Post-traumatic stress disorder after life events

In their interesting article Mol et al (2005), who conclude that life events might cause as many post-traumatic stress disorder (PTSD) symptoms as do traumatic events. The design and conclusions of the study raise some doubts.

Our first concern relates to the assumption that a particular symptom or disorder may be diagnosed in the absence of the fundamental nature or essence of the disorder. The authors claim to identify PTSD in the absence of (a) a traumatic event and (b) a response involving intense fear, helplessness or horror. Both these criteria are diagnostic A criteria of the DSM–IV and essential features of PTSD. Diagnosing PTSD with disregard for a traumatic event is like diagnosing a major depressive disorder in the absence of depressed mood.

Our assumption regarding the broad use of the PTSD diagnosis is strengthened by the instrument used for assessing PTSD symptoms, which has high sensitivity but lacks specificity (Carlson, 1997). In addition, it is questionable whether a self-report scale can assess the clinical relevance of symptoms. Our concern is corroborated by the results in Table 4. The only item on which the life events group scored higher than the traumatic events group was the non-specific symptom of ‘having trouble concentrating’, whereas the traumatic events group scored higher on ‘trauma-specific items’ such as amnesia and hyperarousal.

Another concern is the selection of traumatic events. Accidents, sudden death of a loved one and witnessing violence are categorised as traumatic events but gave relatively low PTSD scores. In our opinion, such events may evoke a range of reactions such as guilt, anger, sadness, anxiety and apathy. Again, if criterion A2 – a response involving intense fear, helplessness or horror – has not been assessed, it is questionable whether these experiences were really traumatic.

The conclusion that life events can generate as many PTSD symptoms as traumatic events is unjustified. At most it could be concluded that some of the PTSD items might not be specific to trauma but are more general stress-related symptoms.