title: Cumulative traumas and risk thresholds: 12-month PTSD in the World Mental Health (WMH) surveys.
abstract: BACKGROUND
  Clinical research suggests that posttraumatic stress disorder (PTSD) patients exposed to multiple traumatic events (TEs) rather than a single TE have increased morbidity and dysfunction. Although epidemiological surveys in the United States and Europe also document high rates of multiple TE exposure, no population-based cross-national data have examined this issue.
  
  
  METHODS
  Data were analyzed from 20 population surveys in the World Health Organization World Mental Health Survey Initiative (n = 51,295 aged 18+). The Composite International Diagnostic Interview (3.0) assessed 12-month PTSD and other common DSM-IV disorders. Respondents with 12-month PTSD were assessed for single versus multiple TEs implicated in their symptoms. Associations were examined with age of onset (AOO), functional impairment, comorbidity, and PTSD symptom counts.
  
  
  RESULTS
  19.8% of respondents with 12-month PTSD reported that their symptoms were associated with multiple TEs. Cases who associated their PTSD with four or more TEs had greater functional impairment, an earlier AOO, longer duration, higher comorbidity with mood and anxiety disorders, elevated hyperarousal symptoms, higher proportional exposures to partner physical abuse and other types of physical assault, and lower proportional exposure to unexpected death of a loved one than cases with fewer associated TEs.
  
  
  CONCLUSIONS
  A risk threshold was observed in this large-scale cross-national database wherein cases who associated their PTSD with four or more TEs presented a more "complex" clinical picture with substantially greater functional impairment and greater morbidity than other cases of PTSD. PTSD cases associated with four or more TEs may merit specific and targeted intervention strategies.
authors: Department of Psychiatry and Clinical Psychology, Institute for Development, Research, Advocacy, and Applied Care (IDRAAC), St. George Hospital University Medical Center, Beirut, Lebanon.
authors: Elie G
authors: EG
authors: Karam
authors: Matthew J
authors: MJ
authors: Friedman
authors: Eric D
authors: ED
authors: Hill
authors: Ronald C
authors: RC
authors: Kessler
authors: Katie A
authors: KA
authors: McLaughlin
authors: Maria
authors: M
authors: Petukhova
authors: Laura
authors: L
authors: Sampson
authors: Victoria
authors: V
authors: Shahly
authors: Matthias C
authors: MC
authors: Angermeyer
authors: Evelyn J
authors: EJ
authors: Bromet
authors: Giovanni
authors: G
authors: de Girolamo
authors: Ron
authors: R
authors: de Graaf
authors: Koen
authors: K
authors: Demyttenaere
authors: Finola
authors: F
authors: Ferry
authors: Silvia E
authors: SE
authors: Florescu
authors: Josep Maria
authors: JM
authors: Haro
authors: Yanling
authors: Y
authors: He
authors: Aimee N
authors: AN
authors: Karam
authors: Norito
authors: N
authors: Kawakami
authors: Viviane
authors: V
authors: Kovess-Masfety
authors: María Elena
authors: ME
authors: Medina-Mora
authors: Mark A Oakley
authors: MA
authors: Browne
authors: José A
authors: JA
authors: Posada-Villa
authors: Arieh Y
authors: AY
authors: Shalev
authors: Dan J
authors: DJ
authors: Stein
authors: Maria Carmen
authors: MC
authors: Viana
authors: Zahari
authors: Z
authors: Zarkov
authors: Karestan C
authors: KC
authors: Koenen
mesh_terms: D000293:Adolescent; D000328:Adult; D017668:Age of Onset; D002648:Child; D015897:Comorbidity; D005060:Europe / Q000453:epidemiology; D005260:Female; D006306:Health Surveys / Q000379:methods / Q000706:statistics & numerical data*; D006801:Humans; D038622:Internationality; D008016:Life Change Events; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology / Q000523:psychology; D015995:Prevalence; D012307:Risk Factors; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology* / Q000523:psychology*; D013315:Stress, Psychological / Q000453:epidemiology* / Q000523:psychology; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: PTSD; World Mental Health Surveys; comorbidity; epidemiology; functional impairment
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