Structure Of Posttraumatic Stress Disorder Symptoms Research Articles

The structure of symptoms of posttraumatic stress disorder according to DSM-5 and assessed by PDS-5 – preliminary results

<b>Background</b><br /> The structure of posttraumatic stress disorder (PTSD) symptoms has been studied and discussed since the introduction of PTSD as a diagnostic entity in the DSM-III (Diagnostic and Statistical Manual of Mental Disorders III) in 1980. Many studies supported a four-factor or a five-factor models, both inconsistent with DSM-IV. It is unclear whether current DSM-5 criteria appropriately reflect the empirical structure of PTSD symptoms.<br /> <br /> <b>Participants and procedure</b><br /> In this study the structure of PTSD symptoms was examined by confirmatory factor analysis conducted on the data obtained from 388 individuals (150 males and 239 females aged 18-83) who experienced a traumatic event and completed the PDS-5 (Posttraumatic Diagnostic Scale-5), a self-report scale according to the DSM-5 criteria.<br /> <br /> <b>Results</b><br /> Fitting of different models based on DSM-IV, DSM-5 and other the most common four- and five-factor conceptualizations of PTSD symptoms structure was examined. The data analyses demonstrated the best fit of the six-factor model based on the conceptualization of Elhai et al. (2011) with the additional factor of negative cognitions and mood.<br /> <br /> <b>Conclusions</b><br /> The DSM-5 diagnostic criteria do not reflect the empirical PTSD symptom structure. The data suggest also that it is reasonable to separate the core PTSD symptoms from broad PTSD symptomatology.

Supplemental Material for Item Order Effects in the Evaluation of Posttraumatic Stress Disorder Symptom Structure

Supplemental Material for Item Order Effects in the Evaluation of Posttraumatic Stress Disorder Symptom Structure

Dimensional structure of DSM-5 posttraumatic stress symptoms: Support for a hybrid Anhedonia and Externalizing Behaviors model

Several revisions to the symptom clusters of posttraumatic stress disorder (PTSD) have been made in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Central to the focus of this study was the revision of PTSD's tripartite structure in DSM-IV into four symptom clusters in DSM-5. Emerging confirmatory factor analytic (CFA) studies have suggested that DSM-5 PTSD symptoms may be best represented by one of two 6-factor models: (1) an Externalizing Behaviors model characterized by a factor which combines the irritability/anger and self-destructive/reckless behavior items; and (2) an Anhedonia model characterized by items of loss of interest, detachment, and restricted affect. The current study conducted CFAs of DSM-5 PTSD symptoms assessed using the PTSD Checklist for DSM-5 (PCL-5) in two independent and diverse trauma-exposed samples of a nationally representative sample of 1484 U.S. veterans and a sample of 497 Midwestern U.S. university undergraduate students. Relative fits of the DSM-5 model, the DSM-5 Dysphoria model, the DSM-5 Dysphoric Arousal model, the two 6-factor models, and a newly proposed 7-factor Hybrid model, which consolidates the two 6-factor models, were evaluated. Results revealed that, in both samples, both 6-factor models provided significantly better fit than the 4-factor DSM-5 model, the DSM-5 Dysphoria model and the DSM-5 Dysphoric Arousal model. Further, the 7-factor Hybrid model, which incorporates key features of both 6-factor models and is comprised of re-experiencing, avoidance, negative affect, anhedonia, externalizing behaviors, and anxious and dysphoric arousal symptom clusters, provided superior fit to the data in both samples. Results are discussed in light of theoretical and empirical support for the latent structure of DSM-5 PTSD symptoms.

Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from the National Health and Resilience in Veterans Study.

