Reformulating PTSD for DSM-V: Life after Criterion A
The diagnosis of posttraumatic stress disorder has been criticized on numerous grounds, but principally for three reasons
(a) the alleged pathologizing of normal events, (b) the inadequacy of Criterion A, and (c) symptom overlap with other
disorders. A proposal for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is put
forward that involves abolishing Criterion A, narrowing the B criteria to focus on the core phenomena of flashbacks and
nightmares, and narrowing the C and D criteria to reduce overlap with other disorders.
The idea of a disorder such as PTSS that could be explained entirely by an environmental event rather than by the
characteristics of a person or their interaction, was in marked contrast to other disorders in the DSM and was immediately
controversial. It soon became clear, however, that traumatic events were much more prevalent than had been assumed,
and that typically only a minority of individuals developed PTSD afterwards, facts that fundamentally challenged the
conceptual basis of the disorder.
Criticisms
1. PTSD pathologizes normal distress
a. Reactions to extreme stress are time-limited, and that PTSD symptoms will resolve naturally of their own
accord with no lasting harm to the person.
- Studies show that extreme stress sometimes leads to severe and long-lasting psychopathology,
as well as to a variety of serious medical conditions
b. ‘Symptoms’ of PTSD are ubiquitous reactions to stressful events found in people suffering from normal
distress
- Raises the question what normal is, this has not yet been answered
c. PTSD is not biologically distinguishable from normal distress
- PTSD is distinguishable from other anxiety disorders and depression
2. Inadequacy of criterion A
a. Other disorders are linked to traumatic (criterion A) events
- The existence of criterion A implies a unique relationship between trauma and PTSD, however,
trauma is associated with depression, GAD, panic disorder and substance use too. Despite this,
there is considerable evidence that these events do not increase the risk for other disorders
independently of the increased risk for PTSD, suggesting that PTSD does indeed play a central
role in the psychological response to trauma.
b. Insufficient specificity of criterion A
- Originally, PTSD was tied to rare, extreme events but has since been expanded to include
indirect trauma exposure. Critics argue this "criterion creep" has diluted the concept, associating
PTSD with non-Criterion A events such as divorces, financial stress, or even frightening media.
However, research shows most such cases don't meet full PTSD diagnostic criteria. Variability in
stress reactivity underscores that some "insufficient" events might still provoke PTSD in highly
susceptible individuals.
c. Excessive specificity of criterion A
- The passage critiques the DSM-IV's Criterion A2 for PTSD, which requires individuals to have
responded to a traumatic event with intense fear, helplessness, or horror. Research suggests that
PTSD can develop even without these specific reactions. The assumption that initial
trauma-related emotions remain stable over time is
questioned, as psychological and biological evidence
indicates that trauma-related memories and emotions can
change, making A2 overly restrictive.
3. Symptom overlap with other disorders
- The passage critiques PTSD's diagnostic criteria for overlapping with
other disorders like depression and anxiety. Many PTSD symptoms,
such as intrusive thoughts, avoidance, emotional numbing, and
hyperarousal, are not unique to PTSD, raising concerns about
diagnostic specificity. Dysphoria symptoms, common in depression,
contribute to this overlap, and the broadened Criterion A1 may
inflate PTSD rates by misclassifying grief-related conditions.
- However, two symptoms—flashbacks and posttraumatic
nightmares—are distinctive to PTSD. Flashbacks involve vivid,
multisensory reliving of trauma without temporal context, while
nightmares occur in up to 70% of sufferers and differ from other
sleep disturbances.
