, C. L., Holub, J., & Bartkowiak, J. (2011). From shattered assumptions to weakened worldviews: trauma symptoms signal anxiety buffer disruption. Journal of Loss & Trauma. https://doi.org/10.1080/15325024.2011.572030

6 Ibid.

7 Ibid.

8 Harris (2011)

9 Wang, W., Song, S., Chen, X., & Yuan, W. L. (2021). When learning goal orientation leads to learning from failure: the roles of negative emotion coping orientation and positive grieving. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2021.608256

10 Stroebe, W., Schut, H., & Stroebe, M. S. (2005). Grief work, disclosure and counseling: Do they help the bereaved?. https://doi.org/10.1016/j.cpr.2005.01.004

11 Harris (2011)

12 Bruce, E. J., & Schultz, C. L. (2001). Nonfinite Loss and Grief: a psychoeducational approach. https://openlibrary.org/books/OL8601025M/Nonfinite_Loss_and_Grief

13 Ibid.

14 Cianfrini, L. R., Richardson, E. J., & Doleys, D. (2021). Pain psychology for clinicians: A Practical Guide for the Non-Psychologist Managing Patients with Chronic Pain. Oxford University Press.

15 Ibid.

16 Wetherell, J. L. (2012). Complicated grief therapy as a new treatment approach. Dialogues in Clinical Neuroscience. https://doi.org/10.31887/dcns.2012.14.2/jwetherell

17 Ibid.

18 Ibid.

19 Iglewicz, A., Shear, M. K., Reynolds, C. F., Simon, N. M., Lebowitz, B. D., & Zisook, S. (2019). Complicated grief therapy for clinicians: An evidence‐based protocol for mental health practice. https://doi.org/10.1002/da.22965

20 Speedlin, S., Milligan, K., Haberstroh, S., & Duffey, T. (2016). Using acceptance and commitment therapy to negotiate losses and life transitions. Research Gate.

21 Bohlmeijer, E. T., Fledderus, M., Rokx, T., & Pieterse, M. E. (2011). Efficacy of an early intervention based on acceptance and commitment therapy for adults with depressive symptomatology: Evaluation in a randomized controlled trial. https://doi.org/10.1016/j.brat.2010.10.003

22 Malmir, T., Jafari, H., Ramezanalzadeh, Z., & Heydari, J. (2017). Determining the effectiveness of acceptance and commitment therapy (ACT) on life expectancy and anxiety among bereaved patients. https://doi.org/10.5455/msm.2017.29.242-246

23 Ibid.

24 Ibid. 

From Late Detection to Self-Discovery: Diagnosing Autism in Adulthood

Navigating New Horizons

Adulthood is often celebrated as a time of personal growth, independence, and achieving milestones (e.g., buying a home and career advancement). Each life experience involves responsibilities, unexpected life circumstances, and challenges that mold an individual. Amidst the whirlwind of adult life, how does one navigate an adulthood diagnosis of autism spectrum disorder (ASD)? Typically, ASD is diagnosed during childhood, where an individualized plan and support may more readily exist. While adults can achieve numerous feats, receiving an autism diagnosis in adulthood can be a validating and liberating experience.

Adulthood Autism Diagnosis Journey 

Autism is a neurodevelopmental condition categorized by challenges in two main areas: communication and interaction with others, and repeated certain behaviors or focus on particular interests.[1] Common indicators of autism include interpreting statements literally, struggling to grasp others' thoughts or words, experiencing heightened anxiety in social situations, and maintaining a strict daily routine - with anxiety arising from any alterations to it.[2] The most effective way to diagnose autism involves working with a team of licensed mental health and healthcare professionals (e.g., primary care doctor, neurologist, psychiatrist) with experience in autism. These trained professionals observe an individual's behavior and review their medical and developmental history.[3]

Behaviors consistent with autism must have manifested during childhood, making it crucial to recollect those exhibited during that period in an interview or questionnaire. The assessment can still be completed if an individual cannot recall developmental histories. Furthermore, an individual's family members can participate in the evaluation and provide developmental histories.[4] Throughout the assessment process, individuals should anticipate questions that pertain to difficulties in navigating social communication and interaction, sensory sensitivities, repetitive behaviors, and highly specific interests.[5] Following the assessment, an individual may receive a diagnosis of autism or not. If an autism diagnosis is confirmed, it is recommended to actively seek support and ongoing services, and access available resources to address any questions or concerns.

Self-Perception Before and After Diagnosis

The stigma that may accompany an autism diagnosis is often shaped by how the public interprets the observable traits of Autistic individuals. Turnock et al. (2022) notes that various factors can moderate or influence this stigma, including the extent and quality of interactions with autistic individuals, cultural influences, gender differences, personal variations, and how a diagnosis is revealed or disclosed.[6] Addressing and diminishing this stigma promotes greater awareness, simplifies the diagnosis process, and provides a more supportive environment for those with autism.[7]

A study by Leedham et al. (2019) examines the experience of 11 adult participants who received an autism diagnosis aged at, or over, 40 years.[8] The nine-question interview resulted in answers that can be categorized into themes, including: 

• a hidden condition

• the process of acceptance

• the impact of others post-diagnosis

• a new identity on the autism spectrum 

The 11 participants expressed their life experiences and self-perception before their diagnosis. Some participants stated that they internalized beliefs of being "wrong," "flawed," or "bad" because of connections that felt "failed".[9] Participants shared that they mimicked "normal" behaviors as a survival function, but that these behaviors resulted in feelings of exhaustion and unhappiness.[10]

A study by Stagg & Belcher (2019) examined 9 participants between the ages of 52 and 54 who received their autism diagnosis later in life.[11] This cohort shared similar life experiences to the Leedham et al. study, with some participants indicating they “never made friends”, social events were difficult, and they felt utterly isolated.[12] Additionally, two studies by Atherton et al. (2021) examined a total of 428 participant's life experiences to measure their quality of life relative to their diagnostic age. The correlation found that the diagnostic age later in life was associated with poorer quality of life. The participants stated painful experiences that affected their self-perception amidst sensory discomforts and recalling social miscommunications.[13]

Conversely, Leedham et al. note that after diagnosis, participants expressed feeling more free, better about themselves, less anxiety, and better self-awareness.[14] Participants indicated they had devised positive coping strategies to address anxiety and being overwhelmed. Lastly, there was a significant shift from self-judgment to self-empathy once they were aware of their diagnosis. Stagg & Belcher note that participants indicated post-diagnosis: feeling like it was a eureka moment, a complete relief, being stunned because it was not obvious to them before, and identifying that now they are viewing themselves in a different light.[15] Likewise, Atherton et al. (2021) found that their participants expressed that the diagnosis brought a sense of clarity.[16]

Value of Adulthood Autism Diagnosis

After interviewing participants diagnosed later in life, there were a few repeating challenges expressed throughout navigating the diagnostic process. These challenges included the obstacles of getting diagnosed, weighty emotional responses, and realizing the diagnosis explains the differences they recognized about themselves earlier in life.[17] The assessment's waitlist and wait times, lack of autism specialists, and the cost of care were specific obstacles highlighted in the studies. Throughout the interviews, participants noticed there was a lack of public awareness about autism, which contributed to their unmet needs. However, they could see that their autistic traits matched others with autism or the diagnosis criteria.[18] 

