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The stressor Criterion-A1 and PTSD:

A matter of opinion?
Alexander McFarlane
Journal of Anxiety Disorders

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 Journal of Anxiety Disorders 23 (2009) 77–86

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

The stressor Criterion-A1 and PTSD: A matter of opinion?

Miranda Van Hooff *, Alexander C. McFarlane, Jenelle Baur, Maria Abraham, Daniel J. Barnes
University of Adelaide, The Centre for Military and Veterans’ Health, Level 2/122 Frome Street, Adelaide, South Australia 5000, Australia

A R T I C L E I N F O A B S T R A C T

Considerable controversy exists with regard to the interpretation and definition of the
Article history:
Received 15 November 2007 stressor ‘‘A1’’ criterion for Post Traumatic Stress Disorder (PTSD). At present, classifying an
Received in revised form 10 April 2008 event as either traumatic (satisfying DSM-IV Criterion-A1 for PTSD), or non-traumatic (life
Accepted 10 April 2008 event) is determined by the rater’s subjective interpretation of the diagnostic criteria. This
Keywords:
has implications in research and clinical practice. Utilizing a sample of 860 Australian
PTSD adults, this study is the first to provide a detailed examination of the impact of event
Post Traumatic Stress Disorder categorization on the prevalence of trauma and PTSD. Overall, events classified as non-
Diagnosis traumatic were associated with higher rates of PTSD. Unanimous agreement between
Classification raters occurred for 683 (79.4%) events. As predicted, the categorization method employed
Trauma (single rater, multiple rater-majority, multiple rater-unanimous) substantially altered the
Life events prevalence of Criterion-A1 events and PTSD, raising doubts about the functionality of PTSD
diagnostic criteria. Factors impacting on the categorization process and suggestions for
minimizing discrepancies in future research are discussed.
! 2008 Elsevier Ltd. All rights reserved.

1. Introduction defines a traumatic event as being an event ‘‘of an

Post Traumatic Stress Disorder (PTSD) is unusual in
psychiatric nomenclature because the aetiological agent,
namely the traumatic stressor, is defined within the
diagnostic criteria implying a direct casual link between a
definable external factor and consecutive symptoms (Maier,
2006). Since definition of stress disorder in DSM-III
(American Psychiatric Association, 1980), the effects of
traumatic stress have been widely researched. However, the
definition of the boundaries of the stressor ‘‘A1’’ criterion has
emerged as one of the most controversial aspects of the
diagnostic criteria (Breslau & Davis, 1987; March, 1993;
Solomon & Canino, 1990; Spitzer, First, & Wakefield, 2007).
For example, according to DSM-IV (American Psychiatric
Association, 1994) to qualify as a traumatic event such an
event should involve ‘‘actual or threatened death or serious
injury, or threat to the physical integrity of self or others’’ (p.
427). In contrast, ICD-10 (World Health Organization, 1992)
* Corresponding author. Tel.: +61 8 8303 5200; fax: +61 8 8303 5368.
E-mail address: miranda.vanhooff@adelaide.edu.au (M. Van Hooff).
exceptionally threatening or catastrophic nature, which is
likely to cause pervasive distress in almost anyone’’ (p. 147).
The lack of clarity and vagueness of the Criterion-A1
language has consequently lead to an over-application of the
construct of ‘trauma’ resulting in what McNally has termed a
‘‘conceptual bracket creep’’ (McNally, 2003; Spitzer et al.,
2007), resulting in the abuse of this diagnosis in real life
settings (Rosen & Taylor, 2007).
Considerable debate exists about whether or not events
that typically do not meet Criterion-A1 (referred to as life
events, non-traumatic events or low magnitude events)
can result in the development of PTSD (Avina & O’Donohue,
2002; Gold, Marx, Soler-Baillo, & Sloan, 2005; McNally,
2003). It is implied in DSM-IV that an extremely traumatic
event has a unique etiological effect in comparison to less
dramatic life events and that there is a quantitatively and
qualitatively different relationship between these two
types of events and consequent psychopathology (Lindy,
Green, & Grace, 1987). If this is the case, then while a
person who has experienced a ‘‘life event’’ may describe
this event as ‘‘traumatic,’’ a diagnosis of PTSD generally
cannot be given if that event does not meet DSM-IV PTSD

