Psychiatr Clin N Am 25 (2002) 775–790

Rationale for a posttraumatic stress

spectrum disorder
Charles Moreau, MDa,b, Sidney Zisook, MDa,b,*
a
Department of Psychiatry, University of California, San Diego,
9500 Gilman Drive, La Jolla, CA 92093-0603R, USA
b
Psychiatry Service, San Diego Veterans Affairs Healthcare System,
3350 La Jolla Village Drive, San Diego, CA 92161-0002, USA

The core features of posttraumatic stress disorder (PTSD) include expo-

sure to an event that involves actual or threatened death or serious injury to
the self or others with an associated response of intense fear, helplessness, or
horror and symptoms from each of three clusters involving reexperiencing
the event, avoiding stimuli related to the event and psychic numbness, and
persistent increased arousal [1]. Although descriptions of the effects of such
events on individuals have long existed, PTSD was not recognized as a dis-
tinct diagnostic entity until its incorporation into the Diagnostic and Statis-
tical Manual, 3rd Edition [2]. For at least a century before PTSD was
officially born, investigators noted somatic, physiologic, and behavioral
consequences of trauma, currently embedded in the DSM-IV criteria. As
early as 1871, Da Costa described the autonomic cardiac symptoms of
soldiers exposed to the horrors of the Civil War [3]. During the early
1900s, psychoanalysts observed ‘‘traumatic neurosis’’ that resulted from dif-
ferent forms of trauma. In World War I, ‘‘shell shock’’ was understood as a
form of brain trauma caused by the terror induced by exploding shells.
Although Lindemann emphasized acute and distorted grief reactions in the
aftermath of the 1941 Coconut Grove disaster, survivors and family mem-
bers of victims were left with nervousness, fatigue, nightmares, and other
symptoms that resembled current conceptions of PTSD [4].
The diagnosis that came closest to what we know as PTSD in DSM-I
was ‘‘gross stress reaction’’ [5]. This diagnosis suggested that everyone
had a breaking point and, given a severe enough trauma, it would be rela-
tively ‘‘natural’’ to have a severe reaction. In DSM-II, the corresponding
category was renamed ‘‘transient emotional reaction,’’ which emphasized

* Corresponding author.
E-mail address: [email protected] (S. Zisook).

0193-953X/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.
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the temporary nature of the psychological response to an overwhelming

trauma [6]. It was not until after long-term post-war follow-up studies of
Vietnam veterans that investigators realized these ‘‘reactions’’ were anything
but temporary for many of the affected veterans. With the introduction of
DSM-III, PTSD was born. In the initial iteration, symptoms needed to be
present for at least 6 months before the diagnosis could be made, but in
DSM-III-R the required duration was shortened to 1 month [7].
In DSM-IV, the category of acute stress disorder, manifested by the same
constellation of symptoms as PTSD, was added. The major difference
between acute stress disorder and PTSD is that the duration of symptoms
and distress is less than 1 month in the former disorder. If symptoms persist
for more than 1 month, the diagnosis changes to PTSD. The ‘‘stressor’’ cri-
teria in DSM-IV was broadened to include a subjective component—exper-
iencing the trauma with helplessness and horror—and include traumas that
are witnessed or occur to loved ones or are personally experienced. Finally,
in DSM-IV, the individual must experience avoidance and psychic numbing
rather than just avoidance [2].
Perhaps no other diagnostic category has gone through as many altera-
tions and permutations as has PTSD. Until recently, many investigators and
clinicians considered PTSD a product of malingering or a form of person-
ality disorder [8]. Over the last 10 or so years, however, the validity of PTSD
has become well established and is currently considered one of the most
prevalent and disabling psychiatric disorders in civilian and military popu-
lations [9]. It is still not clear whether PTSD, as currently conceptualized, is
a distinct and homogeneous category (Fig. 1) or whether it would be more
accurate to think of PTSD as being part of one or more dimensions or spec-
tra (Fig. 2). PTSD is rarely found alone; it is often comorbid with several
other psychiatric diagnoses, which calls into question the use of the current
categorization of PTSD. In the rest of this manuscript, the authors present
the case that PTSD can best be understood as existing along at least three
spectra: (1) one based on symptom severity (or diagnostic threshold), (2)
another based on the nature of the stressor, and (3) a final one based on
potential responses to trauma.

