Association of DSM-IV Posttraumatic Stress Disorder With Traumatic Experience Type and History in the World Health Organization World Mental Health Surveys | Colorectal Surgery | JAMA Psychiatry | JAMA Network
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Table 1.  Lifetime Prevalence of TE Types, Distribution of Randomly Selected TE Types Among Those With Any Lifetime TE, and Associations of Randomly Selected TEs With DSM-IV CIDI-Diagnosed PTSD Across All WMH Surveys
Lifetime Prevalence of TE Types, Distribution of Randomly Selected TE Types Among Those With Any Lifetime TE, and Associations of Randomly Selected TEs With DSM-IV CIDI-Diagnosed PTSD Across All WMH Surveys
Table 2.  Odds of DSM-IV CIDI-Diagnosed PTSD Associated With Randomly Selected TEs as a Function of TE Type and Prior Lifetime Exposure of the Same TE Type Among People Exposed to 1 or More Lifetime TEs Across All WMH Surveysa
Odds of DSM-IV CIDI-Diagnosed PTSD Associated With Randomly Selected TEs as a Function of TE Type and Prior Lifetime Exposure of the Same TE Type Among People Exposed to 1 or More Lifetime TEs Across All WMH Surveysa
Table 3.  Odds of DSM-IV CIDI-Diagnosed PTSD Associated With Randomly Selected TE as a Function of Prior Lifetime TE Exposure Across All WMH Surveysa
Odds of DSM-IV CIDI-Diagnosed PTSD Associated With Randomly Selected TE as a Function of Prior Lifetime TE Exposure Across All WMH Surveysa
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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.

Abstract

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.

Introduction

Although most people are exposed to traumatic experiences (TEs)1 at some time in their lives, lifetime posttraumatic stress disorder (PTSD) prevalence ranges from 1.3% to 8.8%.2 This discrepancy raises questions about determinants of PTSD after TE exposure. One line of research on this topic shows that PTSD prevalence is highest for TEs involving interpersonal violence.3-5 Another line of research suggests that TE history is a risk factor for subsequent PTSD, with prior TEs involving violence possibly of special importance.6-8 However, these studies did not examine prior TEs comprehensively, making it unclear whether the special importance of TEs involving interpersonal violence is limited to personal experience of this violence or includes witnessing extreme violence9; whether all types of prior TEs are equally important3,10 or only those involving violence11; whether repeated exposure to similar TEs is of special importance12,13; and whether some prior TEs inoculate against future PTSD by building resilience.14,15 We address these uncertainties herein by examining associations of disaggregated TE types and histories of PTSD in a unique sample of 34 676 respondents from the World Health Organization (WHO) World Mental Health (WMH) surveys.16

Methods
Samples

The WMH surveys are a coordinated set of community epidemiologic surveys in countries throughout the world.17 This report focuses on the 22 WMH surveys in 20 countries that assessed lifetime PTSD after randomly selected TEs (using the procedures described below). Three surveys that assessed these random TEs were conducted in countries classified by the World Bank as low or lower-middle income (Colombia, Peru, and Ukraine); 7 in countries classified as upper-middle income (Brazil, Bulgaria, Colombia [administered after the previously mentioned Colombian survey, when the country income rating had increased], Lebanon, Mexico, Romania, and South Africa); and 12 in countries classified as high income (Belgium, France, Germany, Israel, Italy, Japan, the Netherlands, New Zealand, Northern Ireland, Spain [separate national and regional surveys], and the United States) (eTable 1 in the Supplement). Each survey was based on a multistage clustered area probability sample of adult household residents. The target population was the entire country in most surveys, all urbanized areas in 3 (Colombia, Mexico, and Peru), and specific metropolitan areas in 4 (Sao Paulo, Brazil; Medellin, Colombia; Murcia, Spain; and 6 cities in Japan). Response rates ranged from 45.9% (France) to 97.2% (Medellin), with a mean rate of 71.3% across surveys. This study was approved by the institutional review boards of the participating institutions. Participants provided written or oral informed consent using procedures approved by local institutional review boards (a complete list of institutional review board and consent features is given in eTable 2 in the Supplement).

