The underlying dimensions of DSM-5 posttraumatic stress disorder symptoms in an epidemiological sample of Chinese earthquake survivors

The current study investigated the underlying dimensions of DSM-5 PTSD symptoms in an epidemiological sample of Chinese earthquake survivors. The sample consisted of 810 females and 386 males, with a mean age of 47.9 years (SD = 10.0, range: 16–73). PTSD symptoms were assessed using the PTSD Checklist for DSM-5, and alternative models were evaluated with confirmatory factor analysis. Results indicated that a six-factor model comprised of intrusion, avoidance, negative affect, anhedonia, dysphoric arousal, and anxious arousal factors emerged as the best fitting model. The current findings add to limited literature on the latent structure of PTSD symptoms described in the recently released DSM-5, and carry implications for further trauma-related research and clinical practice.     

Evidence for a unique PTSD construct represented by PTSD's D1-D3 symptoms

Two models of posttraumatic stress disorder (PTSD) have received the most empirical support in confirmatory factor analytic studies: King, Leskin, King, and Weathers’ (1998) Emotional Numbing model of reexperiencing, avoidance, emotional numbing and hyperarousal; and Simms, Watson, and Doebbeling's (2002) Dysphoria model of reexperiencing, avoidance, dysphoria and hyperarousal. These models only differ in placement of three PTSD symptoms: sleep problems (D1), irritability (D2), and concentration problems (D3). In the present study, we recruited 252 women victims of domestic violence and tested whether there is empirical support to separate these three PTSD symptoms into a fifth factor, while retaining the Emotional Numbing and Dysphoria models’ remaining four factors. Confirmatory factor analytic findings demonstrated that separating the three symptoms into a separate factor significantly enhanced model fit for the Emotional Numbing and Dysphoria models. These three symptoms may represent a unique latent construct. Implications are discussed.     

Loss as a determinant of PTSD in a cohort of adult survivors of the 1988 earthquake in Armenia: implications for policy

OBJECTIVE: To study the relationship of post-traumatic stress disorder (PTSD) to severity of the disaster experience. METHOD: A sample of 1785 adult participants of an epidemiological study initiated in the immediate aftermath of the 1988 earthquake in Armenia were interviewed about 2 years following the disaster based on the NIMH DIS-Disaster Supplement. All 154 cases of pure PTSD were compared with 583 controls without symptoms satisfying psychiatric diagnoses of interest. RESULTS: PTSD cases included more persons from areas with the worst destruction. Having the highest level of education compared to lowest (OR 0.6 [95% CI 0.4-0.9]), being accompanied at the moment of the earthquake (OR 0.6 [95% CI 0.4-0.9]) and making new friends after the earthquake (OR 0.6 [95% CI 0.5-0.8]) were protective for PTSD. PTSD risk increased with the total amount of loss to the family (OR for highest level of loss 4.1 [95% CI 2.3-7.5]). CONCLUSION: Based on this large population sample, we believe that early support to survivors with high levels of loss may reduce PTSD following earthquakes.     

A cross-sectional study among survivors of the 2008 Sichuan earthquake: prevalence and risk factors of posttraumatic stress disorder

Objective

The objective of this study is to estimate the prevalence of probable posttraumatic stress disorder (PTSD), explore the related risk factors among Sichuan earthquake survivors in different counties and compare the findings in our study to others.

Method

A cross-sectional sample survey was conducted to collect data in heavily (n=367) and moderately damaged counties (n=337). We used the PTSD Check List—Civilian Version (PCL-C), which consists of 17 items corresponding to each symptom of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Results

The prevalence of probable PTSD in heavily damaged counties (48.2%) was higher than that in moderately damaged counties (14.5%). Many associated risk factors were identified in the cross-sectional study.

Conclusion

Female, Han nationality, low monthly income, fear during earthquake and low social support in the past year were significant risk factors in heavily damaged counties, while the probable PTSD in moderately damaged counties was related to female, youth, fear during earthquake and low social support.     

The structure of ICD-11 post traumatic stress disorder in a clinical sample of refugees based on the International Trauma Interview

Background

The ICD-11 proposes fundamental changes to the PTSD diagnostic criteria, prompting thorough validation. While this is ideally carried out based on diagnostic interviews, most—and in the case of transcultural psychiatry all—studies have relied on self-reported measures. In this study, we used the International Trauma Interview (ITI) to assess the factor structure of ICD-11 PTSD symptoms in a sample of trauma-affected refugees.