0887-6185/$ – see front matter ! 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.janxdis.2008.04.001
78 M. Van Hooff et al. / Journal of Anxiety Disorders 23 (2009) 77–86
Criterion-A1. In the absence of sufficient evidence to
support a diagnosis of PTSD, adjustment disorder would
become the relevant diagnosis, as this disorder requires an
identifiable stressor of any severity. The real conundrum,
therefore, is how do we define a stressor as ‘‘traumatic’’
without relying on our own subjective interpretation of the
definition of Criterion-A1 and, if PTSD symptoms occur in
response to life events, should Criterion-A1 be widened to
incorporate such stressors (Avina & O’Donohue, 2002; Gold
et al., 2005)?
A number of cases have been reported whereby PTSD
symptoms have been experienced as a result of tradition-
ally defined ‘‘non-traumatic’’ or ‘‘life events.’’ For example,
in response to miscarriage, spousal affair (Helzer, Robins, &
McEvoy, 1987), marital disruption and collapse of adoption
arrangements (Burstein, 1985), non-serious nor life-
threatening physical assault (Seidler & Wagner, 2006),
work-related stressors, caring for a chronically ill loved one
(Scott & Stradling, 1994), and loss of cattle due to foot and
mouth disease (Olff, Koeter, Van Haaften, Kersten, &
Gersons, 2005).
Inconsistent findings, however, have been reported in
studies comparing PTSD prevalence rates following
Criterion-A1 and other non-traumatic life events. Kilpa-
trick et al. (1998) examined prevalence of PTSD in a sample
who had experienced no event, a ‘‘low magnitude event’’
(non-traumatic life event) or a ‘‘high magnitude event’’
(Criterion-A1 event) and found only a minimal increase in
overall PTSD prevalence when broadening the A1 criterion
to include low magnitude events such as the non-violent
death of a loved one, serious illness and sudden divorce. In
a similar study, Hovens and Van der Ploeg (1993) found no
significant differences between the non-traumatic life
event and no event groups on self-reported PTSD scores
using both the MMPI-PTSD and the Mississippi PTSD scale
for civilians (Keane, Caddell, & Taylor, 1988; Keane, Malloy,
& Fairbank, 1984), but significantly higher PTSD scores in
those classified as experiencing a Criterion-A1 event.
In contrast, most other studies have reported similar or
greater mean PTSD scores and/or PTSD prevalence in
individuals reporting non-traumatic life events compared
to those who report Criterion-A1 events (Bodkin, Pope,
Detke, & Hudson, 2007; Gold et al., 2005; Mol et al., 2005;
Solomon & Canino, 1990; Spitzer et al., 2000).
In general, studies examining the prevalence of
Criterion-A1 events and PTSD utilize one of three methods
of categorization; (1) a single rater determines whether an
event meets Criterion-A1 according to his/her interpreta-
tion of the definition specified in ICD-10 or DSM-IV
(Roemer, Orsillo, Borkovec, & Litz, 1998); (2) multiple
raters independently rate the event with majority agree-
ment being required before an event is categorized as
meeting Criterion-A1 according to the definition specified
in ICD-10 or DSM-IV (Hovens & Van der Ploeg, 1993); (3)
multiple raters independently rate events with unanimous
agreement being required before an event is categorized as
meeting Criterion-A1 according to the definition specified
in ICD-10 or DSM-IV (Bodkin et al., 2007). Other studies
appear to use multiple raters, who discuss and reach a
consensus as a group as to which events meet Criterion-A1
according to the definition specified in ICD-10 or DSM-IV
(Gold et al., 2005; Goodman, Corcoran, Turner, Yuan, &
Green, 1998).
One problem inherent in both the single and multiple
rater categorization systems is the level of subjectively
required on behalf of the raters to interpret Criterion-A1.
The use of multiple raters (rather than a single rater) is an
attempt to reduce such subjectivity. However, further
discrepancies then arise according to which method of
agreement is employed—majority or unanimous. This
dilemma is illustrated in a study of 27 psychiatric
inpatients conducted by Hovens and Van der Ploeg
(1993). Using a majority method of scoring, 5 raters
categorized 15 events as meeting DSM-IV Criterion-A1. In
contrast however, only 1 event was unanimously agreed
upon by all 5 raters as meeting DSM-IV Criterion-A1. Such
discrepancy in prevalence of Criterion-A1 events between
the unanimous and majority coding methods highlights
the need to consolidate the methods of event categoriza-
tion across studies. Although the unanimous method of
classification in this instance may reduce categorization
discrepancies, it also has the potential to lower PTSD
prevalence rates due to the lower overall prevalence of
Criterion-A1 events. The impact of categorization differ-
ences is somewhat overlooked in research into PTSD
resulting from Criterion-A1 and non-traumatic life events,
but could account for some of the discrepancies that have
emerged in the literature.
The current study is the first to provide a detailed
examination of the impact of event categorization on the
prevalence rates of trauma and PTSD. There are three
primary aims of this study. First, to explore in detail the
types of events that lead to the most disagreement among
raters. Second, to provide a descriptive account of whether
the prevalence of Criterion-A1 events and non-traumatic
life events differs according to the categorization method
employed (single rater, multiple raters—majority method,
multiple raters—unanimous method). Third, to statistically
examine the subsequent differences in lifetime PTSD
prevalence resulting from Criterion-A1 events and non-
traumatic life events, and to determine whether PTSD
prevalence also differs according to the type of categor-
ization method used.
2. Method
2.1. Participants
Participants were part of a larger longitudinal study
examining the psychiatric outcomes of childhood expo-
sure to a natural disaster. The original cohort, recruited
from 1983 to 1985, comprised 806 children aged between
5 and 12 years who were attending primary school in a
rural region of South Australia, vastly devastated by the
1983 Ash Wednesday Bushfires (McFarlane, 1987b;
McFarlane, Policansky, & Irwin, 1987). A control group of
725 unexposed primary school children from a socio-
demographically matched neighbouring rural community
were recruited 16 months following the fires.
There were 1011 bushfire survivors and controls that
were followed-up in adulthood, approximately 20 years
later. The remaining participants from the original sample
 M. Van Hooff et al. / Journal of Anxiety Disorders 23 (2009) 77–86
were either deceased (N = 20), withdrew (N = 111), refused
to participate (N = 148), could not be contacted (N = 193)
or were excluded for other reasons (N = 48). Of the 1011
that were followed-up and agreed to participate, 20 had
incomplete data (i.e. did not complete the interview
component of the study, the lifetime traumatic events
measure or the entire PTSD assessment measures) and
were excluded from the analyses. A further 129 partici-
pants were excluded because they either had not
experienced a traumatic event, or had experienced a
lifetime traumatic event but specifically stated that the
event had no adverse impact on them and therefore
requested not to complete the PTSD symptom questions
for that event. Finally, 2 were excluded because they were
unable to nominate which single event out of all their
lifetime traumatic events was their ‘‘worst.’’ The final
sample therefore comprised 860 participants, including
433 (50.3%) females and 427 (49.7%) males, ranging in age
between 23 and 34 years (M = 28.3, S.D. = 2.30). Two thirds
of the sample was either married (40.8%) or living in a de
facto relationship (26.6%), 4% of participants were cur-
rently separated or divorced and 28.7% had never been
married. Sixty-nine percent of participants had completed
year 12 and 68.6% had completed post-school qualifica-
tions such as a trade, certificate, diploma or degree. Sixty-
five percent of participants were employed fulltime, 16.3%
were employed part time, 2.2% were unemployed and
15.8% were not currently in the labor force.
2.2. Measures
2.2.1. Demographics
Demographic characteristics were assessed using ques-
tions drawn from the National Survey of Mental Health and
Wellbeing (Australian Bureau of Statistics, 1998, 1999).
2.2.2. Lifetime exposure to traumatic events
Lifetime exposure to trauma was assessed using the
standard set of 10 Criterion-A events from the Compo-
site International Diagnostic Interview (CIDI) (World
Health Organization, 1997). These were direct combat,
life-threatening accident, fire, flood or natural disaster,
witnessed someone badly injured or killed, rape, sexual
molestation, serious physical attack or assault, threa-
tened with a weapon/held captive/kidnapped, tortured
or victim of terrorists, and other stressful event. In
addition, the researchers included seven other event
types (domestic violence, witnessed domestic violence,
threatened/harassed without a weapon, finding a dead
body, witnessing someone suicide or attempt suicide,
child physical abuse, child emotional abuse). These
events were chosen based on the authors’ clinical and
research experience with traumatized populations.
Participants were asked whether they had experienced
any of these events and whether they experienced a
great shock due to any of these events happening to
someone close to them. They were then asked to
