The stressor Criterion-A1 and PTSD: A matter of opinion?

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Abstract

Considerable controversy exists with regard to the interpretation and definition of the stressor “A1” criterion for Post Traumatic Stress Disorder (PTSD). At present, classifying an event as either traumatic (satisfying DSM-IV Criterion-A1 for PTSD), or non-traumatic (life event) is determined by the rater's subjective interpretation of the diagnostic criteria. This has implications in research and clinical practice. Utilizing a sample of 860 Australian adults, this study is the first to provide a detailed examination of the impact of event categorization on the prevalence of trauma and PTSD. Overall, events classified as non-traumatic were associated with higher rates of PTSD. Unanimous agreement between raters occurred for 683 (79.4%) events. As predicted, the categorization method employed (single rater, multiple rater-majority, multiple rater-unanimous) substantially altered the prevalence of Criterion-A1 events and PTSD, raising doubts about the functionality of PTSD diagnostic criteria. Factors impacting on the categorization process and suggestions for minimizing discrepancies in future research are discussed.

Introduction

Post Traumatic Stress Disorder (PTSD) is unusual in psychiatric nomenclature because the aetiological agent, namely the traumatic stressor, is defined within the diagnostic criteria implying a direct casual link between a definable external factor and consecutive symptoms (Maier, 2006). Since definition of stress disorder in DSM-III (American Psychiatric Association, 1980), the effects of traumatic stress have been widely researched. However, the definition of the boundaries of the stressor “A1” criterion has emerged as one of the most controversial aspects of the diagnostic criteria (Breslau & Davis, 1987; March, 1993; Solomon & Canino, 1990; Spitzer, First, & Wakefield, 2007). For example, according to DSM-IV (American Psychiatric Association, 1994) to qualify as a traumatic event such an event should involve “actual or threatened death or serious injury, or threat to the physical integrity of self or others” (p. 427). In contrast, ICD-10 (World Health Organization, 1992) defines a traumatic event as being an event “of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone” (p. 147). The lack of clarity and vagueness of the Criterion-A1 language has consequently lead to an over-application of the construct of ‘trauma’ resulting in what McNally has termed a “conceptual bracket creep” (McNally, 2003, Spitzer et al., 2007), resulting in the abuse of this diagnosis in real life settings (Rosen & Taylor, 2007).

Considerable debate exists about whether or not events that typically do not meet Criterion-A1 (referred to as life events, non-traumatic events or low magnitude events) can result in the development of PTSD (Avina & O’Donohue, 2002; Gold, Marx, Soler-Baillo, & Sloan, 2005; McNally, 2003). It is implied in DSM-IV that an extremely traumatic event has a unique etiological effect in comparison to less dramatic life events and that there is a quantitatively and qualitatively different relationship between these two types of events and consequent psychopathology (Lindy, Green, & Grace, 1987). If this is the case, then while a person who has experienced a “life event” may describe this event as “traumatic,” a diagnosis of PTSD generally cannot be given if that event does not meet DSM-IV PTSD Criterion-A1. In the absence of sufficient evidence to support a diagnosis of PTSD, adjustment disorder would become the relevant diagnosis, as this disorder requires an identifiable stressor of any severity. The real conundrum, therefore, is how do we define a stressor as “traumatic” without relying on our own subjective interpretation of the definition of Criterion-A1 and, if PTSD symptoms occur in response to life events, should Criterion-A1 be widened to incorporate such stressors (Avina & O’Donohue, 2002; Gold et al., 2005)?

A number of cases have been reported whereby PTSD symptoms have been experienced as a result of traditionally defined “non-traumatic” or “life events.” For example, in response to miscarriage, spousal affair (Helzer, Robins, & McEvoy, 1987), marital disruption and collapse of adoption arrangements (Burstein, 1985), non-serious nor life-threatening physical assault (Seidler & Wagner, 2006), work-related stressors, caring for a chronically ill loved one (Scott & Stradling, 1994), and loss of cattle due to foot and mouth disease (Olff, Koeter, Van Haaften, Kersten, & Gersons, 2005).

Inconsistent findings, however, have been reported in studies comparing PTSD prevalence rates following Criterion-A1 and other non-traumatic life events. Kilpatrick et al. (1998) examined prevalence of PTSD in a sample who had experienced no event, a “low magnitude event” (non-traumatic life event) or a “high magnitude event” (Criterion-A1 event) and found only a minimal increase in overall PTSD prevalence when broadening the A1 criterion to include low magnitude events such as the non-violent death of a loved one, serious illness and sudden divorce. In a similar study, Hovens and Van der Ploeg (1993) found no significant differences between the non-traumatic life event and no event groups on self-reported PTSD scores using both the MMPI-PTSD and the Mississippi PTSD scale for civilians (Keane, Caddell, & Taylor, 1988; Keane, Malloy, & Fairbank, 1984), but significantly higher PTSD scores in those classified as experiencing a Criterion-A1 event.

