































Graduate Student Journal of Psychology          Copyright 2012 by the Department of Counseling and Clinical Psychology 
2012, Vol. 14               Teachers College, Columbia University 

102 
 

  
Differences Among Ethnic Groups in Trauma Type and 

PTSD Symptom Severity 
 

Emily Trepasso-Grullon 
California School of Professional Psychology, Alliant International University 

 
Psychologists are interested in individual characteristics associated with posttraumatic stress 
disorder (PTSD) to better understand stress and stress responses.  The current literature is mixed 
about differences among ethnic groups for trauma and PTSD symptom endorsement and severity.  
Culture-specific perspectives lend different interpretations of potentially traumatic events, 
suggesting that members from different ethnic groups experience stressors differently and may 
consequently endorse different symptoms.  Although some studies have examined differences 
among ethnic groups with respect to mental illness, research on the relationship between ethnicity 
and endorsement of trauma or PTSD symptoms is limited.  Further, few studies have explored 
explanations for such differences.  Group differences in symptom endorsement between individuals 
from African American, Hispanic, and non-Hispanic Caucasian ethnic groups will be examined.  
Additionally, hypothesized reasons for these differences (such as response bias and methodological 
issues) will be explored.  This review highlights the importance of considering ethnicity-specific as 
well as methodological factors that influence endorsement of traumatic events and PTSD symptoms 
in response to traumatic stressors.  This review will guide treatment providers in understanding and 
appropriately assessing PTSD symptoms by enhancing their understanding of the role of culture. 
 
 

Posttraumatic stress disorder (PTSD) has been a topic of 
interest for more than 30 years.  PTSD affects people from 
all ethnic groups; however, cultural dynamics complicate 
understanding PTSD across ethnic groups.  For example, 
some studies suggest that unique cultural factors increase 
ethnic minorities’ risk for PTSD (Breslau et al., 1998; 
Marsella, Friedman, & Spain, 1996; Pole, Gone, & Kulkarni, 
2008).  Cultural experiences, values, and beliefs influence the 
interpretation of and reaction to traumatic stressors, 
expression of PTSD symptoms, symptom severity, coping 
skills for dealing with symptoms, likelihood of seeking and 
completing treatment programs, and response style on self-
report instruments (Brewin, Andrews, & Valentine, 2000; 
Elhai & Ford, 2007; Jobson & O’Kearney, 2008; Matlow & 
DePrince, 2012; Stephens et al., 2011).  Additionally, type of 
trauma exposure, perceived severity, and level of engagement 
in treatment affect development of PTSD differently across 
ethnic groups (Brewin et al., 2000).   

PTSD is characterized by a response of intense 
helplessness, fear, or horror, to actual or threatened death, 
serious injury, or threat to the physical integrity of oneself, or 
learning about a traumatic event that occurred to a close 
friend or relative.  Several traumatic events recognized by the 
American Psychiatric Association (2000) include: military 
combat; assault (e.g., sexual assault, non-sexual attack, 
torture, robbery, mugging); natural or manmade disasters; 

                                                 
Emily Trepasso-Grullon, M.S., California School of 

Professional Psychology, Alliant International University, San 
Diego, CA. 

Correspondence concerning this article should be addressed 
to Emily Trepasso-Grullon, 10455 Pomerado Road, San Diego, 
CA 92131. Email: emilygrullon@gmail.com 

incarceration; being in an accident, kidnapped or taken 
hostage; or diagnosed with life-threatening illness.  In 
addition to responding with intense helplessness, fear, or 
horror, individuals must also experience at least one re-
experiencing symptom (e.g., nightmares, intrusive or 
unwanted thoughts, flashbacks), three avoidance symptoms 
(e.g., avoiding stimuli associated with the event, 
conversations, people, or places that remind the individual 
about the event, difficulty remembering important parts about 
the event, decreased interest in activities that used to be 
enjoyable, feeling emotionally numb, guilty, or depressed), 
and two hyper-arousal symptoms (e.g., difficulty sleeping, 
being easily startled, “on edge,” or tense). Additionally, 
symptoms must cause impaired functioning in social, 
occupational, or other areas for a period of one month or 
more.  Duration of symptoms determines whether an acute 
(one to three months), chronic (three or more months), or 
delayed onset (symptoms begin six months after the event) 
specifier is used (American Psychiatric Association, 2000).   

Diagnostic criteria for PTSD have changed over the 
years, indicating that clinicians’ understanding of PTSD is 
constantly evolving.  The Diagnostic and Statistical Manual, 
Third Edition (DSM-III) required an individual to experience 
a catastrophic event outside the normal human range of 
experience.  In contrast, the DSM Fourth Edition, Text 
Revision (DSM-IV-TR) requires an individual to be exposed 
to a traumatic event and respond with intense helpless, fear, 
and horror (American Psychiatric Association, 2000).  
Criteria for PTSD for the DSM, Fifth Edition (DSM-5) are 
currently under review.  The goal of this revision is to make 
diagnostic criteria more specific to PTSD and to increase 
validity of the diagnosis across samples (Friedman, Resick, 
Bryant, & Brewin, 2011).   