Interviews were administered face-to-face in respondent homes after obtaining informed consent. Interviews were translated used a standardized WHO protocol.18 Fieldwork used consistent quality control procedures.19 Part 1 of the interview was administered to all respondents (n = 101 454) and assessed core DSM-IV mental disorders. Part 2, administered to all part 1 respondents with core disorders and a probability subsample of other respondents (n = 54 601), assessed additional disorders and correlates, including PTSD. The part 2 sample was weighted to match population geographic and/or sociodemographic distributions and to adjust for undersampling of noncases in part 1. More details about WMH sampling and weighting are available elsewhere.20 The analysis sample included the 34 676 part 2 respondents who reported lifetime TE exposure. Data were collected from 2001 to 2012.

Measures
Traumatic Experiences

The surveys assessed 29 TE types, with reports of lifetime exposure followed by questions about age at first occurrence of each type. Exploratory factor analysis found 6 meaningful TE factors (referred to below as TE groups) representing exposure to organized violence (eg, a civilian in war zone, a relief worker in war zone, or a refugee); participation in organized violence (eg, combat experience, witnessed atrocities); experience of physical violence (eg, witnessed violence at home as a child, beaten by a caregiver as a child, or beaten by someone else other than romantic partner); experience of sexual violence (eg, raped, sexually assaulted, or beaten by romantic partner); accidents and/or injuries (eg, natural disaster, automobile crash); and 3 TE types not loaded with any others (mugged and/or threatened with a weapon, man-made disaster, and unexpected death of loved one).1 One random occurrence of 1 randomly selected TE type was selected using a random numbers table for each respondent who reported lifetime TE exposure, representing the respondent’s random TE.

Posttraumatic Stress Disorder

We assessed DSM-IV PTSD with the Composite International Diagnostic Interview (CIDI),21 a fully structured lay interview that assesses a wide range of common mental disorders. The present analysis focuses only on PTSD, which was assessed separately for the random TE and the lifetime TE nominated by the respondent as having caused the most PTSD symptoms. We used DSM-IV criteria in the assessments. Clinical reappraisal interviews using the Structured Clinical Interview for DSM-IV (SCID)22 blinded to CIDI diagnoses of PTSD (but instructed to focus on the same TE as that assessed in the CIDI to guarantee valid comparison of diagnoses) documented moderate CIDI-SCID concordance23 (area under the receiver operating characteristic curve, 0.69) for PTSD. Sensitivity and specificity were 38.3% and 99.1%, respectively. Although only a minority of clinical cases were detected, the likelihood ratio (sensitivity/[1 − specificity]) was 42.0, which is well above the 10.0 typically considered definitive for a positive finding of a screen,24 leading to a very high proportion of CIDI cases (86.1%) being confirmed by the SCID.

Statistical Analysis

Data were analyzed from October 1, 2015, to September 1, 2016. Reports of random events were weighted by the inverse of random TE probability of selection multiplied by part 2 weight. This finding generated a sample representative of all TEs experienced by all respondents. This weight was then standardized within each survey to equal the number of respondents undergoing assessment for PTSD. Logistic regression with controls for surveys, respondent ages at random TE exposure and at interview, and respondent sex was then used to estimate associations of random TE type and TE history with PTSD. Odds ratios (ORs) for random TE type were scaled to have a product of 1.0, which means that ORs significantly different from 1.0 are different from the mean odds of PTSD across all TE types. This model was then elaborated to include information about prior TE exposure.

We used the design-adjusted Akaike information criterion (AIC)25 to evaluate model fit and design-based Wald χ2 tests to confirm significance of the associations. Incremental importance of prior TE exposure was evaluated by estimating individual-level associated PTSD probabilities based first on the final model and again based on a reduced final model that excluded information about prior TEs. A receiver operating characteristic curve was calculated from each set of associated probabilities,26 and the area under the curve was computed to quantify overall accuracy.27 The method of replicated 10-fold cross-validation with 20 replicates (ie, 200 separate estimates of model coefficients) was used to correct for overestimation of accuracy when estimating and evaluating models in a single sample.28

Results
TE Prevalence and TE-Specific PTSD Prevalence

Exposure to lifetime TEs was reported by a weighted 70.3% of part 2 respondents (34 676 respondents; 55.4% [SE, 0.6%] men and 44.6% [SE, 0.6%] women; mean [SE] age, 43.7 [0.2] years). The mean (SE) number of lifetime exposures was 4.5 (0.04) among those with any exposures (eTable 3 in the Supplement). The most common TEs were unexpected death of a loved one (16.7% [SE, 0.4%] of all exposures) and direct exposure to death or serious injury (15.8% [SE, 0.6%]) (Table 1). Accidents and/or injuries were the most common TE group (25.0% [SE, 0.6%]), followed by TEs associated with participating in organized violence (20.4% [SE, 0.6%]).

