Latent dimensions of posttraumatic stress disorder and their relations with alcohol use disorder

  • Tracey L. BiehnEmail author
  • Ateka A. Contractor
  • Jon D. Elhai
  • Marijo Tamburrino
  • Thomas H. Fine
  • Gregory Cohen
  • Edwin Shirley
  • Philip K. Chan
  • Israel Liberzon
  • Joseph R. Calabrese
  • Sandro Galea
Original Paper



The objective of this study was to evaluate the relationship between factors of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) using confirmatory factor analysis (CFA) in order to further our understanding of the substantial comorbidity between these two disorders.


CFA was used to examine which factors of PTSD’s dysphoria model were most related to AUD in a military sample. Ohio National Guard soldiers with a history of overseas deployment participated in the survey (n = 1215). Participants completed the PTSD Checklist and a 12-item survey from the National Survey on Drug Use used to diagnosis AUD.


The results of the CFA indicated that a combined model of PTSD’s four factors and a single AUD factor fit the data very well. Correlations between PTSD’s factors and a latent AUD factor ranged from correlation coefficients of 0.258–0.285, with PTSD’s dysphoria factor demonstrating the strongest correlation. However, Wald tests of parameter constraints revealed that AUD was not more correlated with PTSD’s dysphoria than other PTSD factors.


All four factors of PTSD’s dysphoria model demonstrate comparable correlations with AUD. The role of dysphoria to the construct of PTSD is discussed.


Posttraumatic stress disorder Alcohol use disorder Cormorbidity Confirmatory factor analysis 


Compliance with ethical standards

Financial support

This project was funded by the Department of Defense Congressionally Directed Medical Research Program W81XWH-O7-1-0409, the “Combat Mental Health Initiative.”


The authors have no perceived or actual conflicts of interest related to this project. The sponsor had no role in study design, data collection, analysis, interpretation of results, report writing or manuscript submission.