Participants explained that their late diagnosis was due to the lack of awareness about autism during their childhoods. Although family members had suspicions, they were unable to find explanations why their child did not appear neurotypical. Later in life, when participants received their diagnosis, they experienced relief and emotional validation. Additionally, the new diagnosis assisted participants in understanding their identity and challenges in a new light. One participant expressed that being able to articulate themselves and their diagnosis better was amazing and validating. Ghanouni & Seaker (2023) noted that although participants knew they were different from a young age, the new understanding allowed them to re-examine their previous life experiences.[19] The diagnosis allowed participants to explain their understanding of their needs and their relationships. For example, Leedham et al. (2019) explains that a participant’s partner can now take the lead in situations where they know the participant is uncomfortable, whereas in the past they might have thought their partner was simply acting awkwardly.[20] 

Understanding Co-Occurring Conditions: Autism & Comorbidities

Navigating the path to an adult autism diagnosis is a multi-faceted journey that extends well beyond receiving a single diagnosis and is rarely homogenous. Autism frequently intersects with other conditions, collectively known as co-occurring conditions or comorbidities. A recent study by Jadav and Bal (2022) delved into the correlation between the age of diagnosis and the emergence of co-occurring psychiatric conditions among adults on the autism spectrum.[21] They found that adults who received their autism diagnosis at the age of 21 or older reported significantly higher rates of anxiety disorders, depression, and dysthymia than those diagnosed before the age of 21.

These findings underscore the importance of comprehending the impact of various psychiatric conditions on the lives of adults with autism. In particular, life experiences (e.g., enduring societal exclusion, grappling with a diminished self-image, and enduring bullying) can significantly contribute to the prevalence of depression and anxiety disorders among this population.[22] Furthermore, the study highlights that generational mental health stigmas and a lack of awareness can influence the timing and willingness of adults to seek a diagnosis. According to Barlattani (2023), ADHD has the highest prevalence among psychiatric comorbidities in autism, followed by anxiety disorders. 70% of people with autism experience one comorbid psychiatric disorder, increasing the need to adapt and implement diagnostic tools for adults with autism.[23] Thus, acquiring a proper and valid diagnosis proves invaluable by offering autistic individuals of all ages significant benefits, especially for those experiencing comorbid conditions.

If you or someone you know has or suspects that they have Autism Spectrum Disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support. Note: the University of Washington’s UW Autism Center offers many resources and provider options.

Contributed by: Kelly Valentin

Editor: Jennifer (Ghahari) Smith, Ph.D.

references

1 Ghanouni, P., & Seaker, L. (2023). What does receiving autism diagnosis in adulthood look like? Stakeholders’ experiences and inputs. International Journal of Mental Health Systems, 17(1). https://doi.org/10.1186/s13033-023-00587-6

2 Signs of autism in adults. (2023, March 8). nhs.uk. https://www.nhs.uk/conditions/autism/signs/adults/

3 Ghanouni & Seaker (2023)

4 Autism spectrum Disorder. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

5 Ibid.

6 Turnock, A., Langley, K., & Jones, C. R. G. (2022). Understanding Stigma in Autism: A Narrative review and Theoretical model. Autism in Adulthood, 4(1), 76–91. https://doi.org/10.1089/aut.2021.0005

7 Ibid.

8 Leedham, A., Thompson, A. R., Smith, R., & Freeth, M. (2019). ‘I was exhausted trying to figure it out’: The experiences of females receiving an autism diagnosis in middle to late adulthood. Autism, 24(1), 135–146. https://doi.org/10.1177/1362361319853442

9 Ibid.

10 Ibid.

11 Stagg, S. D., & Belcher, H. (2019). Living with autism without knowing: receiving a diagnosis in later life. Health Psychology and Behavioral Medicine, 7(1), 348–361. https://doi.org/10.1080/21642850.2019.1684920

12 Leedham, A., Thompson, A. R., Smith, R., & Freeth, M. (2019). ‘I was exhausted trying to figure it out’: The experiences of females receiving an autism diagnosis in middle to late adulthood. Autism, 24(1), 135–146. https://doi.org/10.1177/1362361319853442

13 Atherton, G., Edisbury, E., & Piovesan, A. (2021). Autism Through the Ages: A Mixed methods approach to understanding how age and age of diagnosis affect quality of life. Journal of Autism and Developmental Disorders, 52(8), 3639–3654. https://doi.org/10.1007/s10803-021-05235-x

14 Leedham et al., (2019)

15 Stagg & Belcher (2019)

16 Atherton et al., (2021)

17 Ghanouni & Seaker (2023)

18 Ibid.

19 Ibid.

20 Leedham et al., (2019)

21 Jadav, N., & Bal, V. H. (2022). Associations between co‐occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research. Autism Research, 15(11), 2112–2125. https://doi.org/10.1002/aur.2808

22 Ibid.

23 Barlattani, T. (2023). Autism spectrum disorders and psychiatric comorbidities: a narrative review. Journal of Psychopathology. https://doi.org/10.36148/2284-0249-N281

Wounds Outside of Combat: Sexual Trauma in the Military

Sexual Violence: A Prevailing Issue

Sexual violence persists within all branches of the armed forces and in recent years, reports of sexual assault and harassment have garnered national attention. Sexual harassment and assault are also more prevalent within the military than in the majority of civilian organizations. While the armed forces progress in addressing this challenging issue, understanding sexual violence in a military context offers a lesser-known perspective on sexual trauma’s challenges.

In 2020, Fort Hood specialist Vanessa Guillen was assaulted and killed by a fellow soldier within her chain-of-command. This event was one of many that year that increased visibility on issues in the armed forces’ efforts against sexual violation. Even before Vanessa Guillen’s murder, the military was under pressure to improve their culture and overcome rampant reports of sexual assault. In 2004, a Department of Defense (DOD) task force aiming to provide resources to sexual assault survivors made recommendations for systematic changes to better support soldiers who experience sexual violence.[1] Those recommendations included developing a central point of accountability and a unified response system.[2] A year later, the military acknowledged that mandating commanders to be notified of crimes of sexual violence was a deterrent to soldiers who feared retaliation from their supervisors, peers, assailant (all of whom have the potential to be the same person) after reporting and removed this requirement.[3] The task force concluded their investigation by creating training on Sexual Assault Prevention and Response (SAPR) that has been led by the SAPR office, headquartered at the Pentagon. In the subsequent decades, the DOD and Department of Veteran Affairs have continued implemented several policies to improve treatment, clarify reporting procedures and provide long-term support to sexual assault victims.[4]

In 2022, public backlash over the discovery of murdered soldiers at Fort Cavazos, Texas spurred the military to add sexual harassment as a crime under the Uniform Code of Military Justice (UCMJ).[5] Still, despite decades of efforts against sexual violence, in the last two fiscal years research conducted by the Department of Veterans’ Affairs reported an increase of soldiers who filed unrestricted reports after being sexual assaulted and/or harassed. According to a fiscal year 2022 report submitted by the Pentagon, the rate of sexual assaults had risen 1% from the previous year.[6] Officials maintain that the increase of sexual assault reports is a positive step toward addressing the cultural problem because it implies that soldiers have less of a fear of retaliation or ostracization.[7] However, for service members, their families and future recruits, this increase potentially signals that the military is still searching for an enduring solution to the corrosive issue of sexual violence.[8] 

Defining Military Sexual Trauma (MST)

Military sexual trauma (MST) is a term used by the armed forces and Veterans Affairs (VA) to refer to sexual harassment and/or sexual assault that occurs in the military. According to the Department of Veterans Affairs, MST is specifically defined as: physical assault of a sexual nature, battery of a sexual nature, or sexual harassment (unsolicited verbal or physical contact of a sexual nature which is threatening in character) which occurred while the former member of the Armed Forces was serving on duty, regardless of duty status or line of duty determination.[9] Unlike other organizations, the VA extends the definition of MST to sexual harassment to encompass both physical and verbal instances of sexual encounters to which service members did not consent.