Posttraumatic stress disorder occurred after a weighted 4.0% of random TEs. Being a relief worker in a war zone (0.3% [SE, 0.1%] of all TEs) was the only TE not associated with any PTSD cases in the sample. Significant variation in PTSD prevalence was found across the remaining 28 TEs (χ227 = 237.1; P < .001), with highest weighted PTSD prevalence for rape (17.4% [SE, 2.7%]), kidnapping (11.3% [SE, 3.2%]), and other sexual assaults (11.0% [SE, 1.7%]) and the lowest (other than for being a relief worker) for natural disasters (0.2% [SE, 0.1%]) and being a civilian in a war zone (0.7% [SE, 0.4%]) or a region of terror (1.4% [SE, 0.6%]). The odds of developing PTSD among people exposed to randomly selected TEs by country income, survey response rate, and length of recalls, controlling for survey, sex, age at random event, and age at interview, are given in eTable 4 in the Supplement.

Differential Associations of TE Types With PTSD

Model 1 (Table 2) estimated the relative odds of PTSD across random TE types when controlling for prior same-type exposures. Given the rarity of prior same-type exposures, the latter were coded at the level of the 6 TE groups, with all respondents having prior same-type exposures in a single group collapsed into a group-level measure. Only 5 of the 6 group-level measures were analyzed, however, because too few respondents previously experienced same-type TEs involving exposure to organized violence for analysis.

The odds of PTSD differed significantly across TE types in model 1 (χ227 = 224.1; P < .001) owing to a significant between-group difference in mean odds (χ25 = 73.9; P < .001) and significant within-group differences in odds for TEs in each of 4 groups, including exposure to organized violence (χ23 = 34.4; P < .001), participation in organized violence (χ24 = 14.0; P = .007), accidents and/or injuries (χ25 = 46.9; P < .001), and the residual group of other TEs (χ22 = 6.9; P = .03). In the 2 remaining groups, ORs were not significant as a set (experience of physical violence, χ23 = 4.5; P = .22) or were significant as a set (experience of sexual violence with 7 TEs in the set, χ27 = 65.1; P < .001) but not significantly different from each other (χ26 = 10.2; P = .12).

Prior lifetime group-level, same-type TE exposure was significantly associated with PTSD in model 1 (χ25 = 14.2; P = .01) owing to a significantly higher odds of PTSD after experience of physical violence in the presence vs absence of a prior same-type TE (OR, 3.2; 95% CI, 1.3-7.9) and a significantly lower odds of PTSD after participation in organized violence in the presence vs absence of a prior same-type TE (OR, 0.2; 95% CI, 0.1-0.8). The other 3 group-level ORs for prior same-type TEs were nonsignificant.

The associated variables in model 2 were based on model 1 results to include each TE type within the 4 groups that had significant within-group OR differences in model 1, a single measure for any experience of sexual violence, and measures of prior same-type participation in organized violence and experience of physical violence. Four random TE types or groups had significantly elevated ORs, and 4 others had significantly reduced ORs in model 2. Three in each set of 4 were substantially elevated, including being kidnapped (OR, 4.7; 95% CI, 2.5-8.8), witnessing atrocities (OR, 4.0; 95% CI, 1.0-16.3), and experience of sexual violence (OR, 2.7; 95% CI, 2.0-3.6); 3 were reduced, including being a civilian in a war zone (OR, 0.3; 95% CI, 0.1-0.7) or in a region of terror (OR, 0.3; 95% CI, 0.1-0.8) and natural disaster (OR, 0.1; 96% CI, 0.0-0.2). The other significant ORs were modest in magnitude but associated with very common TEs, including unexpected death of a loved one (16.7% of all TEs; OR, 1.4; 95% CI, 1.0-2.0) and direct exposure to death or serious injury (15.8% of all TEs; OR, 0.7; 95% CI, 0.4-0.9). Based on these results, we estimated model 3 with only the 8 significant TEs in model 2 plus dummy variables for prior same-type participation in organized violence and experience of physical violence. Model 3 fit (AIC = 2943.3) was superior to that of models 1 (AIC = 3326.2) and 2 (AIC = 3283.4). Results were similar to those of model 2.