To evaluate the prevalence of DSM-5 posttraumatic stress disorder (PTSD) and factor structure of PTSD symptomatology in a nationally representative sample of US veterans and examine how PTSD symptom clusters are related to depression, anxiety, suicidal ideation, hostility, physical and mental health-related functioning, and quality of life. Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative survey of 1,484 US veterans conducted from September through October 2013. Confirmatory factor analyses were conducted to evaluate the factor structure of PTSD symptoms, and structural equation models were constructed to examine the association between PTSD symptom clusters and external correlates. 12.0% of veterans screened positive for lifetime PTSD and 5.2% for past-month PTSD. A 5-factor dysphoric arousal model and a newly proposed 6-factor model both fit the data significantly better than the 4-factor model of DSM-5. The 6-factor model fit the data best in the full sample, as well as in subsamples of female veterans and veterans with lifetime PTSD. The emotional numbing symptom cluster was more strongly related to depression (P < .001) and worse mental health-related functioning (P < .001) than other symptom clusters, while the externalizing behavior symptom cluster was more strongly related to hostility (P < .001). A total of 5.2% of US veterans screened positive for past-month DSM-5 PTSD. A 6-factor model of DSM-5 PTSD symptoms, which builds on extant models and includes a sixth externalizing behavior factor, provides the best dimensional representation of DSM-5 PTSD symptom clusters and demonstrates validity in assessing health outcomes of interest in this population.

Elucidating the transdiagnostic dimensional structure of trauma-related psychopathology: Findings from VA cooperative study 504 – risperidone treatment for military service related chronic post traumatic stress disorder

BackgroundThree of the most common trauma-related mental disorders—posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD)—are highly comorbid and share common transdiagnostic symptom dimensions of threat (i.e., fear) and loss (i.e., dysphoria) symptomatology. However, empirical evaluation of the dimensional structure of component aspects of these disorders is lacking. MethodsUsing structured clinical interview data from U.S. military veterans with chronic military-related PTSD, we evaluated the transdiagnostic dimensional structure of PTSD, MDD, and GAD symptoms. We then examined the relationship between the best-fitting transdiagnostic model of these symptoms, and measures of physical and mental functioning, and life satisfaction and well-being. ResultsExploratory factor analysis revealed that a 3-factor transdiagnostic model comprised of loss (i.e., dysphoria), threat (i.e., anxious arousal, re-experiencing, and avoidance symptoms), and somatic anxiety (i.e., physiological manifestations of anxiety) symptoms provided the best representation of trauma-related PTSD, MDD, and GAD symptoms. Somatic anxiety symptoms were independently associated with physical functioning, while loss symptoms were independently associated with mental functioning and life satisfaction and well-being. LimitationsEvaluation of study aims in a relatively homogeneous sample of veterans with chronic, military-related PTSD. ConclusionsResults of this study suggest that a 3-factor transdiagnostic model best characterizes the dimensional structure of PTSD, MDD, and GAD symptoms in military veterans with chronic military-related PTSD. This model evidenced external validity in demonstrating differential associations with measures of physical and mental functioning, and life satisfaction and well-being. Results provide support for emerging contemporary models of psychopathology, which emphasize transdiagnostic and dimensional conceptualizations of mental disorders. Such models may have utility in understanding the functional status of trauma survivors.

PTSD prevalence and symptom structure of DSM-5 criteria in adolescents and young adults surviving the 2011 shooting in Norway

BackgroundDiagnostic criteria for Posttraumatic Stress Disorder (PTSD) have been revised for DSM-5. Two key changes include alteration of the clustering of PTSD symptoms and new PTSD symptom criteria related to negative alterations in cognition and mood. In this study, we empirically investigated these changes. MethodsWe interviewed 325 adolescents and young adults who survived the 2011 youth camp shooting at Utøya Island, Norway. The UCLA PTSD Reaction Index for DSM-IV was used to assess symptoms of PTSD. In addition, 11 questions were added to assess the four new symptom criteria within the new DSM-5 symptom categories. ResultsPTSD prevalence did not differ significantly whether DSM-IV (11.1%) or DSM-5 (11.7%) criteria were used and the Cohen׳s Kappa for consistency between the diagnoses was 0.061. Confirmatory factor analyses showed that the four-factor structure of the DSM-5 fit the data adequately according to the conceptual model outlined. LimitationsThe homogeneity of this sample of highly exposed subjects may preclude generalization to less severely exposed groups. Also, we did not assess criterion G in regard to symptoms causing clinically significant distress and functional impairment. ConclusionThe prevalence of PTSD was quite similar regardless of diagnostic system. The relatively low concordance between the diagnoses has implications for eligibility for a diagnosis of PTSD.

