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Subthreshold Posttraumatic Stress Disorder in the World Health Organization World Mental Health Surveys
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Background Although only a few people exposed to a traumatic event (TE) develop posttraumatic stress disorder (PTSD), symptoms that do not meet full PTSD criteria are common and often clinically significant. Individuals with these symptoms sometimes have been characterized as having subthreshold PTSD, but no consensus exists on the optimal definition of this term. Data from a large cross-national epidemiologic survey are used in this study to provide a principled basis for such a definition.Methods The World Health Organization World Mental Health Surveys administered fully structured psychiatric diagnostic interviews to community samples in 13 countries containing assessments of PTSD associated with randomly selected TEs. Focusing on the 23,936 respondents reporting lifetime TE exposure, associations of approximated DSM-5 PTSD symptom profiles with six outcomes (distress-impairment, suicidality, comorbid fear-distress disorders, PTSD symptom duration) were examined to investigate implications of different subthreshold definitions.Results Although consistently highest outcomes for distress-impairment, suicidality, comorbidity, and PTSD symptom duration were observed among the 3.0% of respondents with DSM-5 PTSD rather than other symptom profiles, the additional 3.6% of respondents meeting two or three of DSM-5 criteria B-E also had significantly elevated scores for most outcomes. The proportion of cases with threshold versus subthreshold PTSD varied depending on TE type, with threshold PTSD more common following interpersonal violence and subthreshold PTSD more common following events happening to loved ones.Conclusions Subthreshold DSM-5 PTSD is most usefully defined as meeting two or three of DSM-5 criteria B-E. Use of a consistent definition is critical to advance understanding of the prevalence, predictors, and clinical significance of subthreshold PTSD.
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“The prevalence of self-reported modest-to-severe posttraumatic stress symptoms in the global general population ranged from 7 % to 53.8 % during the pandemic (Xiong et al., 2020; Krishnamoorthy et al., 2020), compared to the world average of 3.9 %–7.8 % prior to the pandemic (McLaughlin et al., 2015; Koenen et al., 2017).”
From Efficacy and mechanisms of mobile application-delivered Acceptance and Commitment Therapy for posttraumatic stress disorder in China: Study protocol for a randomized controlled trial (2022) · cites this paper as McLaughlin et al., 2015
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“In a survey of 23,936 people with trauma exposure conducted by the World Health Organization World Mental Health Surveys across 13 countries, 6.6% evidenced clinical or subclinical PTSD symptoms consistent with DSM-V criteria (McLaughlin et al., 2014).”
From Maladaptive autonomic regulation in PTSD accelerates physiological aging (2015) · cites this paper as McLaughlin et al., 2014
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“While this condition does not fulfill the diagnosis of PTSD, it is found to be more prevalent in the community [4].”
From Effects of mindfulness-based cognitive therapy for Chinese adults with PTSD symptoms: protocol for a randomised controlled trial (2024) · cites this paper as [4]
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“The concept of partial/subthreshold PTSD was established in the 1990s (Bryant, 1996; McLaughlin et al., 2015; Schützwohl & Maercker, 1999).”
BackgroundAdler, A. B., Svetlitzky, V., & Gutierrez, I. A. (2020) · BJPsych Open · doi:10.1192/bjo.2020.81 · Cited by 24
Dahl, A. A., Østby-Deglum, M., Oldenburg, J., Bremnes, R. M., Dahl, O., Klepp, O., Wist, E., & Fosså, S. D. (2016) · Journal of Cancer Survivorship · doi:10.1007/s11764-016-0529-4 · Cited by 24
Examining PTSD treatment choice among individuals with subthreshold PTSD
Bergman, H. E., Kline, A. C., Feeny, N. C., & Zoellner, L. A. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.07.010 · Cited by 23
Conti, L., Fantasia, S., Violi, M., Dell’Oste, V., Pedrinelli, V., & Carmassi, C. (2023) · Brain Sciences · doi:10.3390/brainsci13121730 · Cited by 36
“At the same time, fear, worry, intrusive thoughts, and avoidance, essential diagnostic elements in the assessment of PTSD, are considered in the theoretical description of the mechanism of emotion regulation, suggesting an interplay between this latter and even subthreshold forms of PTSD [20,21].”