  1. 1.
    Erbes C, Westermeyer J, Engdahl B, Johnsen E (2007) Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Mil Med 172:359–363CrossRefPubMedGoogle Scholar
  2. 2.
    Debell F, Fear NT, Head M, Batt-Rawden S, Greenberg N, Wessely S, Goodwin L (2014) A systematic review of the comorbidity between PTSD and alcohol misuse. Soc Psych Psych Epid 49:1401–1425CrossRefGoogle Scholar
  3. 3.
    McCauley JL, Killeen T, Gros DF, Brady KT, Back SE (2012) Posttraumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment. Clin Psychol-Sci Pract 19:283–304CrossRefGoogle Scholar
  4. 4.
    Bell NS, Harford T, McCarroll JE, Senier L (2004) Drinking and spouse abuse among US Army soldiers. Alcohol Clin Exp Res 28:1890–1897CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Stahre MA, Brewer RD, Fonseca VP, Naimi TS (2009) Binge drinking among US active-duty military personnel. Am J Prev Med 36:208–217. doi: 10.1016/j.amepre.2008.10.017 CrossRefPubMedGoogle Scholar
  6. 6.
    Simms LJ, Watson D, Doebbeling BN (2002) Confirmatory factor analyses of posttraumatic stress symptoms in deployed and nondeployed veterans of the Gulf War. J Abnorm Psychol 111:637–647CrossRefPubMedGoogle Scholar
  7. 7.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn. Author, Washington, DCGoogle Scholar
  8. 8.
    Brown PJ, Wolfe J (1994) Substance abuse and post-traumatic stress disorder comorbidity. Drug Alcohol Depend 35:51–59CrossRefPubMedGoogle Scholar
  9. 9.
    Stewart SH (1996) Alcohol abuse in individuals exposed to trauma: a critical review. Psychol Bull 120:83–112CrossRefPubMedGoogle Scholar
  10. 10.
    Hien DA, Jiang H, Campbell AN, Hu MC, Miele GM, Cohen LR, Brigham GS, Capstick C, Kulaga A, Robinson J, Suarez-Morales L, Nunes EV (2010) Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s Clinical Trials Network. Am J Psychiatry 167:95–101CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    McFall ME, Mackay PW, Donovan DM (1992) Combat-related posttraumatic stress disorder and severity of substance abuse in Vietnam veterans. J Stud Alcohol 53:357–363CrossRefPubMedGoogle Scholar
  12. 12.
    Saladin ME, Brady KT, Dansky BS, Kilpatrick DG (1995) Understanding comorbidity between PTSD and substance use disorders: two preliminary investigations. Addict Behav 20:643–655CrossRefPubMedGoogle Scholar
  13. 13.
    King DW, Leskin GA, King LA, Weathers FW (1998) Confirmatory factor analysis of the clinician-administered PTSD Scale: evidence for the dimensionality of posttraumatic stress disorder. Psychol Assess 10:90–96CrossRefGoogle Scholar
  14. 14.
    Elhai JD, Palmieri PA (2011) The factor structure of posttraumatic stress disorder: a literature update, critique of methodology, and agenda for future research. J Anxiety Disord 25:849–854CrossRefPubMedGoogle Scholar
  15. 15.
    Yufik T, Simms LJ (2010) A meta-analytic investigation of the structure of posttraumatic stress disorder symptoms. J Abnorm Psychol 119:764–776CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Watson D (2009) Differentiating the mood and anxiety disorders: a quadripartite model. Annu Rev Clin Psychol 5:221–247CrossRefPubMedGoogle Scholar
  17. 17.
    Meis LA, Erbes CR, Kaler ME, Arbisi PA, Polusny MA (2011) The structure of PTSD among two cohorts of returning soldiers: before, during, and following deployment to Iraq. J Abnorm Psychol 120:807–818CrossRefPubMedGoogle Scholar
  18. 18.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Association, Washington, DCGoogle Scholar
  19. 19.
    Gootzeit J, Markon K (2011) Factors of PTSD: differential specificity and external correlates. Clin Psychol Rev 31:993–1003. doi: 10.1016/j.cpr.2011.06.005 CrossRefPubMedGoogle Scholar
  20. 20.
    Contractor AA, Durham TA, Brennan JA, Armour C, Wutrick HR, Frueh BC, Elhai JD (2014) DSM-5 PTSD’s symptom dimensions and relations with major depression’s symptom dimensions in a primary care sample. Psychiatry Res 215(1):146–153CrossRefPubMedGoogle Scholar
  21. 21.
    Forbes D, Lockwood E, Elhai JD, Creamer M, O’Donnell M, Bryant R, McFarlane A, Silove D (2011) An examination of the structure of posttraumatic stress disorder in relation to the anxiety and depressive disorders. J Affect Disord 132:165–172CrossRefPubMedGoogle Scholar
  22. 22.
    Stewart SH, Mitchell TL, Wright KD, Loba P (2004) The relations of PTSD symptoms to alcohol use and coping drinking in volunteers who responded to the Swissair Flight 111 airline disaster. J Anxiety Disord 18:51–68CrossRefPubMedGoogle Scholar
  23. 23.
    Stewart SH, Pihl RO, Conrod PJ, Dongier M (1998) Functional associations among trauma, PTSD, and substance-related disorders. Addict Behav 23:797–812CrossRefPubMedGoogle Scholar
  24. 24.
    Maguen S, Stalnaker M, McCaslin S, Litz BT (2009) PTSD subclusters and functional impairment in Kosovo peacekeepers. Mil Med 174:779–785CrossRefPubMedGoogle Scholar