nominate which of these events was their worst lifetime
event and to provide a brief description of that event.
PTSD was assessed in reference to this self-nominated
worst lifetime event.
79
To enable a detailed examination of event types, events
that were reported by participants in response to ‘any
other stressful event’ were examined and further cate-
gorised. If three or more participants reported a similar
event it was assigned its own category, leading to a further
8 event categories (death of a loved one, loved one
attempted/committed suicide, miscarriage, still birth,
relationship problems/separation, parent divorce/leaving,
job stressors, medical illness/complication experienced by
a loved one). An ‘other’ category remained for the events
that were reported by one or two participants, such as
death of a pet and abortion. Events were also divided into
three broad categories: events that happened to self,
witnessing an event that happened to another, and
learning about an event happening to another.
2.2.3. Lifetime PTSD
PTSD was assessed using a computerized version of the
Composite International Diagnostic Interview. The CIDI is a
structured, standardised and comprehensive interview
used to assess current and lifetime prevalence of mental
disorders in adults, based on the Diagnostic and Statistical
Manual for Mental Disorders—4th edition (DSM-IV;
American Psychiatric Association, 1994). The CIDI was
chosen in this study for three main reasons; it is designed
to be administered by lay interviewers, it is a widely used
instrument in epidemiological surveys, and has previously
been validated in a Australian Population as part of the
1997 Australian National Mental Health and Wellbeing
Survey (Andrews & Peters, 1998).
A diagnosis of PTSD was scored according to the standard
CIDI scoring criteria of 0 (‘indeterminate diagnosis’), 1
(‘criteria not met’), 3 (‘positive criteria met but exclusion not
met’) and 5 (‘all diagnostic criteria met’). The participants
were diagnosed with lifetime PTSD if they scored 3 or 5.
Studies have found that the CIDI has excellent inter-
rater reliability, and satisfactory test-retest reliability and
validity in Australia and a variety of other settings
worldwide (Andrews & Peters, 1998; Wittchen et al.,
1991). To ensure reliability and validity in the current
study, research psychologists who had extensive experi-
ence and training in telephone recruitment, interviewing
and psychiatric assessment conducted the interviews. A
panel consisting of a psychiatrist and three research
psychologists reviewed the scoring of structured inter-
views on a weekly basis.
2.3. Procedure
Original participants were traced to their current
addresses through archived school admission records, the
State Department of Births, Deaths and Marriages, the
Australian Electoral Commission, and advertisements in
local newspapers. A National Death Registry was used to
identify the deceased. Initial contact with the participants
was by letter, followed by a telephone call from a research
psychologist inviting them to participate. Informed consent
was obtained from participants after the nature of the
procedures had been fully explained. Consenting partici-
pants were asked to participate in a 1-h telephone interview
and complete and return a self-report booklet. Participants
80 M. Van Hooff et al. / Journal of Anxiety Disorders 23 (2009) 77–86
did not receive compensation for their participation. The
University of Adelaide Human Research Ethics Committee
and the Australian Institute of Health and Welfare research
committee approved the study protocol, and the investiga-
tion was carried out in accordance with the latest version of
the Declaration of Helsinki.
In order to achieve the aims of this study, three raters,
blind to each other’s ratings, independently coded each of
the worst lifetime events using the participant’s narratives
of the event. They were coded as either a Criterion-A1
event or non-traumatic life event in strict accordance with
DSM-IV Criterion-A1. The three raters comprised a
psychiatrist and two research psychologists, all with
extensive experience in PTSD.
Analyses were then conducted using the following
categorization methods: (1) the scoring of each single
rater, (2) the majority scoring method, whereby the
stressor was coded as a Criterion-A1 or non-traumatic life
event according to the category nominated by at least two
of the three raters, and (3) the unanimous scoring method,
whereby an event was coded as a Criterion-A1 or non-
traumatic life event only if all raters unanimously agreed
so, and equivocal if there was any disagreement.
2.4. Statistics
Descriptive statistics allowed for the exploration of the
level of disagreement between raters for each event type
and the proportion of events that were coded as Criterion-
A1 and non-traumatic life events using the five different
categorization methods (rater 1, rater 2, rater 3, majority,
unanimous). Kappa was calculated to determine the level
of agreement between the three individual raters.
Chi-square analyses examined if there was a significant
difference between the proportions of participants that
met lifetime PTSD criteria for non-traumatic life events
compared to Criterion-A1 events. This was conducted
separately for the different categorization methods.
Relative risks were also calculated. Descriptive statistics
were used to examine the prevalence of PTSD for different
event types.
The Statistical Package for the Social Sciences (SPSS)
Version 11 was used to conduct the statistical analyses. A
p < .05 significance level was chosen.
3. Results
3.1. Categorization of traumatic and non-traumatic events
Overall, unanimous agreement occurred for 683 (79.4%)
events. The greatest level of agreement between raters
occurred for events that were witnessed (88.7%), followed
by events that happened to self (84.9%), and then events
that were learnt about (63.1%). Specific event types
associated with the highest level of disagreement
included: being threatened/harassed without a weapon
(unanimous agreement on only 34.2% of occasions), child
physical abuse (66.7%), and events that were learnt about
but not experienced directly (see Table 1). There was
unanimous agreement on all cases of direct combat, rape,
being tortured, and having a stillbirth baby, with these
events consistently classified by all raters as meeting
Criterion-A1 for PTSD. In relation to non-traumatic life
events, unanimous agreement was reached for the
following events: relationship problems, parental
divorce/separation, and job stressors, with all three raters
rating these events as a non-Criterion-A1 event.
In general, raters 1 and 2 (both research psychologists)
had the highest level of agreement (Kappa = .680). Rater 3,
the psychiatrist, had the lowest level of agreement with
rater 1 (Kappa = .538), followed by rater 2 (Kappa = .593).
All Kappa statistics were significant at p < .001.
3.2. Prevalence of non-traumatic life, Criterion-A1 and
equivocal events using the different methods of categorization
As can be seen in Table 2, the proportion of lifetime
Criterion-A1 traumatic events varied according to the
categorization method employed. As expected, the major-
ity method resulted in a highest prevalence of Criterion-A1
traumatic events (79.8%) in this population in comparison
to the unanimous method of categorization (66.7%).
3.3. Prevalence of PTSD for non-traumatic life events,
Criterion-A1 events and equivocal events using the different
methods of categorization
In total, 68 (7.91%) of the 860 participants that reported
a ‘‘worst’’ event met lifetime DSM-IV criteria for PTSD.
Table 3 reports relative risks of having PTSD following a
non-traumatic life event compared to Criterion-A1 event
(and an equivocal event) using the different categorization
methods. In all the categorization methods, non-traumatic
life events were associated with significantly higher
lifetime PTSD prevalence rates than Criterion-A1 events
(single rater categorization: rater 1: N = 860, X2(1) = 5.752,
p = .016; rater 2: N = 860, X2(1) = 5.965, p = .015; rater 3:
N = 860, X2(1) = 4.851, p = .028; majority categorization:
N = 860, X2(1) = 3.855, p = .05; unanimous categorization:
N = 683, X2(1) = 14.805, p = .001). The unanimous categor-
ization method also led to significantly higher PTSD
prevalence in the non-traumatic life events compared to
equivocal events group (N = 286, X2(1) = 14.607, p < .001).
However, there was no statistically significant difference
between the rates of lifetime PTSD resulting from
Criterion-A1 and equivocal events (N = 751,
X2(1) = 1.356, p = .294). The highest risk of PTSD for the
non-traumatic life event group relative to the Criterion-A1
event group occurred when the unanimous method was
used. Participants reporting non-traumatic life events
were 2.63 (CI = 1.60–4.32) times more likely than those
reporting Criterion-A1 events to meet PTSD criteria using
this method.
Interestingly, all the PTSD positive cases in the
equivocal group using the unanimous categorization
method moved to the Criterion-A1 group when the
majority method was used. That is, two out of three raters
agreed that that all of the PTSD positive equivocal events
were Criterion-A1 events.
Fig. 1 shows the specific event types that led to the
highest PTSD prevalence using the unanimous method.
Criterion-A1 event types that were associated with the
 M. Van Hooff et al. / Journal of Anxiety Disorders 23 (2009) 77–86 81

