The factor structure of posttraumatic stress disorder: A literature update, critique of methodology, and agenda for future research

doi:10.1016/j.janxdis.2011.04.007

Journal of Anxiety Disorders

Volume 25, Issue 6, August 2011, Pages 849-854

https://doi.org/10.1016/j.janxdis.2011.04.007 Get rights and content

Abstract

We present an update of recent literature (since 2007) exploring the factor structure of posttraumatic stress disorder (PTSD) symptom measures. Research supporting a four-factor emotional numbing model and a four-factor dysphoria model is presented, with these models fitting better than all other models examined. Variables accounting for factor structure differences are reviewed, including PTSD query instructions, type of PTSD measure, extent of trauma exposure, ethnicity, and timing of administration. Methodological and statistical limitations with recent studies are presented. Finally, a research agenda and recommendations are offered to push this research area forward, including suggestions to validate PTSD's factors against external measures of psychopathology, test moderators of factor structure, and examine heterogeneity of symptom presentations based on factor structure examination.

Highlights

► Across the literature, the best fitting factor structure for PTSD is based on the emotional numbing and dysphoria PTSD models. ► Several moderators of PTSD's factor structure have been revealed, including assessment and measurement conditions, war exposure, culture, gender and timing of administration. ► Numerous methodological and statistical limitations are apparent with studies reporting on the factor structure of PTSD.

Section snippets

Definitional caveats

We first clarify that our focus is on the structure of PTSD symptom measures, rather than the disorder's structure generally. The instruments are primarily based on the 17 DSM-IV PTSD symptoms. Other potentially important auxiliary symptoms to PTSD (depression, phobic and general anxiety, interpersonal sensitivity, substance abuse, and conduct problems) are typically not incorporated into these studies. Including such symptoms in CFA that are important posttraumatic sequelae, in addition to

Significance

The factor structure of PTSD measures is an important topic of continued study for several reasons. First, this issue can provide insight into fundamental psychopathology issues regarding core constructs that represent PTSD. Such an endeavor is significant in that recent papers have questioned the disorder's construct validity, and thus distinctiveness as a diagnostic entity, because of PTSD's numerous clinical features that overlap with mood and anxiety disorders (Frueh et al., 2010, McHugh

Current status

Based on the culmination of PTSD CFAs conducted to date, we arrive at several conclusions. First, with all but extremely rare exceptions, DSM-IV's three-factor PTSD model (reexperiencing, effortful avoidance/emotional numbing, and hyperarousal) does not adequately capture the underlying symptom structure for PTSD measures; this model evidences a worse relative fit compared to other models, typically fitting poorly on its own (reviewed in Yufik & Simms, 2010). Second, little empirical data

Limitations with the literature's current status

We identify several substantial problems with recent studies continuing to report on the structure of PTSD symptom measures. Several problems are specific to the PTSD area; others are relevant to CFA in general. We strongly encourage researchers to consider these issues.

First, King, King, Orazem, and Palmieri (2006) suggested that because of the large volume of published CFAs investigating well-supported PTSD models, using EFA to study the structure of PTSD symptom measures was simply no longer

Future research directions

We believe that to advance knowledge on the factor structure of PTSD symptom measures, future research should focus on several important, specific issues.

First, CFAs of PTSD symptom measures should include validity data to test the relationship between obtained factors and external variables, in an attempt to demonstrate the construct validity of each of PTSD's factors. Specifically, external variables should include constructs that previous theory and/or empirical work have suggested are

References (74)