In contrast, most other studies have reported similar or greater mean PTSD scores and/or PTSD prevalence in individuals reporting non-traumatic life events compared to those who report Criterion-A1 events (Bodkin, Pope, Detke, & Hudson, 2007; Gold et al., 2005, Mol et al., 2005; Solomon & Canino, 1990; Spitzer et al., 2000).

In general, studies examining the prevalence of Criterion-A1 events and PTSD utilize one of three methods of categorization; (1) a single rater determines whether an event meets Criterion-A1 according to his/her interpretation of the definition specified in ICD-10 or DSM-IV (Roemer, Orsillo, Borkovec, & Litz, 1998); (2) multiple raters independently rate the event with majority agreement being required before an event is categorized as meeting Criterion-A1 according to the definition specified in ICD-10 or DSM-IV (Hovens & Van der Ploeg, 1993); (3) multiple raters independently rate events with unanimous agreement being required before an event is categorized as meeting Criterion-A1 according to the definition specified in ICD-10 or DSM-IV (Bodkin et al., 2007). Other studies appear to use multiple raters, who discuss and reach a consensus as a group as to which events meet Criterion-A1 according to the definition specified in ICD-10 or DSM-IV (Gold et al., 2005; Goodman, Corcoran, Turner, Yuan, & Green, 1998).

One problem inherent in both the single and multiple rater categorization systems is the level of subjectively required on behalf of the raters to interpret Criterion-A1. The use of multiple raters (rather than a single rater) is an attempt to reduce such subjectivity. However, further discrepancies then arise according to which method of agreement is employed—majority or unanimous. This dilemma is illustrated in a study of 27 psychiatric inpatients conducted by Hovens and Van der Ploeg (1993). Using a majority method of scoring, 5 raters categorized 15 events as meeting DSM-IV Criterion-A1. In contrast however, only 1 event was unanimously agreed upon by all 5 raters as meeting DSM-IV Criterion-A1. Such discrepancy in prevalence of Criterion-A1 events between the unanimous and majority coding methods highlights the need to consolidate the methods of event categorization across studies. Although the unanimous method of classification in this instance may reduce categorization discrepancies, it also has the potential to lower PTSD prevalence rates due to the lower overall prevalence of Criterion-A1 events. The impact of categorization differences is somewhat overlooked in research into PTSD resulting from Criterion-A1 and non-traumatic life events, but could account for some of the discrepancies that have emerged in the literature.

The current study is the first to provide a detailed examination of the impact of event categorization on the prevalence rates of trauma and PTSD. There are three primary aims of this study. First, to explore in detail the types of events that lead to the most disagreement among raters. Second, to provide a descriptive account of whether the prevalence of Criterion-A1 events and non-traumatic life events differs according to the categorization method employed (single rater, multiple raters—majority method, multiple raters—unanimous method). Third, to statistically examine the subsequent differences in lifetime PTSD prevalence resulting from Criterion-A1 events and non-traumatic life events, and to determine whether PTSD prevalence also differs according to the type of categorization method used.

Section snippets

Participants

Participants were part of a larger longitudinal study examining the psychiatric outcomes of childhood exposure to a natural disaster. The original cohort, recruited from 1983 to 1985, comprised 806 children aged between 5 and 12 years who were attending primary school in a rural region of South Australia, vastly devastated by the 1983 Ash Wednesday Bushfires (McFarlane, 1987b; McFarlane, Policansky, & Irwin, 1987). A control group of 725 unexposed primary school children from a

Categorization of traumatic and non-traumatic events

Overall, unanimous agreement occurred for 683 (79.4%) events. The greatest level of agreement between raters occurred for events that were witnessed (88.7%), followed by events that happened to self (84.9%), and then events that were learnt about (63.1%). Specific event types associated with the highest level of disagreement included: being threatened/harassed without a weapon (unanimous agreement on only 34.2% of occasions), child physical abuse (66.7%), and events that were learnt about but

Discussion

This study is the first published report detailing the impact of event categorization on the prevalence rates of trauma and PTSD. The first aim of the study was to explore the types of events that lead to the highest level of disagreement among raters. Overall, complete agreement between the three raters was attained for 79.4% of the events. This is slightly lower than the level of agreement (87%: 90 out of 103) between two raters reported in a study by Bodkin et al. (2007) but higher than the

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