PTSD Risk Associated With Prior Lifetime Exposure to Other TEs

Significant model 3 variables were used as controls in model 4 (Table 3), which evaluated associations of prior lifetime TEs other than the random TE with random-TE PTSD. Prior TEs were significant overall (χ228 = 165.6; P < .001) and significantly different across types (χ227 = 56.7; P < .001). Odds ratios in the prior sexual violence group were significant overall (χ27 = 37.1; P < .001) and significantly different within the group (χ26 = 17.4; P = .008). Odds ratios for 2 other TE groups were significant overall but not significantly different within the group, including participation in organized violence overall (χ25 = 15.5; P = .008) and within the group (χ24 = 4.9; P = .30) and experience of physical violence overall (χ23 = 13.0; P = .005) and within the group (χ22 = 0.6; P = .75). Based on these results, model 5 included a count of prior lifetime TE types experienced in each of the 2 groups in which the model 4 TE-specific ORs were significant overall but not significantly different within the group. The model also included separate dummy variables for the 2 significant lifetime experiences of sexual violence TEs in model 4 (rape and other sexual assault). The fit of model 5 was superior to that of model 4 (AIC = 2933.2 vs AIC = 3528.4). All 4 ORs for prior TE exposure in model 5 were significantly elevated, 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). We also evaluated the possibility that the 4 ORs associated with prior lifetime TE exposure varied depending on random TE type, but that model performed less well than model 5 (AIC = 3076.9 vs AIC = 2933.2).

Sensitivity Analysis

Model 5 was estimated separately in subsamples defined by country income (high vs low and middle), survey response rate (<60% vs ≥60%), and median length of recall (0-15 vs ≥16 years from the age at random TE occurrence to the age at interview). Three of the 14 coefficients in the model (ie, 8 random TE types, 2 same-type prior TEs, and 4 other prior TEs) differed meaningfully across subgroups in at least 1 comparison. The significantly reduced OR for being a civilian in a region of terror was confined to respondents who subsequently immigrated to a high-income country (OR, 0.1; 95% CI, 0.0-0.4) compared with a middle- or a low-income country (OR, 1.2; 95% CI, 0.4-3.7) (χ21 = 7.8; P = .005). The significantly elevated OR for witnessing atrocities was confined to respondents in middle- and low-income countries (OR, 18.6; 95% CI, 4.5-76.8) compared with those in high-income countries (OR, 0.5; 95% CI, 0.2-1.6) (χ21 = 15.3; P < .001). In addition, the significantly elevated OR associated with prior participation in organized violence was confined to surveys with response rates of 60% or higher (OR, 1.3; 95% CI, 1.1-1.6) compared with surveys with response rates lower than 60% (OR, 0.6; 95% CI, 0.4-1.0) (χ21 = 7.8; P = .005).

Incremental Importance of Information About Prior TE Exposure

The incremental importance of information about prior TE exposure in model 5 was evaluated by estimating individual-level associated probabilities of PTSD, with the first evaluation based on model 5 and the second evaluation on a model that excluded the model 5 variables associated with prior TE exposure. A receiver operating characteristic curve for each set of probabilities based on replicated 10-fold cross-validation found an area under the curve of 0.74 for model 5 and 0.70 for the reduced model. Sensitivity among the 4% of respondents with the highest associated probabilities was 17.8% in model 5 and 16.7% in the reduced model; the 4% threshold was set because this value is the prevalence of PTSD in the sample.