Specific examples include, but are not limited to:[10]

• Being coerced or pressured into any kind of sexual activity (with the potential fear of negative repercussions if an individual does not consent, or promises any kind of advantage if they engage) 

• Any form of physical contact or action without consent, including when a person is in a state that renders them completely incapable of communicating (e.g., sleeping, sick, intoxicated)

• Being forced to engage in sexual activity through physical harm such as slapping, kicking, punching or assault with any form of a weapon

• Being touched or grabbed in a sexual way during hazing or training

• Any unwanted comments about a person’s body or sexual activities that they perceive to violate a personal boundary

• Sexual advances that are spoken, gestured, sent through the phone or online

Like the DOD, the VA acknowledges sexual harassment with similar gravity to sexual assault, implementing resources such a hotline, victim advocates, and VA police for any individual who seeks resources or wishes to file a report.[11]

Common Symptoms Post-Trauma

After a sexually traumatizing event, veterans experience elevated rates of mental disorders, physical ailments, and difficulty building interpersonal relationships.

Specific impacts on health include:

Mental  

MST survivors have a high lifetime rate of post-traumatic stress disorder (PTSD) for both men at women, at 65% and 45% respectively.[12] Veterans who report MST and have PTSD are also likely to have comorbid major depression, anxiety, eating disorders, and substance use disorders. MST also exacerbates pre-existing mental health conditions, worsening the symptoms of conditions prior to the trauma-inducing event.[13]

Physical

Sexual difficulties, chronic pain and/or gastrointestinal disease are common physical health problems for service members recovering from sexual assault and/or harassment. [14] Survivors’ cognitive function is also impaired - many recovering service members report reduced ability to pay attention, concentrate and remember details.[15]

Interpersonal Relationships  

In some cases, veterans who experienced sexual abuse harbor trust issues and have problems engaging in social activities and intimacy. Struggling to progress out of isolation, many survivors also report difficulties finding or maintaining work after their military service.[16]

Prevalence of MST in Different Groups

Regardless of a person’s socioeconomic gender, ethnicity or identity there is still a chance that they are vulnerable to predatory behavior and sexual violence. Surveys indicate that 1% of active duty men and nearly 5% of active duty women are victimized in any given 12-month period.[17] In another study conducted in 2016, researchers from the University of Mary Washington compiled statistics on veterans reporting military sexual trauma across the following databases: PsycINFO, PubMed, and PILOTS.[18] The results revealed that 15.7% of current military personnel and veterans report MST when the measure includes both harassment and assault.[19] Additionally, 13.9% report MST when the measure assesses only assault and 31.2% report MST when the measure assesses only harassment.[20] Across all military branches MST was significantly higher among veterans who reported using VA healthcare services.[21]

Women

Women are significantly more likely to experience and report MST than their male counterparts.[22] Roughly one-in-three women veterans have told their VA health care provider they experienced sexual harassment or assault while in the military.[23] Women with MST also have higher rates of PTSD than those with other traumas: 60% and 43%, respectfully.[24]

Men

Contrary to common misconceptions, men are also victims of sexual violence. Male service members have a 3.9% likelihood of reporting abuse when the measure includes both harassment and assault, and a 1.9% likelihood when the measure assesses only assault. Fearing judgment and alienation, male victims underreport sexual assault and/or harasment; Rossellini et al. (2017) note the true number of such men might exceed that of women, as men have a much lower rate of reporting to authorities than their female counterparts.[25] 

Ethnic Minorities

Ethnic minorities (particularly women of color) experience MST at greater levels than their Caucasian counterparts, with research conducted in 2023 at Washington University in St. Louis revealing that 21% of ethnic minority female veterans compared with 1% of ethnic minority male veterans have experienced MST.[26] Black women are also the most-likely to delay disclosure of MST.[27]

LGBTQ+

Research at Washington University in St. Louis also discovered that while non-LGBTQ service members report MST at a rate of 14%, those identifying as sexual minorities report MST at nearly twice the rate at 26%.[28] Experiencing the greatest rate of sexual harassment/assault, nearly 1-in-3 transgender service members (30%) report MST. 

Other Demographics

In a 2022 study conducted at Pennsylvania University, researchers found that those who experienced adversity or trauma during childhood were more likely to experience Military Sexual Trauma (MST) during their service (Auman-Bauer 2022).[29]

Other factors that exacerbate a person’s potential to be sexually assaulted or harassed in the military include:

• Age/young adults

• Having a low level of education

• Being unmarried

• Having a lower rank

• Being within their first contract of recently entered service         

Post-Trauma Care & Recovery

Peer support has emerged as a form of treatment that mitigates symptoms of loneliness and isolation, and is a common example of clinical care and support during an MST survivor’s journey through recovery. Organizations like the Women Veterans Network (WoVeN) and Veterans Sisters are examples of peer support with the mission to increase community and connection and provide resources for women veterans.

Penn State University researchers who identified the connection between MST and previous combat experience and childhood trauma propose screening service members prior to leaving the military in order to try to determine how to best treat them.[30] Under this proposal, the military hands the patients’ information off to the VA, to then provide specific trauma-informed care to service members who have experienced trauma as they transition out of active-duty.[31]

The mobile app Beyond MST provides self-help tips, assessments, and skills-based tools to support the health and well-being of MST survivors. Designed by the VA, this app comes at no cost, does not disclose a person’s personal information, and helps service members regain hope and heal.[32]

Post-MST Psychotherapy

The Veterans Affairs Office of Research and Development conducted a study in 2006 to determine which treatment methods were most effective in treating post-MST symptoms.[33] As the researchers determined, treating sexual violence in military settings is unique and departs from clinical approaches to civilian sexual trauma for two reasons: veterans with MST are likely violated by trusted military personnel and victims are often without access to immediate treatment.[34] Although MST treatments continue to evolve, effective therapies include Cognitive Behavorial Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR), and narrative therapy. In certain instances, psychiatrists also prescribe anti-anxiety medication and/or anti-depressants.[35]

Brothers in Arms? Regaining Trust in the Military

As the armed forces continue to work to appeal to a younger generation, the slow improvement with addressing sexual assault has the potential to impact the number and diversity of recruits. In 2021 Secretary of Defense General (Gen.) Lloyd Austin established the Independent Review Commission on Sexual Assault in the Military to improve efforts in accountability, prevention, and victim care.[36] After receiving the commission’s results, Gen. Austin accepted every proposed policy change, and later remarked, “These investments are pivotal to restore the trust of our service members, as well as those considering military service.”[37] The accepted changes include increasing workers within the sexual assault response workforce, including victim advocates and sexual assault response coordinators.

