Subthreshold posttraumatic stress disorder in the world health organization world mental health surveys

Katie A McLaughlin; Karestan C Koenen; Matthew J Friedman; Ayelet Meron Ruscio; Elie G Karam; Victoria Shahly; Dan J Stein; Eric D Hill; Maria Petukhova; Jordi Alonso; Laura Helena Andrade; Matthias C Angermeyer; Guilherme Borges; Giovanni de Girolamo; Ron de Graaf; Koen Demyttenaere; Silvia E Florescu; Maya Mladenova; Jose Posada-Villa; Kate M Scott; Tadashi Takeshima; Ronald C Kessler

doi:10.1016/j.biopsych.2014.03.028

Subthreshold posttraumatic stress disorder in the world health organization world mental health surveys

Biol Psychiatry. 2015 Feb 15;77(4):375-84. doi: 10.1016/j.biopsych.2014.03.028. Epub 2014 Apr 12.

Authors

Katie A McLaughlin¹, Karestan C Koenen², Matthew J Friedman³, Ayelet Meron Ruscio⁴, Elie G Karam⁵, Victoria Shahly⁶, Dan J Stein⁷, Eric D Hill⁶, Maria Petukhova⁶, Jordi Alonso⁸, Laura Helena Andrade⁹, Matthias C Angermeyer¹⁰, Guilherme Borges¹¹, Giovanni de Girolamo¹², Ron de Graaf¹³, Koen Demyttenaere¹⁴, Silvia E Florescu¹⁵, Maya Mladenova¹⁶, Jose Posada-Villa¹⁷, Kate M Scott¹⁸, Tadashi Takeshima¹⁹, Ronald C Kessler²⁰

Affiliations

¹ Department of Psychology (KAM), University of Washington, Seattle, Washington.
² Department of Epidemiology (KCK), Mailman School of Public Health, Columbia University, New York, New York.
³ National Center for PTSD (MJF), U.S. Department of Veterans Affairs and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
⁴ Department of Psychology (AMR), University of Pennsylvania, Philadelphia, Pennsylvania.
⁵ Institute for Development, Research, Advocacy & Applied Care (EGK), Medical Institute for Neuropsychological Disorders, St. George Hospital University Medical Center, Faculty of Medicine, Balamand University, Beirut, Lebanon.
⁶ Department of Health Care Policy (VS, EDH, MP, RCK), Harvard Medical School, Boston, Massachusetts.
⁷ Department of Psychiatry and Mental Health (DJS), University of Cape Town, Cape Town, South Africa.
⁸ Health Services Research Unit (JA), Institut Hospital del Mar d'Investigacions Mèdiques, Consorcio de Investigacion Biomèdica en Red en Epidemiología y Salud Pública, Universitat Pompeu Fabra, Barcelona, Spain.
⁹ Section of Psychiatric Epidemiology-LIM 23 (LHA), Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil.
¹⁰ Center for Public Mental Health (MCA), Gösing am Wagram, Austria.
¹¹ Department of Epidemiological Research (GB), Division of Epidemiological and Psychosocial Research, National Institute of Psychiatry (Mexico) & Metropolitan Autonomous University, Mexico City, Mexico.
¹² Istituto di Ricovero e Cura a Carattere Scientifico, Centro S. Giovanni di Dio Fatebenefratelli (GdG), Brescia, Italy.
¹³ Netherlands Institute of Mental Health and Addiction (RdG), Utrecht, The Netherlands.
¹⁴ Department of Psychiatry (KD), University Hospital Gasthuisberg, Leuven, Belgium.
¹⁵ Health Services Research and Evaluation Center (SEF), Bulgarian Center for Human Relations, National School of Public Health Management and Professional Development, Bucharest, Romania.
¹⁶ New Bulgarian University (MM), Sofia, Bulgaria.
¹⁷ Department of Psychiatry (JP-V), Universidad Colegio Mayor de Cundinamarca, Bogota, Colombia.
¹⁸ Department of Psychological Medicine (KMS), Otago University, Dunedin, New Zealand.
¹⁹ National Institute of Mental Health (TT), National Center of Neurology and Psychiatry, Ogawa-Higashi, Kodaira, Tokyo, Japan.
²⁰ Department of Health Care Policy (VS, EDH, MP, RCK), Harvard Medical School, Boston, Massachusetts. Electronic address: Kessler@hcp.med.harvard.edu.

Abstract

Background: Although only a few people exposed to a traumatic event (TE) develop posttraumatic stress disorder (PTSD), symptoms that do not meet full PTSD criteria are common and often clinically significant. Individuals with these symptoms sometimes have been characterized as having subthreshold PTSD, but no consensus exists on the optimal definition of this term. Data from a large cross-national epidemiologic survey are used in this study to provide a principled basis for such a definition.

Methods: The World Health Organization World Mental Health Surveys administered fully structured psychiatric diagnostic interviews to community samples in 13 countries containing assessments of PTSD associated with randomly selected TEs. Focusing on the 23,936 respondents reporting lifetime TE exposure, associations of approximated DSM-5 PTSD symptom profiles with six outcomes (distress-impairment, suicidality, comorbid fear-distress disorders, PTSD symptom duration) were examined to investigate implications of different subthreshold definitions.

Results: Although consistently highest outcomes for distress-impairment, suicidality, comorbidity, and PTSD symptom duration were observed among the 3.0% of respondents with DSM-5 PTSD rather than other symptom profiles, the additional 3.6% of respondents meeting two or three of DSM-5 criteria B-E also had significantly elevated scores for most outcomes. The proportion of cases with threshold versus subthreshold PTSD varied depending on TE type, with threshold PTSD more common following interpersonal violence and subthreshold PTSD more common following events happening to loved ones.

Conclusions: Subthreshold DSM-5 PTSD is most usefully defined as meeting two or three of DSM-5 criteria B-E. Use of a consistent definition is critical to advance understanding of the prevalence, predictors, and clinical significance of subthreshold PTSD.

Keywords: Epidemiology; Nosology; PTSD; Partial PTSD; Posttraumatic stress disorder; Subthreshold PTSD.

Publication types

Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Diagnostic and Statistical Manual of Mental Disorders
Female
Health Surveys
Humans
Male
Mental Health*
Prevalence
Severity of Illness Index
Stress Disorders, Post-Traumatic / complications
Stress Disorders, Post-Traumatic / diagnosis*
Stress Disorders, Post-Traumatic / epidemiology*
World Health Organization

Abstract

Publication types

MeSH terms

Grants and funding