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  • Financial disclosure

  • Dr. Kessler has been a consultant for Analysis Group, GlaxoSmithKline Inc., Kaiser Permanente, Merck & Co, Inc., Ortho-McNeil Janssen Scientific Affairs, Pfizer Inc., Sanofi-Aventis Groupe, Shire US Inc., SRA International, Inc., Takeda Global Research & Development, Transcept Pharmaceuticals Inc., Wellness and Prevention, Inc., and Wyeth-Ayerst; has served on advisory boards for Eli Lilly & Company, Mindsite, and Wyeth-Ayerst; and has had research support for his epidemiological studies from Analysis Group Inc., Bristol-Myers Squibb, Eli Lilly & Company, EPI-Q, Ortho-McNeil Janssen Scientific Affairs., Pfizer Inc., Sanofi-Aventis Groupe, and Shire US, Inc. He owns stock in Datastat, Inc. Dr. Demyttenaere has served on advisory boards for, speaker bureaus for, and has research grants from Astra Zeneca, Eli Lilly, GSK, Lundbeck, Takeda, Servier. Dr. Haro has been a consultant and served on speaker bureaus for Eli Lilly and Co., has board memberships at Lundbeck and Roche, and has had research support from GlaxoSmithKline. Dr. Kawakami has been a part-time physician at the Riken Institute, a consultant for Junpukai Foundation and the Sekisui Corporation, has served on speaker bureaus for GlaxoSmithKline, Ezai, and Pfizer, received royalties from Fujitsu Software Technologies, Ltd., Chuo-Hoki-Shuppan, Igaku-Shoin, Kyobundo, Life Science, Maruzen, Nanko-do, and Nanzan-do, and has received research support from Fujitsu Software Technologies, Ltd. Dr. Stein has been a consultant for Servier and Biocodex.



Clinical research suggests that posttraumatic stress disorder (PTSD) patients exposed to multiple traumatic events (TEs) rather than a single TE have increased morbidity and dysfunction. Although epidemiological surveys in the United States and Europe also document high rates of multiple TE exposure, no population-based cross-national data have examined this issue.


Data were analyzed from 20 population surveys in the World Health Organization World Mental Health Survey Initiative (n = 51,295 aged 18+). The Composite International Diagnostic Interview (3.0) assessed 12-month PTSD and other common DSM-IV disorders. Respondents with 12-month PTSD were assessed for single versus multiple TEs implicated in their symptoms. Associations were examined with age of onset (AOO), functional impairment, comorbidity, and PTSD symptom counts.


19.8% of respondents with 12-month PTSD reported that their symptoms were associated with multiple TEs. Cases who associated their PTSD with four or more TEs had greater functional impairment, an earlier AOO, longer duration, higher comorbidity with mood and anxiety disorders, elevated hyperarousal symptoms, higher proportional exposures to partner physical abuse and other types of physical assault, and lower proportional exposure to unexpected death of a loved one than cases with fewer associated TEs.


A risk threshold was observed in this large-scale cross-national database wherein cases who associated their PTSD with four or more TEs presented a more “complex” clinical picture with substantially greater functional impairment and greater morbidity than other cases of PTSD. PTSD cases associated with four or more TEs may merit specific and targeted intervention strategies.