Still, the military has added work to do before it fully controls the sexual assault and harassment within its ranks. In 2013, the investigative documentary The Invisible War earned critical and commercial success for shedding light on the pervasive issue of sexual assault in every military branch.[38] Featuring stories from over 25 soldiers, the documentary was groundbreaking in its final message: a female soldier in combat zones is more likely to be raped by a fellow soldier than killed by enemy fire.[39]

Although the film was made over a decade ago, this statistic still stands, and the victims of sexual assault carry symptoms of PTSD, agoraphobia, and depression - much like their counterparts who endured combat. According to the Rape, Abuse and Incest National Network, these destructive long-term physical, psychological, and social effects of sexual violence on the victims cannot be underestimated, and as veterans integrate into the civilian world, mental illnesses put them at higher risks of homelessness, unemployment, and suicide.[40] Leaders in and outside of the military continue to gain awareness into the emotional and mental impacts of sexual violence. However, the military must not only attempt to eliminate sexual violence by developing new policies and regulations - it must also address the intangible part of its culture that has allowed this violence to persist.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Department of Defense. Task Force Report on Care for Victims of Sexual Assault. National Center on Domestic and Sexual Violence Website. http://www.ncdsv.org/images/DOD_TaskForceReportOnCareForVictimsOfSexualAssault_4-2004.pdf

2 National Resource Center on Domestic Violence (NRCDV). (2021). Sexual violence in the military. NRCDV Website. https://vawnet.org/sc/sexual-violence-military-0

3 Ibid.

4 Ibid.

5 Chappell, B. (2022, January 27). Vanessa Guillen’s murder led the U.S. to deem military sexual harassment a crime. National Public Radio Website. https://www.npr.org/2022/01/27/1076143481/vanessa-guillen-murder-military-sexual-harassment-crime

6 Ware, D. (2023, April 28). Reports of sexual assaults increased in the Navy, Air Force, and Marines in 2022; Army saw a decline. American Legion Website. https://www.legion.org/news/258848/reports-sexual-assaults-increased-navy-air-force-and-marines-2022-army-saw-decline#:~:text=There%20were%208%2C942%20reports%20of,slight%20increase%20from%20last%20year

7 Ibid.

8 U.S. Department of Defense. (2022, September 2). DOD takes measures as sexual assault annual report numbers released. U.S. Department of Defense Website.https://www.defense.gov/News/News-Stories/Article/Article/3148495/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

9  U.S. Congress. (2004). United States Code: Uniform Code of Military Justice, 38 USC 1720D: Counseling and treatment for sexual trauma. Retrieved from the Library of Congress, https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section1720D&num=0&edition=prelim

10 U.S. Department of Veterans Affairs. (2023, May 18). Military Sexual Trauma. U.S. Department of Veterans Affairs Website. https://www.mentalhealth.va.gov/msthome/index.asp

11 U.S. Department of Veterans Affairs. (2022, December 12). VA’s Anti-Harassment and Anti-Sexual Assault Policy. U.S. Department of Affairs Website. https://www.va.gov/stop-harassment/policy/

12 Disabled American Veterans (DAV). (2023). What is Military Sexual Trauma? DAV Website. https://www.dav.org/get-help-now/veteran-topics-resources/military-sexual-trauma-mst/

13 Ibid.

14 Ibid. 

15 Ibid.

16 Ibid.

17 Bicksler, B., Farris, C., Ghosh-Dastidar, B., Jaycox, L.H., Kilpatrick, D., Kistler, S., Street, A., Tanielian, T., Williams, K.H. (2014).Sexual Assault and Sexual Harassment in the U.S. Military. Rand Corporation Website. https://www.rand.org/pubs/research_reports/RR870z2-1.html

18 Wilson L. C. (2018). The Prevalence of Military Sexual Trauma: A Meta-Analysis. Trauma, violence & abuse, 19(5), 584–597. https://doi.org/10.1177/1524838016683459

19 Ibid.

20 Ibid.

21 Barth, S. K., Kimerling, R. E., Pavao, J., McCutcheon, S. J., Batten, S. V., Dursa, E., Peterson, M. R., & Schneiderman, A. I. (2016). Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. American journal of preventive medicine, 50(1), 77–86. https://doi.org/10.1016/j.amepre.2015.06.012

22 Wilson (2018)

23 Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J. A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky, A. M., & Kessler, R. C. (2017). Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army. American journal of public health, 107(5), 732–739. https://doi.org/10.2105/AJPH.2017.303693

24 Yaeger, D., Himmelfarb, N., Cammack, A., & Mintz, J. (2006). DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. Journal of general internal medicine, 21 Suppl 3(Suppl 3), S65–S69. https://doi.org/10.1111/j.1525-1497.2006.00377.x

25 Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J. A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky, A. M., & Kessler, R. C. (2017). Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army. American journal of public health, 107(5), 732–739. https://doi.org/10.2105/AJPH.2017.303693

26 Barth, S. K., Kimerling, R. E., Pavao, J., McCutcheon, S. J., Batten, S. V., Dursa, E., Peterson, M. R., & Schneiderman, A. I. (2016). Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. American journal of preventive medicine, 50(1), 77–86. https://doi.org/10.1016/j.amepre.2015.06.012

27 Goldbach, J. T., Schrager, S. M., Mamey, M. R., Klemmer, C., Holloway, I. W., & Castro, C. A. (2023). Development and Validation of the Military Minority Stress Scale. International journal of environmental research and public health, 20(12), 6184. https://doi.org/10.3390/ijerph20126184

28 Ibid.

29 Ibid.

30 Bauer, K.A. (2022, August 24). Military sexual trauma more likely among veterans with prior adversity, trauma. Social Science Research Institute at the University of Pennsylvania Website. https://www.psu.edu/news/social-science-research-institute/story/military-sexual-trauma-more-likely-among-veterans-prior/

31 Ibid.

32 Galovski, T. E., Street, A. E., Creech, S., Lehavot, K., Kelly, U. A., & Yano, E. M. (2022). State of the Knowledge of VA Military Sexual Trauma Research. Journal of general internal medicine, 37(Suppl 3), 825–832. https://doi.org/10.1007/s11606-022-07580-8

33 Goldbach et. al (2023)

34 Suris, A.M. (2006). Treatment for veterans with military sexual trauma. VA Office of Research and Development. https://classic.clinicaltrials.gov/ct2/show/NCT00371644#contactlocation

35 Ibid.

36 U.S. Department of Defense. (2022, September 2). DOD Takes Proactive Measures as Sexual Assault Annual Report Numbers Released. Department of Defense Website. https://www.defense.gov/News/News-Stories/Article/Article/3148495/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

37 United States Air Force. (2022, September 5). DOD Takes Proactive Measures as Sexual Assault Annual Report Numbers Released. United States Air Force Website. https://www.aflcmc.af.mil/NEWS/Article-Display/Article/3149016/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

38 Huval, R.I. (2013, May 10). Sen Kristen Gillibrand credits The Invisible War with shaping new bill. Public Broadcasting Station Website. https://www.pbs.org/independentlens/blog/sen-gillibrand-credits-the-invisible-war-in-shaping-new-bill/

39 Ibid.

40 Thurston, A. (2022, November 9). Why veterans remain at greater risk of homelessness. The Brink, pioneering research from Boston University Website. https://www.bu.edu/articles/2022/why-veterans-remain-at-greater-risk-of-homelessness/

Autism Diagnosis & Treatment: Understanding Racial Disparities

Diagnostic Symptoms & Patterns 

Autism Spectrum Disorder (ASD) is a neurological developmental disability that causes individuals to have lifelong difficulties in communication, interpretation and behavior. ASD is most commonly referred to as a developmental disorder because symptoms first appear within the first two years of a person’s life.[1] Commonly observed ASD symptoms within a child’s first 24 months include:[2]