TREPASSO-GRULLON 
 

103 
 

Despite the addition of PTSD to the DSM-III in 1980 by 
the American Psychiatric Association (2000), relatively few 
studies have explored the experience of members of non-
Caucasian ethnic groups who have lived through a traumatic 
stressor (Triffleman & Pole, 2010).  Therefore, these groups 
are greatly underrepresented in current research (Kramer, 
Ross, & Davidson, 2001).  Some meta-analyses and major 
epidemiologic studies (e.g., Brewin et al., 2000; Kessler et al., 
2005) explored PTSD but omitted ethnicity from their 
analyses entirely, grouped all minorities into broad groups, or 
grouped all minorities into one ‘supergroup’ to compare to 
non-Hispanic Caucasian adults as a reference group (e.g., 
Breslau et al., 1998; Brewin et al., 2000).  Moreover, studies 
that have examined ethnicity present mixed conclusions about 
the relationship between ethnic groups, trauma type, and 
PTSD symptom endorsement (Roberts, Gilman, Breslau, 
Breslau, & Koenen, 2011).  These differences may be 
attributed to a number of factors, such as protective and risk 
factors.  

Many people do not develop symptoms that warrant a 
diagnosis of PTSD after exposure to a traumatic event (U.S. 
Department of Health and Human Services, 2009).  Lifetime 
prevalence for PTSD among American adults is between 
3.5% and 6.8% (Kessler et al., 2005).  However, a more 
recent study suggests that lifetime prevalence of PTSD is on 
the rise.  According to Roberts and colleagues (2011), African 
American adults have a higher lifetime prevalence (8.7%) 
than Hispanic adults and Caucasian adults (7.0% and 7.4%, 
respectively).  Also, African American individuals are more 
likely to meet criteria for PTSD than Hispanic individuals or 
non-Hispanic Caucasian individuals (Asnaani, Richey, 
Dimaite, Hinton, & Hofmann, 2010).   

The rates of PTSD are lower than rates of other mental 
illnesses (Roberts et al., 2011).  Low rates of PTSD in 
comparison to other mental illnesses may be due to various 
protective factors such as social support, religion, reframing 
the traumatic event as a learning experience and catalyst for 
positive change, accepting one’s actions during the event, or 
the perception that one responded effectively during the 
stressor despite being afraid (Charney, 2004; Kleim & Ehlers, 
2009).  Nevertheless, such coping mechanisms for trauma 
differ across ethnic groups.  For example, some studies have 
suggested that African American adults and Hispanic adults 
identify religion as a coping skill. However, in these studies, 
African American adults were more likely than Caucasian 
adults (Bradley, Schwartz, & Kaslow, 2005; Greenawalt et 
al., 2011; Weist et al., 2007) and Hispanic adults (Ford, 2012) 
to identify religion as a primary coping mechanism.  Coping 
skills may also mediate PTSD symptoms and substance use, 
such that individuals with coping skills for PTSD symptoms 
are less likely to use substances and consequently are less 
likely to experience severe PTSD symptoms (Yeater, Austin, 
Green, & Smith, 2010).   

Several risk factors are associated with the development 
of PTSD.  These include low socioeconomic status (SES), 
low education, low intelligence, pre-existing psychiatric 
disorders such as depression or anxiety (Kessler, Sonnega, 

Bromet, Hughes, & Nelson, 1995; Shalev et al., 1998), family 
history of mental illness (Brady, Killeen, Brewerton, & 
Lucerini, 2000; Breslau, 2002; Brewin et al., 2000; Ozer, 
Best, Lipsey, & Weiss, 2008; Ullman & Filipas, 2001), 
childhood trauma (Andrews, Brewin, Rose, & Kirk, 2000; 
Breslau, 2002; Brewin et al., 2000; Wu, Schairer, Dellor, & 
Grella, 2010), re-exposure to traumatic events in adulthood 
(Khoury, Tang, Bradley, Cubells, & Ressler, 2010), and 
repeated exposure to the same or multiple traumas (Al-Saffar, 
Borgå, Edman, & Hällström, 2003; Green et al., 2000; 
Matlow & DePrince, 2012).  

