Elsevier

Biological Psychiatry

Volume 68, Issue 5, 1 September 2010, Pages 465-473
Biological Psychiatry

Archival Report
The Role of Criterion A2 in the DSM-IV Diagnosis of Posttraumatic Stress Disorder

https://doi.org/10.1016/j.biopsych.2010.04.032Get rights and content

Background

Controversy exists about the utility of DSM-IV posttraumatic stress disorder (PTSD) criterion A2 (A2): that exposure to a potentially traumatic experience (PTE; PTSD criterion A1) is accompanied by intense fear, helplessness, or horror.

Methods

Lifetime DSM-IV PTSD was assessed with the Composite International Diagnostic Interview in community surveys of 52,826 respondents across 21 countries in the World Mental Health Surveys.

Results

Of 28,490 representative PTEs reported by respondents, 37.6% met criterion A2, a proportion higher than the proportions meeting other criteria (B–F; 5.4%–9.6%). Conditional prevalence of meeting all other criteria for a diagnosis of PTSD given a PTE was significantly higher in the presence (9.7%) than absence (.1%) of A2. However, as only 1.4% of respondents who met all other criteria failed A2, the estimated prevalence of PTSD increased only slightly (from 3.64% to 3.69%) when A2 was not required for diagnosis. Posttraumatic stress disorder with or without criterion A2 did not differ in persistence or predicted consequences (subsequent suicidal ideation or secondary disorders) depending on presence-absence of A2. Furthermore, as A2 was by far the most commonly reported symptom of PTSD, initial assessment of A2 would be much less efficient than screening other criteria in quickly ruling out a large proportion of noncases.

Conclusions

Removal of A2 from the DSM-IV criterion set would reduce the complexity of diagnosing PTSD, while not substantially increasing the number of people who qualify for diagnosis. Criterion A2 should consequently be reconceptualized as a risk factor for PTSD rather than as a diagnostic requirement.

Section snippets

Samples

Data come from WMH surveys in 21 countries, 5 low-income or lower-middle-income (Colombia, India, Nigeria, People's Republic of China [Beijing and Shanghai], and Ukraine), 6 upper-middle-income (Brazil, Bulgaria, Lebanon, Mexico, Romania, and South Africa), and 10 high-income (Belgium, France, Germany, Israel, Italy, Japan, Netherlands, New Zealand, Spain, and United States) countries (Table 1). A total of 102,247 respondents were interviewed in these surveys. Part I of the interviews, which

Prevalence of DSM-IV PTSD Criteria A1 and A2

Lifetime exposure to PTEs was reported by 67.9% of respondents (72.8% in high-income, 61.7% in upper-middle-income, and 63.1% in low-income/lower-middle-income countries). Disaggregated comparisons (detailed results available on request) found the higher exposure in high-income countries due largely to automobile accidents. Weighted mean number of PTEs per respondent with any was 4.5 (4.7 in high-income, 4.1 in upper-middle-income, and 4.6 in low-income/lower-middle-income countries) for 305.6

Discussion

This study found that PTEs are commonly occurring, that a much higher proportion of the randomly selected PTEs meet criterion A2 than any other DSM-IV PTSD criterion, that conditional prevalence of meeting diagnostic threshold based on other criteria is significantly higher in the presence than absence of A2, and that only a small fraction of respondents who meet diagnostic threshold based on other criteria fail to meet A2. The last of these results means the sample-specific prevalence of PTSD

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