,The writers propose that the way forward for the PTSD diagnosis is to abolish Criterion A and refocus PTSD around a
smaller set of core symptoms. It is highly unlikely that any formulation for criterion A will be found that deals with all the
problems and inconsistencies that have been identified. Additionally, due to individual differences in sensitization and
vulnerability, specifying triggering events is not just difficult, but undesirable. Criterion A could be weakened until any
event would qualify, but the writers think the criterion would be better dispensed altogether. Criterion A simply describes
the usual context of PTSD without contributing itself to diagnostic precision. The writers believe that Criterion A can be
substituted by the presence or absence of a set of core symptoms. There is evidence that screening measures with a few
as 4 to 6 items perform as well as 17 items in detecting PSTD. Our proposal is that PTSD should be refocused around the
core phenomenon of re-experiencing in the present, in the form of intrusive multisensory images accompanied by marked
fear or horror, an event now perceived as having severely threatened a person’s physical or psychological well-being. The
intention is to highlight the features that are most salient to the individual with PTSD, that are the primary focus of
psychological treatment, and that make PTSD distinct from other anxiety disorders and from depression.
Abolishing Criterion A for PTSD would align it with other psychiatric disorders, removing the need to determine if an event
qualifies as trauma or to rely on retrospective reports of past emotions. This change would account for individual
vulnerability, professional training, and shifting perceptions over time, ensuring those affected by distressing events aren’t
disqualified from diagnosis. Clinicians could focus on symptoms and appropriate treatment without concerns about
restrictive trauma definitions, reducing the risk of neglecting the treatment needs of those with PTSD-like symptoms.
However, the two main objections to abolishing Criterion A for PTSD are departure from original conceptualization and
risk of trivializing suffering. Critics argue this change strays from PTSD's original framework, which emphasized the role of
traumatic events. Proponents counter that new research shows trauma interacts with individual risk factors, and the
definition should evolve accordingly. There is concern that removing Criterion A might diminish the perceived severity of
catastrophic events. Proponents argue such events will still be strongly associated with PTSD through reexperiencing
symptoms, while removing the criterion allows for recognizing other outcomes like depression, anxiety, or substance
abuse.
Advantages of Focusing on Core Symptoms:
- Simplified Diagnosis: Easier identification in non-specialist settings.
- Greater Homogeneity: Excluding dysphoria-related symptoms reduces overlap with other disorders.
- Flexibility: Clinicians can identify reexperiencing even in highly avoidant patients through trauma descriptions.
- Research Alignment: Focus on fear and horror links PTSD diagnosis with psychological and neuroscience
research.
Disadvantages of Focusing on Core Symptoms:
- Debate Over Core Features: Disagreement exists about whether avoidance, numbing, or reexperiencing is most
central to PTSD.
- Overlap with Depression: Numbing symptoms, argued by some as core, overlap significantly with depression,
reducing PTSD specificity.
- Unclear Mechanisms: The distinction between effortful avoidance and emotional numbing remains unresolved,
complicating theoretical understanding.
Predictors of PSTD and symptoms in adults: a meta-analysis
Seven predictors stood out:
1. Prior trauma
2. Prior psychological adjustment
3. Family history of psychopathology
4. Perceived life threat during the trauma
5. Posttrauma social support
6. Peritraumatic emotional responses
7. Peritraumatic dissociation
All yielded significant effect sizes, with family history, prior trauma, and prior adjustment the smallest (weighted r = .17)
and peritraumatic dissociation the largest (weighted r = .35). The results suggest that peritraumatic psychological
processes, not prior characteristics, are the strongest predictors of PTSD.
In 1980, PTSD was formally recognized in the DSM-III, consolidating previously separate syndromes. Neurobiological
models, emphasizing roles for the amygdala, hippocampus, and the hypothalamic–pituitary–adrenal (HPA) axis, have
since clarified how high adrenergic arousal during trauma influences memory formation and the persistence of symptoms.
The recognition of acute stress disorder (ASD) in the DSM-IV addressed short-term trauma reactions.
,However, ASD does not reliably predict chronic PTSD, although dissociative phenomena during or shortly after trauma
may serve as indicators.