- Limited social interaction (avoiding eye contact, disinterest in interactive games)

- Repetitive behaviors (playing with the same toy, having obsessive interests) 

-Delayed language and/mobility 

-Mood or emotional reactions that deviate from the norm

-High comorbidity with anxiety, depression, and attention-deficit hyperactivity disorder (ADHD)

As a spectrum disorder, it is common to see different combinations and severities of ASD symptoms in each diagnosed person. Regardless of which symptoms manifest in a person, treatment typically still has the potential to effectively mitigate some of ASD’s long-term challenges. With proper intervention and therapy, adults with ASD are often capable of achieving significant autonomy and social integration.[3] But, early detection is crucial. The American Academy of Pediatrics recommends that all children receive “well-child visits” (including screening for autism) at 18 and 24 month appointments; the sooner a child with symptoms receives an accurate screening, the sooner they are able to begin effective intervention and treatment.[4] Through assessment methods such as observation, blood tests and interactive tests, the accuracy of ASD assessments continues to improve - thus improving the odds of developmental and social progress in children with ASD.[5] 

In 2023, there was a groundbreaking shift in autism diagnosis statistics: for the first year in U.S. history, Black and Hispanic youth were diagnosed at a higher rate than their White counterparts.[6] This comes after decades of underrepresentation of autism in minority populations. However, understanding racial differences in access, culture and environment among marginalized communities provides insight into the progress required to see continual improvements in ASD disparities.

Early Assumptions 

When Leo Kanner first published his observations in 1943, he referred to this condition as “early infantile autism” and asserted that it occurred most often in children belonging to White middle and upper-class families.[7] Unfortunately, Kanner overlooked the reality that the parents who could typically seek help regarding their child’s developmental problems were likely those with resources, privilege and access to appropriate healthcare. In the 1940s those parents were almost exclusively White, and decades later White children continue to have disproportionate access to autism treatment and resources.[8,9] Research from the Center for Disease Control (CDC) has since established that ASD has no disposition toward a particular ethnic group, so factors other than biological differences contribute to White American children receiving the quickest and most frequent ASD diagnosis of all socioeconomic groups.[10] 

ASD in Black Children

According to a 2017 study conducted by the American Journal of Public Health, Black children are 19 percent less likely than their White counterparts to receive an autism diagnosis.[11] Similarly to other health disparities in America, high poverty rates and limited access to treatment facilities contribute to autism’s underdiagnosis in Black Americans. Research continues to identify racism as one of the greatest determinants in a person’s long-term health.[12] It is estimated that Black Americans live four years less than their White counterparts from compounding issues that contribute to a poorer quality of life (e.g., Black Americans are under-represented in higher income jobs and have a disproportionately high rate of chronic diseases in comparison to their White counterparts).[13] 

Addressing this socioeconomic gap is crucial to improving Black Americans’ ASD diagnosis. Research conducted between 2002 and 2010 on the prevalence of autism in White, Black and Hispanic children found autism diagnosis was higher in high socioeconomic Black Americans than their counterparts. Therefore, diminishing socioeconomic differences is key to improving ASD diagnosis for all Black Americans, who remain the demographic with the lowest average annual income in America.[14,15] 

Diagnosis issues also tend to arise when Black families seek autism treatment facilities with concerns. The majority of school documentation of ASD children identifies the child’s history as “bad behavior” instead of a developmental disorder.[16] A 2007 study conducted at the University of Pennsylvania found that Black children with ASD are 5.1 times more likely to be misdiagnosed with behavior disorders before they are correctly diagnosed with autism.[17] Another 2007 study found that African-American children were 5.1 times more likely than White children to receive a diagnosis of adjustment disorder, and 2.4 times more likely to receive a diagnosis of conduct disorder.[18] 

Racist stigmas labeling Black children as rude, unruly, and aggressive also extends to teachers. A 2020 American Psychological Association study on 178 prospective teachers across universities in southeastern states revealed that the majority of teachers within the study inaccurately observed anger in both genders of Black children at higher rates than of White children. The implications of this study extend to autism: teachers and other school administrators (e.g., school psychologists) play an instrumental role in referring children for further behavioral assessments.[19]

ASD in Hispanic Children

In past decades, Hispanic children were diagnosed at an average 65% lower rate than their White counterparts.[20] Recent strides in autism awareness within the Hispanic community have contributed to their improvements in ASD diagnosis, but there are still improvements to make in resources, treatment accessibility and awareness. Similarly to Black children, Latino children often have delayed diagnoses caused by low socioeconomic standings and limited accessibility to treatment and resources.

Spanish is also the second highest primary language spoken in the U.S, and is a factor that has been identified as both a barrier to identifying ASD and a communication challenge between parents and healthcare providers. In a 2004 study by Shapiro et al. 16 young, low-income Hispanic mothers described feelings of “alienation” in their interactions with healthcare providers.[21] The mothers described how information was not always explained enough and if a translator is not present, they felt as though they missed a lot of information.[22] Another study conducted in 2016 by Steinberg et al. found that Spanish-speaking parents are often asked less about their developmental concerns even if their child is known to be at risk, and have reported trouble connecting with providers because they are treated as though they lack knowledge.[23] These experiences not only dissuade parents from asking questions, but also intensify a caregiver’s skepticism, as families with limited English proficiency report less trust in providers compared to English proficient families.[24]

Emerging solutions to disparities in ASD diagnosis/treatment

There are growing resources available to help families from underrepresented communities better understand and identify ASD in their children, aiding in diagnosis and treatment and help close these racial disparities. 

• The Autism Society of Los Angeles (ASLA) runs a hotline at (424) 299-1531 to help parents navigate the diagnosis and healthcare landscape. This organization also offers services in English and Spanish, providing families the resources they need without a financial burden.[25]

• The Children's Hospital, Los Angeles employs liaisons to connect families to further assessment, locate other treatment facilities and gain general support. This hospital is physically located in Los Angeles, and it also provides a virtual autism assessment that can be accessed at: https://chla.purview.net/patient/start.

• “Autism in Black” is a non-profit that aims to provide support to black parents who have a child on the spectrum, through educational and advocacy services like podcasts, free consultations and  hosting outreach events to better educate local communities. Managed by licensed mental health providers, “Autism in Black” is grounded in a mission to improve awareness of and reduce the stigma associated with ASD in the Black community.[26]

• The Center for Disease Control (CDC) has a “Learn the Signs. Act Early.” program that provides free resources in English and Spanish to monitor children’s development starting at 2 months of age. Additionally, by downloading the CDC’s free Milestone Tracker mobile app, caregivers can log and monitor their child’s behavior to later share with healthcare providers.[27]

Community-based Intervention for ASD

JAMA Pediatrics (2022) conducted analysis of decades of autism studies and found that compounding factors increase the likelihood of early morbidity for individuals with autism in comparison to the general population as well as for minorities in comparison to their White counterparts.[28] Under this consideration, marginalized individuals with ASD are uniquely vulnerable to compounding issues related to how they must navigate the world due to their racial identity and neurodivergence (e.g., non-verbal communication, self-harming, and dependence on a caretaker).[29]

 People of color have a higher likelihood of limited availability of treatment centers, fewer services provided by Medicare providers, and of belonging to a lower socioeconomic group.[30] Equal access to healthcare is the foundation for children with mental disabilities to find the resources and treatment plans that will enable them to not only survive but also reach their full. With Hispanic people comprising both the largest minority population in the United States and the majority of the 25 million people in the United States with limited English proficiency, healthcare must continue to make adjustments in order to ensure that ASD is not only diagnosed accurately for this population, but healthcare providers also need to ensure that this demographic continues to feel supported as they navigate this complex condition.[31] Similarly, Black Americans continue to face the greatest discrimination of any group in America, and improving access to timely quality ASD treatment is crucial.[32]

As a growing pediatric concern, ASD was found to occur in 1-in-125 children in 2018 only to triple to 1-in-36 in 2023.[33] As the ASD population increases and the conversation shifts towards finding the resources to assist individuals on the spectrum better integrate into their communities, understanding the health disparities that affect progress is paramount. By diminishing the barriers to affordable and accessible care for marginalized communities, autism advocates will continue to become better equipped to serve the diverse population of individuals with ASD.

