PTSD is not the emblematic disorder of the COVID-19 pandemic; adjustment disorder is

Several research teams across the world have been sounding the alarm about the deleterious effects of the COVID-19 pandemic on mental health (e.g., [1‐3]). Some groups have published extremely high rates of posttraumatic stress symptoms and disorder (PTSD; [4‐7]) raising deep concerns with respect to the population’s mental health. However, certain criteria must be met in establishing a diagnosis of PTSD. Among these is the sound identification of a life-threat [8, 9]. This criterion is often overlooked in PTSD research involving self-report inventories, and with respect to the COVID-19 pandemic it has been considered as met de facto. For instance, although one study [6] did use a measure of trauma exposure, the authors did not consider the life-threat requirement in their computation of PTSD prevalence. Other studies [4, 5, 7] relied solely on cut-off scores from self-report measures of PTSD symptoms to determine prevalence estimate. In this study, we aimed to examine the prevalence of PTSD ‘caseness’ (i.e., meeting enough criteria to be classified as a case for a disorder) during the pandemic compared to other, less frequently mentioned stressor-related disorders like adjustment disorder (AD), not taking the life-threat criterion for granted.

AD is the forme fruste of PTSD; the more mundane diagnostic entity of the DSM-5’s Trauma- and stressor-related disorders category [10]. It is the personal tragedy without the life-threat: the job losses, the worrying about significant others, the catastrophic financial losses, the prolonged separations, the disputes and divorce, or the painful grief of having lost a loved one [8, 11‐13]. Importantly, the symptom profiles of AD and PTSD overlap substantially. Thus, we wondered if the pandemic-related stress-response syndromes would be better captured by the polymorphous diagnosis of AD, a common but neglected disorder [10] for which professionals lack guidance on the treatment guidelines [14].

The current study used a cross-sectional survey sample of COVID -19 pandemic-exposed adults living in five “most hardly” hit countries – China, the United States of America, France, Italy, and Canada – to determine the prevalence of Trauma- and Stressor-related disorders.

The overall proportion of participants meeting the clinical threshold for PTSD was 6.7% and 55% for AD, suggesting that AD is by far the more prevalent form of distress experienced during the COVID-19 pandemic, not PTSD. This was the case for all five countries surveyed in this study (results not shown for conciseness).

Remarkably, we found that a single question, the PDI’s life-threat item, captured 95% of the PTSD cases, a very robust finding that concurs with the published literature [25]. However, reporting this experience was not as common as one would think, with less than 7% of the sample endorsing it. It is therefore inappropriate to consider the life-threat criterion as met universally during the pandemic. Even the association between receiving a COVID-19 diagnosis and feeling that one’s life had been threatened was found to be rather weak in this sample. Although several recent studies have reported alarming rates of posttraumatic stress, the experience of life-threat was usually inferred from either a positive COVID-19 diagnosis or by being exposed to the pandemic per se (see [4‐6]). These studies, therefore, have inflated the true rate of PTSD, clouding the fact that AD is more prevalent than PTSD. The assessment of PTSD without evaluating the life-threat trauma criterion is not methodologically sound, and such practices should be discontinued due to the risk of disseminating misleading information to the public, the treatment providers and the policy planners.

Instead of blindly classifying distressed cases as PTSD, we found three mutually exclusive AD profiles. The first and largest AD group experienced at least one pandemic event eliciting ‘trauma-like’ peritraumatic responses of intense fear, helplessness, and horror but in the absence of any personal life-threat. It is interesting to note that in the 5^th revision of the DSM, the subjective dimension of trauma exposure (the so-called PTSD criterion A2 from DSM-IV, which consisted of fear, helplessness, and horror reactions) was abandoned, allegedly for lack of predictive power [26]. However, in life situations where the life-threat is diffuse or ambiguous, the reporting of such experiences identified many clinically distressed individuals. A second group of distressed individuals experienced intense sadness/grief as part of their worst experience of the COVID-19, which suggests the presence of a depressive-like reaction related to some form of personal loss. A third group worried primarily and intensely about the safety of others during the pandemic, to the point of becoming clinically distressed themselves.

Such findings provide further evidence for AD as a polymorphous event-based stress-response syndrome, not unlike PTSD or prolonged grief [27]; (see also [28, 29]). It is time to acknowledge that in the aftermath of most disasters or most tragedies, a small but important number of individuals will develop PTSD; however, an equally important group, and more numerous groups, of individuals will develop an AD, not PTSD.

There is currently no published placebo-controlled evidence-based treatment for AD, representing an important knowledge gap. It is time to stop confusing AD for PTSD. AD is the elephant in the room. It needs to be acknowledged as an important outcome in the aftermath of disasters and be taken seriously as a full-fledged diagnostic entity.

This study has several limitations. The rates of AD and PTSD cases reported here were obtained in an inherently biased convenience sample. Although the rates of AD and PTSD may vary depending on the sampling strategy employed, the ratio of AD to PTSD in each of the five countries that we surveyed was similar and always largely in favor of AD. This suggests that our finding is a robust one, which would be replicated in an epidemiological study using an unbiased (random) sampling strategy. The term probable AD or PTSD was used in this report, to remind the reader that a psychiatric diagnosis cannot be inferred using self-report measures and cut-off scores [30].

The intention behind this study was to illustrate that once the experience of perceived life-threat is measured rather than taken for granted, AD is much more common than PTSD during the COVID-19 pandemic and will likely exert its consequences on mental wellness across the globe for the months and years to come. CART analyses suggested the presence of three different forms of AD which may require different treatment approaches. Unfortunately, there is currently no evidence-based treatment for AD, representing a knowledge gap that requires urgent attention.