Prevalence
The National Vietnam Veterans Readjustment Study (NVVRS) found that 30.9% of male and 26.0% of female Vietnam
veterans met lifetime PTSD criteria, with current prevalence at 15.2% for men and 8.5% for women. Among civilians,
lifetime PTSD prevalence rates vary. The National Comorbidity Study (NCS) reported 7.8%, with women twice as likely as
men to develop PTSD (10.4% vs. 5.0%). Other studies found rates of 9.2% among urban adults and 12.3% among
women nationally. Immigrants and refugees, especially those fleeing war or repression, exhibit even higher rates—52% in
Central American refugees and substantial rates in Cambodian refugees. Data showed 60%-70% of people experience
qualifying traumatic events, but only 7%-10% develop PTSD, leading to the DSM-IV revision emphasizing intense
emotional responses (e.g., fear or helplessness) over event rarity.
The present meta-analysis, informed by Brewin et al.’s findings, narrowed its focus to non-demographic predictors related
to psychological processing and traumatic event characteristics. It excluded demographic variables like gender and
ethnicity due to their weak predictive value and limited relevance to trauma processing. Seven predictors were selected
based on sufficient empirical research: (1) prior trauma, (2) pre-trauma psychological adjustment, (3) family
psychopathology, (4) perceived life threat, (5) social support, (6) peritraumatic emotionality, and (7) peritraumatic
dissociation. Factors like comorbid disorders and survivor guilt were excluded due to their retrospective nature or lack of
predictive capacity.
A history of prior trauma was found to have a small but statistically significant relationship with PTSD symptoms or
diagnosis (average r = .17), with stronger associations observed for noncombat interpersonal violence compared to
combat or accidental trauma. The strength of the relationship did not differ according to the type of sample studied.
A history of psychological problems prior to a traumatic event was found to have a small but statistically significant
relationship with increased PTSD symptoms (weighted r = .17), with stronger associations observed for those with prior
depression (r = .32) and for individuals exposed to noncombat interpersonal violence or accidents. The types of prior
adjustment problems associated with increases PTSD symptoms included previous mental health treatment, pretrauma
emotional problems, pretrauma anxiety or affective disorders and antisocial personality disorder prior to military service.
The relationship was also stronger when less time had passed since the traumatic event and in interview-based studies
compared to self-report studies.
A family history of psychopathology was found to have a small but significant relationship with higher PTSD symptoms or
diagnosis (weighted r = .17), with stronger associations observed for individuals exposed to noncombat interpersonal
violence (r = .31) and in interview-based studies (r = .28) compared to self-report studies (r = .04).
Perceived life threat during a traumatic event was significantly associated with higher PTSD symptoms or diagnosis
(weighted r = .26), with stronger effects observed when more time had passed since the event (6 months to 3 years: r =
.44) and in cases of noncombat interpersonal violence (r = .36) compared to accidents (r = .20).
Perceived social support following trauma was inversely associated with PTSD symptoms (weighted r = -.28), with
stronger effects found in studies with longer time intervals between the trauma and PTSD assessment (strongest after
more than 3 years: r = -.42) and in combat trauma studies (r = -.26) compared to noncombat interpersonal violence (r =
-.11).
Peritraumatic emotional responses, such as fear, helplessness, horror, guilt, and shame, were positively correlated with
PTSD symptoms (weighted r = .26), with individuals reporting more intense negative emotions during or immediately after
the trauma experiencing higher levels of PTSD symptoms.
Peritraumatic dissociation, including experiences of dissociation during or immediately after the traumatic event, was
moderately correlated with higher PTSD symptoms (weighted r = .35). This relationship was strongest among individuals
seeking mental health services (r = .60), when 6 months to 3 years had elapsed between the trauma and PTSD
assessment (r = .45), and in studies using self-report measures (r = .48). The relationship did not vary by trauma type but
was weaker in medical and community samples.