Validation of the five-factor model of PTSD symptom structure among delinquent youth.

This study compared the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM–IV–TR; American Psychiatric Association, 2000) diagnostic 3-factor structure of posttraumatic stress disorder (PTSD) symptoms with leading 4-factor models and the newly proposed 5-factor dysphoric arousal model in a sample of 1,363 juvenile-justice-involved adolescents (990 boys, 373 girls). Structural equation modeling suggested that the 5-factor dysphoric arousal model fit significantly better than each of the other models. The model fit better for girls than for boys, and girls evidenced stronger factor loadings for items on all but the Anxious Arousal factor. The factors of the 5-factor model were then tested as mediators of the association between interpersonal and noninterpersonal trauma and mental health problems. Interpersonal trauma was associated with PTSD symptoms for boys and girls, whereas noninterpersonal trauma exposure was only associated with PTSD symptoms for boys, despite equal levels of exposure across genders, suggesting that girls may be more sensitive to the effects of interpersonal, but not noninterpersonal, trauma. Patterns in mediation were moderated by gender, as girls’ data showed stronger paths leading to depression/anxiety, somatic complaints, and suicidal ideation through PTSD symptoms, whereas for boys, paths were stronger leading to anger/irritability symptoms. Mediation results suggested differential patterns of influence for dysphoric versus anxious arousal and also indicate the importance of numbing for delinquent youth. These results add to the evidence base supporting the 5-factor dysphoric arousal model in establishing developmentally sensitive criteria for the diagnosis of PTSD among traumatized youth.

Sudden Unexpected Versus Violent Death and PTSD Symptom Development

Changes to posttraumatic stress disorder (PTSD) trauma criterion in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) have been an area of much scrutiny and debate. One of the proposed changes included removing sudden unexpected death (SUD) from the list of potentially traumatic events. This study tested the extent to which unexpected death differed from violent death and other traumas as measured by PTSD symptoms. Our results indicated a significant difference in symptom development between those experiencing sudden violent death and sudden unexpected, but nonviolent, death. Additional analyses at the DSM–IV symptom cluster level, as well as with Simms, Watson, and Doebbeling’s (2002) factor structure of PTSD symptoms, suggested further distinctions between event types and symptom development. The extent to which SUD should be included in the trauma criterion is considered.

Do gender and age moderate the symptom structure of PTSD? Findings from a national clinical sample of children and adolescents

A substantial body of evidence documents that the frequency and intensity of posttraumatic stress disorder (PTSD) symptoms are linked to such demographic variables as female sex (e.g., Kaplow et al., 2005) and age (e.g., Meiser-Stedman et al., 2008). Considerably less is known about relations between biological sex and age with PTSD's latent factor structure. This study systematically examined the roles that sex and age may play as candidate moderators of the full range of factor structure parameters of an empirically supported five-factor PTSD model (Elhai et al., 2011). The sample included 6591 trauma-exposed children and adolescents selected from the National Child Traumatic Stress Network's Core Data Set. Confirmatory factor analysis using invariance testing (Gregorich, 2006) and comparative fit index difference values (Cheung and Rensvold, 2002) reflected a mixed pattern of test item intercepts across age groups. The adolescent subsample produced lower residual error variances, reflecting less measurement error than the child subsample. Sex did not show a robust moderating effect. We conclude by discussing implications for clinical assessment, theory building, and future research.