Table 1
Levels of agreement among ratings of non-traumatic life events and Criterion-A1 events based on the unanimous categorization method

Disagree N (%) Agree N (%) Total N

Non-traumatic Criterion-A1

Event happened to self total 72 (15.1) 74 (15.5) 332 (69.5) 478

Direct combat – – 2 (100.0) 2
Life-threatening accident 8 (9.4) 2 (2.4) 75 (88.2) 85
Fire, flood, or natural disaster 16 (9.2) 21 (12.1) 136 (78.6) 173
Rape – – 18 (100.0) 18
Sexual molestation 2 (7.4) – 25 (92.6) 27
Serious physical attack/assault 3 (14.3) – 18 (85.7) 21
Threatened with a weapon/held captive/kidnapped 2 (10.5) – 17 (89.5) 19
Tortured or victim of terrorists – – 2 (100.0) 2
Domestic violence 5 (20.8) 3 (12.5) 16 (66.7) 24
Threatened/harassed without a weapon 25 (65.8) 8 (21.1) 5 (13.2) 38
Finding dead body 4 (26.7) – 11 (73.3) 15
Child abuse—physical 2 (33.3) – 4 (66.7) 6
Child abuse—emotional 2 (10.5) 17 (89.5) – 19
Miscarriage 1 (25.0) 3 (75.0) – 4
Still-birth – – 3 (100.0) 3
Relationship problems/separation – 8 (100.0) – 8
Parents divorced/parent left – 4 (100.0) – 4
Job loss/stressors – 3 (100.0) – 3
Other event that happened to self 2 (28.6) 5 (71.4) – 7

