title: The stressor criterion for posttraumatic stress disorder: does it matter?
abstract: OBJECTIVE
  The definition of the stressor criterion (DSM criterion A1) for posttraumatic stress disorder (PTSD) is hotly debated with major revisions being considered for DSM-5. We examine whether symptoms, course, and consequences of PTSD vary predictably with the type of stressful event that precipitates symptoms.
  
  
  METHODS
  We used data from the 2009 PTSD diagnostic subsample (N = 3,013) of women from the Nurses' Health Study II. We asked respondents about exposure to stressful events that qualified under DSM-III or DSM-IV or did not qualify under DSM criterion A1. Respondents selected the event they considered worst and reported subsequent PTSD symptoms. Among participants who met all other DSM-IV PTSD criteria, we compared distress, symptom severity, duration, impairment, receipt of professional help, and 9 physical, behavioral, and psychiatric sequelae (eg, physical functioning, unemployment, depression) by precipitating event group. Various assessment tools were used to determine fulfillment of PTSD criteria B through F and to assess these 14 outcomes.
  
  
  RESULTS
  Participants with PTSD from DSM-III events reported, on average, 1 more symptom (DSM-III, mean = 11.8 symptoms; DSM-IV, mean = 10.7 [P < .001]; non-DSM, mean = 10.9 [P < .01]) and more often reported that symptoms lasted 1 year or longer compared to participants with PTSD from other groups (DSM-III vs DSM-IV, P < .01; DSM-III vs non-DSM, P < .001). However, sequelae of PTSD did not vary systematically with precipitating event type.
  
  
  CONCLUSIONS
  Results indicate the stressor criterion as defined by the DSM may not be informative in characterizing PTSD symptoms and sequelae. In the context of ongoing DSM-5 revision, these results suggest that criterion A1 could be expanded in DSM-5 without much consequence for our understanding of PTSD phenomenology. Events not considered qualifying stressors under the DSM produced PTSD as consequential as PTSD following DSM-III events, suggesting PTSD may be an aberrantly severe but nonspecific stress response syndrome.
authors.affiliation: Departments of Society, Human Development, and Health and Epidemiology, Harvard School of Public Health, Boston, MA, USA. aroberts@hsph.harvard.edu
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Roberts
authors.forename: Bruce P
authors.initials: BP
authors.lastname: Dohrenwend
authors.forename: Allison E
authors.initials: AE
authors.lastname: Aiello
authors.forename: Rosalind J
authors.initials: RJ
authors.lastname: Wright
authors.forename: Andreas
authors.initials: A
authors.lastname: Maercker
authors.forename: Sandro
authors.initials: S
authors.lastname: Galea
authors.forename: Karestan C
authors.initials: KC
authors.lastname: Koenen
mesh_terms: D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006306:Health Surveys / Q000706:statistics & numerical data; D006801:Humans; D008016:Life Change Events; D008875:Middle Aged; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis* / Q000523:psychology