Skip to main content

Advertisement

SpringerLink
Log in

Dimensionality of DSM-5 posttraumatic stress disorder and its association with suicide attempts: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III

  • Original Paper
  • Published:
Social Psychiatry and Psychiatric Epidemiology Aims and scope Submit manuscript

Abstract

Background

Emerging confirmatory factor analytic (CFA) studies suggest that posttraumatic stress disorder (PTSD) as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is best characterized by seven factors, including re-experiencing, avoidance, negative affect, anhedonia, externalizing behaviors, and anxious and dysphoric arousal. The seven factors, however, have been found to be highly correlated, suggesting that one general factor may exist to explain the overall correlations among symptoms.

Methods

Using data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, a large, national survey of 36,309 U.S. adults ages 18 and older, this study proposed and tested an exploratory bifactor hybrid model for DSM-5 PTSD symptoms. The model posited one general and seven specific latent factors, whose associations with suicide attempts and mediating psychiatric disorders were used to validate the PTSD dimensionality.

Results

The exploratory bifactor hybrid model fitted the data extremely well, outperforming the 7-factor CFA hybrid model and other competing CFA models. The general factor was found to be the single dominant latent trait that explained most of the common variance (~76%) and showed significant, positive associations with suicide attempts and mediating psychiatric disorders, offering support to the concurrent validity of the PTSD construct.

Conclusions

The identification of the primary latent trait of PTSD confirms PTSD as an independent psychiatric disorder and helps define PTSD severity in clinical practice and for etiologic research. The accurate specification of PTSD factor structure has implications for treatment efforts and the prevention of suicidal behaviors.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Alegría M, Fortuna LR, Lin JY, Norris FH, Gao S, Takeuchi DT, Jackson JS, Shrout PE, Valentine A (2013) Prevalence, risk, and correlates of posttraumatic stress disorder across ethnic and racial minority groups in the United States. Med Care 51(12):1114–1123

    Article  PubMed  PubMed Central  Google Scholar 

  2. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):617–627

    Article  PubMed  PubMed Central  Google Scholar 

  3. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU (2012) Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res 21(3):169–184

    Article  PubMed  PubMed Central  Google Scholar 

  4. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):593–602

    Article  PubMed  Google Scholar 

  5. Pietrzak RH, Goldstein RB, Southwick SM, Grant BF (2011) Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Anxiety Disord 25(3):456–465

    Article  PubMed  Google Scholar 

  6. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn (DSM-IV), text revision. American Psychiatric Association, Washington, DC

    Google Scholar 

  7. Goldstein RB, Smith SM, Chou SP, Saha TD, Jung J, Zhang H, Pickering RP, Ruan WJ, Huang B, Grant BF (2016) The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol 51(8):1137–1148

    Article  PubMed  Google Scholar 

  8. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders. 5th edn. American Psychiatric Association, Arlington

    Book  Google Scholar 

  9. Wisco BE, Marx BP, Miller MW, Wolf EJ, Mota NP, Krystal JH, Southwick SM, Pietrzak RH (2016) Probable posttraumatic stress disorder in the US veteran population according to DSM-5: results from the National Health and Resilience in Veterans Study. J Clin Psychiatry 77(11):1503–1510

    Article  PubMed  Google Scholar 

  10. Smith SM, Goldstein RB, Grant BF (2016) The association between post-traumatic stress disorder and lifetime DSM-5 psychiatric disorders among veterans: data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). J Psychiatr Res 82:16–22

    Article  PubMed  Google Scholar 

  11. Friedman MJ (2013) Finalizing PTSD in DSM-5: getting here from there and where to go next. J Trauma Stress 26(5):548–556

    Article  PubMed  Google Scholar 

  12. Miller MW, Wolf EJ, Kilpatrick D, Resnick H, Marx BP, Holowka DW, Keane TM, Rosen RC, Friedman MJ (2013) The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in U.S. national and veteran samples. Psychol Trauma 5(6):501–512

    Article  Google Scholar 

  13. 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(4):345–351

    Article  PubMed  Google Scholar 

  14. Tsai J, Harpaz-Rotem I, Armour C, Southwick SM, Krystal JH, Pietrzak RH (2015) Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from the National Health and Resilience in Veterans Study. J Clin Psychiatry 76(5):546–553

    Article  PubMed  Google Scholar 

  15. Armour C, Mullerova J, Elhai JD (2016) A systematic literature review of PTSD’s latent structure in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV to DSM-5. Clin Psychol Rev 44:60–74

    Article  PubMed  Google Scholar 

  16. 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 Psychiatr Res 61:106–113