, The meta-analysis shows that PTSD symptom responses are not random, with systematic and replicable predictors
emerging despite various challenges in the research. Two types of predictors were identified: distal factors (e.g., prior
adjustment, trauma history, and family psychopathology) with smaller effect sizes (below .20), and more proximal factors
(e.g., perceived life threat, social support, emotional responses, and dissociation) with larger effect sizes (above .20).
While most findings aligned with previous research, social support showed a smaller effect in this study. However, these
predictors explained less than 20% of the variability in PTSD responses, suggesting that unique factors related to the
individual and the traumatic event may be more influential.
The meta-analysis revealed that social support, while previously identified as a strong predictor of PTSD, showed a
smaller effect size (r = .28) compared to Brewin et al.'s (2000) finding (r = .40), with peritraumatic dissociation being the
strongest predictor in this study (r = .35). The strength of the relationship between social support and PTSD symptoms
varied depending on the time elapsed since the trauma, being stronger in studies where PTSD was assessed more than
three years after the event. This suggests that social support may act as a form of secondary prevention or have
cumulative effects over time. Additionally, most studies focused on emotional support, which may aid in psychological
processing of traumatic events, rather than addressing practical needs.
The impact of moderators (type of event, time elapsed since the event, type of sample, and method of assessment) on
the prediction of PTSD symptoms was not consistent across all predictors. The type of event was the most significant
moderator. Time elapsed since the event was a significant moderator for four predictors, but the results were mixed: for
life threat and peritraumatic dissociation, the effect was stronger when 6 months to 3 years had passed, while prior
adjustment and social support showed different patterns. Method of assessment (interviews vs. self-report) also had an
impact, with interviews yielding stronger effects for two predictors, but the overall significance of this finding is unclear.
Despite these findings, the moderation of PTSD prediction was not consistently strong across all analyses.
The meta-analysis highlights the issue of assuming homogeneity in traumatic events when analyzing their impact on
PTSD, which may oversimplify the complexity of different types of trauma. For instance, prior trauma is often treated as a
uniform predictor, but various aspects of trauma, such as its lethality, repetition, timing, and the individual’s developmental
stage, can significantly influence PTSD outcomes. These differences are often overlooked in studies that aim to predict
PTSD. The analysis suggests that a more nuanced understanding of PTSD is needed, focusing less on the pre-existing
conditions or the specific nature of traumatic events, and more on the consequences of exposure, particularly the chronic
and fluctuating nature of PTSD. The study also notes that diagnostic methods may bias results: individuals in partial
remission may be underrepresented in studies using diagnostic criteria, while symptom measures may provide a more
accurate reflection of PTSD severity.
Peritraumatic dissociation (dissociation during or immediately after trauma) emerged as a strong predictor of PTSD. The
psychological experience during trauma—how an individual appraises and reacts to it—may be just as important as static
factors like prior trauma or family history. This supports the idea that acute stress disorder (ASD) might precede PTSD in
some cases, particularly after severe events. However, not everyone with PTSD experiences dissociation, suggesting it's
not a universal feature of the disorder.
The relationship between peritraumatic dissociation and the physiological response to trauma, such as arousal levels,
requires more research. Brain structures like the amygdala and hippocampus, involved in PTSD, may play a role in how
individuals process trauma, but it's unclear if these changes are due to the trauma itself or preexisting vulnerabilities.
The study also discusses challenges in measuring peritraumatic dissociation in real-time, as it is typically assessed
retrospectively. Further studies are needed to understand how dissociative experiences during trauma contribute to PTSD
symptoms, considering the severity of the traumatic event and how dissociation relates to physiological arousal. In
summary, the psychological response to trauma, especially dissociation, is a key factor in predicting PTSD, and future
research should explore its complex relationship with other symptoms and underlying brain mechanisms.
Lecture 1
“A life-threatening illness or debilitating medical condition is not necessarily considered a
traumatic event. Medical incidents that qualify as traumatic events involve sudden, catastrophic
events (e.g., waking during surgery, anaphylactic shock).” - not corona
Criticism that part A of DSM is too limited to certain events, and that the disorder is too focused on
cause.