Socio-demographic variables, such as geographic 
location, social status, acculturation, and perceived 
discrimination, may also affect the type of trauma 
experienced, PTSD endorsement, and symptom severity 
(Koenen, Goodwin, Struening, Hellman, & Guardino, 2003).  
For example, individuals who are members of a minority 
group may be more likely to live in lower income 
communities, be less acculturated to the dominant group, 
experience hardships such as discrimination, and are 
consequently more likely to be exposed to potentially 
traumatic events such as dangerous shootings or other threats 
to the physical integrity of oneself or others (Brewin et al., 
2000; Breslau, 2002; Chipman, Palmieri, & Hobfoll, 2011; 
Turner & Lloyd, 2004).  Although the trend is changing, 
current research suggests that individuals of minority groups 
are also less likely than Caucasian adults to pursue higher 
education (Orfield & Lee, 2005).  Regardless of magnitude of 
exposure to traumatic stressors, individuals who are less 
educated are more likely to develop PTSD than are 
individuals who are more educated (Breslau, Peterson, 
Poisson, Schultz, & Lucia, 2004).  

Independent of SES and education level, comorbidity of 
PTSD with other diagnoses is the norm rather than the 
exception.  About 80% of individuals diagnosed with PTSD 
are diagnosed with at least one other disorder (Grinage, 2003; 
Kilpatrick et al., 2003; Najavitis, Schmitz, Gotthardt, & 
Weiss, 2005) such as depression (Kessler et al., 1995; Shalev 
et al., 1998) or substance use (Najavitis et al., 2005; Yeater et 
al., 2010; Wolff et al., 2010).  Substance use may be a method 
of avoiding distressing intrusive thoughts and other PTSD-
related symptoms; however, substance users may not 
recognize the relationship between behavior and avoidance 
(Wolff et al., 2010).  Co-occurring disorders make 
understanding unique PTSD characteristics more difficult 
because they compound impairment in social, occupational, 
or other areas of functioning (Breslau, 2002; Brunello et al., 
2001; Hein, Cohen, & Campbell, 2005; Najavits, Norman, 
Kivlahan, & Kosten, 2010; Najavitis et al., 2005).   

Ethnicity may also affect the likelihood of seeking and 
completing treatment.  Individuals from ethnic minority 
groups are less likely than Caucasian individuals to seek 
treatment for PTSD unless they know where to obtain 
treatment, have resources to pay for treatment, and have 
symptoms that significantly disrupt one or more areas of 
functioning (Roberts et al., 2011; Wang et al., 2005).  In 
comparison to Caucasian and African American adults, 



ETHNICITY, TRAUMA, AND PTSD SYMPTOM SEVERITY 
 

104 
 

Hispanic adults are more likely to wait longer to seek mental 
health services due to concern of stigmatization.  Likewise, 
Lester, Resick, Young-Xu, and Artz (2010) found that 
African American respondents were significantly more likely 
to drop out of or not begin therapy, even when age, income, 
education, treatment expectations, and trauma exposure 
variables were taken into account.  It is questionable whether 
differences in trauma exposure among ethnic groups are due 
to actual differences or due to other factors such as SES.  
Controlling for SES and exposure to traumatic events 
removed differences between African American and 
Caucasian subjects in some studies (Kulka et al., 1990; 
Monnier, Elhai, Frueh, Sauvageot, & Magruder, 2002) but not 
others (Alim, Charney, & Mellman, 2006; Lester et al., 2010).  
For example, African American veterans reported higher rates 
of PTSD and greater symptom severity than Caucasian 
veterans; however, these differences ceased to exist when 
controlling for SES and type of exposure to trauma (Kulka et 
al., 1990; Green et al., 1990).   

Counselor or researcher ethnicity may also influence 
individuals’ likelihood of being open and honest when 
reporting symptoms (Sue, Rivera, Capodilupo, Lin, & Torino, 
2010).  For example, patients from ethnic minority groups 
who are paired with a counselor from a non-minority ethnic 
group (i.e., an African American patient with a Caucasian 
counselor) are more likely to drop out of treatment 
prematurely than those paired with an ethnically-matched 
counselor (Rosenheck, Fontana, & Cottrol, 1995).  Such 
factors may result in underreporting of symptoms and 
symptom severity until they are unable to cope with 
symptoms (MacDonald & Calhou, 2010).  Since minorities 
tend to wait to seek services until symptoms are unbearable, 
severity of symptoms and willingness to endorse symptoms 
may be significantly higher for African American or Hispanic 
individuals than for Caucasian individuals seeking counseling 
to ensure that they receive psychotherapeutic treatment when 
necessary.  In addition, they may be more likely to seek more 
inexpensive services from mental health providers with less 
training, to feel disrespected and misunderstood by providers, 
and to drop out of treatment prematurely (Roberts et al., 
2011; Lester et al., 2010; Ruef, Litz, & Schlenger, 2000).  
This underscores the importance of reducing stigmatization, 
building rapport and trust, as well as other factors that may 
influence patient disclosure to minimize omission of valuable 
information.   

