Empirical examination of a proposed refinement to DSM-IV posttraumatic stress disorder symptom criteria using the National Comorbidity Survey Replication data
Abstract
OBJECTIVE: Recently, changes have been proposed to DSM-IV diagnostic criteria for post-traumatic stress disorder (PTSD) to refine the diagnosis because of concerns about its construct validity. Specifically, Spitzer et al. suggested narrowing the PTSD definition of trauma, specifying a symptom onset time frame after the trauma, and removing symptoms that overlap with other anxiety and mood disorders. We examined whether removing these overlapping anxiety/mood disorder symptoms resulted in differences (compared to the original DSM-IV PTSD criteria) in PTSD prevalence rates, diagnostic caseness, comorbidity and mental health-related disability, structural validity, and internal consistency. METHOD: Cross-sectional data were examined from the National Comorbidity Survey Replication (N = 5692), a multistage area household probability sample of U.S. residents. PTSD diagnostic and symptom data and diagnostic data for other Axis I disorders were taken from the Composite International Diagnostic Interview. The study was conducted from February 2001 to December 2003. RESULTS: After removing PTSD symptoms overlapping with those of other anxiety and mood disorders, we found that the lifetime PTSD prevalence dropped only from 6.81% to 6.42%. Nevertheless, a sizeable proportion of PTSD-diagnosed persons would consequently lose PTSD caseness. Little difference was found between the criteria sets in diagnostic comorbidity and disability, structural validity, and internal consistency. CONCLUSIONS: These data provide evidence that PTSD's overlapping anxiety and mood disorder symptoms are not responsible for PTSD's prevalence, diagnostic comorbidity, and construct validity. Although the proposed symptom criteria revision would result in fewer symptoms by which to evaluate PTSD, it may not address questions raised about the diagnosis' construct validity.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
According to data from the National Comorbidity Survey, of those diagnosed with PTSD, 54% reported having a major depressive episode, 28% reported having GAD, 28% reported alcohol abuse/dependence, and over 43% identified as having three or more other diagnosed conditions.
“According to data from the National Comorbidity Survey, of those diagnosed with PTSD, 54% reported having a major depressive episode, 28% reported having GAD, 28% reported alcohol abuse/dependence, and over 43% identified as having three or more other diagnosed conditions [68].”
From The Cyclical Battle of Insomnia and Mental Health Impairment in Firefighters: A Narrative Review (2024) · cites this paper as [68]
Symptoms from a specific mental health condition will not cause another mental health condition but rather increase the susceptibility to separate, independent comorbidities.
“This suggests that symptoms from a specific mental health condition will not cause another mental health condition but rather increase the susceptibility to separate, independent comorbidities.”
From The Cyclical Battle of Insomnia and Mental Health Impairment in Firefighters: A Narrative Review (2024) · cites this paper as [68]
After controlling for overlapping symptoms, the overall PTSD prevalence only decreased by 0.39%, from 6.81 to 6.42%.
“After controlling for overlapping symptoms, the overall PTSD prevalence only decreased by 0.39%, from 6.81 to 6.42% [68].”
From The Cyclical Battle of Insomnia and Mental Health Impairment in Firefighters: A Narrative Review (2024) · cites this paper as [68]
Cites
Hu, L., & Bentler, P. M. (1999) · Structural Equation Modeling A Multidisciplinary Journal · doi:10.1080/10705519909540118 · Cited by 108,788 · see citing works
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005) · Archives of General Psychiatry · doi:10.1001/archpsyc.62.6.593 · Cited by 20,391 · see citing works
Hu, L.-T., & Bentler, P. M. (1998) · Psychological Methods · doi:10.1037/1082-989x.3.4.424 · Cited by 12,298 · see citing works
Kessler, R. C., & Üstün, T. B. (2004) · International Journal of Methods in Psychiatric Research · doi:10.1002/mpr.168 · Cited by 4,771 · see citing works
Flora, D. B., & Curran, P. J. (2004) · Psychological Methods · doi:10.1037/1082-989x.9.4.466 · Cited by 3,105 · see citing works
Wittchen, H.-U. (1994) · Journal of Psychiatric Research · doi:10.1016/0022-3956(94)90036-1 · Cited by 2,348 · see citing works
Rethinking the mood and anxiety disorders: A quantitative hierarchical model for DSM-V.