Symptom severity
Using DSM-III criteria, the National Comorbidity Survey found a life-
time prevalence of PTSD of 7.8%. This survey also recognized the impact
of several noncombat forms of trauma, including rape and molestation in
women and witnessing someone being badly injured or killed [10]. Using
similar criteria to identify patients with PTSD, numerous studies have dem-
onstrated substantial biopsychosocial impairment for occupation [11],
somatic distress and concomitant medical illness [12], poor quality of life
[13], suicidality [14,15], impaired intimacy [16], increased burden to spouse
or partner [17], and social dysfunction [18]. Other studies, however, have
 C. Moreau, S. Zisook / Psychiatr Clin N Am 25 (2002) 775–790 777

Fig. 1. DSM-IV Classification of PTSD. aResponse involved intense fear, helplessness, or

horror; bEach cluster is more than 1 month duration.

begun to demonstrate comparable impairment in individuals who experi-

ence only some, but not all, symptoms of PTSD.
Marshall et al [19] reviewed studies that demonstrated that subthreshold
PTSD caused by various stressors was as common as full PTSD. In the
National Vietnam Veterans Readjustment Study [20], partial PTSD was
defined by levels of dysfunction equivalent to PTSD, the presence of two
of three symptom clusters, or meeting most criteria in each of the three clus-
ters. Subthreshold PTSD was reported in 22.5% of men and 21.2% of wom-
en exposed to war-related trauma in Vietnam. In a longitudinal study of 132
persons involved in serious motor vehicle accidents, 28.5% met criteria for
two symptom clusters 1 to 4 months after the accident [11]. Of 136 survivors
of a plane crash into two apartments, 20% met criteria for two symptom
clusters followed for 6 months [21]. 146 political prisoners in the former
German Democratic Republic were compared to subjects in that country
who had not experienced trauma. 29% met criteria for partial PTSD, which
was defined as satisfying criteria in the reexperiencing cluster and either
 778
C. Moreau, S. Zisook / Psychiatr Clin N Am 25 (2002) 775–790

Fig. 2. A Dimensional Approach to Stress-Related Disorders Spectra: 1. Symptom Severity or diagnostic thresholds; 2. Nature of Stressor; 3. Response to
trauma.
 C. Moreau, S. Zisook / Psychiatr Clin N Am 25 (2002) 775–790 779