Understanding the expression of PTSD symptoms among 
ethnic groups has significant clinical implications.  Such 
understanding will enhance providers’ cultural competence in 
delivery of treatment interventions aimed at addressing and 
alleviating PTSD symptoms.  This review will first examine 
the differences in type of trauma experienced as well as the 
impact of trauma on persons of different ethnic groups in 
terms of self-reported symptom severity.  Then, response 
style and measurement bias will be explored as proposed 
explanatory factors for discrepancies among prior studies.  
Finally, recommendations for future research will be 
provided.  

Trauma Type and Symptom Severity 
 

Certain traumas are reported as being more distressing 
than others.  The development of PTSD and the type of 
traumatic stressor may influence disclosure of experience 
(Bedard-Gilligan, Jaeger, Echiverri-Cohen, & Zoellner, 
2012).  In general, individuals who develop PTSD after 
exposure to a traumatic stressor report greater difficulty in 
disclosing their traumatic event and details of the event than 
those who did not develop PTSD.  Individuals who reported 
sexual and childhood trauma reported greater difficulty 
disclosing their trauma than individuals who reported other 
traumas (Bedard-Gilligan et al., 2012).  Ethnicity may also 
impact comfort with disclosure.  African American adults 
were less likely than Caucasian adults to disclose incidence of 
sexual trauma; and reported regret at disclosing their 
experience due to negative reactions of their confidant 
(Jacques-Tiura, Tkatch, Abbey, & Wegner, 2010).  This may 
be due to social factors such as guilt, shame, mistrust of the 
interviewer, and fear of the consequences of disclosure 
(Jacques-Tiura et al., 2010).   

Although a few studies (e.g., Breslau, 1998; Mainous, 
Smith, Acierno, & Geesey, 2005) suggest that ethnicity is 
unrelated to trauma type, other studies (i.e., Alim et al., 2006; 
Breslau et al., 2006; Marshall, Schell, & Miles, 2009; Norris, 
1992; Roberts et al., 2011) suggest that differences do exist.  
For example, Caucasian individuals are more likely than 
African American individuals to experience robbery or 
disaster (Norris, 1992) and to learn about a traumatic event to 
someone they are close to (Roberts et al., 2011), whereas 
African American individuals are more likely than Caucasian 
individuals to be exposed to assaultive violence, such as 
physical assault, homicide, and rape (Alim et al., 2006; 
Breslau et al., 1998).  In addition, African American and 
Hispanic adults are more likely than Caucasian adults to 
report childhood maltreatment, witnessing domestic violence, 
and war-related events as traumatic events (Roberts et al., 
2011; Alim et al., 2006).  Controlling for demographic 
differences does not eliminate differences between groups 
(Alim et al., 2006; Spoont, Hodges, Murdoch, & Nugent, 
2009).  That is, Alim and colleagues (2006) found that 
controlling for demographic variables decreased exposure to 
traumatic events but did not eliminate differences between 
ethnic groups and type of trauma reported.  Therefore, type of 
trauma is important to consider because different traumas 
elicit symptoms differently across ethnic groups.   

‘Symptom severity’ is a term frequently used to describe 
the magnitude of distress experienced by an individual in 
response to particular traumatic events (Brewin et al., 2000).  
Although some studies suggest that there are no differences 
between individuals from African American, Hispanic, and 
Caucasian ethnic groups with respect to symptom severity 
(Adams & Boscarino, 2011; Mainous et al., 2005; Montoya, 
Covarrubias, Patek, & Graves, 2003; Ozer et al., 2008), other 
studies suggest that there are differences (Breslau et al., 2006; 
Marshall et al., 2009; Pole et al., 2008; Pole, Best, Metzler, & 
Marmar, 2005; Pole et al., 2008; Rosenheck & Ortega, 2000; 