Factor structure of PTSD symptoms in opioid-dependent patients rating their overall trauma history

BackgroundThe current standard for posttraumatic stress disorder (PTSD) diagnosis is a 3-factor model (re-experiencing, avoidance, and hyperarousal). Two 4-factor models of PTSD, the emotional numbing model (re-experiencing, avoidance, emotional numbing, and hyperarousal) and the dysphoria model (re-experiencing, avoidance, dysphoria, and hyperarousal), have considerable empirical support in the extant literature. However, a newer 5-factor model of PTSD has been introduced that is receiving interest. The 5-factor model differs from the four-factor models in its placement of three symptoms (irritability, sleep disturbance, and concentration difficulties) into a separate cluster termed dysphoric arousal. We empirically compared the theoretical factor structures of 3-, 4-, and 5-factor models of PTSD symptoms to find the best fitting model in a sample of opioid-dependent hospitalized patients. MethodsConfirmatory factor analyses were conducted on the 17 self-reported PTSD symptoms of the Posttraumatic Checklist – Civilian Version (PCL-C) in a sample of 151 men and women with opioid dependence. ResultsBoth four-factor models fit the observed data better than the three-factor model of PTSD; the dysphoria model was preferred to the emotional numbing model in this sample. The recently introduced five-factor model fit the observed data better than either four factor model. ConclusionsPTSD is a heterogeneous disorder comprised of symptoms of re-experiencing, avoidance, numbing, and dysphoria. Three symptoms, irritability, sleep disturbance, and concentration difficulties, may represent a unique latent construct separate from these four symptom clusters in opioid-dependent populations who have experienced traumatic events.

Symptoms of Post-Traumatic Stress Disorder in Bereaved Children and Adolescents: Factor Structure and Correlates

This study investigated the factor structure and correlates of posttraumatic stress-disorder (PTSD) symptoms among children and adolescents confronted with the death of a loved one. Three hundred thirty-two bereaved children and adolescents (aged 8-18; 56.9 % girls) who all received some form of psychosocial support after their loss, completed self-report measures of PTSD, together with measures tapping demographic and loss-related variables, depression, prolonged grief, and functional impairment. Parent-rated indices of impairment were also collected. We first evaluated the fit of six alternative models of the factor structure of PTSD symptoms, using confirmatory factor analyses. Outcomes showed that the 4-factor numbing model from King et al. (Psychological Assessment 10, 90-96, 1998), with distinct factors of reexperiencing, avoidance, emotional numbing, and hyperarousal fit the data best. Of all participants, 51.5 % met DSM-IV criteria for PTSD. PTSD-status and scores on the PTSD factors varied as a function of age and gender, but were unrelated to other demographic and loss-related variables. PTSD-status and scores on the PTSD factors were significantly associated symptom-levels of depression, prolonged grief, and functional impairment. Findings complement prior evidence that the DSM-IV model of the factor structure of PTSD symptoms may not represent the best conceptualization of these symptoms and highlight the importance of addressing PTSD symptoms in children and adolescents seeking help after bereavement.

Symptom structure of PTSD: support for a hierarchical model separating core PTSD symptoms from dysphoria

BackgroundAs of yet, no collective agreement has been reached regarding the precise factor structure of posttraumatic stress disorder (PTSD). Several alternative factor-models have been proposed in the last decades.ObjectiveThe current study examined the fit of a hierarchical adaptation of the Simms et al. (2002) dysphoria model and compared it to the fit of the PTSD model as depicted in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), a correlated four-factor emotional numbing, and a correlated four-factor dysphoria model.MethodsData were collected using the Clinician-Administered PTSD Scale in a mixed-trauma sample of treatment-seeking PTSD patients (N=276).ResultsAll examined models provided superior fit to the three-factor model of DSM-IV. The hierarchical four-factor solution provided a better fit than competing models.ConclusionThe present study provides empirical support for a conceptualization of PTSD that includes a higher-order PTSD factor that encompasses re-experiencing, arousal, and effortful avoidance sub-factors and a dysphoria factor.