The diagnosis of posttraumatic stress disorder has been criticized on numerous grounds, but principally for three reasons
(a) the alleged pathologizing of normal events, (b) the inadequacy of Criterion A, and (c) symptom overlap with other
disorders. A proposal for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is put
forward that involves abolishing Criterion A, narrowing the B criteria to focus on the core phenomena of flashbacks and
nightmares, and narrowing the C and D criteria to reduce overlap with other disorders.
The idea of a disorder such as PTSS that could be explained entirely by an environmental event rather than by the
characteristics of a person or their interaction, was in marked contrast to other disorders in the DSM and was immediately
controversial. It soon became clear, however, that traumatic events were much more prevalent than had been assumed,
and that typically only a minority of individuals developed PTSD afterwards, facts that fundamentally challenged the
conceptual basis of the disorder.
Criticisms
1. PTSD pathologizes normal distress
a. Reactions to extreme stress are time-limited, and that PTSD symptoms will resolve naturally of their own
accord with no lasting harm to the person.
- Studies show that extreme stress sometimes leads to severe and long-lasting psychopathology,
as well as to a variety of serious medical conditions
b. ‘Symptoms’ of PTSD are ubiquitous reactions to stressful events found in people suffering from normal
distress
- Raises the question what normal is, this has not yet been answered
c. PTSD is not biologically distinguishable from normal distress
- PTSD is distinguishable from other anxiety disorders and depression
2. Inadequacy of criterion A
a. Other disorders are linked to traumatic (criterion A) events
- The existence of criterion A implies a unique relationship between trauma and PTSD, however,
trauma is associated with depression, GAD, panic disorder and substance use too. Despite this,
there is considerable evidence that these events do not increase the risk for other disorders
independently of the increased risk for PTSD, suggesting that PTSD does indeed play a central
role in the psychological response to trauma.
b. Insufficient specificity of criterion A
- Originally, PTSD was tied to rare, extreme events but has since been expanded to include
indirect trauma exposure. Critics argue this "criterion creep" has diluted the concept, associating
PTSD with non-Criterion A events such as divorces, financial stress, or even frightening media.
However, research shows most such cases don't meet full PTSD diagnostic criteria. Variability in
stress reactivity underscores that some "insufficient" events might still provoke PTSD in highly
susceptible individuals.
c. Excessive specificity of criterion A
- The passage critiques the DSM-IV's Criterion A2 for PTSD, which requires individuals to have
responded to a traumatic event with intense fear, helplessness, or horror. Research suggests that
PTSD can develop even without these specific reactions. The assumption that initial
trauma-related emotions remain stable over time is
questioned, as psychological and biological evidence
indicates that trauma-related memories and emotions can
change, making A2 overly restrictive.
3. Symptom overlap with other disorders
- The passage critiques PTSD's diagnostic criteria for overlapping with
other disorders like depression and anxiety. Many PTSD symptoms,
such as intrusive thoughts, avoidance, emotional numbing, and
hyperarousal, are not unique to PTSD, raising concerns about
diagnostic specificity. Dysphoria symptoms, common in depression,
contribute to this overlap, and the broadened Criterion A1 may
inflate PTSD rates by misclassifying grief-related conditions.
- However, two symptoms—flashbacks and posttraumatic
nightmares—are distinctive to PTSD. Flashbacks involve vivid,
multisensory reliving of trauma without temporal context, while
nightmares occur in up to 70% of sufferers and differ from other
sleep disturbances.
