title: The role of criterion A2 in the DSM-IV diagnosis of posttraumatic stress disorder.
abstract: 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.
authors.affiliation: Department of Psychiatry and Clinical Psychology, Saint George Hospital, University Medical Center, Beirut, Lebanon.
authors.forename: Elie George
authors.initials: EG
authors.lastname: Karam
authors.forename: Gavin
authors.initials: G
authors.lastname: Andrews
authors.forename: Evelyn
authors.initials: E
authors.lastname: Bromet
authors.forename: Maria
authors.initials: M
authors.lastname: Petukhova
authors.forename: Ayelet Meron
authors.initials: AM
authors.lastname: Ruscio
authors.forename: Mariana
authors.initials: M
authors.lastname: Salamoun
authors.forename: Nancy
authors.initials: N
authors.lastname: Sampson
authors.forename: Dan J
authors.initials: DJ
authors.lastname: Stein
authors.forename: Jordi
authors.initials: J
authors.lastname: Alonso
authors.forename: Laura Helena
authors.initials: LH
authors.lastname: Andrade
authors.forename: Matthias
authors.initials: M
authors.lastname: Angermeyer
authors.forename: Koen
authors.initials: K
authors.lastname: Demyttenaere
authors.forename: Giovanni
authors.initials: G
authors.lastname: de Girolamo
authors.forename: Ron
authors.initials: R
authors.lastname: de Graaf
authors.forename: Silvia
authors.initials: S
authors.lastname: Florescu
authors.forename: Oye
authors.initials: O
authors.lastname: Gureje
authors.forename: Debra
authors.initials: D
authors.lastname: Kaminer
authors.forename: Roman
authors.initials: R
authors.lastname: Kotov
authors.forename: Sing
authors.initials: S
authors.lastname: Lee
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Lépine
authors.forename: Maria Elena
authors.initials: ME
authors.lastname: Medina-Mora
authors.forename: Mark A
authors.initials: MA
authors.lastname: Oakley Browne
authors.forename: José
authors.initials: J
authors.lastname: Posada-Villa
authors.forename: Rajesh
authors.initials: R
authors.lastname: Sagar
authors.forename: Arieh Y
authors.initials: AY
authors.lastname: Shalev
authors.forename: Tadashi
authors.initials: T
authors.lastname: Takeshima
authors.forename: Toma
authors.initials: T
authors.lastname: Tomov
authors.forename: Ronald C
authors.initials: RC
authors.lastname: Kessler
mesh_terms: D003625:Data Collection; D039721:Diagnostic and Statistical Manual of Mental Disorders; D004644:Emotions / Q000502:physiology; D006306:Health Surveys; D006801:Humans; D008016:Life Change Events; D011569:Psychiatric Status Rating Scales; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis* / Q000523:psychology; D059020:Suicidal Ideation