Posttraumatic stress disorder in time of COVID-19: Trauma or not trauma, is that the question?

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1111/acps.13336.

Many studies have reported negative outcomes of the COVID‐19 pandemic on people's mental health. Notably, high prevalence rates of posttraumatic stress disorder (PTSD) symptoms have been described in healthcare workers (26.9% [20.3%–33.6%]), in individuals with COVID‐19 (23.8% [16.6%–31.0%]), and in the general population (19.3% [15.3%–23.2%]). According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM‐5), the diagnosis of PTSD requires, in addition to these symptoms, exposure to a traumatic event, defined in criterion A as direct or indirect exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. While healthcare workers and individuals with COVID‐19 have for the most part been directly (or indirectly) exposed to actual or threatened death, it is unclear whether the pandemic context as a whole or some specific pandemic‐related consequences such as quarantine measures and socio‐economic repercussions might be considered as traumatic and meet criterion A for the general population. We defend the idea that the pandemic context stresses the need to reopen the old debate on criterion A.

First, recent findings suggest that pandemic‐related events could be associated with the subsequent occurrence of PTSD symptoms. Quarantine, for example, while not meeting criterion A, appears to be a major risk factor for post‐pandemic PTSD as suggested by Yuan et al. (2021). A high prevalence rate of probable PTSD 1 month after the lift of the first quarantine was also found in the COSAMe national survey, a cross‐repeated study including French University Students. Notably, this survey highlighted that quarantine was more likely to be considered as “traumatic” by students than being infected with SARS‐CoV2, and even more than being hospitalized for COVID‐19 among students with probable PTSD.

If the debate on whether or not the pandemic and quarantine measures are traumatic or stressful is inextricable, it resonates with the progressive evolution of criterion A across the DSM editions. Although the diagnosis of PTSD has always been conditioned to the experience of a traumatic event, the last edition of the DSM removed the subjective response to the traumatic event from criterion A, which has been considered by several authors as a clarification to distinguish between a traumatic and a stressful event. Importantly, these discrepancies result in large variations in prevalence rates. For example, Kilpatrick et al. found that 25% of lifetime DSM‐IV PTSD failed to meet DSM‐5 criteria. This variability as well as the many situations where the type of event studied does not strictly meet criterion A led several authors to circumvent the problem. Some have introduced the notion of “potentially traumatic event” to refer to traumatic events inter‐changeably with criterion A, others defined COVID‐19 pandemic as a “traumatic stressor.” Beyond those avoidance strategies, we are convinced that an overly restrictive view of what the DSM‐5 arbitrarily defines as a traumatic event carries the risk to hamper the provision of appropriate care for the patients concerned.

Although some specific types of traumas may have prognostic value, several studies support that the presence or absence of criterion A is not a determinant factor to predict the evolution of mental health symptoms after a stressful event. Roberts et al. found that mental and physical sequelae of PTSD did not vary with precipitating event type (considered qualifying or not qualifying stressors according to the DSM‐IV), and concluded that PTSD may be explained by an aberrantly severe but nonspecific stress response syndrome. In the same vein, van den Berg et al. (2017) found that patients reporting a stressful event (not meeting the A1 criterion of the DSM‐IV‐TR) presented at least the same levels of PTSD symptom severity as patients reporting a traumatic event (as defined by DSM‐IV‐TR), suggesting that stressful life events, not classified as traumatic, can nonetheless generate PTSD symptoms. Thus, in the COVID‐19 pandemic context, the strict application of DSM‐5 criterion A could leave a large number of patients without the appropriate care.

The COVID‐19 pandemic context reopens the long‐standing debate around the definition of a traumatic event, which has changed considerably across the DSM editions. There is indeed an urgent need to question the nosography of PTSD as well as the relevance of criterion A in order not to leave a large number of people with PTSD symptoms without the appropriate care.