Watson, D. (2005) · Journal of Abnormal Psychology · doi:10.1037/0021-843x.114.4.522 · Cited by 1,332 · cited 2× · see citing works
“One such proposal involved effectively reorganizing anxiety and mood disorders into fear and misery/ distress disorder categories, respectively, to better account for shared emotional processes and comorbidity rates among conditions such as generalized anxiety disorder, major depressive disorder, and PTSD.(25,26) Furt…”
BackgroundYoung, A. H. (1996) · Princeton University Press eBooks · doi:10.1515/9781400821938 · Cited by 1,132 · see citing works
The psychometric properties of the Composite International Diagnostic Interview
Andrews, G., & Peters, L. (1998) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s001270050026 · Cited by 881 · see citing works
Simms, L. J., Watson, D., & Doebbeling, B. N. (2002) · Journal of Abnormal Psychology · doi:10.1037//0021-843x.111.4.637 · Cited by 699 · see citing works
The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category
Summerfield, D. A. (2001) · BMJ · doi:10.1136/bmj.322.7278.95 · Cited by 689 · see citing works
Progress and Controversy in the Study of Posttraumatic Stress Disorder
McNally, R. J. (2002) · Annual Review of Psychology · doi:10.1146/annurev.psych.54.101601.145112 · Cited by 584 · see citing works
The stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation
Breslau, N., & Kessler, R. C. (2001) · Biological Psychiatry · doi:10.1016/s0006-3223(01)01167-2 · Cited by 526 · see citing works
The structure of common DSM-IV and ICD-10 mental disorders in the Australian general population
SLADE, T., & WATSON, D. (2006) · Psychological Medicine · doi:10.1017/s0033291706008452 · Cited by 419 · see citing works
Saving PTSD from itself in DSM-V
Spitzer, R. L., First, M. B., & Wakefield, J. C. (2007) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2006.09.006 · Cited by 353 · see citing works
Are avoidance and numbing distinct PTSD symptom clusters?
Asmundson, G. J. G., Stapleton, J. A., & Taylor, S. J. (2004) · Journal of Traumatic Stress · doi:10.1007/s10960-004-5795-7 · Cited by 300 · see citing works
Katz, S. J., Kessler, R. C., Frank, R. G., Leaf, P. J., Lin, E. H. B., & Edlund, M. J. (1997) · American Journal of Public Health · doi:10.2105/ajph.87.7.1136 · Cited by 228 · see citing works
PTSD: A problematic diagnostic category
McHugh, P. R., & Treisman, G. J. (2006) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2006.09.003 · Cited by 203 · see citing works
FRANKLIN, C. L., & ZIMMERMAN, M. (2001) · The Journal of Nervous and Mental Disease · doi:10.1097/00005053-200108000-00008 · Cited by 156 · see citing works
Symptom structure of posttraumatic stress disorder in a nationally representative sample
McWilliams, L. A., Cox, B. J., & Asmundson, G. J. G. (2004) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2004.06.003 · Cited by 117 · see citing works
Franklin, C. L., Sheeran, T. F., & Zimmerman, M. A. (2002) · Psychological Assessment · doi:10.1037//1040-3590.14.4.467 · Cited by 77 · see citing works
Challenges to the PTSD construct and its database: The importance of scientific debate
Rosen, G. M., & Frueh, B. C. (2006) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2006.09.007 · Cited by 28 · see citing works
Self-citation
Flagged first, then by citations
Cited by
Sorted by citations
A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD
Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., Humayun, A., Jones, L. M., Kagee, A., Rousseau, C., et al. (2017) · Clinical Psychology Review · doi:10.1016/j.cpr.2017.09.001 · Cited by 678 · see citing works
Flory, J. D., & Yehuda, R. (2015) · Dialogues in Clinical Neuroscience · doi:10.31887/dcns.2015.17.2/jflory · Cited by 629 · see citing works
Jacobson, N. C., & Newman, M. G. (2017) · Psychological Bulletin · doi:10.1037/bul0000111 · Cited by 576 · see citing works