Help and support are available: If you or someone you know is struggling to obtain an ASD diagnosis and/or treatment, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 National Institutes of Health. Autism Spectrum Disorder. National Institute of Health Website. Updated 2023. Accessed June 12, 2023.  https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

2 Centers for Disease Control and Prevention. Signs and Symptoms of Autism of Spectrum Disorder. Centers for Disease Control and Prevention Website. Updated March 28, 2022. Accessed June 12, 2023. https://www.cdc.gov/ncbddd/autism/signs.html

3 Whiteley, P., Carr, K., & Shattock, P. (2019). Is Autism Inborn And Lifelong For Everyone?. Neuropsychiatric disease and treatment, 15, 2885–2891. https://doi.org/10.2147/NDT.S221901

4 Durkin, M. S., Maenner, M. J., Baio, J., Christensen, D., Daniels, J., Fitzgerald, R., Imm, P., Lee, L. C., Schieve, L. A., Van Naarden Braun, K., Wingate, M. S., & Yeargin-Allsopp, M. (2017). Autism Spectrum Disorder Among US Children (2002-2010): Socioeconomic, Racial, and Ethnic Disparities. American journal of public health, 107(11), 1818–1826. https://doi.org/10.2105/AJPH.2017.304032

5 Ibid.

6 Centers for Disease Control and Prevention. Autism Prevalence Higher, According to Data from 11 ADDM Communities. Centers for Disease Control and Prevention Website Updated March 23, 2023. Accessed June 10, 2023. 

7 Rosen, N. E., Lord, C., & Volkmar, F. R. (2021). The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond. Journal of autism and developmental disorders, 51(12), 4253–4270. https://doi.org/10.1007/s10803-021-04904-1

8 American Psychiatric Association. (2023). New Research Points to Disparities in Autism Prevalence and Access to Care. Last updated April 23, 2023. Accessed June 20, 2023. https://www.psychiatry.org/news-room/apa-blogs/disparities-in-autism-prevalence-and-access

9 Mandell, D.S., Listerud, J., Levy, S.E., Pinto-Martin, J.A. (2002). Race Differences in the Age at Diagnosis Among Medicaid-Eligible Children with Autism. Journal of Child & Adolescent Psychiatry, 41(12), 1447-1453. https://doi.org/10.1097/00004583-200212000-00016.

10 Centers for Disease Control and Prevention. Spotlight on Closing the Racial and Ethnic Gaps in the Identification of Autism Spectrum Disorder among 8-year-old-Children. Centers for Disease Control and Prevention Website. Last updated March 23, 2023. Accessed June 23, 2023. https://www.cdc.gov/ncbddd/autism/addm-community-report/spotlight-on-closing-racial-gaps.html

11 Ibid.

12 Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PloS one, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511

13 Price, J. H., Khubchandani, J., McKinney, M., & Braun, R. (2013). Racial/ethnic disparities in chronic diseases of youths and access to healthcare in the United States. BioMed research international, 2013, 787616. https://doi.org/10.1155/2013/787616

14 Mehta, N. K., Lee, H., & Ylitalo, K. R. (2013). Child health in the United States: recent trends in racial/ethnic disparities. Social science & medicine (1982), 95, 6–15. https://doi.org/10.1016/j.socscimed.2012.09.011

15 The Urban Institute.(2009). Racial and Ethnic Disparities among Low-Income Families [Fact sheet]. https://www.urban.org/sites/default/files/publication/32976/411936-racial-and-ethnic-disparities-among-low-income-families.pdf

16 Mandell, D. S., Ittenbach, R. F., Levy, S. E., & Pinto-Martin, J. A. (2007). Disparities in diagnoses received prior to a diagnosis of autism spectrum disorder. Journal of autism and developmental disorders, 37(9), 1795–1802. https://doi.org/10.1007/s10803-006-0314-8

17 Halberstadt, A. G., Cooke, A. N., Garner, P. W., Hughes, S. A., Oertwig, D., & Neupert, S. D. (2022). Racialized emotion recognition accuracy and anger bias of children’s faces. Emotion, 22(3), 403–417. https://doi.org/10.1037/emo0000756

18 Ibid.

19 Centers for Disease Control and Prevention. Spotlight on Closing the Racial and Ethnic Gaps in the Identification of Autism Spectrum Disorder among 8-year-old-Children. Centers for Disease Control and Prevention Website. Last updated March 23, 2023. Accessed June 23, 2023. https://www.cdc.gov/ncbddd/autism/addm-community-report/spotlight-on-closing-racial-gaps.html

20 Shapiro, J., Monzó, L. D., Rueda, R., Gomez, J. A., & Blacher, J. (2004). Alienated advocacy: perspectives of Latina mothers of young adults with developmental disabilities on service systems. Mental retardation, 42(1), 37–54. https://doi.org/10.1352/0047-6765(2004)42<37:AAPOLM>2.0.CO;2

21 Ibid.

22 Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The "Battle" of Managing Language Barriers in Health Care. Clinical pediatrics, 55(14), 1318–1327. https://doi.org/10.1177/0009922816629760

23 Ibid.

24 Warm Line. (2021). Autism Society of Los Angeles. https://www.autismla.org/1/program/speaker-series/

25 Advocacy, Education, and Support. (2023). Autism in Black. https://www.autisminblack.org/

26 About CDC’s Learn the Signs. Act Early. Program. (2023). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/wicguide/about-cdcs-learn-the-signs-act-early-program.html

27 Ferrán, C. L., Hutton, B., Page, M.L., Driver, J.A., Ridao, M., Arroyo, A.A., Valencia, A., Saint-Gerons, D.M.,Tabarés-Seisdedos, R. (2022). Mortality in Persons With Autism Spectrum Disorder or Attention-Deficit/Hyperactivity Disorder. JAMA Pediatr, 176(4), e216401. https://doi.org/10.1001/jamapediatrics.2021.6401

28 Ibid.

29 Ibid.

30 Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The "Battle" of Managing Language Barriers in Health Care. Clinical pediatrics, 55(14), 1318–1327. https://doi.org/10.1177/0009922816629760

31 Dietrich, S., Hernandez, E. (2022). What Languages Do We Speak in the United States? United States Census Bureau Website. Last updated December 06, 2022. Accessed June 27, 2023.

32 The Texas Politics Project. Most Discriminated Group (April 2022). The Texas Politics Project at the University of Texas at Austin Website. https://texaspolitics.utexas.edu/set/most-discriminated-group-april-2022

33 Centers for Disease Control and Prevention. Data and Statistics on Autism Spectrum Disorder, Centers for Disease Control and Prevention Website. Last updated April 4, 2023. Accessed June 25, 2023.