BackgroundSun, D., Gold, A. L., Swanson, C. A., Haswell, C. C., Brown, V. M., Stjepanović, D., Workgroup, V. M.-A. M., Beckham, J. C., Brancu, M., Calhoun, P. S., et al. (2020) · Translational Psychiatry · doi:10.1038/s41398-020-0739-4 · Cited by 23
PTSD and Suicidal Behaviors Amongst L'Aquila 2009 Earthquake Young Survivors
Carmassi, C., Bertelloni, C. A., Dell’Oste, V., Luperini, C., Marazziti, D., Rossi, R., & Dell’Osso, L. (2021) · Frontiers in Public Health · doi:10.3389/fpubh.2021.590753 · Cited by 23
“To assess the presence of partial PTSD, we adopted the criteria proposed by previous studies corresponding to the endorsement of two or three symptom clusters (27, 36).”
BackgroundMethodFranz, M. R., Kumar, S. A., Brock, R. L., Calvi, J. L., & DiLillo, D. (2021) · Journal of Family Psychology · doi:10.1037/fam0000865 · Cited by 25
Post-Traumatic Stress Disorder Trajectories the Year after COVID-19 Hospitalization
Serra, R., Borrazzo, C., Vassalini, P., Nicolantonio, C. D., Koukopoulos, A. E., Tosato, C., Cherubini, F., Alessandri, F., Ceccarelli, G., Mastroianni, C. M., et al. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19148452 · Cited by 27
“A PCL-5 total >30 can also be used in order to indicate the presence of a clinically relevant PTSD symptomatology [28].”
MethodClancy, K. J., Devignes, Q., Kumar, P., May, V., Hammack, S. E., Akman, E., Casteen, E. J., Pernia, C. D., Jobson, S. A., Lewis, M. W., et al. (2023) · Neuropsychopharmacology · doi:10.1038/s41386-023-01593-5 · Cited by 22
Carmassi, C., Corsi, M., Gesi, C., Bertelloni, C. A., Faggioni, F., Calderani, E., Massimetti, G., Saggese, G., Bonuccelli, A., Orsini, A. A., et al. (2017) · Epilepsy & Behavior · doi:10.1016/j.yebeh.2017.02.025 · Cited by 23
Neilson, E. C., Norris, J., Bryan, A. E. B., & Stappenbeck, C. A. (2016) · Journal of Sex & Marital Therapy · doi:10.1080/0092623x.2016.1208127 · Cited by 23
Zhao, C., Zhao, Z., Levin, M. E., Lai, L., Shi, C., Hu, J., Chen, W., & Ren, Z. (2023) · Behaviour Research and Therapy · doi:10.1016/j.brat.2023.104440 · Cited by 22
PTSD as a mediator of the relationship between trauma and psychotic experiences
Strelchuk, D., Hammerton, G., Wiles, N., Croft, J., Turner, K. M., Heron, J., & Zammit, S. (2020) · Psychological Medicine · doi:10.1017/s0033291720004821 · Cited by 24
Kaminer, D., Booysen, D. D., Ellis, K., Kristensen, C. H., Patel, A., Robjant, K., & Sardana, S. M. (2024) · Journal of Traumatic Stress · doi:10.1002/jts.23031 · Cited by 22
Carmassi, C., Corsi, M., Bertelloni, C. A., Pedrinelli, V., Massimetti, G., Peroni, D. G., Bonuccelli, A., Orsini, A. A., & Dell’Osso, L. (2020) · Seizure · doi:10.1016/j.seizure.2020.06.021 · Cited by 22
Li, J., Li, J., Zhang, W., Wang, G., & Qu, Z. (2023) · The Lancet Regional Health - Western Pacific · doi:10.1016/j.lanwpc.2023.100699 · Cited by 24
Rossi, A. A., Panzeri, A., Fernández, I., Invernizzi, R., Taccini, F., & Mannarini, S. (2024) · Scientific Reports · doi:10.1038/s41598-024-72274-6 · Cited by 26
McCaslin, S. E., Maguen, S., Metzler, T. J., Bosch, J. O., Neylan, T. C., & Marmar, C. R. (2015) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2015.10.016 · Cited by 22
Nievergelt, C. M., Maihofer, A. X., Klengel, T., Atkinson, E. G., Chen, C., Choi, K. W., Coleman, J. R. I., Dalvie, S., Duncan, L. E., Logue, M. W., et al. (2018) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/458562 · Cited by 24
“Extensive epidemiologic work has shown that subthreshold PTSD is highly prevalent and debilitating.(72,73) In our analysis, persons with subthreshold PTSD are classified as controls, which would likely reduce our power to find genetic associations.”