Witnessing an event that happened to another total 16 (11.3) 3 (2.1) 122 (86.5) 141
Witness someone badly injured or killed 6 (5.7) – 99 (94.3) 105
Witnessed domestic violence 6 (28.6) 2 (9.5) 13 (61.9) 21
Witness someone suicide/attempt suicide 4 (28.6) – 10 (71.4) 14
Other witnessed event – 1 (100.0) – 1

Learning about an event happening to another total 89 (36.9) 32 (13.3) 120 (49.8) 241
Direct combat – 1 (100.0) – 1
Life-threatening accident 22 (20.8) – 84 (79.2) 106
Fire, flood, or natural disaster 3 (60.0) 1 (20.0) 1 (20.0) 5
Witness someone badly injured or killed 2 (40.0) 2 (40.0) 1 (20.0) 5
Rape 6 (75.0) – 2 (25.0) 8
Sexual molestation 7 (87.5) 1 (12.5) 8
Serious physical attack/assault 3 (30.0) 1 (10.0) 6 (60.0) 10
Threatened with a weapon/held captive/kidnapped – – 1 (100.0) 1
Tortured or victim of terrorists 1 (100.0) – – 1
Domestic violence 1 (16.7) – 5 (83.3) 6
Witnessed domestic violence – 1 (100.0) – 1
Threatened/harassed without a weapon 2 (100.0) – – 2
Finding dead body – 2 (100.0) – 2
Witness someone suicide/attempt suicide 2 (40.0) 3 (60.0) – 5
Child abuse—physical – 1 (100.0) – 1
Death of a loved one 11 (40.7) 6 (22.2) 10 (37.0) 27
Attempted/committed suicide 21 (70.0) 1 (3.3) 8 (26.7) 30
Medical illness/complications 5 (45.5) 4 (36.4) 2 (18.2) 11
Other learned about event 3 (27.3) 8 (72.7) – 11

highest rates of PTSD included rape (N = 8, 44.4% of rape
victims), and sexual molestation (N = 7, 25.9%). Non-
traumatic life event types that had high levels of PTSD
prevalence included miscarriage (N = 3, 75%), relationship
problems (N = 4, 50%), child emotional abuse (N = 6, 31.6%),
and job stressors (N = 1, 33.3%). Of the participants that
reported PTSD in response to child emotional abuse, 5 of 7
(6 non-traumatic life events and 1 equivocal using the
unanimous method) described school bullying. In total, 10
participants reported school bullying (either under the
arm of emotional abuse or in the other event section),
resulting a lifetime PTSD prevalence of 50%.
4. Discussion
This study is the first published report detailing the
impact of event categorization on the prevalence rates of
trauma and PTSD. The first aim of the study was to explore
the types of events that lead to the highest level of
disagreement among raters. Overall, complete agreement
between the three raters was attained for 79.4% of the
events. This is slightly lower than the level of agreement
(87%: 90 out of 103) between two raters reported in a study
by Bodkin et al. (2007) but higher than the 41% (11 out of
27) agreement between five raters in Hovens and Van der
Ploeg’s (1993) study. The three studies together suggest an
inverse relationship between level of agreement and the
number of raters, emphasizing the degree of subjectivity
that is required to interpret DSM-IV Criterion-A1. The
current study is the largest study of its kind published to
date.
Several events were unanimously agreed upon as
traumatic (meeting Criterion-A1 for PTSD). These were
direct combat, rape, being tortured, and giving birth to a
82 M. Van Hooff et al. / Journal of Anxiety Disorders 23 (2009) 77–86