hyperarousal or avoidance clusters [22]. A community study that used

standardized telephone interviews of 1002 persons asked about trauma, and
positive replies were given a DSM-IV PTSD symptom checklist. Persons
with partial PTSD had clinically meaningful levels of functional impairment
in association with their symptoms [23]. Impairment could not be directly
attributed to PTSD symptoms in this sample, however, because there was
no control for comorbid conditions.
More recently, Marshall et al [19] found that 2608 of 9358 individuals on
National Anxiety Disorders Screening Day 1997 had at least one PTSD
symptom for at least 1 month’s duration. Impairment increased linearly
with each increasing number of subthreshold PTSD symptoms. Even after
controlling for the presence of major depressive disorder, individuals with
subthreshold PTSD were at elevated risk for suicidal ideation. A limitation
of this study includes the assessment of impairment by self-report and fail-
ure to assess for specific areas of impairment, such as occupational or social
functioning.
Subthreshold symptoms may represent a prodrome of the full syndrome
or residual symptoms of PTSD in partial remission. Regarding the former
possibility, individuals who react to trauma with dissociation are at elevated
risk for later developing the full syndrome of PTSD [9]. For many patients,
mild symptoms, such as numbing of affect and irritability limited to the rec-
ollection of trauma, persist indefinitely. Even after treatment, many individ-
uals with PTSD continue to suffer from residual symptoms years after the
full syndrome is no longer present [19]. Although not yet empirically vali-
dated, individuals with residual symptoms may be more susceptible to devel-
oping the full syndrome after subsequent traumatic exposure than
individuals with full symptom and functional recovery. Further complicat-
ing matters, a characteristic course of PTSD is fluctuating symptom severity,
with persons meeting full criteria for diagnosis intermittingly over the course
of many years [24].
One side of the severity spectrum contains individuals with subthreshold
symptoms. In the middle of the spectrum is uncomplicated PTSD, and on the
other side of the severity spectrum is PTSD complicated with multiple comor-
bidities. More than 80% of patients with chronic PTSD have at least one
comorbid psychiatric condition, most often mood, anxiety, or substance use
disorders [10]. When comorbidity is present, PTSD is often misdiagnosed,
chronic, more severe and impairing, and more difficult to treat [9].

Stressor criteria
An important evolution in the diagnostic criteria for PTSD concerns
the inclusion of the victim’s appraisal of the event. Before DSM-III, many
clinicians limited the diagnosis to individuals exposed to combat or only the
severest forms of civilian trauma. In DSM-III and DSM-III-R, the event
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was required to be objectively catastrophic and out of keeping with ordinary

events of life. Automobile accidents or death of a loved one did not qualify.
Although discussed in the text of DSM-III-R, the person’s response to the
event was not included in the criterion set. DSM-IV, on the other hand, lists
criterion A as exposure to a traumatic event in which both of the following
conditions were present:
1. The person experienced, witnessed, or was confronted with an event or
events that involved actual or threatened death or serious injury or a
threat to the physical integrity of self or others.
2. The person’s response involved intense fear, helplessness, or horror
Perry et al [25] showed that the severity of PTSD symptoms in burn vic-
tims was not proportional to the extent of injury but rather to the person’s
perception of injury. A clear definition of criterion A is of absolute impor-
tance because it is necessary for the diagnosis of PTSD. For example, per-
sons who suffer from all other symptom clusters would not meet the
diagnosis of PTSD if the precipitating stressful event failed to qualify as a
criterion A trauma. Snow et al [26] found that the prevalence of PTSD
among 2858 Vietnam veterans ranged from 1.8% to 15% depending on
whether combat exposure was defined relatively narrowly or broadly. The
significance of the person’s subjective reaction to a traumatic event is under-
scored by Yehuda’s study of adult offspring of Holocaust survivors [27].
Adult offspring of Holocaust survivors were more likely than demographi-
cally similar comparison subjects to designate a non–life-threatening event
as their most distressing event, despite having experienced potentially life-
threatening events. Although both groups had a similar number of trau-
matic events, there was a greater prevalence of PTSD in the adult offspring
of Holocaust survivors. Davidson and Foa [8] state ‘‘clinical observations
seem to suggest that for some persons the loss of a job or marital separation
may also give rise to this syndrome, leading to criteria B (re-experiencing), C
(avoidance and numbing), and D (hyperarousal) symptoms of PTSD.’’ Two
studies assessed the impact of ‘‘low-magnitude’’ trauma that showed that
marital disruption, death of a loved one, failed adoption plans, miscarriage,
and poisoning may lead to PTSD [28,29]. The nature of the stressor is
believed to have considerable breadth, from the loss of a job or marital sepa-
ration to the loss of a loved one or involvement in a serious accident or
involvement in abuse or combat.
Two recently published studies illustrate how individuals may reex-
perience a stressful event, avoid reminders of the event, and have hype-
rarousal with associated significant impairment yet fail to qualify for the
diagnosis of PTSD if the stressful event is not deemed traumatic by
DSM-IV. In the first study, Pfefferbaum et al [30] discovered that 20% of
69 sixth grade children met criteria for reexperiencing, avoidance, and
hyperarousal and had difficulties functioning 2 years after the bombing of
the Oklahoma City Alfred P. Murrah Federal Building, despite living 100
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miles away and not knowing anyone killed or injured. The authors did note
that media exposure was a significant predictor of symptomatology. In a
second study, Zisook et al [31] reported chronic and debilitating symptoms
of PTSD in a group of mostly middle-age and older widows and widowers,
even after relatively chronic terminal illnesses and when the death had been
expected. Although PTSD was more prevalent when the death was
‘‘unnatural’’ (ie, suicide or homicide), it was still seen in almost 10% of the
sample after spouses died of natural causes. A spectrum of stressors and a
spectrum of symptoms below the DSM-IV threshold produce impairment
and a need for treatment. These spectra must be elucidated further in future
diagnostic manuals.