BackgroundSelf-citationÞórarinsdóttir, K., Holmes, E. A., Hardarson, J., Stephenssen, E. S., Jonasdottir, M. H., Kanstrup, M., Singh, L., Hauksdóttir, A., Halldorsdottir, T., Guðmundsdóttir, B., et al. (2022) · JMIR Formative Research · doi:10.2196/37382 · Cited by 17
“Posttraumatic stress symptoms, even when subthreshold for a diagnosis of PTSD, can be associated with substantial distress, functional impairment, and comorbidity [5].”
BackgroundMcKeon, G., Steel, Z., Wells, R., Newby, J. M., Hadži-Pavlović, D., Vancampfort, D., & Rosenbaum, S. (2019) · BMJ Open · doi:10.1136/bmjopen-2019-030668 · Cited by 18
“The long-term impact of traumatic stress on mental health has been identified as one of the major determinants of impairment and disability across the globe.(8) Adverse consequences of PTSD include impairments in psychosocial functioning,(9) substance abuse,(10) comorbid mental disorders(9) and an increase risk of sui…”
BackgroundChildhood psychological maltreatment, sense of self, and PTSD symptoms in emerging adulthood
Watts, J. R., Lazzareschi, N. R., Liu, Y., & O’Sullivan, D. (2022) · Journal of Counseling & Development · doi:10.1002/jcad.12455 · Cited by 19
Rentmeesters, N., & Hermans, D. (2023) · European Journal of Psychotraumatology · doi:10.1080/20008066.2022.2156558 · Cited by 29
“McLaughlin et al. (2015) concluded that no clear definition of subclinical PTSD exists, and proposed that complying with at least two of any of the DSM-5 criteria B to E identifies the group with the highest negative outcome.”
BackgroundMethodResultInfluentialTrautmann, S., Reineboth, M., Trikojat, K., Richter, J., Hagenaars, M. A., Kanske, P., & Schäfer, J. (2018) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.09.001 · Cited by 19
“Exposure to traumatic events is associated with a higher risk for various mental disorders such as posttraumatic stress disorder (Karam et al., 2014; McLaughlin et al., 2015), anxiety disorders (Asselmann, Wittchen, Lieb, Perkonigg, & Beesdo-Baum, 2017), depressive disorders (Suliman et al., 2009)…”
Ruork, A. K., McLean, C. L., & Fruzzetti, A. E. (2021) · Violence Against Women · doi:10.1177/10778012211013895 · Cited by 18
Popescu, M., Popescu, E.-A., DeGraba, T. J., & Hughes, J. (2022) · NeuroImage Clinical · doi:10.1016/j.nicl.2022.103297 · Cited by 20
“…in a diagnostic category, this intermediate group was inhomogeneous, as it included participants who met various criteria used to define subthreshold (subclinical) PTSD (McLaughlin et al., 2015), as well as participants who did not meet the criteria for inclusion in this diagnostic category.”
BackgroundMindlis, I., Morales-Raveendran, E., Goodman, E., Xu, K. Y., Vila-Castelar, C., Keller, K., Crawford, G., James, S., Katz, C., Crowley, L., et al. (2016) · Journal of Asthma · doi:10.1080/02770903.2016.1263650 · Cited by 15
“While no consensus exists on the optimal classification of sub-threshold PTSD [29,30], the guidelines set forth by McLaughlin et al.”
BackgroundMethodA dimensional approach to assessing psychiatric risk in adults born very preterm
Kroll, J., Froudist‐Walsh, S., Brittain, P. J., Tseng, C.-E. J., Karolis, V. R., Murray, R. M., & Nosarti, C. (2018) · Psychological Medicine · doi:10.1017/s0033291717003804 · Cited by 18
Sprang, G., & Garcia, A. R. (2022) · Journal of Child & Adolescent Trauma · doi:10.1007/s40653-022-00465-2 · Cited by 17
“Even those who do not qualify for a diagnosis of PTSD may report clinically significant symptoms and functional impairment (Carrion et al., 2002; McLaughlin et al., 2015).”