Table 2 associate’’ which appears in the accompanying text in

Numbers (proportions) of events classified as non-traumatic life,
Criterion-A1 and equivocal using the different methods of categorization
Non-traumatic Criterion-A1
N (%) N (%)
Rater 1 170 (19.8) 690 (80.2)
Rater 2 179 (20.8) 681 (79.2)
Rater 3 220 (25.6) 640 (74.4)
Majority 174 (20.2) 686 (79.8)
Unanimous 109 (12.7) 574 (66.7)
stillborn baby. Non-traumatic life events that were
unanimously agreed upon were relationship problems,
parental divorce/separation, and job stressors. In general,
the Criterion-A1 events that yielded the greatest level of
consensus were those involving direct interpersonal
violence, except for the category of being ‘‘threatened
without a weapon.’’ This suggests that events of lesser
intensity are likely to be the events to cause more
disagreement between raters. The unanimous consensus
between raters for rape supports earlier work by Hovens
and Van der Ploeg (1993). The question of whether this
finding is a true and accurate finding or merely an artifact
of one’s existing knowledge about the link between rape
and PTSD remains to be answered.
Further to this, there were a number of event types that
led to high levels of disagreement between raters. These
events included being threatened without a weapon and
events occurring to a close friend or relative. DSM-IV
(American Psychiatric Association, 1994) Criterion-A1
states that the person has been exposed to a traumatic
event in which ‘‘the person experienced, witnessed, or was
confronted with an event or events that involved actual or
threatened death or serious injury, or threat to the physical
integrity of self or others’’ (p. 427). In examples where the
participant was threatened without a weapon, disagree-
ment between raters was generally focused on the
interpretation and definition of the phrase ‘‘threatened
death or serious injury.’’ Is it possible, for instance, for a
verbal threat of death or serious injury over the telephone
to satisfy this description therefore constituting a Criter-
ion-A1 event, or does the threat need to be more direct, for
example, in person? Such a distinction is not made in DSM-
IV and requires some degree of subjective interpretation
on behalf of the raters to make an accurate judgment.
In relation to events occurring to another, contention
arose in the interpretation of the phrase ‘‘threat of death or
injury experienced by a family member or other close
DSM-IV (American Psychiatric Association, 1994, p. 424).
How does one define the term ‘‘family member’’ or ‘‘close
Equivocal associate’’? The subjective interpretation of the term
N (%)
‘‘family member’’ can vary anywhere from a member of
one’s immediate family to a distant cousin, depending on
the participant and rater’s concept of family. Such variation
in individual assessments becomes further compounded in
177 (20.6) a large sample.
Other traumas that led to confusion and contention
between raters were ‘‘learning about serious medical
illness of family member or other close associate’’ and
‘‘learning about the death of a loved one.’’ DSM-IV specifies
the death of a family member or other close associate as a
Criterion-A1 event if that death is unexpected or violent.
However, given that death is commonly unexpected, to
include such experiences in the definition of Criterion-A1
could potentially inflate the PTSD prevalence rate. These
events are likely to happen to the majority of people over
the course of a lifetime and, hence, have little meaning as
per the notion of traumatic stressors.
One way of resolving this issue is to ensure that all
participants provide sufficient details in their narratives to
allow independent raters to make an informed decision
about the nature of the event and the relationship between
the participant and the victim. This, however, is not always
a possibility, especially in large-scale epidemiological
surveys using multiple instruments, where raters are
often time limited in their assessments.
The fact that events that were witnessed had lower
inter-rater reliability than those that were directly
experienced suggests that the perceived distress is more
subjective in the witnessed events than events where there
is direct impact of a threat. Even greater confusion exists
within the learned event category, in part due to that lack
of clarity in the descriptors in the text of DSM-IV. On the
basis of this observation, a more precise definition of these
constructs should be developed in the DSM-V text.
The second aim of the study was to ascertain whether or
not the categorization method employed (single rater,
multiple raters-majority, multiple raters-unanimous) suf-
ficiently altered the prevalence of Criterion-A1 events in
our study population. Results derived from a descriptive
comparison of prevalence rates suggested that it did. Of
those who experienced an event, the proportion that were
categorised as traumatic varied from 66.7% using the
unanimous method to 80.2% using rater 1’s interpretation
and classification of events.

Table 3
Lifetime PTSD prevalence for non-traumatic life events (NT), Criterion-A1 events (Crit-A1) and equivocal events (E) using the different methods of
categorization

Non-traumatic N (%) Criterion-A1 N (%) Equivocal N (%) RR (95% CI) p

Rater 1 21 (12.4) 47 (6.8) 1.81 (1.12–2.95) .016

Rater 2 22 (12.3) 46 (6.8) 1.82 (1.13–2.94) .015
Rater 3 25 (11.4) 43 (6.7) 1.69 (1.06–2.70) .028
Majority 20 (11.5) 48 (7.0) 1.64 (1.00–2.69) .050

Unanimous 20 (18.3) 40 (7.0) 8 (4.5)