Discussion

Our finding that PTSD is elevated after TEs involving extreme interpersonal violence is broadly consistent with previous research.6-8,29-31 Our findings of lower-than-mean ORs among civilians in a war zone or a region of terror and those who experience natural disaster, in comparison, are perplexing given the results regarding atrocities and numerous focused studies of high levels of PTSD after disasters.32,33 However, further investigation provides plausible explanations. Many WMH respondents who were civilians in war zones or regions of terror were elderly respondents reporting about childhood experiences during World War II. Direct exposure to war-related traumas was rare among these respondents. Studies of refugees from more recent conflicts, in comparison, show that PTSD is often,34,35 although not always,36,37 common in populations exposed to war-related traumas. Our finding about low PTSD risk among such civilians consequently has to be interpreted narrowly. The WMH finding of low PTSD prevalence after natural disasters, in comparison, is likely to differ from the results of disaster-focused studies because the latter studies overrepresent highly traumatized survivors.38,39 Consistent with this possibility, rigorous studies of representative disaster survivor samples find PTSD prevalence comparable to the WMH estimate.40,41

Our finding that prior participation in sectarian violence is associated with low levels of PTSD after random TE participation is indirectly consistent with research documenting low PTSD prevalence among policemen42 and other first responders43 and among Israeli settlers exposed to repeated bombings.14,44 These results could be owing to selection and/or to prior exposures promoting resilience.45 Experimental animal studies46 and observational human studies47 support the resilience possibility, although research showing that intervening psychopathologic features due to prior TEs mediate the association between TE history and subsequent PTSD48 confirms that prior TEs are more likely to create vulnerability than resilience. Research on the “healthy warrior effect” supports the selection possibility.45,49 Both processes might be at work, although we have no way to confirm their relative importance.

Our finding that prior experience of physical violence is associated with elevated PTSD risk after repeated exposure helps make sense of the fact that our initial models did not replicate previous findings that PTSD rates are especially high after experience of physical violence.6-8 This failure occurred because the pattern applied only to repeated exposures, which were controlled for in our models. For sexual violence, in comparison, we found that prior exposure was not relevant. This finding might seem to contradict studies showing that repeated experience of sexual assault is associated with poor mental health,50-52 but those studies focus on those with experience of childhood sexual assault who were vs were not assaulted again as adults, whereas the WMH finding compares adults with experience of sexual assault who were vs were not previously assaulted.

We also found that prior exposure to some other TEs was associated with generalized vulnerability to subsequent PTSD. Although ongoing research is investigating pathways leading to such generalized vulnerability,42,47,53 we know of no work on differential effects of TE types in this regard. However, suggestive related evidence exists on differences in associations of childhood adversities with adult mental disorders across different childhood adversity types54,55 and profiles.56,57

Limitations

The study has several major limitations. First, the cross-sectional design introduced the possibility of recall inaccuracy that could have biased estimates. Recall inaccuracy is relevant in this regard because extensive research shows that people with PTSD differ significantly from others in their trauma memories.58-60 Second, PTSD was assessed with a fully structured diagnostic interview that had imperfect concordance with clinical diagnoses. Third, no attempt was made to assess individual differences in vulnerabilities that could have influenced TE exposure or PTSD, possibly introducing bias into estimates of relative importance of TE types. Intervening mental disorders associated with prior TEs, which we will consider in a separate report, are special cases.3,10,11

Conclusions

Within the context of these limitations, we refined previous evidence that PTSD is especially common after TEs involving assaultive violence by showing that this effect applies to witnessing TEs and to personal experience of TEs and is limited to repeated exposures. We also confirmed that prior exposures to some TEs are more associated with resilience than vulnerability. Finally, we confirmed the finding of previous studies that broader TE history is associated with generalized vulnerability to PTSD but that this association is limited to prior TEs involving assaultive violence. Although leaving many questions unresolved about causal pathways and mechanisms, these results are valuable in advancing understanding of the complex ways in which specific TE types and histories are associated with PTSD and in providing an empirical foundation for more focused investigations of these specifications in future studies.

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Article Information

Corresponding Author: Ronald C. Kessler, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (kessler@hcp.med.harvard.edu).

Accepted for Publication: November 5, 2016.

Correction: This article was corrected on May 17, 2017, to add a funding source for Dr Liu to the Funding/Support section.

Published Online: January 4, 2017. doi:10.1001/jamapsychiatry.2016.3783

Author Contributions: Dr Kessler had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Alonso, Bromet, de Girolamo, Haro, Koenen, Kovess-Masfety, Shahly, Kessler.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Liu, Alonso, Kovess-Masfety, O’Neill, Shahly, Kessler.

Critical revision of the manuscript for important intellectual content: Liu, Petukhova, Sampson, Aguilar-Gaxiola, Alonso, Andrade, Bromet, de Girolamo, Haro, Hinkov, Kawakami, Koenen, Lee, Medina-Mora, Navarro-Mateu, O’Neill, Piazza, Posada-Villa, Scott, Stein, ten Have, Torres, Gureje, Zaslavsky, Kessler.

