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Original Investigation
March 2017

Association of DSM-IV Posttraumatic Stress Disorder With Traumatic Experience Type and History in the World Health Organization World Mental Health Surveys

Author Affiliations
  • 1Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 2Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 3Center for Reducing Health Disparities, University of California, Davis, Health System, Sacramento
  • 4Hospital del Mar Research Institute, Parc de Salut Mar, Pompeu Fabra University, Barcelona, Spain
  • 5Group 9/Program 06–Evaluation of Health Services of Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
  • 6Section of Psychiatric Epidemiology–Laboratórios de Investigação Médica No. 23, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
  • 7Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York
  • 8Istituto di Ricovero e Cura a Carattere Scientifico, Fatebenefratelli, Brescia, Italy
  • 9Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, Centro de Investigación Biomédica en Red de Salud Mental, Universitat de Barcelona, Barcelona, Spain
  • 10National Center for Public Health and Analyses, Ministry of Health, Sofia, Bulgaria
  • 11Department of Mental Health, School of Public Health, University of Tokyo, Tokyo, Japan
  • 12Ecole des Hautes Etudes en Santé Publique, EA 4057, Paris Descartes University, Paris, France
  • 13Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong, China
  • 14Dirección de Investigaciones Epidemiológicas y Psicosociales, National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico
  • 15Servicio Murciano de Investigación y Formación en Salud Mental, Subdirección General de Planificación, Innovación y Cronicidad, Servicio Murciano de Salud, Instituto Murciano de Investigación Biosanitaria–Arrixaca, CIBERESP, Murcia, Spain
  • 16School of Psychology, Ulster University, Londonderry, Northern Ireland
  • 17Facultad de Salud Pública y Administración, Universidad Cayetano Heredia, Lima, Peru
  • 18National Institute of Health, Lima, Peru
  • 19Faculty of Social Sciences, Colegio Mayor de Cundinamarca University, Bogota, Colombia
  • 20Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
  • 21Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, Republic of South Africa
  • 22Trimbos-Instituut, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
  • 23Center for Excellence on Research in Mental Health, CES University, Medellin, Colombia
  • 24Department of Psychiatry, University College Hospital, Ibadan, Nigeria
JAMA Psychiatry. 2017;74(3):270-281. doi:10.1001/jamapsychiatry.2016.3783
Key Points

Question  How does posttraumatic stress disorder prevalence vary by the type of traumatic experience and history of exposure to traumatic experiences?

Findings  In this study of cross-national epidemiologic data from 34 676 respondents, prevalence of posttraumatic stress disorder was elevated after traumatic experiences involving assaultive violence, but only for repeated physical assaults. Repeated exposure to different types of traumatic experiences was associated with resilience or vulnerability, and a more general history of exposure to violence, but not to other traumatic experience types, was associated with generalized vulnerability to posttraumatic stress disorder.

Meaning  These results advance understanding of the complex ways in which specific traumatic experience types and histories are associated with posttraumatic stress disorder.


Importance  Previous research has documented significant variation in the prevalence of posttraumatic stress disorder (PTSD) depending on the type of traumatic experience (TE) and history of TE exposure, but the relatively small sample sizes in these studies resulted in a number of unresolved basic questions.

Objective  To examine disaggregated associations of type of TE history with PTSD in a large cross-national community epidemiologic data set.

Design, Setting, and Participants  The World Health Organization World Mental Health surveys assessed 29 TE types (lifetime exposure, age at first exposure) with DSM-IV PTSD that was associated with 1 randomly selected TE exposure (the random TE) for each respondent. Surveys were administered in 20 countries (n = 34 676 respondents) from 2001 to 2012. Data were analyzed from October 1, 2015, to September 1, 2016.

Main Outcomes and Measures  Prevalence of PTSD assessed with the Composite International Diagnostic Interview.

Results  Among the 34 676 respondents (55.4% [SE, 0.6%] men and 44.6% [SE, 0.6%] women; mean [SE] age, 43.7 [0.2] years), lifetime TE exposure was reported by a weighted 70.3% of respondents (mean [SE] number of exposures, 4.5 [0.04] among respondents with any TE). Weighted (by TE frequency) prevalence of PTSD associated with random TEs was 4.0%. Odds ratios (ORs) of PTSD were elevated for TEs involving sexual violence (2.7; 95% CI, 2.0-3.8) and witnessing atrocities (4.2; 95% CI, 1.0-17.8). Prior exposure to some, but not all, same-type TEs was associated with increased vulnerability (eg, physical assault; OR, 3.2; 95% CI, 1.3-7.9) or resilience (eg, participation in sectarian violence; OR, 0.3; 95% CI, 0.1-0.9) to PTSD after the random TE. The finding of earlier studies that more general history of TE exposure was associated with increased vulnerability to PTSD across the full range of random TE types was replicated, but this generalized vulnerability was limited to prior TEs involving violence, including participation in organized violence (OR, 1.3; 95% CI, 1.0-1.6), experience of physical violence (OR, 1.4; 95% CI, 1.2-1.7), rape (OR, 2.5; 95% CI, 1.7-3.8), and other sexual assault (OR, 1.6; 95% CI, 1.1-2.3).

Conclusion and Relevance  The World Mental Health survey findings advance understanding of the extent to which PTSD risk varies with the type of TE and history of TE exposure. Previous findings about the elevated PTSD risk associated with TEs involving assaultive violence was refined by showing agreement only for repeated occurrences. Some types of prior TE exposures are associated with increased resilience rather than increased vulnerability, connecting the literature on TE history with the literature on resilience after adversity. These results are valuable in providing an empirical rationale for more focused investigations of these specifications in future studies.