Trauma-related conditions
Stressful events are known to precipitate and exacerbate various psychi-
atric conditions. In the ICD-10 classification [32], acute and chronic PTSD,
adjustment disorders, and personality change after catastrophic stress are
included in a stress and trauma section. Similarly, the DSM-IV Advisory
Subcommittee unanimously voted to classify PTSD in a new stress response
category [33]. One proposal for classification might include PTSD at the
severe end of a spectrum of stress-related disorders, with adjustment disor-
ders at the other. In that vein, McFarlane et al [34] showed that responses to
trauma are heterogeneous and include PTSD, major depressive disorder,
drug abuse, other anxiety disorders, and eating disorders. According to
Yehuda and McFarlane [35], ‘‘the relative rareness of pure PTSD, compared
to the presence of more complex forms, suggests that traumatic stress may
precipitate a whole host of symptoms and conditions.’’ In this section, the
authors review several stress-related conditions and examine their associa-
tions with PTSD.

Complicated grief
Diagnostic and Statistical Manual-IV includes bereavement as a ‘‘V’’
code contained in the section ‘‘other conditions that may be a focus of clin-
ical attention.’’ Despite clinical observations by various authors, including
Freud [36], Lindemann [4], Bowlby [37], Parkes [38], and Horowitz [39], that
prolonged grief reactions are functionally impairing and often differ from
diagnostic classifications of depression or other established psychiatric dis-
orders, the makers of DSM-IV excluded complicated or prolonged grief
as an axis I diagnosis because of a lack of empirical evidence regarding the
symptoms [40]. Since that decision was made, at least two separate groups of
investigators have provided empirical data suggesting that a diagnostic cat-
egory of complicated grief may be appropriate.
Prigerson et al [41] found a distinction between depressive symptoms and
symptoms of complicated grief in 82 recently widowed elderly individuals.
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Complicated grief is characterized by persistent intense grief, with yearning,

pining, and longing for the deceased, recurrent intrusive images of the death,
and a distressing admixture of avoidance and preoccupation with reminders
of the loss. Memories of the deceased are either blocked or excessively sad.
Prior episodes of major depression seem to be risks for the development of
complicated grief. Prigerson and colleagues found that bereaved individuals
who meet criteria for complicated grief were substantially more impaired
psychiatrically, socially, and medically and had greater mortality rates than
bereaved individuals who did not evidence complicated grief. Similarly,
Horowitz et al [39] reported that 70 bereaved spouses had symptom patterns
that did not overlap with those of major depressive disorder. Symptoms
included intense intrusive thoughts, pangs of severe emotion, distressing
yearnings, feeling excessively alone and empty, excessively avoiding tasks
reminiscent of the deceased, unusual sleep disturbances, and maladaptive
levels of loss of interest in personal activities more than 1 year after the loss.
Prigerson et al and Horowitz et al emphasized that complicated grief over-
laps with symptoms of PTSD but is not identical to it. Both groups also
found symptoms of complicated grief, even when the death was not partic-
ularly sudden or violent.
The situation may be even more complicated and more akin to PTSD
when the death is ‘‘unnatural’’ and violent, such as a homicide, suicide, or
accidental. In addition to the separation distress seen after such a loss, vio-
lent death also may incite traumatic distress as manifested by cognitive
reenactment of the dying, terror, and avoiding reminders of the dying
[42]. Adults who lost a family member to homicide had recurring images
of the violent death as a disorganizing flashback and dream and showed
greater degrees of bereavement and trauma than normal subjects and other
cohorts of bereaved subjects [43]. Zisook et al [31] found that death from
accident or suicide was associated with PTSD symptoms in newly bereaved
spouses. The consensus criteria [44] developed by Prigerson and colleagues
may help facilitate additional research and the development of standardized
diagnostic criteria. Further study also is needed in this unique population to
address traumatic or complicated grief as a subgroup of PTSD.