BackgroundYu, Z., Kisner, A., Bhatt, A., Polter, A. M., & Marvar, P. J. (2023) · Neuropharmacology · doi:10.1016/j.neuropharm.2023.109460 · Cited by 17
Springer, F., Kuba, K., Ernst, J., Friedrich, M., Glaesmer, H., Platzbecker, U., Vučinić, V., Heyne, S., Mehnert-Theuerkauf, A., & Esser, P. (2023) · Acta Oncologica · doi:10.1080/0284186x.2023.2239477 · Cited by 26
“If the symptoms do not meet full criteria, subthreshold PTSD may be present if two symptom clusters are present [33].”
BackgroundAllely, C. S., & Allely, B. (2020) · Journal of Criminal Psychology · doi:10.1108/jcp-09-2019-0044 · Cited by 17
Dawson, R. L., Calear, A. L., McCallum, S. M., McKenna, S., Nixon, R. D. V., & O’Kearney, R. (2020) · Journal of Traumatic Stress · doi:10.1002/jts.22596 · Cited by 20
van Dongen, D. H. E., Havermans, D. C. D., Deckers, K., Olff, M., Verhey, F. R. J., & Sobczak, S. (2022) · Psychogeriatrics · doi:10.1111/psyg.12830 · Cited by 17
A Call for Trauma Competencies in Nursing Education
Wheeler, K. (2018) · Journal of the American Psychiatric Nurses Association · doi:10.1177/1078390317745080 · Cited by 17
Metadata
- Authors
- McLaughlin, K. A., Koenen, K. C., Friedman, M. J., Ruscio, A. M., Karam, E. G., Shahly, V., Stein, D. J., Hill, E. D., Petukhova, M., Alonso, J., Andrade, L. H., Angermeyer, M. C., Borges, G., de Girolamo, G., de Graaf, R., Demyttenaere, K., Florescu, S. E., Mladenova, M., Posada-Villa, J., Scott, K. M., Takeshima, T., & Kessler, R. C.
- Affiliations
- University of Washington (US)
- Columbia University (US)
- United States Department of Veterans Affairs (US)
- University of Pennsylvania (US)
- University of Balamand (LB)
- Harvard University (US)
- University of Cape Town (ZA)
- Universitat Pompeu Fabra (ES)
- Universidade de São Paulo (BR)
- Universidad Autónoma Metropolitana (MX)
- Universitair Ziekenhuis Leuven (BE)
- National School of Public Health, Management and Professional Development (RO)
- New Bulgarian University (BG)
- University of Otago (NZ)
- National Center of Neurology and Psychiatry (JP)
- Corresponding author
- Kessler, Ronald C.
- ORCID
- Venue
- Biological Psychiatry
- Publisher
- Elsevier BV
- Published
- 2015-02
- Volume
- 77
- Issue
- 4
- Pages
- 375-384
- ISSN
- 0006-3223 (ISSN-L)
- PMC
- PMC4194258
- OpenAlex
- W2123975962
- Cited by
- 275
- References
- 42
- Citations by year
- 2026: 21 · 2025: 22 · 2024: 35 · 2023: 41 · 2022: 24 · 2021: 25 · 2020: 29 · 2019: 17 · 2018: 18 · 2017: 20 · 2016: 11 · 2015: 10
- FWCI
- 16.57
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Biological Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- RECERCAT (Consorci de Serveis Universitaris de Catalunya) (acceptedVersion, other-oa)
- Repositori digital de la UPF (Universitat Pompeu Fabra) (submittedVersion)
- Funders
- National Institutes of Health (5r13mh066849-04, 5r01mh069864-04, 5r01mh070884-05, 5r01mh093612-03)
- National Institute of Mental Health (R13-MH-066849, R01‐MH070884, U01-MH-60220, R01-MH093612, K01MH092526, U01MH060220, R01 MH093612-01, R01‐MH069864)
- National Institute on Drug Abuse (K05DA015799, R01DA016558)
- Fogarty International Center (R03TW006481)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Keywords
- post-traumatic stress disorder, DSM-5 PTSD criteria, trauma exposure, PTSD comorbidity, suicidality, interpersonal violence, World Mental Health Surveys
- MeSH terms
- Female, Health Surveys, Humans, Male, Mental Health, Severity of Illness Index, Stress Disorders, Post-Traumatic, World Health Organization, Prevalence, Diagnostic and Statistical Manual of Mental Disorders
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