,The writers propose that the way forward for the PTSD diagnosis is to abolish Criterion A and refocus PTSD around a
smaller set of core symptoms. It is highly unlikely that any formulation for criterion A will be found that deals with all the
problems and inconsistencies that have been identified. Additionally, due to individual differences in sensitization and
vulnerability, specifying triggering events is not just difficult, but undesirable. Criterion A could be weakened until any
event would qualify, but the writers think the criterion would be better dispensed altogether. Criterion A simply describes
the usual context of PTSD without contributing itself to diagnostic precision. The writers believe that Criterion A can be
substituted by the presence or absence of a set of core symptoms. There is evidence that screening measures with a few
as 4 to 6 items perform as well as 17 items in detecting PSTD. Our proposal is that PTSD should be refocused around the
core phenomenon of re-experiencing in the present, in the form of intrusive multisensory images accompanied by marked
fear or horror, an event now perceived as having severely threatened a person’s physical or psychological well-being. The
intention is to highlight the features that are most salient to the individual with PTSD, that are the primary focus of
psychological treatment, and that make PTSD distinct from other anxiety disorders and from depression.
Abolishing Criterion A for PTSD would align it with other psychiatric disorders, removing the need to determine if an event
qualifies as trauma or to rely on retrospective reports of past emotions. This change would account for individual
vulnerability, professional training, and shifting perceptions over time, ensuring those affected by distressing events aren’t
disqualified from diagnosis. Clinicians could focus on symptoms and appropriate treatment without concerns about
restrictive trauma definitions, reducing the risk of neglecting the treatment needs of those with PTSD-like symptoms.
However, the two main objections to abolishing Criterion A for PTSD are departure from original conceptualization and
risk of trivializing suffering. Critics argue this change strays from PTSD's original framework, which emphasized the role of
traumatic events. Proponents counter that new research shows trauma interacts with individual risk factors, and the
definition should evolve accordingly. There is concern that removing Criterion A might diminish the perceived severity of
catastrophic events. Proponents argue such events will still be strongly associated with PTSD through reexperiencing
symptoms, while removing the criterion allows for recognizing other outcomes like depression, anxiety, or substance
abuse.
Advantages of Focusing on Core Symptoms:
- Simplified Diagnosis: Easier identification in non-specialist settings.
- Greater Homogeneity: Excluding dysphoria-related symptoms reduces overlap with other disorders.
- Flexibility: Clinicians can identify reexperiencing even in highly avoidant patients through trauma descriptions.
- Research Alignment: Focus on fear and horror links PTSD diagnosis with psychological and neuroscience
research.
Disadvantages of Focusing on Core Symptoms:
- Debate Over Core Features: Disagreement exists about whether avoidance, numbing, or reexperiencing is most
central to PTSD.
- Overlap with Depression: Numbing symptoms, argued by some as core, overlap significantly with depression,
reducing PTSD specificity.
- Unclear Mechanisms: The distinction between effortful avoidance and emotional numbing remains unresolved,
complicating theoretical understanding.
Predictors of PSTD and symptoms in adults: a meta-analysis
Seven predictors stood out:
1. Prior trauma
2. Prior psychological adjustment
3. Family history of psychopathology
4. Perceived life threat during the trauma
5. Posttrauma social support
6. Peritraumatic emotional responses
7. Peritraumatic dissociation
All yielded significant effect sizes, with family history, prior trauma, and prior adjustment the smallest (weighted r = .17)
and peritraumatic dissociation the largest (weighted r = .35). The results suggest that peritraumatic psychological
processes, not prior characteristics, are the strongest predictors of PTSD.
In 1980, PTSD was formally recognized in the DSM-III, consolidating previously separate syndromes. Neurobiological
models, emphasizing roles for the amygdala, hippocampus, and the hypothalamic–pituitary–adrenal (HPA) axis, have
since clarified how high adrenergic arousal during trauma influences memory formation and the persistence of symptoms.
The recognition of acute stress disorder (ASD) in the DSM-IV addressed short-term trauma reactions.
,However, ASD does not reliably predict chronic PTSD, although dissociative phenomena during or shortly after trauma
may serve as indicators.