Method

The ITI was administered with a sample of refugees (n = 198), originating mainly from the Greater Middle East. The symptom ratings were subjected to a confirmatory factor analysis (CFA), comparing the ICD-11 concordant three-factor model with alternative two- and one-factor models.

Results

The overall fit was adequate for both the two- and three-factor models, but favored the two-factor model. Results for both models indicated local misspecifications and that item 5, hypervigilance, displayed a suboptimal loading.

Conclusion

The results generally support the use of the ITI in a severely trauma-affected refugee population, albeit with particular attention needed in the administration of item 5. The superior fit of a two-factor model warrants further testing across populations.     

Low posttrauma GABA plasma levels as a predictive factor in the development of acute posttraumatic stress disorder.

BACKGROUND: Gamma amino-butyric acid (GABA) regulates the intensity and the duration of the central hyperadrenergic response in times of high stress and has been negatively associated with anxiety, depression, and sleep problems. We hypothesized that individuals with low plasma GABA levels may be more prone to develop posttraumatic stress disorder (PTSD) in the aftermath of trauma exposure. METHODS: To test this hypothesis, we measured plasma GABA levels in a population of 108 road traffic accident victims on arrival at a traumatology department and assessed them for PTSD 6 weeks later. RESULTS: The mean GABA level (nmol/mL) in the PTSD group (n = 55; M =.20; SD =.08) was significantly lower compared with members of the trauma-exposed group who did not develop PTSD [n = 17; M =.30; SD =.09), t(70) = 3.94, p =.0002]. CONCLUSIONS: Provided that GABA levels in the brain are genetically predetermined, our results would suggest that individuals with low plasma GABA levels are premorbidly more vulnerable to stress-related disorders such as acute PTSD. If replicated, plasma GABA levels measured in the aftermath of trauma exposure might help to identify individuals at high risk for developing PTSD.     

Confirmatory factor analysis of posttraumatic stress symptoms assessed by the Impact of Event Scale-Revised in Chinese earthquake victims: examining factor structure and its stability across sex

The current study investigated the factor structure of posttraumatic stress symptoms assessed by the Impact Event Scale-Revised (IES-R) in a large sample of individuals from China who recently experienced a destructive earthquake. The results of the confirmatory factor analysis indicated that a four-factor structure (intrusion, avoidance-numbing, hyperarousal, and sleep disturbance) emerged as the model best fit in total sample, female and male subsamples, respectively. Moreover, multiple-group confirmatory factor analysis further demonstrated that the four-factor model was quite stable across sex. Implication and limitations for the results are discussed.     

Comparing alternative factor models of PTSD symptoms across earthquake victims and violent riot witnesses in China: evidence for a five-factor model proposed by Elhai et al. (2011)

The present study investigated the factor structure of posttraumatic stress disorder (PTSD) symptoms measured by the PTSD Checklist (PCL) in two large samples exposed to different traumatic events (an earthquake and a violent riot) from China. Despite the samples’ difference in type of trauma, demographics, symptom severity, and elapsed time since trauma exposure, the results of a series of confirmatory factor analyses indicate that a five-factor intercorrelated model (intrusion, avoidance, numbing, dysphoric arousal, and anxious arousal) fit the data significantly better than the other alternative models including: the three-factor DSM-IV model, the four-factor numbing model (King et al., 1998), and the four-factor dysphoria model (Simms et al., 2002) in both samples. Implications and limitations regarding the results are discussed.     

Clinician-administered PTSD scale: a review of the first ten years of research

The Clinician-Administered PTSD Scale (CAPS) is a structured interview for assessing posttraumatic stress disorder (PTSD) diagnostic status and symptom severity. In the 10 years since it was developed, the CAPS has become a standard criterion measure in the field of traumatic stress and has now been used in more than 200 studies. In this paper, we first trace the history of the CAPS and provide an update on recent developments. Then we review the empirical literature, summarizing and evaluating the findings regarding the psychometric properties of the CAPS. The research evidence indicates that the CAPS has excellent reliability, yielding consistent scores across items, raters, and testing occasions. There is also strong evidence of validity: The CAPS has excellent convergent and discriminant validity, diagnostic utility, and sensitivity to clinical change. Finally, we address several concerns about the CAPS and offer recommendations for optimizing the CAPS for various clinical research applications.     