Differentiating the mood and anxiety disorders: A quadripartite model
Watson, D. (2009) · Annual Review of Clinical Psychology · doi:10.1146/annurev.clinpsy.032408.153510 · Cited by 498 · see citing works
Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury
Stein, M. B., & McAllister, T. W. (2009) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2009.08101604 · Cited by 391 · see citing works
Elhai, J. D., & Palmieri, P. A. (2011) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2011.04.007 · Cited by 257 · see citing works
Self-citationStein, D. J., McLaughlin, K. A., Koenen, K. C., Atwoli, L., Friedman, M. J., Hill, E. D., Maercker, A., Petukhova, M., Shahly, V., van Ommeren, M., et al. (2014) · Depression and Anxiety · doi:10.1002/da.22279 · Cited by 221 · see citing works
The gut microbiome and mental health: implications for anxiety- and trauma-related disorders
Malan-Muller, S., Valles-Colomer, M., Raes, J., Lowry, C. A., Seedat, S., & Hemmings, S. M. J. (2018) · OMICS: A Journal of Integrative Biology · doi:10.1089/omi.2017.0077 · Cited by 161 · see citing works
Yang, Z., Oathes, D. J., Linn, K. A., Bruce, S. E., Satterthwaite, T. D., Cook, P. A., Satchell, E. K., Shou, H., & Sheline, Y. I. (2018) · Biological Psychiatry: Cognitive Neuroscience and Neuroimaging · doi:10.1016/j.bpsc.2017.12.006 · Cited by 83 · see citing works
“Although there remain construct questions with regard to symptom overlap with PTSD and MDD, recent research has shown that these high rates of comorbidity continued to occur even when overlapping symptoms were removed from the diagnoses (15,16).”
BackgroundSymptoms of posttraumatic stress disorder in patients with functional neurological symptom disorder
Gray, C., Calderbank, A., Adewusi, J., Hughes, R., & Reuber, M. (2020) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2019.109907 · Cited by 57 · see citing works
Afzali, M. H., Sunderland, M., Batterham, P. J., Carragher, N., & Slade, T. (2017) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867416683815 · Cited by 19 · see citing works
Li, D.-J., Chen, M.-H., Bai, Y.-M., Tsai, S.-J., Cheng, C.-M., Su, T.-P., Chen, T.-J., Yeh, T.-C., & Liang, C.-S. (2022) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2022.10.008 · Cited by 11 · see citing works
The Cyclical Battle of Insomnia and Mental Health Impairment in Firefighters: A Narrative Review
Holland-Winkler, A. M., Greene, D. R., & Oberther, T. J. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13082169 · Cited by 9 · see citing works
Park, S. D., & Kim, S. Y. (2015) · Journal of Physical Therapy Science · doi:10.1589/jpts.27.1369 · Cited by 5 · see citing works
- Authors
- Elhai, J. D., Grubaugh, A. L., Kashdan, T. B., & Frueh, B. C.
- Affiliations
- University of South Dakota (US)
- Medical University of South Carolina (US)
- George Mason University (US)
- Houston Methodist (US)
- Venue
- The Journal of Clinical Psychiatry
- Publisher
- Physicians Postgraduate Press, Inc
- Published
- 2008-04-15
- Volume
- 69
- Issue
- 4
- Pages
- 597-602
- ISSN
- 0160-6689 (ISSN-L)
- OpenAlex
- W2065089903
- Cited by
- 215
- References
- 22
- Citations by year
- 2026: 4 · 2025: 4 · 2024: 12 · 2023: 6 · 2022: 12 · 2021: 13 · 2020: 6 · 2019: 17 · 2018: 11 · 2017: 15 · 2016: 10 · 2015: 21 · 2014: 6 · 2013: 10 · 2012: 11
- FWCI
- 21.49
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- post-traumatic stress disorder, DSM-IV diagnostic criteria, construct validity, PTSD prevalence, structural validity, internal consistency, National Comorbidity Survey Replication
- MeSH terms
- Anxiety Disorders, Cross-Sectional Studies, Disability Evaluation, Humans, Stress Disorders, Post-Traumatic, United States, Reproducibility of Results, Comorbidity, Prevalence, Empirical Research, Diagnostic and Statistical Manual of Mental Disorders
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