Prevalence
The National Vietnam Veterans Readjustment Study (NVVRS) found that 30.9% of male and 26.0% of female Vietnam
veterans met lifetime PTSD criteria, with current prevalence at 15.2% for men and 8.5% for women. Among civilians,
lifetime PTSD prevalence rates vary. The National Comorbidity Study (NCS) reported 7.8%, with women twice as likely as
men to develop PTSD (10.4% vs. 5.0%). Other studies found rates of 9.2% among urban adults and 12.3% among
women nationally. Immigrants and refugees, especially those fleeing war or repression, exhibit even higher rates—52% in
Central American refugees and substantial rates in Cambodian refugees. Data showed 60%-70% of people experience
qualifying traumatic events, but only 7%-10% develop PTSD, leading to the DSM-IV revision emphasizing intense
emotional responses (e.g., fear or helplessness) over event rarity.
The present meta-analysis, informed by Brewin et al.’s findings, narrowed its focus to non-demographic predictors related
to psychological processing and traumatic event characteristics. It excluded demographic variables like gender and
ethnicity due to their weak predictive value and limited relevance to trauma processing. Seven predictors were selected
based on sufficient empirical research: (1) prior trauma, (2) pre-trauma psychological adjustment, (3) family
psychopathology, (4) perceived life threat, (5) social support, (6) peritraumatic emotionality, and (7) peritraumatic
dissociation. Factors like comorbid disorders and survivor guilt were excluded due to their retrospective nature or lack of
predictive capacity.
A history of prior trauma was found to have a small but statistically significant relationship with PTSD symptoms or
diagnosis (average r = .17), with stronger associations observed for noncombat interpersonal violence compared to
combat or accidental trauma. The strength of the relationship did not differ according to the type of sample studied.
A history of psychological problems prior to a traumatic event was found to have a small but statistically significant
relationship with increased PTSD symptoms (weighted r = .17), with stronger associations observed for those with prior
depression (r = .32) and for individuals exposed to noncombat interpersonal violence or accidents. The types of prior
adjustment problems associated with increases PTSD symptoms included previous mental health treatment, pretrauma
emotional problems, pretrauma anxiety or affective disorders and antisocial personality disorder prior to military service.
The relationship was also stronger when less time had passed since the traumatic event and in interview-based studies
compared to self-report studies.
A family history of psychopathology was found to have a small but significant relationship with higher PTSD symptoms or
diagnosis (weighted r = .17), with stronger associations observed for individuals exposed to noncombat interpersonal
violence (r = .31) and in interview-based studies (r = .28) compared to self-report studies (r = .04).
Perceived life threat during a traumatic event was significantly associated with higher PTSD symptoms or diagnosis
(weighted r = .26), with stronger effects observed when more time had passed since the event (6 months to 3 years: r =
.44) and in cases of noncombat interpersonal violence (r = .36) compared to accidents (r = .20).
Perceived social support following trauma was inversely associated with PTSD symptoms (weighted r = -.28), with
stronger effects found in studies with longer time intervals between the trauma and PTSD assessment (strongest after
more than 3 years: r = -.42) and in combat trauma studies (r = -.26) compared to noncombat interpersonal violence (r =
-.11).
Peritraumatic emotional responses, such as fear, helplessness, horror, guilt, and shame, were positively correlated with
PTSD symptoms (weighted r = .26), with individuals reporting more intense negative emotions during or immediately after
the trauma experiencing higher levels of PTSD symptoms.
Peritraumatic dissociation, including experiences of dissociation during or immediately after the traumatic event, was
moderately correlated with higher PTSD symptoms (weighted r = .35). This relationship was strongest among individuals
seeking mental health services (r = .60), when 6 months to 3 years had elapsed between the trauma and PTSD
assessment (r = .45), and in studies using self-report measures (r = .48). The relationship did not vary by trauma type but
was weaker in medical and community samples.
, The meta-analysis shows that PTSD symptom responses are not random, with systematic and replicable predictors
emerging despite various challenges in the research. Two types of predictors were identified: distal factors (e.g., prior
adjustment, trauma history, and family psychopathology) with smaller effect sizes (below .20), and more proximal factors
(e.g., perceived life threat, social support, emotional responses, and dissociation) with larger effect sizes (above .20).