    Article  PubMed  Google Scholar 

  17. Pietrzak RH, Tsai J, Armour C, Mota N, Harpaz-Rotem I, Southwick SM (2015) Functional significance of a novel 7-factor model of DSM-5 PTSD symptoms: results from the National Health and Resilience in Veterans Study. J Affect Disord 174:522–526

    Article  PubMed  Google Scholar 

  18. Liu L, Wang L, Cao C, Qing Y, Armour C (2016) Testing the dimensional structure of DSM-5 posttraumatic stress disorder symptoms in a nonclinical trauma-exposed adolescent sample. J Child Psychol Psychiatry 57(2):204–212

    Article  PubMed  Google Scholar 

  19. Mordeno IG, Nalipay MJ, Sy DJ, Luzano JG (2016) PTSD factor structure and relationship with self-construal among internally displaced persons. J Anxiety Disord 44:102–110

    Article  PubMed  Google Scholar 

  20. Mordeno IG, Carpio JG, Nalipay MJ, Saavedra RL (2017) PTSD’s underlying dimensions in typhoon haiyan survivors: assessing DSM-5 symptomatology-based PTSD models and their relation to posttraumatic cognition. Psychiatr Q 88(1):9–23

    Article  PubMed  Google Scholar 

  21. Seligowski AV, Orcutt HK (2016) Support for the 7-factor hybrid model of PTSD in a community sample. Psychol Trauma 8(2):218–221

    Article  PubMed  Google Scholar 

  22. Armour C (2015) The underlying dimensionality of PTSD in the diagnostic and statistical manual of mental disorders: where are we going? Eur J Psychotraumatol 6:28074

    Article  PubMed  Google Scholar 

  23. LeBouthillier DM, McMillan KA, Thibodeau MA, Asmundson GJ (2015) Types and number of traumas associated with suicidal ideation and suicide attempts in PTSD: findings from a U.S. nationally representative sample. J Trauma Stress 28(3):183–190

    Article  PubMed  Google Scholar 

  24. Sareen J, Cox BJ, Stein MB, Afifi TO, Fleet C, Asmundson GJ (2007) Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosom Med 69(3):242–248

    Article  PubMed  Google Scholar 

  25. Conner KR, Bossarte RM, He H, Arora J, Lu N, Tu XM, Katz IR (2014) Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the veterans health administration health system. J Affect Disord 166:1–5

    Article  PubMed  Google Scholar 

  26. Legarreta M, Graham J, North L, Bueler CE, McGlade E, Yurgelun-Todd D (2015) DSM-5 posttraumatic stress disorder symptoms associated with suicide behaviors in veterans. Psychol Trauma 7(3):277–285

    Article  PubMed  Google Scholar 

  27. Maguen S, Madden E, Cohen BE, Bertenthal D, Neylan TC, Seal KH (2015) Suicide risk in Iraq and Afghanistan veterans with mental health problems in VA care. J Psychiatr Res 68:120–124

    Article  PubMed  Google Scholar 

  28. Pompili M, Sher L, Serafini G, Forte A, Innamorati M, Dominici G, Lester D, Amore M, Girardi P (2013) Posttraumatic stress disorder and suicide risk among veterans: a literature review. J Nerv Ment Dis 201(9):802–812

    Article  PubMed  Google Scholar 

  29. Krysinska K, Lester D (2010) Post-traumatic stress disorder and suicide risk: a systematic review. Arch Suicide Res 14(1):1–23

    Article  PubMed  Google Scholar 

  30. Bullman TA, Kang HK (1994) Posttraumatic stress disorder and the risk of traumatic deaths among Vietnam veterans. J Nerv Ment Dis 182(11):604–610

    Article  CAS  PubMed  Google Scholar 

  31. Kang HK, Bullman TA, Smolenski DJ, Skopp NA, Gahm GA, Reger MA (2015) Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars. Ann Epidemiol 25(2):96–100

    Article  PubMed  Google Scholar 

  32. Carragher N, Sunderland M, Batterham PJ, Calear AL, Elhai JD, Chapman C, Mills K (2016) Discriminant validity and gender differences in DSM-5 posttraumatic stress disorder symptoms. J Affect Disord 190:56–67

    Article  PubMed  Google Scholar 

  33. Panagioti M, Gooding PA, Dunn G, Tarrier N (2011) Pathways to suicidal behavior in posttraumatic stress disorder. J Trauma Stress 24(2):137–145

    Article  PubMed  Google Scholar 

  34. Conner KR, Hesselbrock VM, Meldrum SC, Schuckit MA, Bucholz KK, Gamble SA, Wines JD Jr, Kramer J (2007) Transitions to, and correlates of, suicidal ideation, plans, and unplanned and planned suicide attempts among 3,729 men and women with alcohol dependence. J Stud Alcohol Drugs 68(5):654–662