Somatization
The earliest descriptions of the effects of trauma on individuals focused
on physical manifestations. In defining the new category of PTSD, however,
the framers of DSM-III focused on the psychological symptoms of reexper-
iencing a traumatic event, avoidance and numbing, and hyperarousal. Sub-
sequently, several studies found high rates of somatic symptoms in persons
with PTSD. Most of these studies addressed the relationship between com-
bat-related PTSD and physical symptoms.
Beckham et al [45] showed that somatization and PTSD symptom
severity in Vietnam veterans were related to self-reported health problems
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and not the sole result of self-report bias. In a study of 21,244 Gulf War vet-
erans, the number of physical complaints was higher in veterans with PTSD
compared to those with any other psychological condition, those with a
medical illness, and those labeled as healthy [46]. The most common somatic
symptoms included fatigue, sleep disturbance, joint pain, memory loss,
headache, depressed mood, and difficulty concentrating. In addition to com-
bat-related PTSD, McFarlane et al [12] showed high rates of physical
complaints in a community sample of firemen with PTSD. Based on data
from an event-related potential study that showed that individuals with
PTSD had lower responsiveness to external stimuli and a general difficulty
in evaluating the significance of stimulus change, McFarlane posited that
somatization may be explained by an impaired ability to differentiate rele-
vant from irrelevant stimuli and a tendency to focus on and misinterpret
somatic sensations. In the DSM-IV field trials, high levels of association
between trauma and somatization were reported [24]. A prospective study
by Andreski et al [47] found increased risk of somatization symptoms in per-
sons with PTSD beyond that expected by the presence of comorbid psy-
chiatric disorders.
Rather than considering co-occurring PTSD and somatization disorder
as totally separate conditions, further research is needed to discern whether
somatization may be one potential pathway for trauma to express itself psy-
chologically, just as there are somatic symptoms in depression and other
anxiety disorders. Prospective studies may help discern whether there is a
subgroup of PTSD sufferers who have prominent somatic complaints and
how this subgroup differs from individuals with fewer somatic symptoms.
van der Kolk et al [24] found a substantial number of persons who, even
after their PTSD symptoms had resolved, continued to suffer from high lev-
els of somatization. This group is unlikely to receive effective clinical care if
their symptoms are not viewed from a dimensional perspective.

