The stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation
Introduction
Historical accounts of the diagnosis of posttraumatic stress disorder (PTSD), from its introduction into the psychiatric nosology in DSM-III to the latest DSM edition, DSM-IV, attest to the centrality of the stressor criterion in the definition of this disorder March 1993, O’Brien 1998, Young 1995. The DSM-III edition specified that the traumatic event was of a type that would cause “significant symptoms of distress in almost anyone.” DSM-IIIR introduced an additional feature—namely, that the event was “outside the range of usual human experience.” The standard for determining whether or not an event “qualified” was the clinician’s judgment of the stress that an “average” person would experience under similar circumstances. Clinicians might have varied in their views on the boundaries that separate qualifying from nonqualifying stressors, and some probably viewed any stressor as qualifying if it resulted in the typical PTSD syndrome; however, DSM-III and DSM-IIIR defined the stressor objectively, without reference to the victim’s emotional response. Epidemiologic surveys used the examples in the DSM to form lists of qualifying traumatic events; a clinical judgment about the stress-inducing potential of a particular traumatic event for the average person has not been a methodologically feasible standard.
The DSM-IV definition of the PTSD stressor is a clear departure from previous versions. The definition is divided into two parts—the first part, A1, states the range of qualifying stressors; the second part, A2, requires that the “person’s response involved intense fear, helplessness, or horror.” This two-part definition de-emphasizes the objective features of the trauma and relies instead on the principle that people may perceive and respond differently to outwardly similar events. The shift from the objective nature of the stressor to the subjective experience of the victim is evident not only in the added subjective component (A2), but also in the objective component (A1), where there is no longer a focus on the stressor as an experience that “would be markedly distressing to almost anyone,” but instead on the victim, who must have “experienced,” “witnessed,” or “been confronted by” a threat to physical integrity (O’Brien 1998).
The list of typical traumas in the text of DSM-IV that illustrate A1 leaves no doubt that the intent was to enlarge the variety of experiences that can be used to diagnose PTSD beyond previous definitions. For example, learning about the death of a close relative or friend from any cause, including natural causes, is explicitly included as a qualifying event in DSM-IV, so long as the death was sudden and unexpected; in previous definitions, only a violent death qualified. Learning about traumatic events experienced by a close relative or friend, or being diagnosed with a life-threatening illness are also explicitly included in DSM-IV, whereas their status in previous DSM editions was unclear and, in all likelihood, a subject of debate.
To date, there is no empirical evidence on the net effect of the broader range of stressors in A1, coupled with the added requirement of the subjective response in A2, on the prevalence of exposure to stressors, as defined by the two-part criterion A and the probability of PTSD given exposure. The PTSD field trial, which was designed to test alternative definitions of the stressor criterion (and other PTSD criteria) that were under consideration by the DSM-IV work group, reported that the impact on PTSD prevalence varied little across definitions (Kilpatrick et al 1998). The authors concluded that the inclusion of a subjective component had a minimal effect on the conditional probability of PTSD. The study did not evaluate the impact of the expanded definition of stressors in A1 or the net effect of the two-part criterion as it appears in the official DSM-IV. Roemer et al (1998) and Brewin et al (2000) examined the relationship of each of the three A2 emotional responses to subsequent PTSD (or symptoms of PTSD). Both studies showed that these emotional responses generally predicted PTSD. Additionally, they reported that other types of responses that are not included in A2 also predicted PTSD. Neither study examined the impact of A2 as defined in the DSM-IV (the presence of any of the emotional responses, i.e., intense fear, helplessness, or horror). None of these studies used a community sample and a representative sample of traumatic events experienced in the community.
Using data from the 1996 Detroit Area Survey of Trauma Breslau et al 1998a, Breslau et al 1999a, Breslau et al 1999b, we address the following questions: (1) What are the effects of the broader range of A1 stressors on estimates of exposure to such stressors and PTSD? (2) What is the conditional probability of endorsing A2 given exposure to A1 events, overall, across event types and sociodemographic characteristics? (3) What is the impact of the two-part DSM-IV stressor definition (A1 and A2) on estimates of exposure and PTSD?
Section snippets
Sample and data
The 1996 Detroit Area Survey of Trauma is a representative sample of 2181 persons aged 18–45 years in the Detroit primary metropolitan statistical area (PMSA). The Detroit PMSA is a six-county area that contained 4,226,654 residents at the time of the 1990 census. Of these residents, 1,922,173 were aged 18–45 years; the majority (77%) resided in suburban and rural communities and only a minority (23%) resided in the City of Detroit (US Bureau of Census 1990). A random-,digit dialing method was
The effects of the expanded variety of events in A1 on estimates of exposure and PTSD
The lifetime prevalence of exposure to one or more traumatic events in the list of 19 events used to operationalize the A1 criterion was 89.6% (92.2% in males and 87.1% in females) Breslau et al 1999a, Breslau 1998b. The effect of the broader definition of stressors in A1 on the lifetime prevalence of exposure was evaluated by comparing these estimates to estimates based on partial lists, from which the new event types added in the DSM-IV text were excluded. Note that there is no precise way to
Discussion
In this study, we examined the two-part stressor criterion in DSM-IV in several steps. We first estimated the effects of the enlarged definition in A1 on the prevalence of exposure to stressors that could potentially be used to diagnose PTSD. We then estimated the probability of A2 given exposure to A1 stressors. In these two steps, we compared the newly added stressors in A1 to the narrower list of stressors in previous DSM editions. Finally, we evaluated the net effect of the DSM-IV stressor
Acknowledgements
This work was supported in part by Grant Nos. MH48802 (NB) and MH00507 (RCK) from the National Institute of Mental Health.
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