Subthreshold posttraumatic stress disorder in the world health organization world mental health surveys.
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.
Department of Psychology (KAM), University of Washington, Seattle, Washington.
Katie A
KA
McLaughlin
Department of Epidemiology (KCK), Mailman School of Public Health, Columbia University, New York, New York.
Karestan C
KC
Koenen
National Center for PTSD (MJF), U.S. Department of Veterans Affairs and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
Matthew J
MJ
Friedman
Department of Psychology (AMR), University of Pennsylvania, Philadelphia, Pennsylvania.
Ayelet Meron
AM
Ruscio
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.
Elie G
EG
Karam
Department of Health Care Policy (VS, EDH, MP, RCK), Harvard Medical School, Boston, Massachusetts.
Victoria
V
Shahly
Department of Psychiatry and Mental Health (DJS), University of Cape Town, Cape Town, South Africa.
Dan J
DJ
Stein
Department of Health Care Policy (VS, EDH, MP, RCK), Harvard Medical School, Boston, Massachusetts.
Eric D
ED
Hill
Department of Health Care Policy (VS, EDH, MP, RCK), Harvard Medical School, Boston, Massachusetts.
Maria
M
Petukhova
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.
Jordi
J
Alonso
Section of Psychiatric Epidemiology-LIM 23 (LHA), Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil.
Laura Helena
LH
Andrade
Center for Public Mental Health (MCA), Gösing am Wagram, Austria.
Matthias C
MC
Angermeyer
Department of Epidemiological Research (GB), Division of Epidemiological and Psychosocial Research, National Institute of Psychiatry (Mexico) & Metropolitan Autonomous University, Mexico City, Mexico.
Guilherme
G
Borges
Istituto di Ricovero e Cura a Carattere Scientifico, Centro S. Giovanni di Dio Fatebenefratelli (GdG), Brescia, Italy.
Giovanni
G
de Girolamo
Netherlands Institute of Mental Health and Addiction (RdG), Utrecht, The Netherlands.
Ron
R
de Graaf
Department of Psychiatry (KD), University Hospital Gasthuisberg, Leuven, Belgium.
Koen
K
Demyttenaere
Health Services Research and Evaluation Center (SEF), Bulgarian Center for Human Relations, National School of Public Health Management and Professional Development, Bucharest, Romania.
Silvia E
SE
Florescu
New Bulgarian University (MM), Sofia, Bulgaria.
Maya
M
Mladenova
Department of Psychiatry (JP-V), Universidad Colegio Mayor de Cundinamarca, Bogota, Colombia.
Jose
J
Posada-Villa
Department of Psychological Medicine (KMS), Otago University, Dunedin, New Zealand.
Kate M
KM
Scott
National Institute of Mental Health (TT), National Center of Neurology and Psychiatry, Ogawa-Higashi, Kodaira, Tokyo, Japan.
Tadashi
T
Takeshima
Department of Health Care Policy (VS, EDH, MP, RCK), Harvard Medical School, Boston, Massachusetts. Electronic address: Kessler@hcp.med.harvard.edu.
Ronald C
RC
Kessler
D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006306:Health Surveys; D006801:Humans; D008297:Male; D008603:Mental Health; D015995:Prevalence; D012720:Severity of Illness Index; D013313:Stress Disorders, Post-Traumatic / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology*; D014944:World Health Organization
Epidemiology; Nosology; PTSD; Partial PTSD; Posttraumatic stress disorder; Subthreshold PTSD