The Big Five Personality Traits: Exploring the Connection Between Personality & Mental Health

Origins: The Formation of the Big Five

Some people are more outgoing than others; some prefer to keep to themselves. Some people love to argue and others prefer to keep the peace. Some people are highly organized, making their beds every morning; others can hardly find a pair of socks under the mountain of a pile of clothes. In our own experience of life, we can probably think of a vast variety of individuals with their own personalities, each coping uniquely with the challenges life throws at them.

Personality psychologists have come up with a concept of ‘traits’ – the stable tendencies of individuals – to explain everyday behaviors like journaling, throwing socks on the floor, cleaning after themselves, etc. But how do we figure out which traits are the most important? Are there any traits that serve as the most common among every individual? Can we describe someone’s personality in just a few words? To answer these questions, personality psychologists have tried for more than a century to develop a comprehensive measure of personality traits, resulting in questionnaires such as the Minnesota Multiphasic Personality Inventory (MMPI).

The modern study of personality psychology is attributed to Francis Galton who developed the idea of the lexical approach.[1] This idea explains how language captures the traits most important to people in their everyday lives. It argues that if a trait is important, then it would be encoded in language with individual words such as “nervous” or “outgoing”. Following this reasoning, all of the adjectives in the English dictionary were recorded; screening out words that referred to momentary states (e.g., annoying), the remaining words alluded to psychological attributes (e.g., outgoing, nervous, and neat).[2]

After the researchers had people rate themselves on the recorded adjectives, they did a factor analysis [3,4] which formed groups of adjectives based on their correlation with each other. This resulted in five major factors that had the most adjectives, which we now know as the Big Five Personality Traits: Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience. 

Understanding the Big five Personality Traits

These five factors are best understood as a continuum of traits, each having its own sub-categories (i.e., facets).[5] The following facet examples helps explain the diversity of characteristics within each grouping:[6]

1. Extraversion: friendliness, gregariousness, assertiveness, activity level, excitement seeking, cheerfulness

2. Agreeableness: trust, morality, altruism, cooperation, modesty, sympathy

3. Conscientiousness: self-efficacy, orderliness, dutifulness, achievement-striving, self-discipline, cautiousness

4. Neuroticism: anxiety, anger, depression, self-consciousness, immoderation, vulnerability

5. Openness to Experience: imagination, artistic interests, emotionality, adventurousness, intellect, liberalism

Internalizing these facets also helps us avoid common misunderstandings about the traits. Apart from being a continuum, there is no “right” or “wrong” personality – each trait has its advantages and disadvantages. For example, the extrovert might delve too much into excitement-seeking which can turn out to be reckless at times. The neurotic person, on the other hand, might be anxious, but that will prevent them from reckless behavior.

The Five traits and Mental Health

1. Extraversion

Extraversion is the dimension that ranges from how outgoing and stimulant-seeking a person is to how much they conserve their energy and do not actively engage to earn social rewards. Extraversion includes preferring the company of others as opposed to being alone, aspiring for leadership roles, being physically active, and experiencing more happiness and joy. It captures the most positive emotions – joy, energy, happiness – out of all the traits because of which extraverts are more likely to experience positive moods.[7] Due to its link with positive emotions, individuals who score higher on extraversion tend to have better mental health; they are less likely to suffer from mood and anxiety disorders.[8] These benefits occur not from extraversion itself but because extroverts are often better at maintaining relationships, which are linked to physical and mental health.[9]

The opposite dimension of extraversion is introversion. Introverts are not hermits who isolate themselves; instead, they prefer the company of close friends and family as opposed to large gatherings. Hans Eysenck (1967) posited that introverts are sensitive to stimuli which causes them to prefer solitude.[10] On the other hand, extroverts seek stimulation and excitement which might be linked to higher levels of dopamine – the brain-chemical responsible for pleasure.[11]

2. Agreeableness

The dimension of agreeableness describes an individual’s tendency to put others’ needs ahead of their own, making those low in agreeableness more antagonistic. Agreeable individuals are sympathetic to the needs and feelings of others and trust them more. They prefer cooperation as opposed to competition and tend to be honest, humble, and compliant. In short, individuals high in agreeableness tend to hold other people’s needs above their own; they tend to gain pleasure from serving others and taking care of them.[12] While agreeableness is the least studied factor in the Big Five, most research on it is done by investigating both ends of its spectrum.[13] The opposite end of the agreeableness spectrum – antagonism – encompasses characteristics such as: angry, argumentative, hostile, egotistical, condescending and skeptical.[14]

Unfortunately, these characteristics result in a correlation with antisocial behavior. Research has found that disagreeable individuals are more likely to be involved in crime, aggressive behavior, drug abuse, and gambling.[15-18] Those high in agreeableness, however, show behavior that includes helpfulness, forgiveness, and acceptance.[19] As a result of prosocial behavior, agreeableness comes with many benefits which include, but are not limited to: positive emotions, decreased depression, healthy social connections and relationships as well as greater life satisfaction.[20]

3. Conscientiousness

This dimensional trait measures an individual’s self-discipline and control in order to achieve their goals, making those on the other end of the spectrum more impulsive. Conscientiousness involves willpower; individuals high in this trait can delay gratification, consider the consequences before acting, and work hard toward their goals. As a result, conscientious people are diligent and organized, achieving their goals despite boredom, frustration, or distractions. Similar to individuals low in agreeableness, research has found those low in conscientiousness are more likely to abuse drugs, involve themselves in criminal behavior, and gamble more often.[21]

Due to greater self-control, highly conscientious people tend to enjoy better mental and physical health, including living longer.[22,23] Willpower motivates this cohort to be more-likely to exercise, follow a well-balanced diet, avoid drug abuse, and achieve educational and career goals to try and avoid stressful financial problems. For example, they have been found more likely to eat salads and are less likely to be overweight.[24] They also benefit from better mental health by managing their negative emotions; as a result, perhaps, conscientious people are more likely to have stable marriages.[25]

4. Neuroticism

This spectrum describes how much someone experiences negative emotions as a reaction to a situation. Neuroticism is the tendency to experience negative emotions such as anger, depression, anxiety, shame, and self-consciousness. Highly neurotic individuals may experience negative emotions more frequently and intensely. As a result, they are more prone to mental health issues such as depression, generalized anxiety disorder, PTSD, OCD, substance abuse disorder, and eating disorders.[26-28]

An individual high in neuroticism is less likely to engage in processing their emotions than an individual who does not worry often. To aid a neurotic person in psychotherapy, it is beneficial to help them overcome their inclination to avoid emotions. This is better achieved by helping them realize their emotions as negative, instead of figuring out the origin of their emotions. It is this suppression that harms their mental health, so labeling their emotions as negative serves to alleviate the stress they experience.[29]

5. Openness to Experience

The openness dimension ranges from thinking in abstract, complex ways to thinking more traditionally. Openness is the least intuitive of the Big Five. It has been labeled differently – such as ‘intellect’, ‘culture’, and ‘imagination’ – in many personality questionnaires; McCrae (1996) defined it according to the lines of ‘vivid fantasy’, ‘intellectual curiosity’, ‘behavioral flexibility’, and ‘unconventional attitudes’.[30] Individuals high in openness to experience love to try new things, play with complex ideas, and consider alternative perspectives. Most importantly, they are more likely to name travel as an important personal goal.[31] For example, they are more likely to engage in meditation (associated with new experiences), go to art exhibits, or speak a foreign language.[32] In contrast, low-openness people value the status quo, favor traditional activities, and prefer routine.