  25. 25.
    Sakusic A, Avdibegovic E, Zoricic Z, Pavlovic S, Gaspar V, Delic A (2010) Relationship between anger, alcoholism and symptoms of posttraumatic stress disorders in war veterans. Med Arh 64:354–358PubMedGoogle Scholar
  26. 26.
    Simons JS, Gaher RM, Jacobs GA, Meyer D, Johnson-Jimenez E (2005) Associations between alcohol use and PTSD symptoms among American Red Cross disaster relief workers responding to the 9/11/2001 attacks. Am J Drug Alcohol Abus 31:285–304CrossRefGoogle Scholar
  27. 27.
    Stewart SH, Conrod PJ, Pihl RO, Dongier M (1999) Relations between posttraumatic stress symptom dimensions and substance dependence in a community-recruited sample of substance-abusing women. Psychol Addict Behav 13:78CrossRefGoogle Scholar
  28. 28.
    Taft CT, Kaloupek DG, Schumm JA, Marshall AD, Panuzio J, King DW, Keane TM (2007) Posttraumatic stress disorder symptoms, physiological reactivity, alcohol problems, and aggression among military veterans. J Abnorm Psychol 116:498–507CrossRefPubMedGoogle Scholar
  29. 29.
    Jacobsen LK, Southwick SM, Kosten TR (2001) Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. Am J Psychiatry 158:1184–1190CrossRefPubMedGoogle Scholar
  30. 30.
    Nishith P, Resick PA, Mueser KT (2001) Sleep difficulties and alcohol use motives in female rape victims with posttraumatic stress disorder. J Trauma Stress 14:469–479CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Kaysen D, Dillworth TM, Simpson T, Waldrop A, Larimer ME, Resick PA (2007) Domestic violence and alcohol use: trauma-related symptoms and motives for drinking. Addict Behav 32:1272–1283CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE (2003) Psychometric properties of the PTSD checklist-civilian version. J Trauma Stress 16:495–502CrossRefPubMedGoogle Scholar
  33. 33.
    Forbes D, Creamer M, Biddle D (2001) The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD. Behav Res Ther 39:977–986CrossRefPubMedGoogle Scholar
  34. 34.
    McDonald SD, Calhoun PS (2010) The diagnostic accuracy of the PTSD checklist: a critical review. Clin Psychol Rev 30:976–987CrossRefPubMedGoogle Scholar
  35. 35.
    Kroutil LA, Vorburger M, Aldworth J, Colliver JD (2010) Estimated drug use based on direct questioning and open-ended questions: responses in the 2006 National Survey on Drug Use and Health. Int J Methods Psychiatr Res 19:74–87PubMedGoogle Scholar
  36. 36.
    Muthén BO, Muthén LK (2010) Mplus. Los Angeles, CaliforniaGoogle Scholar
  37. 37.
    Muthén LK, Muthén BO (1998-2010) Mplus user’s guide. 6th edn. Muthén & Muthén, Los AngelesGoogle Scholar
  38. 38.
    Hu L, Bentler PM (1999) Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model 6:1–55CrossRefGoogle Scholar
  39. 39.
    Satorra A, Bentler PM (2001) A scaled difference chi-square test statistic for moment structure analysis. Psychometrika 66:507–514CrossRefGoogle Scholar
  40. 40.
    Flora DB, Curran PJ (2004) An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data. Psychol Methods 9:466–491CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Wirth RJ, Edwards MC (2007) Item factor analysis: current approaches and future directions. Psychol Methods 12:58–79CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Baron RM, Kenny DA (1986) The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 51:1173–1182CrossRefPubMedGoogle Scholar
  43. 43.
    MacKinnon DP (2008) Introduction to statistical mediation analysis. Taylor & Francis Group, New YorkGoogle Scholar
  44. 44.
    Marshall GN, Schell TL, Miles JN (2010) All PTSD symptoms are highly associated with general distress: ramifications for the dysphoria symptom cluster. J Abnorm Psychol 119:126–135CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Miller MW, Wolf EJ, Harrington KM, Brown TA, Kaloupek DG, Keane TM (2010) An evaluation of competing models for the structure of PTSD symptoms using external measures of comorbidity. J Trauma Stress 23:631–638CrossRefPubMedGoogle Scholar
  46. 46.
    Biehn TL, Contractor AA, Elhai JD, Tamburrino M, Fine TH, Prescott MR, Shirley E, Chan P, Slembarski R, Liberzon I, Calabrese JR, Galea S (2013) Relations between the underlying dimensions of PTSD and major depression using an epidemiological survey of deployed Ohio National Guard soldiers. J Affect Disorders 144:106–111CrossRefPubMedGoogle Scholar
  47. 47.
    Biehn TL, Elhai JD, Seligman LD, Tamburrino M, Armour C, Forbes D (2013) Underlying dimensions of DSM-5 posttraumatic stress disorder and major depressive disorder symptoms. Psychol Injury Law 6:290–298CrossRefGoogle Scholar
  48. 48.
    Elhai JD, Contractor AA, Tamburrino M, Fine TH, Cohen G, Shirley E et al (2015) Structural relations between DSM-5 PTSD and Major Depression symptoms in military soldiers. J Affect Disorders 175:373–378CrossRefPubMedGoogle Scholar