Statistical analysis: Liu, Petukhova, Alonso, Shahly, Zaslavsky.

Obtained funding: Alonso, Bromet, de Girolamo, Hinkov, Kawakami, Koenen, Kovess-Masfety, Navarro-Mateu, O’Neill, Posada-Villa, ten Have, Torres, Gureje.

Administrative, technical, or material support: de Girolamo, Lee, Navarro-Mateu, Piazza, Posada-Villa, ten Have.

Study supervision: Sampson, Aguilar-Gaxiola, Alonso, de Girolamo, Medina-Mora, O’Neill, Kessler.

Conflict of Interest Disclosures: Dr Stein reports receiving research grants and/or consultancy honoraria from AMBRF, Biocodex, Cipla, Lundbeck, National Responsible Gambling Foundation, Novartis, Servier, and Sun. Dr Kessler reports receiving support for his epidemiologic studies from Sanofi; serving as a consultant for Johnson and Johnson Wellness and Prevention; serving on an advisory board for the Johnson and Johnson Services, Inc, Lake Nona Life Project; and being a co-owner of DataStat, Inc, a market research firm that performs health care research. No other disclosures were reported.

Funding/Support: Dr Liu’s work was supported in part by training grant T32 MH017119 from the National Institute of Mental Health (NIMH). The World Health Organization (WHO) World Mental Health (WMH) Survey Initiative is supported by grants R01 MH070884 and R01 MH093612-01 from the NIMH; the John D. and Catherine T. MacArthur Foundation; the Pfizer Foundation; grants R13-MH066849, R01-MH069864, and R01 DA016558 from the US Public Health Service; grant FIRCA R03-TW006481 from the Fogarty International Center; the Pan American Health Organization; Eli Lilly and Company; Ortho-McNeil Pharmaceutical, Inc; GlaxoSmithKline; and Bristol-Myers Squibb. The São Paulo Megacity Mental Health Survey is supported by thematic project grant 03/00204-3 from the State of São Paulo Research Foundation. The Bulgarian Epidemiological Study of common mental disorders (EPIBUL) is supported by the Ministry of Health and the National Center for Public Health Protection. The Colombian National Study of Mental Health is supported by the Ministry of Social Protection. The Mental Health Study Medellín–Colombia was performed and supported jointly by the Center for Excellence on Research in Mental Health (CES University) and the Secretary of Health of Medellín. The European Study of the Epidemiology of Mental Disorders project is supported by contracts QLG5-1999-01042, SANCO 2004123, and EAHC 20081308 from the European Commission (the Piedmont Region, Italy), Fondo de Investigación Sanitaria, grant FIS 00/0028 from the Instituto de Salud Carlos III, Spain, grant SAF 2000-158-CE from the Ministerio de Ciencia y Tecnología, Spain, grants CIBER CB06/02/0046, RETICS RD06/0011, and REM-TAP from the Departament de Salut, Generalitat de Catalunya, Spain, Instituto de Salud Carlos III (CIBER CB06/02/0046, RETICS RD06/0011 REM-TAP); by other local agencies; and by an unrestricted educational grant from GlaxoSmithKline. The WMH Japan Survey is supported by grants H13-SHOGAI-023, H14-TOKUBETSU-026, and H16-KOKORO-013 for Research on Psychiatric and Neurological Diseases and Mental Health from the Japan Ministry of Health, Labour and Welfare. The Lebanese Evaluation of the Burden of Ailments and Needs of the Nation is supported by the Lebanese Ministry of Public Health, the WHO (Lebanon), grant R03 TW006481-01 from the National Institute of Health/Fogarty International Center; anonymous private donations to the Institute for Development, Research, Advocacy, and Applied Care (IDRAAC), Lebanon; and unrestricted grants from Algorithm, AstraZeneca, Bella Pharma, Benta, Eli Lilly and Company, GlaxoSmithKline, Lundbeck, Novartis, Phenicia, Servier, and UPO. The Mexican National Comorbidity Survey is supported by grant INPRFMDIES 4280 from the National Institute of Psychiatry Ramon de la Fuente and grant CONACyT-G30544- H from the National Council on Science and Technology, with supplemental support from the PanAmerican Health Organization. Te Rau Hinengaro, the New Zealand Mental Health Survey is supported by the New Zealand Ministry of Health, Alcohol Advisory Council, and the Health Research Council. The Northern Ireland Study of Mental Health was funded by the Health and Social Care Research and Development Division of the Public Health Agency. The Peruvian WMH Study was funded by the National Institute of Health of the