Openness does not have many links with psychiatric disorders; however, researchers argue having too much vivid imagination overlaps with psychotic symptoms like hallucinations or unusual beliefs.[33] Overall, those high in openness are less likely to suffer from anxiety disorder or depression.[34] It is also the only factor linked with intelligence; although the correlation is small, those high in openness tend to score higher in IQ tests.[35] The facets of being highly open to experience allow an individual’s brain to retain its plasticity as they age, minimizing the decline in cognitive abilities.

Again, it is important to note how the five personality traits are a continuum more so than a concrete representation of who we are. Since life is not black and white but nuanced in essence, how we react to situations is equally gray and can differ from situation to situation. Just as our personality traits can determine how we react to circumstances; our circumstances can also impact our personality traits. Nevertheless, it is beneficial and empowering to know our personality features as it can equip us with a better understanding of ourselves and the people around us. It can help us cater to the specific characteristics of our friends and colleagues and at the same time allow us to make better choices considering our personalities.

Contributed by: Musa Zafar

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 De Vries, R. E., Tybur, J. M., Pollet, T. V., & Van Vugt, M. (2016). Evolution, situational affordances, and the HEXACO model of personality. Evolution and human behavior, 37(5), 407-421.

2 Cattell, R. B. (1943). The description of personality: Basic traits resolved into clusters. The journal of abnormal and social psychology, 38(4), 476.

3 Norman, W. T. (1963). Toward an adequate taxonomy of personality attributes: Replicated factor structure in peer nomination personality ratings. The journal of abnormal and social psychology, 66(6), 574.

4 Goldberg, L. R. (1993). The structure of phenotypic personality traits. American psychologist, 48(1), 26.

5 Bratko, D., & Marušić, I. (1997). Family study of the big five personality dimensions. Personality and Individual Differences, 23(3), 365-369.

6 Ibid.

7 Lucas, R. E., Le, K., & Dyrenforth, P. S. (2008). Explaining the extraversion/positive affect relation: Sociability cannot account for extraverts' greater happiness. Journal of personality, 76(3), 385-414.

8 Kotov, R., Gamez, W., Schmidt, F., & Watson, D. (2010). Linking “big” personality traits to anxiety, depressive, and substance use disorders: a meta-analysis. Psychological bulletin, 136(5), 768.

9 Pollet, T. V., Roberts, S. G., & Dunbar, R. I. (2011). Extraverts have larger social network layers: But do not feel emotionally closer to individuals at any layer. Journal of Individual Differences, 32(3), 161.

10 Eysenck, S. B., & Eysenck, H. J. (1967). Salivary response to lemon juice as a measure of introversion. Perceptual and motor skills, 24(3_suppl), 1047-1053.

11 Wacker, J., Chavanon, M. L., & Stemmler, G. (2006). Investigating the dopaminergic basis of extraversion in humans: A multilevel approach. Journal of personality and social psychology, 91(1), 171.

12 Psychology Today. (n.d.). Agreeableness. Retrieved from https://www.psychologytoday.com/us/basics/agreeableness

13 Miller, J. W., & Lynam, D. (Eds.). (2019). The handbook of antagonism: Conceptualizations, assessment, consequences, and treatment of the low end of agreeableness. Academic Press.

14 Graziano, W. G., & Tobin, R. M. (2017). Agreeableness and the five factor model. The Oxford handbook of the five factor model, 1, 105-131.

15 Miller, J. D., & Lynam, D. (2001). Structural models of personality and their relation to antisocial behavior: A meta‐analytic review. Criminology, 39(4), 765-798.

16 Jones, S. E., Miller, J. D., & Lynam, D. R. (2011). Personality, antisocial behavior, and aggression: A meta-analytic review. Journal of Criminal Justice, 39(4), 329-337.

17 Lackner, N., Unterrainer, H. F., & Neubauer, A. C. (2013). Differences in Big Five personality traits between alcohol and polydrug abusers: Implications for treatment in the therapeutic community. International Journal of Mental Health and Addiction, 11(6), 682-692.

18 MacLaren, V. V., Fugelsang, J. A., Harrigan, K. A., & Dixon, M. J. (2011). The personality of pathological gamblers: A meta-analysis. Clinical psychology review, 31(6), 1057-1067.

19 Psychology Today

20 Aknin, L. B., & Whillans, A. V. (2021). Helping and happiness: A review and guide for public policy. Social Issues and Policy

21 Miller, J. D., & Lynam, D. (2001). Structural models of personality and their relation to antisocial behavior: A meta‐analytic review. Criminology, 39(4), 765-798.

22 Kotov, R., Gamez, W., Schmidt, F., & Watson, D. (2010)

23 Kern, M. L., & Friedman, H. S. (2008). Do conscientious individuals live longer? A quantitative review. Health psychology, 27(5), 505.

24 Keller, C., & Siegrist, M. (2015). Does personality influence eating styles and food choices? Direct and indirect effects. Appetite, 84, 128-138.

25 Claxton, A., O’Rourke, N., Smith, J. Z., & DeLongis, A. (2012). Personality traits and marital satisfaction within enduring relationships: An intra-couple discrepancy approach. Journal of Social and Personal Relationships, 29(3), 375-396.

26 Lahey, B. B. (2009). Public health significance of neuroticism. American Psychologist, 64(4), 241.

27 Kotov, R., Gamez, W., Schmidt, F., & Watson, D. (2010) 

28 Samuel, D. B., & Widiger, T. A. (2008). A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: A facet level analysis. Clinical psychology review, 28(8), 1326-1342.

29 Whitbourne, S. K. (2020, January 18). Neuroticism, emotions, and your health. Psychology Today. Retrieved December 6, 2022, from https://www.psychologytoday.com/us/blog/fulfillment-any-age/202001/neuroticism-emotions-and-your-health 

30 McCrae, R. R. (1996). Social consequences of experiential openness. Psychological bulletin, 120(3), 323.

31 Reisz, Z., Boudreaux, M. J., & Ozer, D. J. (2013). Personality traits and the prediction of personal goals. Personality and Individual Differences, 55(6), 699-704.

32 Chapman, B. P., & Goldberg, L. R. (2017). Act-frequency signatures of the Big Five. Personality and Individual Differences, 116, 201-205.

33 Widiger, T. A. (2011). The DSM-5 dimensional model of personality disorder: Rationale and empirical support. Journal of Personality Disorders, 25(2), 222.

34 Kotov, R., Gamez, W., Schmidt, F., & Watson, D. (2010) 

35 DeYoung, C. G., Quilty, L. C., Peterson, J. B., & Gray, J. R. (2014). Openness to experience, intellect, and cognitive ability. Journal of personality assessment, 96(1), 46-52.

Introducing The Seattle Psychiatrist Magazine

Announcing our new MAGAZINE!

The Seattle Psychiatrist Magazine is our new online publication focusing on the analysis and discussion of research and practice in psychiatry and clinical psychology.

We are excited to provide this free resource to the public, in our commitment to improving community-wide mental health while increasing the access to high-quality educational information.

* New articles published monthly!

If there is a topic of interest to you that we have not yet published, please let us know by emailing info@seattleanxiety.com.