Exploratory factor analysis of two measures of posttraumatic stress disorder (PTSD) symptoms in a non-clinical sample of college students

This study investigated the psychometric structure of two widely utilized measures of posttraumatic symptoms in a primarily Caucasian non-clinical sample. Given the prevalence of trauma exposure in non-referred samples, measurement of resulting symptoms is a critical issue. Exploratory factor analysis was utilized to assess and compare the factor structure of the Impact of Event Scale [IES; Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: a measure of subjective stress. Psychosomatic Medicine, 41, 209-218] and the Mississippi Scale for Posttraumatic Stress Disorder, Civilian version [MIS-Civ; Vreven, D. L., Gudanowski, D. M., King, L. A., & King, D. W. (1995). The Civilian Version of the Mississippi PTSD Scale-a psychometric evaluation. Journal of Traumatic Stress, 8, 91-109] in a sample of college students reporting exposure to potentially traumatic events. The psychometric structure of the IES was largely consistent with the two-factor structure widely reported in the literature, while the structure of the MIS-Civ varied considerably in this sample. Notably, non-clinical samples tended to report fewer social and occupational dysfunction than clinical samples predominantly utilized in PTSD research. Implications for use of these instruments in screening samples are discussed.     

Divalproex for the treatment of posttraumatic stress disorder: a retrospective chart review

Objective. Open label trials of divalproex in the treatment of posttraumatic stress disorder (PTSD) show positive results. The objective of this study was to examine the therapeutic effects of divalproex in a larger naturalistic sample of patients with PTSD. Methods. A retrospective analysis was performed on 325 veteran charts identified through a computerized search of PTSD diagnosis matched with pharmacy records (any form of divalproex). The medication names, doses, labs, and dates (except for the divalproex index visit) were blackened. An investigator blinded to the order of visits and blackened information rated the progress notes preceding and following psychopharmacological intervention with divalproex with the Clinical Global Impression Scale for Improvement (CGI-I). Results. Fifty patients met eligibility criteria. Three were treated with divalproex monotherapy and 47 were treated adjunctively. The improved endpoint CGI-I differed significantly from “no change” (P<0.000001). Twenty-five (50%) were rated as very much or much improved on the CGI-I. Patients treated in primary care had a greater improvement compared to those in the mental health setting (P<0.005). Divalproex dosage and serum valproic acid levels (n=37) were well correlated (r?=?0.57, P<0.0005). Conclusion. Divalproex treatment improves the global clinical function of veterans with PTSD. Further controlled study is warranted.     

Prevalence and risk factors for posttraumatic stress disorder: a cross‐sectional study among survivors of the Wenchuan 2008 earthquake in China

Background: The impact of the May 2008 Wenchuan earthquake, measuring a massive 8.0 on the surface wave magnitude scale, on public health in China has been significant and multifaceted. In light of extant data on prevalence and risk factors for posttraumatic stress disorder (PTSD) after other natural diasters, we collected data from the Wenchuan earthquake survivors to estimate the prevalence of PTSD and to characterize a range of PTSD risk factors. Methods: A cross‐sectional multicluster sample survey of 446 respondents (201 from the Qiang ethnic‐minority group, 245 the majority Han Chinese group) was conducted in August 2008 in Beichuan county, Sichuan province, a region that was severely affected by the earthquake. In total, 240 households were represented, with a mean of 2.2 respondents per household. Data were collected from structured interviews and the Harvard Trauma Questionnaire (HTQ) and DSM‐IV criteria were used to diagnose PTSD. Results: The prevalence of PTSD was 45.5% (203/446). Low household income, being from an ethnic minority, living in a shelter or temporary house, death in family, and household damage were factors significantly related to increased odds of PTSD. Conclusions: PTSD is common after a major disaster. Postdisaster mental health recovery programs that include early identification, ongoing monitoring, preventive and intervention programs, and sustained psychosocial support are needed for the highest‐risk population, namely, the bereaved, people without incomes and those with serious household damage. These populations may also benefit from governmental and nongovernmental programs that provide social and economic support, as suggested by earlier studies. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Effect and safety of sertraline for treat posttraumatic stress disorder: a multicenter randomised controlled study

Objective: Although several previous studies have examined the efficacy of sertraline in the treatment of posttraumatic stress disorder (PTSD), none involved Chinese PTSD patients. This study aimed to evaluate sertraline efficacy and adverse events in Chinese patients with PTSD over 12 weeks.