    Article  PubMed  Google Scholar 

  35. van Minnen A, Zoellner LA, Harned MS, Mills K (2015) Changes in comorbid conditions after prolonged exposure for PTSD: a literature review. Curr Psychiatry Rep 17(3):549

    PubMed  Google Scholar 

  36. Panagioti M, Gooding P, Tarrier N (2009) Post-traumatic stress disorder and suicidal behavior: a narrative review. Clin Psychol Rev 29(6):471–482

    Article  PubMed  Google Scholar 

  37. Frewen PA, Schmittmann VD, Bringmann LF, Borsboom D (2013) Perceived causal relations between anxiety, posttraumatic stress and depression: extension to moderation, mediation, and network analysis. Eur J Psychotraumatol 4(1):1–10

    Google Scholar 

  38. Reise SP, Moore TM, Haviland MG (2010) Bifactor models and rotations: exploring the extent to which multidimensional data yield univocal scale scores. J Pers Assess 92(6):544–559

    Article  PubMed  PubMed Central  Google Scholar 

  39. Grant BF, Chu A, Sigman R, Amsbary M, Kali J, Sugawara Y, Jiao R, Ren W, Goldstein R (2014) Source and accuracy statement: National Epidemiologic Survey on Alcohol and Related Conditions–III (NESARC-III). National Institute on Alcohol Abuse and Alcoholism, Rockville

    Google Scholar 

  40. Grant BF, Goldstein RB, Chou SP, Saha TD, Ruan WJ, Huang B, Smith SM, Zhang H, Jung J, Pickering RP, Aivadyan C, Greenstein E, Hasin DS (2011) The alcohol use disorder and associated disabilities interview schedule—diagnostic and statistical manual of mental disorders, fifth edition version (AUDADIS-5). National Institute on Alcohol Abuse and Alcoholism, Rockville

    Google Scholar 

  41. Blackwell DL, Lucas JW, Clarke TC (2014) Summary health statistics for U.S. adults: National Health Interview Survey, 2012. Vital Health Stat 10(260):1–161

    Google Scholar 

  42. Substance Abuse and Mental Health Services Administration (2014) Results from the 2013 National Survey on Drug Use and Health: summary of national findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Author, Rockville

  43. National Institute on Alcohol Abuse and Alcoholism (2015) National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III): Flashcard Booklet. Author, Rockville. https://www.niaaa.nih.gov/sites/default/files/flashcards_glasses_with_description_FINAL_1_6_15.pdf. Accessed 18 Feb 2016

  44. Friedman MJ, Resick PA, Bryant RA, Brewin CR (2011) Considering PTSD for DSM-5. Depress Anxiety 28(9):750–769

    Article  PubMed  Google Scholar 

  45. Grant BF, Goldstein RB, Smith SM, Jung J, Zhang H, Chou SP, Pickering RP, Ruan WJ, Huang B, Saha TD, Aivadyan C, Greenstein E, Hasin DS (2015) The alcohol use disorder and associated disabilities interview schedule-5 (AUDADIS-5): reliability of substance use and psychiatric disorder modules in a general population sample. Drug Alcohol Depend 148:27–33

    Article  PubMed  Google Scholar 

  46. Hasin DS, Greenstein E, Aivadyan C, Stohl M, Aharonovich E, Saha T, Goldstein R, Nunes EV, Jung J, Zhang H, Grant BF (2015) The alcohol use disorder and associated disabilities interview schedule-5 (AUDADIS-5): procedural validity of substance use disorders modules through clinical re-appraisal in a general population sample. Drug Alcohol Depend 148:40–46

    Article  PubMed  Google Scholar 

  47. Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, Pickering RP, Ruan WJ, Smith SM, Huang B, Hasin DS (2015) Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA. Psychiatry 72(8):757–766

    Google Scholar 

  48. Asparouhov T, Muthén B (2009) Exploratory structural equation modeling. Struct Equ Modeling 16(3):397–438

    Article  Google Scholar 

  49. Marsh HW, Morin AJ, Parker PD, Kaur G (2014) Exploratory structural equation modeling: an integration of the best features of exploratory and confirmatory factor analysis. Annu Rev Clin Psychol 10:85–110

    Article  PubMed  Google Scholar 

  50. Browne MW (2001) An overview of analytic rotation in exploratory factor analysis. Multivariate Behav Res 36(1):111–150