Numbing and Dysphoria Symptoms of Posttraumatic Stress Disorder Among Iraq and Afghanistan War Veterans

Iraq and Afghanistan war veterans experience significant rates of posttraumatic stress disorder (PTSD) and other trauma-related mental health conditions. Understanding how specific PTSD symptomatology affects physical health and psychosocial functioning may be useful in improving the conceptualization of PTSD nosology and informing treatment approaches for this population. Confirmatory factor analytic evidence supports four-factor models of PTSD symptoms that classify emotional numbing and/or dysphoria symptoms as a distinct PTSD symptom cluster, and these symptoms appear to be related to poorer psychological adjustment among returning Iraq and Afghanistan war veterans. This review briefly describes current conceptualizations of numbing/dysphoria symptoms of PTSD and summarizes research on the factor structure of PTSD symptoms. Then, the literature on the influence of numbing/dysphoria symptoms on physical and psychological health among these veterans is reviewed, and implications for treatment and directions for future research are presented.

PTSD symptom structure among West African War trauma survivors living in African refugee camps: A factor-analytic investigation

We examined the factor structure of measured posttraumatic stress disorder (PTSD) symptoms in a sample of West African civilian refugees who had fled the civil war in Sierra Leone between 2001 and 2006. Given that such war-affected populations are common but understudied in trauma research, our objective was to examine the similarities and differences in this factor structure compared to prevailing models of PTSD symptom structure. As part of treatment services provided in refugee camps, refugees (2,140 women, 1,662 men, 1 unknown) from Sierra Leone, Liberia, and Guinea completed the 17 symptoms portion of the Posttraumatic Stress Diagnostic Scale (PDS). We used exploratory and confirmatory factor analyses to investigate whether there was a factor structure unique to this population, and made comparisons with the numbing, dysphoria, and aroused intrusion models. Results from the confirmatory analyses showed that the dysphoria model best fit the data (root mean square error of approximation [RMSEA] = .062); however, exploratory analyses revealed that 3 items loaded differently than theoretically expected. Psychological distress cross-loaded on reexperiencing and avoidance factors and physiological reactivity loaded on the avoidance factor instead of the reexperiencing factor. The sleep difficulties item was not well explained, generally; the highest loading (λ = .22) was on the dysphoria factor.

Factor Structure of the PTSD Checklist in a Sample of OEF/OIF Veterans Presenting to Primary Care: Specific and Nonspecific Aspects of Dysphoria.

Although DSM-IV-TR diagnostic criteria for posttraumatic stress disorder (PTSD) include three primary symptom clusters, recent evidence from confirmatory factor analyses suggest that the latent structure of PTSD is better represented by four factors, which will likely be reflected in the upcoming DSM-5. Given this likely transition from three to four clusters, the present study sought to examine specific and non-specific aspects of dysphoria in the factor structure of PTSD symptoms in a sample of OEF/OIF combat veterans presenting to a Veterans Affairs primary care clinic. PTSD symptoms were assessed using the PCL-M (Weathers et al. 1993). Results from confirmatory factor analyses suggested that a dysphoria factor involving a number of non-specific distress symptoms may be an important part of the PTSD symptom profile. After controlling for variance due to general psychological distress, we further found that factor loadings on the dysphoria factor were attenuated but continued to significantly load onto the factor, suggesting that dysphoria may be a specific part of the PTSD symptom constellation.

Exploring the relationship between underlying dimensions of posttraumatic stress disorder and depression in a national, trauma-exposed military sample

Posttraumatic stress disorder (PTSD) and depression are highly comorbid and intercorrelated. Yet little research has examined the underlying processes explaining their interrelationship. In the present survey study, the investigators assessed the combined symptom structure of PTSD and depression symptoms, to examine shared, underlying psychopathological processes. Participants included 740 Canadian military veterans from a national, epidemiological survey, previously deployed on peacekeeping missions and administered the PTSD Checklist and Center for Epidemiological Studies-Depression Scale (CES-D). An eight-factor PTSD/depression model fit adequately. In analyses validating the structure, PTSD's dysphoria factor was more related to depressive affect than to several other PTSD and depression factors. Somatic problems were more related to dysphoria than to other PTSD factors. Only military veterans were sampled, and without the use of structured diagnostic interviews. Results highlight a set of interrelationships that PTSD's dysphoria factor shares with specific depression factors, shedding light on the underlying psychopathology of PTSD that emphasizes dysphoric mood.