Acute stress disorder and dissociation

By current definition, PTSD requires minimum symptom duration of 1
month. Before DSM-IV, persons who experienced PTSD symptoms from
severe trauma for less than 1 month were given the nonspecific diagnosis
of adjustment disorder. The diagnostic nomenclature did not recognize a
difference between persons who experienced mild, transient difficulties
caused by a stressor and persons with severe PTSD symptoms of less than
1 month. To address this problem, the diagnosis of acute stress disorder was
added to DSM-IV, which added a category to handle spectrum-like phe-
nomena. The significant differences between acute stress disorder and PTSD
are an increased emphasis on dissociative symptoms in acute stress disorder
and duration of symptoms of less than 1 month [48]. Several retrospective
and prospective studies found that PTSD was predicted by dissociation at
the time of or immediately after trauma [49]. Acute stress disorder serves
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as an important risk factor for the development of PTSD. Still, there could
be a group with subthreshold or full PTSD symptoms for less than 1 month
who did not experience dissociation and would be diagnosed by current con-
ventions as having an adjustment disorder.
Marshall et al [50] reviewed six prospective and two retrospective studies
to determine the proportion of trauma survivors who had PTSD symptoms
of less than 1 month’s duration or who met full criteria for PTSD yet did not
have prominent dissociative symptoms at the time of trauma. They did not
meet criteria for acute stress disorder. These studies showed a substantial
number of persons with PTSD symptoms of less than 1 month who did not
meet criteria for acute stress disorder, based on a lack of substantial disso-
ciative symptoms around the time of the event. The data showed that acute
stress disorder was indicative of greater severity and chronicity of PTSD,
however. Using a dimensional approach, individuals who do not respond
symptomatically to trauma are at one end of the spectrum. They constitute
the largest number of people along the spectrum of PTSD. A second group
meets criteria for an adjustment disorder. Further along the spectrum of
PTSD severity are persons who also experience peri-traumatic dissociation
(eg, have an acute stress disorder). This group is not only at higher risk to
develop PTSD but also is likely to develop a severe and chronic case. The
most severe point on the spectrum is complicated PTSD, in which depres-
sion, panic disorder, and other comorbid conditions are evident.

Borderline personality disorder

Because of the broad range of symptoms seen in survivors of trauma,
clinicians may incorrectly identify those symptoms as character pathology
rather than a response to trauma [51]. Zanarini et al [52] studied 504 inpa-
tients with personality disorders and found PTSD to be a common comor-
bid disorder among borderline patients. Numerous reports describe
childhood traumatic experiences in adult patients diagnosed with borderline
personality disorder [53–55] and other reports of traumatic childhood expe-
riences as common antecedents of PTSD [56,57]. Although there is currently
a paucity of research in this area, the diagnosis of borderline personality dis-
order often may be a misattribution of symptoms more correctly concep-
tualized as chronic PTSD.

Major depressive disorder and posttraumatic stress disorder

Several studies have found high rates of comorbid major depression in
persons diagnosed with PTSD [10,14,29,58–60]. When PTSD is comorbid
with major depression, a chronic course often results. The relationship
between major depressive disorder and PTSD is complex; the temporal rela-
tionship is variable. Some investigators have demonstrated that preexisting
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depression serves as a risk factor for PTSD [56,61]. Others have found that
depression is often secondary to PTSD [10,61,62]. The complexity of the
relationship is highlighted by a study that examined the development of
PTSD and major depressive disorder in adult offspring of Holocaust survi-
vors. Yehuda and colleagues found a strong relationship between parental
PTSD and the occurrence of PTSD in offspring. Parental trauma exposure
more than parental PTSD, however, was significantly associated with life-
time depressive disorder in offspring [63].
Several investigators have suggested that the three most common impair-
ing psychological sequelae from traumatic stress are PTSD alone, major
depressive disorder alone, or comorbid PTSD and major depressive disorder
[64–67]. Breslau et al [68] reviewed retrospective and prospective data from
the Epidemiologic Study of Young Adults in southeast Michigan [58] to
demonstrate whether traumatic events increased the risk for depression
independent of their PTSD effects. Breslau et al found a markedly increased
risk for major depression in persons with PTSD but not in persons exposed
to trauma who did not develop PTSD. This increased risk suggests that
PTSD and major depression may share a common underlying vulnerability.
Stated otherwise, major depression after traumatic events and PTSD do not
have separate vulnerabilities but exist along a spectrum of potential sequelae
of traumatic experiences.