TREPASSO-GRULLON 
 

105 
 

Stephens et al., 2010).  For example, Mainous et al. (2005) 
initially found no significant differences in symptom severity 
or rates of PTSD diagnosis between Caucasian and African 
American individuals.  However, when trauma type was 
included as a control variable, Caucasian subjects reported 
significantly more distress than did African American 
subjects stemming from hyper-arousal, re-experiencing, and 
avoidance symptom clusters in response to a nonphysical 
trauma.  This suggests that studies which do not account for 
trauma type in analyses may neglect rich information about 
differences among ethnic groups in response to trauma.   
 Marshall and colleagues (2009) found significant 
differences between Hispanic and Caucasian, but not between 
Hispanic and African American, individuals for symptom 
endorsement and severity.  Alternatively, other studies 
suggest that Hispanic adults report greater overall symptom 
severity than African American and Caucasian adults (e.g., 
Breslau et al., 2006; Pole et al., 2008; Pole et al., 2005; 
Rosenheck & Ortega, 2000).  Hispanic adults may also 
experience symptoms differently, such that they are 
significantly more likely to experience hyper-vigilance and 
more severe physiologically-based symptoms than African 
Americans (Marshall et al., 2009).  Alternatively, African 
American adults who reported emotional abuse reported 
greater symptom severity than Hispanic adults.  African 
American adults who reported emotional abuse reported 
greater symptom severity from adult victimization than 
Hispanic or Caucasian adults, even when amount of 
victimization is similar across the groups (Ford, 2012).  
Alternatively, Hispanic adults who suffered physical abuse 
and African American adults who suffered emotional abuse 
were more likely to report greater overall symptom severity 
(Balsam, Lehavot, Beadnall, & Circo, 2010).   
 However, greater overall symptom severity does not 
necessarily equate to greater impairment.  Rosenheck and 
Ortega (2000) posit that the differences in reported symptom 
severity among individuals from Hispanics, African 
Americans, and Caucasian ethic groups are influenced by 
expressed emotion.  These authors attribute Hispanic adults’ 
significantly higher levels on symptom severity to their 
expressive style.  However, both Hispanic and African 
American adults who reported child abuse reported greater 
PTSD severity than Caucasian adults, even when SES was 
taken into consideration (Marshall et al., 2009).  This 
suggests that there are unique within-group cultural features 
irrespective of certain variables (e.g., SES, comfort with 
disclosure, expressed emotion) that may influence 
individuals’ experience of trauma.   
 Some researchers have examined clusters of symptoms 
rather than individual symptoms (e.g., Green et al., 2000; 
Khoury et al., 2010).  Cluster analysis can be problematic 
because it overlooks potentially significant between-group 
differences with respect to individual symptoms.  Although 
some studies have examined differences between groups with 
respect to clusters of symptoms, few studies have examined 
differences in individual symptoms across ethnic groups.  
One study conducted by Marshall and colleagues (2009) 

suggests that Hispanic adults endorse similar individual 
symptoms as Caucasian adults, but the study did not find a 
clear pattern of differences among PTSD clusters.  However, 
the authors did find that Hispanic individuals reported more 
positive symptoms (hyper-vigilance, intrusive thoughts, 
flashbacks, emotional reactivation) than negative symptoms 
(emotional detachment, restricted affect, difficulty sleeping, 
impaired concentration).  Matlow and DePrince (2012) did 
not find significant differences among ethnic groups and total 
PTSD symptom endorsement; however, African American 
respondents were more likely to endorse item 14 of the 
Postttraumatic Diagnostic Scale (PDS)―i.e., feeling irritable 
or having angry outbursts (Foa, 1995).   
 Since differences in individual symptom endorsement 
emerge even when differences in clusters do not emerge, 
theories that rely solely on an overall increase in PTSD 
symptoms or cluster-analysis are helpful but insufficient.  
This suggests that varied results about whether there are 
significant differences between ethnicity and PTSD may be 
due to lack of item-level analyses.  That is, there may be 
significant differences among ethnic groups’ endorsement of 
items, despite non-significant differences among ethnic 
groups in total PTSD symptoms (Matlow & DePrince, 2012).  
This suggests that there are factors associated with certain 
ethnic groups that affect their experience of trauma and 
trauma-related symptoms.  
 In addition to influencing the likelihood of developing 
PTSD, ethnic identity, SES, level of education, acculturation, 
and perceived discrimination also influence the experience 
and severity of trauma (Khaylis, Waelde, & Bruce, 2007; 
Kulka et al., 1990; Green et al., 1990; Matlow & DePrince, 
2012).  More specifically, lower SES, limited access to 
resources, minimal or no social support after a traumatic 
event, and experience of additional stressors such as job loss 
and financial hardship after the event increase symptom 
severity.  Additionally, repeated exposure to multiple 
traumatic events and surviving dangerous events when others 
did not survive increased risk for development of PTSD and 
symptom severity (Brewin et al., 2000; Matlow & DePrince, 
2012).  Symptom severity may also be influenced by 
acculturation and perceived discrimination.  In particular, 
minorities who strongly identify only with their ethnic group 
and not the dominant group may perceive greater stigma and 
discrimination are more likely to report greater PTSD 
symptom severity (Breslau, 2002; Galea et al., 2004; Khaylis 
et al., 2007; Loo et al., 2001).   
 Discrimination is multidimensional in that it can occur 
within subgroups, between minority groups, and between 
minority and majority groups (Ruef et al., 2000).  Perceived 
discrimination accounts for greater differences in mental 
health than does SES.  Individuals who are members of the 
African American ethnic group are more likely to perceive 
discrimination than are individuals who are members of 
Hispanic or Caucasian ethnic groups (Hausmann, Jeong, 
Bost, & Ibrahim, 2008).  Minorities who perceive that they 
have been discriminated against report greater symptom 
severity than individuals who identify with the majority group 