Posttraumatic Stress Disorder Symptom Structure in Chinese Adolescents Exposed to a Deadly Earthquake

This present study examined the structure of posttraumatic stress disorder (PTSD) symptoms in a large sample of Chinese adolescents exposed to a deadly earthquake. A total of 2,800 middle school students aged 12 to 18 years participated in the study 6 months after the "Wenchuan Earthquake". Results of confirmatory factor analysis indicated that a five-factor intercorrelated model composed of intrusion, avoidance, numbing, dysphoric arousal, and anxious arousal, fit data significantly better than both the four-factor numbing model King et al. (Psychological Assessment 10:90-96, 1998) and the four-factor dysphoria model Simms et al. (Journal of Abnormal Psychology 111:637-647, 2002). Further examination of the external convergent and discriminant validity revealed that except for the dysphoric arousal factor, the remaining four PTSD factors yielded significantly different correlations with external measures of anxiety vs. depression. The findings add to the limited literature on the factor structure of PTSD in youths and on the five-factor PTSD model. In addition, they provide more detail into the latent psychopathological processes of PTSD, and inform the forthcoming DSM-5.

Factor structure of posttraumatic stress disorder symptoms in OEF/OIF veterans presenting to a polytrauma clinic.

A significant number of Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) veterans are returning from deployment and presenting to Veterans Health Administration (VHA) polytrauma clinics with elevated rates of posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). Inherent to the accurate assessment and treatment of this diagnostically complex group of veterans is the assumption that the construct of PTSD is the same in this population as in other trauma groups. To our knowledge, no previous study has examined the structure of PTSD in this relevant and fast-growing population of treatment-seeking OEF/OIF veterans. Evidence suggests that the latent structure of PTSD symptoms is best represented by a four-factor model, rather than the three-factor model found in the current DSM-IV-TR. Thus, we examined the three and four-factor models using the PTSD Check List-Civilian (PCL-C) in a sample of treatment-seeking OEF/OIF veterans seen through a VHA polytrauma clinic. A chart review was conducted for OEF/OIF veterans (N = 361) seen through a VHA outpatient polytrauma clinic from September 2007 through August 2008. Participants completed the PCL-C as part of a comprehensive polytrauma evaluation. Confirmatory factor analyses showed that the DSM-IV-TR three-factor model did not fit the data well. A direct comparison showed that the four-factor model provided a superior fit relative to the three-factor model. Results extend the generalizability of the four-factor model to OEF/OIF veterans presenting to Veterans Health Administration (VHA) polytrauma clinics.

An evaluation of competing models for the structure of PTSD symptoms using external measures of comorbidity

Research on the structure of posttraumatic stress disorder (PTSD) symptoms has yielded support for two 4-factor models: the King (King, Leskin, King, & Weathers, 1998) and Simms/Watson models (Simms, Watson, & Doebbeling, 2002). This study evaluated them using data drawn from 1,128 Vietnam veterans by comparing associations with a latent internalizing comorbidity variable and five scales from the MMPI-2 Restructured Clinical (RC) Scales (Tellegen et al., 2003). The Simms/Watson dysphoria factor failed to show evidence of superior convergent or discriminant validity in association with external measures relative to the numbing or hyperarousal factors of the King model. Findings raise questions about proposals to abandon the distinction between numbing and hyperarousal symptoms in favor of a dysphoria-based model.

Posttraumatic Stress Disorder Symptom Structure in Injured Children

Posttraumatic Stress Disorder Symptom Structure in Injured Children