While most findings aligned with previous research, social support showed a smaller effect in this study. However, these
predictors explained less than 20% of the variability in PTSD responses, suggesting that unique factors related to the
individual and the traumatic event may be more influential.
The meta-analysis revealed that social support, while previously identified as a strong predictor of PTSD, showed a
smaller effect size (r = .28) compared to Brewin et al.'s (2000) finding (r = .40), with peritraumatic dissociation being the
strongest predictor in this study (r = .35). The strength of the relationship between social support and PTSD symptoms
varied depending on the time elapsed since the trauma, being stronger in studies where PTSD was assessed more than
three years after the event. This suggests that social support may act as a form of secondary prevention or have
cumulative effects over time. Additionally, most studies focused on emotional support, which may aid in psychological
processing of traumatic events, rather than addressing practical needs.
The impact of moderators (type of event, time elapsed since the event, type of sample, and method of assessment) on
the prediction of PTSD symptoms was not consistent across all predictors. The type of event was the most significant
moderator. Time elapsed since the event was a significant moderator for four predictors, but the results were mixed: for
life threat and peritraumatic dissociation, the effect was stronger when 6 months to 3 years had passed, while prior
adjustment and social support showed different patterns. Method of assessment (interviews vs. self-report) also had an
impact, with interviews yielding stronger effects for two predictors, but the overall significance of this finding is unclear.
Despite these findings, the moderation of PTSD prediction was not consistently strong across all analyses.
The meta-analysis highlights the issue of assuming homogeneity in traumatic events when analyzing their impact on
PTSD, which may oversimplify the complexity of different types of trauma. For instance, prior trauma is often treated as a
uniform predictor, but various aspects of trauma, such as its lethality, repetition, timing, and the individual’s developmental
stage, can significantly influence PTSD outcomes. These differences are often overlooked in studies that aim to predict
PTSD. The analysis suggests that a more nuanced understanding of PTSD is needed, focusing less on the pre-existing
conditions or the specific nature of traumatic events, and more on the consequences of exposure, particularly the chronic
and fluctuating nature of PTSD. The study also notes that diagnostic methods may bias results: individuals in partial
remission may be underrepresented in studies using diagnostic criteria, while symptom measures may provide a more
accurate reflection of PTSD severity.
Peritraumatic dissociation (dissociation during or immediately after trauma) emerged as a strong predictor of PTSD. The
psychological experience during trauma—how an individual appraises and reacts to it—may be just as important as static
factors like prior trauma or family history. This supports the idea that acute stress disorder (ASD) might precede PTSD in
some cases, particularly after severe events. However, not everyone with PTSD experiences dissociation, suggesting it's
not a universal feature of the disorder.
The relationship between peritraumatic dissociation and the physiological response to trauma, such as arousal levels,
requires more research. Brain structures like the amygdala and hippocampus, involved in PTSD, may play a role in how
individuals process trauma, but it's unclear if these changes are due to the trauma itself or preexisting vulnerabilities.
The study also discusses challenges in measuring peritraumatic dissociation in real-time, as it is typically assessed
retrospectively. Further studies are needed to understand how dissociative experiences during trauma contribute to PTSD
symptoms, considering the severity of the traumatic event and how dissociation relates to physiological arousal. In
summary, the psychological response to trauma, especially dissociation, is a key factor in predicting PTSD, and future
research should explore its complex relationship with other symptoms and underlying brain mechanisms.
Lecture 1
“A life-threatening illness or debilitating medical condition is not necessarily considered a
traumatic event. Medical incidents that qualify as traumatic events involve sudden, catastrophic
events (e.g., waking during surgery, anaphylactic shock).” - not corona
Criticism that part A of DSM is too limited to certain events, and that the disorder is too focused on
cause.