ETHNICITY, TRAUMA, AND PTSD SYMPTOM SEVERITY 
 

106 
 

(Bogart et al., 2011; Wagner, Bogart, Galvan, Banks, & 
Klein, 2012).  For example, African American and Hispanic 
adults who reported that they were discriminated against 
reported greater symptom severity than Caucasian adults who 
did not perceive discrimination (Ruef et al., 2000).  They also 
report worse mental health care (Hausmann et al., 2008).  
 Thus, differences in response to trauma are influenced by 
a variety of factors and may be explained by one’s 
experiences and worldview.  This suggests that differences 
between ethnic groups may be due to factors associated with 
particular ethnic groups rather than the ethnic group itself.  
Future studies should consider socio-demographic variables 
in analyses to determine whether differences in trauma type 
and symptom severity between ethnic groups are due to 
ethnicity itself rather than factors associated with all ethnic 
groups.  In a similar vein, differences in response style should 
be considered to rule out between-group differences in 
response styles. 
 

Response Style and Measurement Bias 
 
 Response styles are defined as a person’s way of 
responding to questions such as those in psychological 
assessment inventories (Franklin & Thompson, 2008).  
Several response styles cited in the literature include socially 
desirable responding, acquiescence, and extreme responding 
(Johnson et al., 2011; Marshall et al., 2009).  Response styles 
are important to consider when assessing PTSD because self-
report measures are frequently used to assess symptoms 
(Elhai, Gray, Kashdan, & Franklin, 2005).  Differences in 
response style make it difficult to identify exaggeration in 
patients who may receive secondary gain from a PTSD 
diagnosis.  Response styles may artificially magnify or 
conceal differences in endorsement of trauma and symptom 
severity.  That is, an observed difference may be due to the 
construct of PTSD rather than actual differences between 
groups.  Alternatively, if no differences are found, there may 
be problems with measurement methods that suppress 
differences (Drasgow & Probst, 2004). 
 Most studies on PTSD do not explore response style, 
despite bias in self-reported symptoms (Franklin & 
Thompson, 2008).  In such studies, it is unknown whether 
differences are due to differential response styles or actual 
differences between ethnic groups.  For example, Hispanic 
culture may be more accepting of and open to discussing 
anxiety-related symptoms.  If this is the case, endorsement of 
such items is attributable to differences in cultural norms 
about appropriate sincerity and modesty in social interactions 
(Rosenheck & Ortega, 2000).   
 Another explanation for between-group differences may 
be due to differences in interpretation.  For example, ethnic 
differences may be due to measurement artifacts such as 
differential item functioning (DIF) or problems associated 
with translation (Lewis-Fernandez et al., 2008; Miles et al., 
2008) and sensitivity and severity when assessment 
instruments are used in different populations (McDonald & 
Calhou, 2010).  It is also important that measures are 

translated correctly.  For example, the Posttraumatic Stress 
Disorder Checklist (PCL; Weathers, Litz, Herman, Huska, & 
Keane, 1993) is a frequently used self-report instrument used 
to measure PTSD symptoms and severity (Blanchard et al., 
1996).  Marshall et al. (2009) did not find disparities between 
responses on Spanish and English versions of the PCL. 
However, these authors only included individuals who 
experienced a physical injury that was severe enough to 
warrant hospitalization.  Since prior studies suggest that there 
are group differences in type of trauma experienced, future 
research should evaluate differential item functioning of 
Spanish and English versions of the PCL in groups which 
experienced different types of trauma (Clarke, 2000; Miles et 
al., 2008; Weathers et al., 1993).  Therefore, it is necessary to 
ensure the items in PTSD instruments do not pull for certain 
answers (Miles, Marshall, & Schell, 2008).  
 Social desirability may also affect responses.  Socially 
desirable responding is defined as reporting information that 
portrays oneself in a more favorable light (Johnson et al., 
2011).  Individuals who are from ethnic groups which value 
harmony and conformity are more likely to demonstrate 
socially desirable responding than are individuals from ethnic 
groups which value independence and autonomy (Johnson et 
al., 2011).  For example, individuals from African American 
and Hispanic ethnic groups were more likely to respond to 
PTSD questionnaires in a socially desirable manner when 
compared to individuals from the Caucasian ethnic group 
(Pole et al., 2005).   
 Similarly, acquiescence bias, defined as agreeing or 
disagreeing with the majority of statements, may account for 
differences between ethnic groups such that individuals who 
identify with certain ethnic groups may also be more likely to 
over- or under-endorse certain items (MacIntosh & 
Strickland, 2010; Marshall et al., 2009; Pole et al., 2005).  
Specifically, African American adults are more likely than 
Caucasian adults to demonstrate acquiescence and extreme 
responding in their endorsement of items at the extreme ends 
of response scales, regardless of content (Bachman & 
O’Malley, 1984; Clarke, 2000).  Hispanic individuals are also 
more likely than Caucasian individuals to acquiesce and 
demonstrate extreme responding (Ortega & Rosenheck, 
2000).  In contrast to African American adults, Hispanic 
adults are more likely to agree with items indicating a 
directional bias, which may influence conclusions drawn 
from the data (Bachman & O’Malley, 1984; Clarke, 2000).  
Given these findings, it may appear that Hispanic individuals 
tend to report more symptoms and endorse unusual items that 
consequently lead to inflated scores even when not more 
severely impaired than individuals who are members of non-
Hispanic ethnic groups (Pole et al., 2005).   
 Instruments used to compare response styles among 
clinical samples are increasing in popularity (Franklin & 
Thompson, 2008).  The Trauma Symptom Inventory (TSI; 
Briere, 1995) is cited as a useful instrument for measuring 
response style as well as post-traumatic psychopathology.  
This 100-item structured self-report instrument has three 
validity scales (Response Level, Inconsistency, and Atypical 