NT vs. Crit-A1 20 (18.3) 40 (7.0) 2.63 (1.60–4.32) .001
NT vs. E 20 (18.3) 8 (4.5) 4.06 (1.85–8.90) <.001
Crit-A1 vs. E 40 (7.0) 8 (4.5) 1.54 (.74–3.23) .294
 M. Van Hooff et al. / Journal of Anxiety Disorders 23 (2009) 77–86
Fig. 1. Prevalence of lifetime PTSD (%) for specific event types using the unanimous categorization method.
In previous studies, the proportion of events that has
been classified as Criterion-A1 has ranged from 36% to 85%
using various methods and samples (Gold et al., 2005;
Hovens & Van der Ploeg, 1993; Mol et al., 2005; Roemer
et al., 1998; Spitzer et al., 2000). It is likely that the current
study was at the higher end of this spectrum as it employed
a sample that had been disproportionately exposed to a
natural disaster, a trauma typically classified as a Criterion-
A1 event in the scientific literature.
Ratings of the disaster cases were additionally con-
founded in this study by the problem of a single word
defining a category of exposure. The senior author (rater 3)
had studied the disaster and traveled extensively in the
affected region at the time. This prior knowledge made it
possible for him to interpret, clarify and elaborate on the
often-insufficient explanations provided by the partici-
pants, which gave him a more thorough understanding of
the nature of the bushfire experience. Often descriptions
provided by the participants were subjectively not
distressing, whereas factually they involved significant
risk, which may or may not have been perceived by the
subjects who were children at the time. This difference
further highlights the potential for the misclassification of
the stressor criterion from a few descriptor words, such as
‘‘natural disaster’’ or ‘‘man-made disaster’’ as against a
detailed history or inventory of the disaster (McFarlane,
83
1987a, 1988). Again, researchers are required to use
judgments about the margins of disasters, for example, has
an individual been exposed to hurricane or was it just a
storm? If this is the case, one can argue for a reformulation
of Criterion-A1 to include a more detailed definition of the
type of events to be included under each type of trauma.
The highest level of disagreement overall was between
rater 3 (the rater with the most extensive knowledge and
practical experience in the field of PTSD) and raters 1 and 2
(both research psychologists trained, educated and experi-
enced in psychological assessment rather than treatment).
This provides further support for the argument that past
knowledge and experience is strongly likely to influence
the coding and definition of Criterion-A1 events. As
Weathers and Keane (2007a) pointed out ‘‘. . . there are
no crisp boundaries demarcating ordinary stressors from
traumatic stressors. Further, perception of an event as
stressful depends on subjective appraisal, making it
difficult to define stressors objectively, and independent
of personal meaning making’’ (p. 108). In general, rater 3,
who has considerable clinical and forensic experience, had
a higher threshold of categorization.
The main intention of this paper was not to determine
whether there was a significant difference in the propor-
tion of cases classified as traumatic or non-traumatic using
the majority or unanimous method, but more so to focus
84 M. Van Hooff et al. / Journal of Anxiety Disorders 23 (2009) 77–86
on the effect that classification methods can have on PTSD
prevalence. For this reason differences between the
proportions of cases defined as traumatic using the various
rating methods was derived using descriptive comparisons
only. Future studies should aim to extend the findings to
incorporate a statistical examination of such differences.
The final aim was to examine the differences in lifetime
PTSD prevalence resulting from Criterion-A1 events and
non-traumatic life events, and to determine whether PTSD
prevalence differed according to the type of categorization
method used. In this study sample, the total PTSD
prevalence for those who experienced a traumatic
Criterion-A1 event was 7.91% (68 cases). In line with
previous research, events coded as non-traumatic were
associated with higher lifetime PTSD prevalence (11.4–
18.3%) than Criterion-A1 events (6.7–7.0%), independent of
the coding method employed (single rater, multiple raters-
majority, multiple raters-unanimous) (Gold et al., 2005;
Mol et al., 2005; Solomon & Canino, 1990).
This observation may have emerged as a consequence
of the category of other events (those events not included
in the standard 9 events in the Composite International
Diagnostic Interview and those volunteered by the
participant), a number of which were coded as non-
traumatic. This bias is a consequence of volunteered
reporting rather than systematic enquiry of specific event
types. The theory behind this argument is that participants
generally do not spontaneously report on the occurrence of
an event if that event has not caused them significant
distress. A miscarriage, for example, would not be
volunteered under the category ‘‘any other stressful life
event’’ unless that person found that miscarriage trau-
matic. Recent studies have reported an incidence rate of
miscarriage in a representative sample of Australian
women aged 16–59 years of 33.4% (Smith, Rissel, Richters,
Grulich, & de Visser, 2003). In the current study, however,
only 4 (.9%) women reported having a miscarriage as their
worst event, with all of these women meeting lifetime
diagnostic criteria for PTSD. These results indicate an
underestimate of the true incidence of miscarriage in this
sample and an inflated prevalence of miscarriage related
PTSD. This selected reporting of traumatic events due to a
difference in criterion wording and the impact this can
have on PTSD prevalence rates has been acknowledged in
previous studies (Helzer et al., 1987; Kessler, Sonnega,
Bromet, Hughes, & Nelson, 1995).
Alternatively, the finding of a higher prevalence of PTSD
following non-traumatic events in other studies, such as
Bodkin et al. (2007), may also reflect another methodo-
logical problem that has not been adequately articulated
previously, namely the impact of current mood on recall.
Specifically, in this study of depressed patients the
associated negative affect may be likely to prompt painful
recollections of distressing events, the recall of which is
state dependent. This raises the problem that the
spontaneous recall and nomination of potential distressing
events is vulnerable to the individual mood state. The
threshold for recall is likely to be lowered in distressed
people, increasing the number of events that will be
reported. A further issue is that the A2 criterion of
subjective distress, namely fear, horror and helplessness
expressed in response to the event, may also be influenced
by the current appraisal of the experience rather than
recalling the actual response at the time of exposure.
Again, an individual’s current state may contribute to this
criterion being met, a further potential source of error.
The relative risk of satisfying DSM-IV PTSD diagnostic
criteria for those in the non-traumatic life events group
relative to the Criterion-A1 event group varied depending
on the categorization method. The unanimous method led
to the highest relative risk, with non-traumatic events 2.63
times more likely to result in PTSD than Criterion-A1
events, the majority method led to the lowest relative risk
(RR: 1.64), and the three single raters fell in the middle (RR:
1.69–1.82). Additionally, in the unanimous method, non-
traumatic life events led to a greater relative risk of PTSD
compared to the equivocal events, however, the equivocal
and Criterion-A1 events were not significantly different.
These findings contradicted recent work by Bodkin et al.
(2007) who employed the unanimous method and
