The role of criterion A2 in the DSM-IV diagnosis of posttraumatic stress disorder

Elie George Karam, Gavin Andrews, Evelyn Bromet, Maria Petukhova, Ayelet Meron Ruscio, Mariana Salamoun, Nancy Sampson, Dan J. Stein, Jordi Alonso, Laura Helena Andrade, Matthias Angermeyer, Koen Demyttenaere, Giovanni De Girolamo, Ron De Graaf, Silvia Florescu, Oye Gureje, Debra Kaminer, Roman Kotov, Sing Lee, Jean Pierre LpineMaria Elena Medina-Mora, Mark A. Oakley Browne, Jos Posada-Villa, Rajesh Sagar, Arieh Y. Shalev, Tadashi Takeshima, Toma Tomov, Ronald C. Kessler

Research output: Contribution to journalArticlepeer-review


Background: Controversy exists about the utility of DSM-IV posttraumatic stress disorder (PTSD) criterion A2 (A2): that exposure to a potentially traumatic experience (PTE; PTSD criterion A1) is accompanied by intense fear, helplessness, or horror. Methods: Lifetime DSM-IV PTSD was assessed with the Composite International Diagnostic Interview in community surveys of 52,826 respondents across 21 countries in the World Mental Health Surveys. Results: Of 28,490 representative PTEs reported by respondents, 37.6% met criterion A2, a proportion higher than the proportions meeting other criteria (BF; 5.4%9.6%). Conditional prevalence of meeting all other criteria for a diagnosis of PTSD given a PTE was significantly higher in the presence (9.7%) than absence (.1%) of A2. However, as only 1.4% of respondents who met all other criteria failed A2, the estimated prevalence of PTSD increased only slightly (from 3.64% to 3.69%) when A2 was not required for diagnosis. Posttraumatic stress disorder with or without criterion A2 did not differ in persistence or predicted consequences (subsequent suicidal ideation or secondary disorders) depending on presence-absence of A2. Furthermore, as A2 was by far the most commonly reported symptom of PTSD, initial assessment of A2 would be much less efficient than screening other criteria in quickly ruling out a large proportion of noncases. Conclusions: Removal of A2 from the DSM-IV criterion set would reduce the complexity of diagnosing PTSD, while not substantially increasing the number of people who qualify for diagnosis. Criterion A2 should consequently be reconceptualized as a risk factor for PTSD rather than as a diagnostic requirement.

Original languageEnglish
Pages (from-to)465-473
Number of pages9
JournalBiological Psychiatry
Issue number5
Publication statusPublished - Sep 1 2010


  • Composite International Diagnostic Interview (CIDI)
  • criterion A2
  • diagnosis
  • DSM-IV
  • posttraumatic stress disorder (PTSD)
  • potentially traumatic experience (PTE)
  • World Health Organization World Mental Health (WMH) Surveys

ASJC Scopus subject areas

  • Biological Psychiatry


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