TREPASSO-GRULLON 
 

107 
 

Response).  However, most research conducted with this 
instrument uses college students and may not generalize to 
ethnically diverse or clinical samples.  The Minnesota 
Multiphasic Personality Inventory 2 (MMPI-2; Hathaway & 
McKinley, 1940) and Structured Interview of Reported 
Symptoms (SIRS; Rogers et al., 1992) may also be used to 
assess response styles.  It is important to select instruments 
that have been validated using samples that reflect the 
population of interest.  That is, instruments selected to assess 
PTSD in African American adults should be normed using a 
similar sample of individuals to minimize measurement bias.  
Measurement bias inflates measurement error and 
complicates interpretation of findings.  Since PTSD is 
assessed using various instruments and methods, is also 
important to minimize contamination from measurement bias.  
Sources of measurement bias include problems with 
translation, comprehension, cognition, memory, experimenter 
expectancy (the susceptibility of researchers to find what they 
expect to find), experimenter reactivity (the susceptibility of 
researchers to influence the behavior of subjects either 
intentionally or unintentionally), and social desirability 
(Johnson et al., 2011).   
 In addition to measurement bias from characteristics of 
extraneous variables, the assessor’s, or instruments’, 
administration method may also influence self-report.  
Individuals are more likely to report greater symptom severity 
in response to a traumatic event when interviewed by an 
interviewer than when given a self-report questionnaire 
(Breslau et al., 2006).  Therefore, utilizing both structured 
interviews and questionnaires is recommended to cross 
validate responses.   
 Self-report and clinician-assessed symptoms are 
comparable across ethnic groups (MacDonald, Greene, 
Torres, Frueh, & Morland, 2012).  However, method of 
administration (e.g., computerized or paper-and-pencil) may 
influence results.  Although computer-administered or paper-
and-pencil measures do not always result in differences 
between ethnic groups (Booth-Kewley, Edwards, & 
Rosenfeld, 1992), paper-and-pencil and interviewer-
administration has more of an impact on social desirability 
than does computer administration, especially when questions 
are highly personal, disturbing, intrusive, or sensitive, and 
when the interviewer is of a different ethnicity than the 
respondent (Wood, Nosko, Desmarais, Ross, & Irvine, 2006).  
In such cases, computer administration is beneficial since it 
reduces social desirability and scoring time, while increasing 
accuracy of scoring.  However, computerized assessments can 
introduce user error if participants are not comfortable with 
using computers.  If comfort level with computers is not 
assessed, methodology may impact accuracy such that 
individuals with less computer experience may make more 
errors and thus provide less accurate information about their 
experience with traumatic events (Montoya et al., 2003).  
This may lead clinicians to misdiagnosis individuals (Alim et 
al., 2006).  

Response bias and measurement bias may explain 
discrepancies among research studies aiming to clarify 

whether differences among ethnic groups actually exist or are 
measurement artifacts.  Future studies should carefully and 
comprehensively evaluate the influence of response style and 
measurement bias among ethnic groups to avoid drawing 
incorrect conclusions about PTSD symptom severity and type 
of trauma.  Instruments such as the Greenleaf Extreme 
Response Measure (Greenleaf, 1992) , an instrument with 16 
items that are cross-culturally applicable, and an instrument to 
measure social desirability, such as the Social Desirability 
Scale (Stoeber, 2001) may be helpful to determine whether 
participant responses fit a pattern rather than the construct of 
interest (Clarke, 2000).  Statistical analyses will clarify the 
source of differences between ethnic groups due to unique 
characteristics of members that comprise the groups, rather 
than the instruments used to elicit information about 
traumatic experiences.  Statistically significant differences in 
response style and socially desirable responses would 
necessitate controlling one or both of these variables.   
 Furthermore, most studies have examined ethnic 
minority groups as broad categories.  Some studies (e.g., 
Breslau et al., 2006; Brewin et al., 2000) cluster all ethnic 
minority groups into one ‘supergroup’ to compensate for 
insufficient sample size.  Comparing this ‘supergroup’ of all 
non-Caucasian adults to Caucasian adults as a reference 
group reduces generalizability because important differences 
in the manifestation and experience of symptoms between 
ethnic groups may be overlooked (Roberts et al., 2011).  
Grouping all Hispanic individuals into one categorical group 
neglects the heterogeneity of groups and, consequently, loses 
important information unique to subgroups.  For example, 
Hispanic adults from different regions (e.g., Mexico, Puerto 
Rico, Dominican Republic, and Cuba) have unique aspects of 
their culture that impact manifestation of symptoms as well as 
reporting of symptoms on PTSD instruments.  Future studies 
should include ethnic sub-groups to determine if group 
differences may be accounted for by one sub-group.  
Multimodal assessment is also recommended for assessing 
PTSD symptoms because response style may lead to faulty 
conclusions about ethnic group differences.  Clinician-
administered and self-report measures allow researchers to 
evaluate discrepancies or similarities among individuals’ 
response styles.   
 