Other anxiety disorders

Several authors have elaborated on the phenomenologic similarities
between PTSD and other anxiety disorders for panic disorder [69,70], pho-
bic anxiety [71,72], and generalized anxiety disorder [73]. Episodic physio-
logic arousal or intense fear cued by stimulus exposure is seen in panic
disorder, phobic anxiety, and PTSD. PTSD and generalized anxiety disorder
are associated with poor concentration, irritability, hypervigilance, exagger-
ated startle response, and sleep disturbance. According to the National
Comorbidity Survey [10], the estimates of lifetime prevalence of other anxi-
ety disorders in persons with a lifetime history of PTSD were significantly
greater than persons without a lifetime history of PTSD. Comorbidity may
be explained in part by the significant overlap in symptomatology. As with
major depression, some investigators also have found that anxiety disorders
other than PTSD can occur after trauma, either alone or as a comorbidity
with PTSD [65,66]. This finding suggests that a possible spectrum of anxi-
ety-related symptoms and symptom clusters can follow trauma.
A handful of studies also have examined the relationship of PTSD to
obsessive-compulsive disorder. Historically, Janet observed that obsessive-
compulsive disorder can be a consequence of emotional shock [71]. Kardiner
described ‘‘defensive ceremonials’’ associated with traumatic neuroses [74].
Both conditions are associated with persistent, recurrent, intrusive, and
unwelcome images, thoughts, or memories. The major difference between
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the intrusive thoughts in obsessive-compulsive disorder and thoughts in

PTSD are that the intrusive thoughts in obsessive-compulsive disorder are
viewed by the individual as inappropriate and not related to experienced
trauma. The intense fear, helplessness, or horror associated with the trau-
matic event in PTSD is generally not experienced in patients with obsessive-
compulsive disorder. According to an epidemiologic catchment area survey
of the general population, the risk of obsessive-compulsive disorder is
increased 10-fold in persons with PTSD [29]. In veterans of high war zone
stress, the prevalence of obsessive-compulsive disorder is 5.2% compared
to 0.3% in veterans of low to moderate war zone stress [75]. There seems
to be evidence, albeit limited at this time, of a possible PTSD–obsessive-
compulsive disorder dimension, similar to that observed in other anxiety
disorders.

Summary
An understanding of PTSD and stress-related conditions is in its infancy.
This is not surprising given the fact PTSD was not recognized as a distinct
diagnostic entity until 1980. Since that time, the diagnostic classification has
undergone continuous change as our understanding of PTSD is refined. The
authors believe that PTSD can be best understood through a dimensional
conceptualization viewed along at least three spectra: (1) symptom severity,
(2) the nature of the stressor, and (3) responses to trauma.
Along the severity spectrum, studies that review diagnostic thresholds
reveal significant prevalence of PTSD symptoms and impairment that
results from subthreshold conditions. Comorbidity patterns suggest that
when PTSD is associated with other psychiatric illness, diagnosis is more
difficult and the overall severity of PTSD is considerably greater. With
regard to a stressor criteria spectrum, the diagnostic nomenclature initially
only recognized severe forms of trauma personally experienced. More
recently, however, the person’s subjective response and events occurring
to loved ones were included. This has greatly broadened the stressor criteria
by leading to an appreciation of the range of precipitating stressors and the
potential impact of ‘‘low-magnitude’’ events. Given that responses to trau-
ma vary considerably, another possible spectrum includes trauma-related
conditions. Traumatic grief, somatization, acute stress disorder and dissoci-
ation, personality disorders, depressive disorders, and other anxiety disor-
ders all have significant associations with PTSD.
Further research is needed to clarify and expand the current understand-
ing of PTSD and other trauma-related conditions. Consideration of the
severity of symptoms and the range of stressors coupled with the various
disorders precipitated by trauma should greatly influence scientific research.
The future undoubtedly will bring a refinement of the current understanding
of PTSD and improved treatments.
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