C. Armour et al.
Gender differences in the factor structure of posttraumatic stress disorder symptoms in war-exposed adolescents
Journal of Anxiety Disorders
(2011)
C. Armour et al.
Assessing the factor structure of posttraumatic stress disorder symptoms in participants with and without criterion A2 endorsement
Journal of Anxiety Disorders
(2011)
P.A. Boelen et al.
The factor structure of posttraumatic stress disorder symptoms among bereaved individuals: a confirmatory factor analysis study
Journal of Anxiety Disorders
(2008)
T.C. Buckley et al.
A confirmatory factor analysis of posttraumatic stress symptoms
Behaviour Research and Therapy
(1998)
N. Carragher et al.
Factor structure of posttraumatic stress disorder symptoms in the Australian general population
Journal of Anxiety Disorders
(2010)
B.J. Cox et al.
The symptom structure of posttraumatic stress disorder in the National Comorbidity Replication Survey
Journal of Anxiety Disorders
(2008)
J.D. Elhai et al.
Evidence for a unique PTSD construct represented by PTSD's D1–D3 symptoms
Journal of Anxiety Disorders
(2011)
D. Forbes et al.
Requiring both avoidance and emotional numbing in DSM-V PTSD: Will it help?
Journal of Affective Disorders
(2011)
A.L. Grubaugh et al.
An examination of the construct validity of posttraumatic stress disorder with veterans using a revised criterion set
Behaviour Research and Therapy
(2010)
S.L. Lancaster et al.
A factor analytic comparison of five models of PTSD symptoms
Journal of Anxiety Disorders
(2009)

S. Taylor et al.

Detection and management of malingering in people presenting for treatment of posttraumatic stress disorder: methods, obstacles, and recommendations

The structure of PTSD symptoms: a test of alternative models using confirmatory factor analysis

British Journal of Clinical Psychology

(2007)

R.M. Engdahl et al.

Comparing posttraumatic stress disorder's symptom structure between deployed and non-deployed veterans

Psychological Assessment

(2011)

L.R. Fabrigar et al.

Evaluating the use of exploratory factor analysis in psychological research

Psychological Methods

(1999)

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Literature reviewThe factor structure of posttraumatic stress disorder: A literature update, critique of methodology, and agenda for future research

Abstract

Highlights

Section snippets

Definitional caveats

Significance

Current status

Limitations with the literature's current status

Future research directions

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Behaviour Research and Therapy

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Journal of Affective Disorders

Behaviour Research and Therapy

Journal of Anxiety Disorders

Psychiatry Research

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Psychiatry Research

Clinical Psychology Review

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Dimensionality of posttraumatic stress disorder symptoms in children exposed to disaster: results from confirmatory factor analyses

Journal of Abnormal Psychology

Multisample cross validation of a model of childhood posttraumatic stress disorder symptomatology

Journal of Traumatic Stress

Testing the dimensionality of PTSD and the specificity of the dysphoria factor

Journal of Loss and Trauma

Are avoidance and numbing distinct PTSD symptom clusters?

Journal of Traumatic Stress

Post-traumatic stress disorder in United Nations peacekeepers: an examination of factor structure in peacekeepers with and without chronic pain

Cognitive Behaviour Therapy

Posttraumatic stress disorder after childbirth: analysis of symptom presentation and sampling

Journal of Affective Disorders

Factor structure of posttraumatic stress among western New York undergraduates following the September 11th terrorist attack on the World Trade Center

Journal of Traumatic Stress

Posttraumatic stress disorder instrument wording content is associated with differences in factor structure

Journal of Traumatic Stress

Assessing posttraumatic stress disorder with or without reference to a single, worst traumatic event: examining differences in factor structure

Psychological Assessment

Diagnostic alterations for posttraumatic stress disorder: examining data from the National Comorbidity Survey Replication and National Survey of Adolescents

Psychological Medicine

Structural validity of the Posttraumatic Stress Disorder Checklist among college students with a trauma history

Journal of Interpersonal Violence

Empirical examination of a proposed refinement to DSM-IV posttraumatic stress disorder symptom criteria using the National Comorbidity Survey Replication data

Journal of Clinical Psychiatry

Posttraumatic stress disorder's frequency and intensity ratings are associated with factor structure differences in military veterans

Psychological Assessment

Testing alternative factor models of PTSD and the robustness of the dysphoria factor

Journal of Anxiety Disorders

The structure of PTSD symptoms: a test of alternative models using confirmatory factor analysis

British Journal of Clinical Psychology

Comparing posttraumatic stress disorder's symptom structure between deployed and non-deployed veterans

Psychological Assessment

Evaluating the use of exploratory factor analysis in psychological research

Psychological Methods

Literature review
The factor structure of posttraumatic stress disorder: A literature update, critique of methodology, and agenda for future research