    Article  Google Scholar 

  51. Jennrich RI, Bentler PM (2011) Exploratory bi-factor analysis. Psychometrika 76(4):537–549

    Article  PubMed  PubMed Central  Google Scholar 

  52. Bentler PM (1990) Comparative fit indexes in structural models. Psychol Bull 107(2):238–246

    Article  CAS  PubMed  Google Scholar 

  53. Hu LT, Bentler PM (1999) Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Modeling 6(1):1–55

    Article  Google Scholar 

  54. Asparouhov T, Muthen M, Muthen B (2006) Robust chi square difference testing with mean and variance adjusted test statistics. Mplus Web Notes 10. https://www.statmodel.com/download/webnotes/webnote10.pdf

  55. Muthén LK, Muthén B (1998–2012) Mplus user’s guide. 7 edn. Muthén and Muthén, Los Angeles

  56. Biderman MD, Nguyen NT, Cunningham CJL, Ghorbani N (2011) The ubiquity of common method variance: the case of the Big Five. J Res Pers 45(5):417–429

    Article  Google Scholar 

  57. Burke JD, Boylan K, Rowe R, Duku E, Stepp SD, Hipwell AE, Waldman ID (2014) Identifying the irritability dimension of ODD: application of a modified bifactor model across five large community samples of children. J Abnorm Psychol 123(4):841–851

    Article  PubMed  PubMed Central  Google Scholar 

  58. Patrick CJ, Hicks BM, Nichol PE, Krueger RF (2007) A bifactor approach to modeling the structure of the psychopathy checklist-revised. J Pers Disord 21(2):118–141

    Article  PubMed  PubMed Central  Google Scholar 

  59. Simms LJ, Gros DF, Watson D, O’Hara MW (2008) Parsing the general and specific components of depression and anxiety with bifactor modeling. Depress Anxiety 25(7):E34–E46

    Article  PubMed  Google Scholar 

  60. Simms LJ, Prisciandaro JJ, Krueger RF, Goldberg DP (2012) The structure of depression, anxiety and somatic symptoms in primary care. Psychol Med 42(1):15–28

    Article  CAS  PubMed  Google Scholar 

  61. Yang Y, Sun Y, Zhang Y, Jiang Y, Tang J, Zhu X, Miao D (2013) Bifactor item response theory model of acute stress response. PloS One 8(6):e65291

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. 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(6):849–854

    Article  PubMed  Google Scholar 

  63. Pettersson E, Turkheimer E, Horn EE, Menatti AR (2012) The general factor of personality and evaluation. Eur. J Pers 26(3):292–302

    Google Scholar 

  64. Toyinbo PA, Vanderploeg RD, Donnell AJ, Mutolo SA, Cook KF, Kisala PA, Tulsky DS (2016) Development and initial validation of military deployment-related TBI quality-of-life item banks. J Head Trauma Rehabil 31(1):52–61

    Article  PubMed  Google Scholar 

  65. Yufik T, Simms LJ (2010) A meta-analytic investigation of the structure of posttraumatic stress disorder symptoms. J Abnorm Psychol 119(4):764–776

    Article  PubMed  PubMed Central  Google Scholar 

  66. Haviland MG, Banta JE, Sonne JL, Przekop P (2016) Posttraumatic stress disorder-related hospitalizations in the United States (2002–2011): rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis 204(2):78–86

    Article  PubMed  Google Scholar 

  67. Curtin SC, Warner M, Hedegaard H (2016) Increase in suicide in the United States, 1999–2014. NCHS Data Brief 241:1–8

    Google Scholar 

  68. Selaman ZM, Chartrand HK, Bolton JM, Sareen J (2014) Which symptoms of post-traumatic stress disorder are associated with suicide attempts? J Anxiety Disord 28(2):246–251

    Article  PubMed  Google Scholar 

  69. Reise SP, Scheines R, Widaman KF, Haviland MG (2013) Multidimensionality and structural coefficient bias in structural equation modeling: a bifactor perspective. Educ Psychol Meas 73(1):5–26

    Article  Google Scholar 

  70. Scott K, Lewis CC (2015) Using measurement-based care to enhance any treatment. Cogn Behav Pract 22(1):49–59

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. CSR, Incorporated, 4250 N. Fairfax Dr., Suite 500, Arlington, VA, 22203, USA

    Chiung M. Chen, Young-Hee Yoon & Thomas C. Harford

  2. National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 5635 Fishers Lane, Bethesda, MD, 20892, USA

    Bridget F. Grant

Authors
  1. Chiung M. Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Young-Hee Yoon
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thomas C. Harford
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Bridget F. Grant
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Chiung M. Chen.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 23 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chen, C.M., Yoon, YH., Harford, T.C. et al. Dimensionality of DSM-5 posttraumatic stress disorder and its association with suicide attempts: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol 52, 715–725 (2017). https://doi.org/10.1007/s00127-017-1374-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00127-017-1374-0

Keywords

Search

Navigation