  49. 49.
    Elhai JD, Biehn TL, Armour C, Klopper JJ, Frueh BC, Palmieri PA (2011) Evidence for a unique PTSD construct represented by PTSD’s D1-D3 symptoms. J Anxiety Disord 25:340–345CrossRefPubMedGoogle Scholar
  50. 50.
    Armour C, Carragher N, Elhai JD (2013) Assessing the fit of the dysphoric arousal model across two nationally representative epidemiological surveys: the Australian NSMHWB and the United States NESARC. J Anxiety Disord 27:109–115CrossRefPubMedGoogle Scholar
  51. 51.
    Armour C, O’Connor M, Elklit A, Elhai JD (2013) Assessing PTSD’s latent structure in elderly bereaved European trauma victims: evidence for a five factor dysphoric and arousal model. J Nerv Ment Dis 201:901–906CrossRefPubMedGoogle Scholar
  52. 52.
    Liu P, Wang L, Cao C, Wang R, Zhang J, Zhang B, Wu Q, Zhang H, Zhao Z, Fan G, Elhai JD (2014) The underlying dimensions of DSM-5 posttraumatic stress disorder symptoms in an epidemiological sample of Chinese earthquake survivors. J Anxiety Disord 28:345–351CrossRefPubMedGoogle Scholar
  53. 53.
    Tsai J, Harpaz-Rotem I, Armour C, Southwick SM, Krystal JH, Pietrzak RH (2014) Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from the National Health and Resilience in Veterans Study. J Clin Psychiat 76:546–553Google Scholar
  54. 54.
    Armour C, Tsai J, Durham TA, Charak R, Biehn TL, Elhai JD, Pietrzak RH (2015) Dimensional structure of DSM-5 posttraumatic stress symptoms: support for a hybrid anhedonia and externalizing behaviors model. J Psychiat Res 61:106–113CrossRefPubMedGoogle Scholar
  55. 55.
    Pietrzak RH, Goldstein MB, Malley JC, Rivers AJ, Johnson DC, Southwick SM (2010) Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. J Affect Disord 123:102–107CrossRefPubMedGoogle Scholar
  56. 56.
    Weiss NH, Tull MT, Viana AG, Anestis MD, Gratz KL (2012) Impulsive behaviors as an emotion regulation strategy: examining associations between PTSD, emotion dysregulation, and impulsive behaviors among substance dependent inpatients. J Anxiety Disord 26:453–458CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Verdejo-García A, Lawrence AJ, Clark L (2008) Impulsivity as a vulnerability marker for substance-use disorders: review of findings from high-risk research, problem gamblers and genetic association studies. Neurosci Biobehav R 32:777–810CrossRefGoogle Scholar
  58. 58.
    Marshall-Berenz EC, Vujanovic AA, MacPherson L (2011) Impulsivity and alcohol use coping motives in a trauma-exposed sample: the mediating role of distress tolerance. Pers Indiv Differ 50:588–592CrossRefGoogle Scholar
  59. 59.
    O’Hare T, Sherrer MV, Yeamen D, Cutler J (2009) Correlates of post-traumatic stress disorder in male and female community clients. Social Work Mental Health 7:340–352CrossRefGoogle Scholar
  60. 60.
    Coffey SF, Schumacher JA, Brady KT, Cotton BD (2007) Changes in PTSD symptomatology during acute and protracted alcohol and cocaine abstinence. Drug Alcohol Depend 87:241–248CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Back SE (2010) Toward an improved model of treating co-occurring PTSD and substance use disorders. Am J Psychiatry 167:11–13CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Cole DA, Maxwell SE (2003) Testing mediational models with longitudinal data: questions and tips in the use of structural equation modeling. J Abnorm Psychol 112:558–577CrossRefPubMedGoogle Scholar
  63. 63.
    Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL (2004) Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New Engl J Med 351:13–22CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Tracey L. Biehn
    • 1
    • 2
    Email author
  • Ateka A. Contractor
    • 2
    • 9
  • Jon D. Elhai
    • 2
    • 3
  • Marijo Tamburrino
    • 4
  • Thomas H. Fine
    • 4
  • Gregory Cohen
    • 5
  • Edwin Shirley
    • 6
  • Philip K. Chan
    • 6
  • Israel Liberzon
    • 7
  • Joseph R. Calabrese
    • 8
  • Sandro Galea
    • 5
  1. 1.St. Cloud VA Health Care SystemSt. CloudUSA
  2. 2.Department of PsychologyUniversity of ToledoToledoUSA
  3. 3.Department of PsychiatryUniversity of ToledoToledoUSA
  4. 4.Department of PsychiatryUniversity of ToledoToledoUSA
  5. 5.Mailman School of Public HealthColumbia UniversityNew YorkUSA
  6. 6.Department of PsychiatryCase Western Reserve University, University Hospitals Case Medical CenterClevelandUSA
  7. 7.Mental Health Service, VA Ann Arbor Health System, Department of PsychiatryUniversity of MichiganAnn ArborUSA
  8. 8.Department of PsychiatryCase Western Reserve UniversityClevelandUSA
  9. 9.VA Boston Healthcare System, Massachusetts Veterans Epidemiology Research and Information CenterBostonUSA

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