reported no differences in PTSD prevalence between
non-traumatic life events and Criterion-A1 events. They,
however, included participants who had experienced no
event in their non-traumatic group, which may in part
explain this discrepancy.
Hovens and Van der Ploeg (1993) employed the
majority method and are one of few studies that reported
greater PTSD severity in response to Criterion-A events
compared to non-traumatic life events. Other studies
reported discrepancies in PTSD prevalence but did not
provide an adequate explanation of how they arrived at
their findings. Gold et al. (2005), for example, noted that
they categorized their events according to consensus
between two raters. They excluded events that did not
provide enough information for accurate classification.
Without further information, it could be assumed that the
events were discussed in collaboration (rather than blind)
and a final decision was made together as a group. Mol
et al. (2005) failed to adequately explain their classification
system except to say that the events were classified based
on examples given in DSM-IV. Given the discrepancies in
trauma and PTSD prevalence evident in this study, research
should aim to consolidate their categorization methods so
that more accurate comparisons can be made between
studies. The findings of the current study are of specific
interest to any research study reporting PTSD prevalence
rates as it highlights the potential to limit the compar-
ability between studies and to lead to inflated or
understated PTSD prevalence rates following the same
type of trauma across studies.
This study is unable to comment on which categoriza-
tion method is the most reliable in predicting PTSD
prevalence. However, it could be argued that the unan-
imous method would lead to the most accurate categor-
ization of events as all raters (regardless of their previous
experience, knowledge and expertise) must be in complete
agreement before an event is included or excluded from
the Criterion-A1 category, diluting the subjective bias. This
method of unanimous classification, however, must be
differentiated from the method whereby two or more
raters discuss the event and together reach a consensus
regarding how the event is to be classified. This method of
 M. Van Hooff et al. / Journal of Anxiety Disorders 23 (2009) 77–86
classification is vulnerable to persuasion by those who are
more knowledgeable, or more forthright in their opinions,
which then becomes a replication of the single rater
method.
While the sample that met PTSD criteria in the current
study was small, certain events showed a strong relation-
ship with PTSD. Criterion-A1 events that were associated
with the highest rates of PTSD included rape and sexual
molestation. The non-traumatic life event types included
miscarriage, bullying, and relationship problems. The
finding that sexual traumas led to high levels of PTSD is
common and well-accepted in the literature (Boudreaux,
Kilpatrick, Resnick, Best, & Saunders, 1998; Breslau et al.,
1998; Creamer, Burgess, & McFarlane, 2001; Cuffe et al.,
1998; Hapke, Schumann, Rumpf, John, & Meyer, 2006;
Kilpatrick et al., 2003). Non-traumatic life events, however,
and their association with PTSD are more controversial.
There is a small body of literature focusing on PTSD as a
result of miscarriage and bullying, with PTSD rates
following bullying ranging from 65% to 92% (Leymann &
Gustafsson, 1996; Matthiesen & Einarsen, 2004; Tehrani,
2004). These samples, however, were recruited from
bullying victim groups. Engelhard, van den Hout, and
Arntz (2001) argue for miscarriage to be included as a
Criterion-A1 event rather than a non-traumatic life event.
Prevalence of PTSD after pregnancy loss has been reported
to range from 26% (miscarriage and still-birth) to 39%
(miscarriage alone) (Bowles et al., 2006; Engelhard et al.,
2001). However, 4 months after the miscarriage, Engelhard
et al. (2001) found this prevalence dropped from 26% to 7%,
mainly due to participant attrition.
Relationship problems have been reported to be a
strong predictor of PTSD symptoms. Gold et al. (2005),
for example, found that 80% (eight out of ten) of those
that reported relationship problems met PTSD criteria.
Second to the expected death/serious illness of close
person, relationship problems had the largest number of
participants meeting PTSD criteria. Similarly, Kilpatrick
et al. (1998) found that out of eight PTSD positive
cases in their non-traumatic life events group, six
were the result of deaths or serious illnesses in the
past year, and the other two were a result of divorce and
being fired. Mol et al. (2005) found that relational
problems had the highest mean PTSD scores of the non-
traumatic life events, whereas, death of a loved one
(sudden or non-sudden) had two of the lowest. All of
these studies, however, utilized small samples. Inter-
estingly, death of a loved one (whether sudden or not)
was not associated with especially high levels of PTSD in
the current study.
It should be noted that the current study did not control
for the confounding effects of as sex (in certain trauma
types and populations), prior trauma and psychiatric and
family psychiatric history, dissociation, treatment experi-
ence or substance abuse on PTSD prevalence rates or the
reporting of traumatic events (Brewin, Andrews, &
Valentine, 2000; Ouimette, Read, & Brown, 2005; Ozer,
Best, Lipsey, & Weiss, 2003). Furthermore, the aim of this
study was not to determine whether Criterion-A1 or non-
traumatic life events result in the highest PTSD prevalence,
but rather to examine if the difference between the groups
85
in PTSD prevalence varies according to the categorization
method employed.
Presence of intrusive and distressing recollections of
events, other than those considered to be traumatic is
another issue that needs to be considered at length by the
field. Perhaps the question should not be simplified as to
whether Criterion-A1 is a valid stressor or not, but whether
or not the event in question is the primary etiological
factor in the individual’s disorder, or secondary to other
individual risk factors, such as past psychiatric disorder.
The role of the event is more likely to be central in high
intensity stressors than in low intensity stressors where
individual vulnerability has a greater probability of playing
a primary role. Unfortunately, discussions about PTSD are
often polarized because of the role this diagnosis plays in
determining causation, and hence negligence, in many
litigation settings (Maier, 2006). This role of the disorder in
attributing causation in compensation creates under-
standable controversy around the diagnosis. The asso-
ciated polarization of argument in legal settings
undermines careful analysis of the margins of the disorder
and favors broad and sweeping polemical arguments about
the validity of PTSD as a psychiatric disorder, which
contribute little to rationale scientific discourse.
In conclusion, large margins of error in relation to PTSD
and trauma prevalence rates will continue to prevail until
the level of subjectivity involved in interpreting and
categorizing traumatic events is eliminated. Traditionally,
Criterion-A1 was intended to refer to the objective element
of the trauma, with Criterion-A2 relating to the subjective
elements of the experience (Creamer, McFarlane, &
Burgess, 2005; Weathers & Keane, 2007b), As this study
and others have shown however, interpreting Criterion-A1
is a highly subjective process influenced not only by the
personal experience of the victim but also the experiences
and mindset of those who rate them. Significant attention
should be given to the language used to define Criterion-A1
in the next revision of DSM-V in order to ensure further
compatibility between studies.
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