Conclusion 
 
 The purpose of this review was to highlight differences 
in response to traumatic events.  Differences among ethnic 
groups underscore the importance of cultural competency 
when assessing PTSD.  Possible explanatory factors for these 
differences were examined to enhance understanding about 
the differences in trauma and PTSD symptoms experienced 
by members of different ethnic groups.  Previous research 
shows that there are qualitative differences between 
individuals from Caucasian, African American, and Hispanic 
groups in terms of interpretations of traumatic events and 
self-reported PTSD symptoms.  Response style and 
measurement bias may help to explain these findings.  Future 



ETHNICITY, TRAUMA, AND PTSD SYMPTOM SEVERITY 
 

108 
 

studies should include measures of acculturation to explore 
the impact of level of acculturation on self-reported PTSD 
symptoms, since treatment practices that were normed on 
Caucasian-dominant populations may need to be revised to 
better address issues relevant to ethnic minority groups.  

Furthermore, in many cases, sub-groups are combined 
into largely generalized groups.  By doing so, researchers are 
neglecting within-group differences and increasing the 
possibility of drawing incorrect conclusions about between-
group differences.  Existing literature about ethnic differences 
and PTSD is also limited by global groupings of participants 
into minority and majority groups, as well as by failure to 
consider differences in trauma type, symptom severity, and 
the impact of response and measurement bias on participant 
responding.  Although the examination of ethnic differences 
is becoming more popular in contemporary research, many 
studies do not consider the impact of acculturation and 
perceived discrimination, nor do they take into account the 
heterogeneity of ethnic groups.  Therefore, future researchers 
should examine differences among ethnic sub-groups rather 
than combining minorities into general groups (e.g., African 
Americans, Hispanics, and Caucasian adults) or combining 
them into one large supergroup.  Future studies should also 
allow subjects to indicate the sub-group with which they 
identify.  This would allow researchers to build a more 
precise picture of differences and similarities among ethnic 
groups with respect to trauma and PTSD symptom severity.  
Recruiting a sample of trauma survivors that is large enough 
to be representative of the larger group inclusive of subgroups 
would provide a closer examination of differences in 
symptom manifestation, expression, and appropriate attention 
to differences in response style.  
 Although a few researchers (e.g., Adams & Boscarino, 
2011; Kessler et al., 1995; Mainous et al., 2005; Montoya et 
al., 2003; Ozer et al., 2008; Spoont et al., 2009) maintain that 
there are no differences among ethnic groups for type of 
trauma experienced and PTSD symptom severity, other 
researchers (e.g., Khaylis et al., 2007; Kulka et al., 1990; 
Green et al., 2000) provide evidence for between-group 
differences among ethnic groups.  This review highlights the 
importance of considering multiple factors when drawing 
conclusions about individuals from different ethnicities with 
PTSD.  Several explanations have been offered to explain 
differences among trauma type and symptom severity 
reporting among ethnic groups in the literature.  Socio-
economic status, acculturation, perceived discrimination, 
response style, and measurement bias may differentially 
contribute to differences among ethnic groups.  Additionally, 
differences in individual life experiences can influence 
interpretation of trauma and, consequently, manifestation of 
PTSD symptoms.  A multimethod approach including self-
reports and clinician-administered, qualitative instruments 
may be helpful for understanding culturally specific factors 
related to PTSD. 
 Researchers and therapists would benefit from increasing 
their awareness about differences among ethnic groups in 
terms of the types of trauma they are more likely to 

experience, as well as the perceived severity of trauma-related 
symptoms when working with PTSD.  In particular, 
awareness of between-group ethnic differences would avoid 
prescribing a blanket solution to assessing and treating 
patients with PTSD symptoms.  Addressing the 
aforementioned concerns will enhance researchers’ and 
mental health providers’ understanding and conceptualization 
of PTSD and may consequently improve the quality of future 
research studies and treatment interventions. 
 

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