Ministry of Health of Peru. The Romania WMH study projects—Policies in Mental Health Area and National Study Regarding Mental Health and Services Use—were performed by National School of Public Health and Health Services Management (former National Institute for Research and Development in Health), with technical support of Metro Media Transilvania, the National Institute of Statistics−National Centre for Training in Statistics, SCCheyenne Services SRL, Statistics Netherlands, and were funded by the Ministry of Public Health (former Ministry of Health) with supplemental suport of Eli Lilly Romania SRL. The South Africa Stress and Health Study is supported by grant R01-MH059575 from the US NIMH and National Institute of Drug Abuse (NIDA) with supplemental funding from the South African Department of Health and the University of Michigan. The Psychiatric Enquiry to General Population in Southeast Spain–Murcia Project has been financed by regional health authorities Servicio Murciano de Salud and Consejería de Sanidad y Política Social of Murcia, and Fundación para la Formación e Investigación Sanitarias of Murcia. The Ukraine Comorbid Mental Disorders during Periods of Social Disruption study is funded by grant RO1-MH61905 from the US NIMH. The US National Comorbidity Survey Replication is supported by grant U01-MH60220 from the US NIMH, with supplemental support from NIDA, the Substance Abuse and Mental Health Services Administration, grant 044708 from the Robert Wood Johnson Foundation, and the John W. Alden Trust. This study was also supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico grant 307623/2013-0 from the Brazilian Council for Scientific and Technological Development (Dr Andrade) and by the Medical Research Council of South Africa (Dr Stein).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Group Information: The World Health Organization World Mental Health Survey Collaborators include Sergio Aguilar-Gaxiola, MD, PhD (Center for Reducing Health Disparities, University of California, Davis, Health System); Ali Al-Hamzawi, MD (College of Medicine, Al-Qadisiya University, Diwaniya governorate, Iraq); Mohammed Salih Al-Kaisy, MD (Day Care And Rehabilitation Center, Ibn Seena Teaching Hospital, Mosul, Iraq); Jordi Alonso, MD, PhD (Hospital del Mar Research Institute, Parc de Salut Mar, Pompeu Fabra University, and Group 9/Program 06–Evaluation of Health Services of Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain); Laura Helena Andrade, MD, PhD (Section of Psychiatric Epidemiology–Laboratórios de Investigação Médica No. 23, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil); Corina Benjet, PhD (Department of Epidemiologic and Psychosocial Research, National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico); Guilherme Borges, ScD (Instituto Nacional de Psiquiatría, Calzada Mexico Xochimilco No. 101–Col San Lorenzo Huipulco, Mexico); Evelyn J. Bromet, PhD (Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York); Ronny Bruffaerts, PhD (Universitair Psychiatrisch Centrum–Katholieke Universiteit Leuven, Campus Gasthuisberg, Leuven, Belgium); Brendan Bunting, PhD (School of Psychology, Ulster University, Londonderry, Northern Ireland); Jose Miguel Caldas de Almeida, MD, PhD (Chronic Diseases Research Center and Department of Mental Health, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal); Graca Cardoso, MD, PhD (Departamento de Saúde Mental, Faculdadae de Ciencias Medicas, Universidade Nova de Lisboa, Lisbon, Portugal); Somnath Chatterji, MD (Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland); Alfredo H. Cia, MD (Anxiety Clinic and Research Center, Buenos Aires, Argentina); Louisa Degenhardt, PhD (National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia); Giovanni de Girolamo, MD (Istituto di Ricovero e Cura a Carattere Scientifico, Fatebenefratelli, Brescia, Italy); Peter de Jonge, PhD (Developmental Psychology, Department of Psychology, Rijksuniversiteit Groningen, and Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, Groningen, the Netherlands); Koen Demyttenaere, MD, PhD (Department of Psychiatry, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium); John Fayyad, MD (IDRAAC, Beirut, Lebanon); Silvia Florescu, MD, PhD (National School of Public Health, Management and Professional Development, Bucharest, Romania); Oye Gureje, PhD, DSc, FRCPsych (Department of Psychiatry, University College Hospital, Ibadan, Nigeria); Josep Maria Haro, MD, PhD (Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain); Yanling He, MD (Shanghai Mental Health Center, Shanghai Jiao Tong University, School of Medicine, Shanghai, China); Hristo Hinkov, MD (National Center for Public Health and Analyses, Ministry of Health, Sofia, Bulgaria); Chi-yi Hu, PhD, MD (Shenzhen Institute of Mental Health and Shenzhen Kangning Hospital, Shenzhen, China); Yueqin Huang, MD, MPH, PhD (Institute of Mental Health, Peking University, Beijing, China); Aimee Nasser Karam, PhD (IDRAAC, Beirut, Lebanon); Elie G. Karam, MD (Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Balamand University, Faculty of Medicine, and IDRAAC, Beirut, Lebanon); Norito Kawakami, MD, DMSc (Department of Mental Health, School of Public Health, University of Tokyo, Tokyo, Japan); Ronald C. Kessler, PhD (Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts); Andrzej Kiejna, MD, PhD (Faculty of Dentistry, Wroclaw Medical University, and University of Lower Silesia, Wroclaw, Poland); Viviane Kovess-Masfety, MD, PhD (Ecole des Hautes Etudes en Santé Publique, EA 4057, Paris Descartes University, Paris, France); Sing Lee, PhD (Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong); Jean-Pierre Lepine, MD (Hôpital Lariboisière Fernand Widal, Assistance Publique Hôpitaux de Paris, Institut National de la Santé et de la Recherche Medicale, Unité Mixte de Recherche en Santé 1144, University Paris Diderot and Paris Descartes, Paris, France); Daphna Levinson, PhD (Mental Health Services, Ministry of Health, Jerusalem, Israel); John McGrath, PhD (Queensland Brain Institute, The University of Queensland, and Queensland Centre for Mental Health Research, Queensland, Australia); Maria Elena Medina-Mora, PhD (Direccion de Investigaciones Epidemiologicas y Psicosociales, National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico); Jacek Moskalewicz, DrPH (Institute of Psychiatry and Neurology, Warsaw, Poland); Fernando Navarro-Mateu, MD, PhD (Subdirección General de Planificación, Innovación y Cronicidad, Servicio Murciano de Salud, Instituto Murciano de Investigación Biosanitaria–Arrixaca, and CIBERESP, Murcia, Spain); Beth-Ellen Pennell, MA (Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor); Marina Piazza, MPH, ScD (Facultad de Salud Publica y Administracion, Universidad Cayetano Heredia, and National Institute of Health, Lima, Peru); Jose Posada-Villa, MD (Faculty of Social Sciences, Colegio Mayor de Cundinamarca University, Bogota, Colombia); Kate M. Scott, PhD (Department of Psychological Medicine, University of Otago, Dunedin, New Zealand); Tim Slade, PhD (National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia); Juan Carlos Stagnaro, MD, PhD (Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina); Dan J. Stein, FRCPC, PhD (Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, Republic of South Africa); Margreet ten Have, PhD (Trimbos-Instituut, Netherlands Institute of Mental Health and Addiction, Utrecht); Yolanda Torres, MPH (Center for Excellence on Research in Mental Health, CES University, Medellin, Colombia); Maria Carmen Viana, MD, PhD (Department of Social Medicine, Federal University of Espírito Santo, Vitoria, Brazil); Harvey Whiteford, PhD (School of Public Health, The University of Queensland; and Queensland Centre for Mental Health Research, Queensland, Australia); David R. Williams, MPH, PhD (Department of Society, Human Development, and Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts); and Bogdan Wojtyniak, ScD (Centre of Monitoring and Analyses of Population Health, National Institute of Public Health-National Institute of Hygiene, Warsaw, Poland).

Disclaimer: The views and opinions expressed in this article are those of the authors and should not be construed to represent the views of WHO or other sponsoring organizations, agencies, or governments.

Additional Contributions: We thank the staff of the WMH Data Collection and Data Analysis Coordination centres for assistance with instrumentation, fieldwork, and consultation on data analysis.

Additional Information: A complete list of all within-country and cross-national WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/.

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