Methods: In total, 72 PTSD patients were randomly assigned to receive sertraline (135?mg daily) or a placebo for 12 weeks. Impact of Event Scale-Revised subscores constituted the primary outcome, with Clinical Global Impression Scale-Severity scores and adverse events as secondary outcomes.

Results: Sixty-five subjects completed the study, and their data were included in the final analysis. Sertraline showed greater efficacy in enhancing Impact of Event Scale-Revised and Clinical Global Impression Scale-Severity scores at 6 and 12 weeks relative to that of the placebo. The most common adverse event was nausea, which occurred in 12 (33.3%) and 8 (22.2%) patients in the sertraline and placebo groups, respectively. No sertraline-related deaths were recorded.

Conclusions: In summary, we demonstrated that 12 weeks of sertraline was efficacious and well-tolerated in Chinese patients with PTSD.     

汶川地震幸存者灾后心理反应影响因素的典型相关分析

目的采用典型回归的方法分析不同危险因素共同对经历汶川地震的受灾人群灾后创伤后应激障碍（PTSD）临床症状的影响模式。方法281例经历过汶川大地震且年龄≥18岁的受灾人群接受了自行编制的调查问卷、PTSD-17项筛查问卷（PCL-C）和艾森克人格问卷成人版的调查。结果单因素分析结果表明女性更容易经常做噩梦和出现身体反应;神经质水平与易激惹呈正相关。典型相关分析发现内外向分低（r=-0．30）、神经质分低（r=-0．52）、男性（r=-0．73）更容易出现A1痛苦回忆（r=0．31）和丧失兴趣（r=0．34）;而较少出现A2经常噩梦（r=-0．45）、A5身体反应（r=-0．44）和C5惊跳反应（r=-0．34）。结论性格特征与性别可能共同决定个体创伤后应激反应是兴奋还是抑制的倾向。     

An evaluation of the DSM-5 factor structure for posttraumatic stress disorder in survivors of traumatic injury

Confirmatory factor analytic studies of the latent structure of DSM-5 PTSD symptoms using self-report data (Elhai et al., 2012, Miller et al., 2013) have found that the four-factor model implied by the DSM-5 diagnostic criteria provided adequate fit to their data. However, the fit of this model is yet to be assessed using data derived from gold standard structured interview measures. This study evaluated the fit of the DSM-5 four-factor model and an alternative four-factor model in 570 injury survivors six years post-injury using the Clinician Administered PTSD Scale (Blake et al., 1990), updated to include items measuring new DSM-5 symptoms. While both four-factor models fitted the data well, very high correlations between the ‘Intrusions’ and ‘Avoidance’ factors in both models and between the ‘Negative Alterations in Cognitions and Mood’ and ‘Arousal and Reactivity’ factors in the DSM-5 model and the ‘Dysphoria’ and ‘Hyperarousal’ factors in the alternative model were evident, suggesting that a more parsimonious two-factor model combining these pairs of factors may adequately represent the latent structure. Such a two-factor model fitted the data less well according to χ² difference testing, but demonstrated broadly equivalent fit using other fit indices. Relationships between the factors of each of the four-factor models and the latent factors of Fear and Anxious-Misery/Distress underlying Internalizing disorders (Krueger, 1999) were also explored, with findings providing further support for the close relationship between the Intrusion and Avoidance factors. However, these findings also suggested that there may be some utility to distinguishing Negative Alterations in Cognition and Mood symptoms from Arousal and Reactivity symptoms, and/or Dysphoria symptoms from Hyperarousal symptoms. Further studies are required to assess the potential discriminant validity of the two four-factor models.     

Affect intensity and lability: the role of posttraumatic stress disorder symptoms in borderline personality disorder

Background: Emotion dysregulation is likely a core psychological process underlying the heterogeneity of presentations in borderline personality disorder (BPD) and is associated with BPD symptom severity. Emotion dysregulation has also been independently associated with posttraumatic stress disorder (PTSD), a disorder that has been found to co‐occur with BPD in 30.2% of cases in a nationally representative sample. However, relatively little is known about the specific relationships between emotion dysregulation and PTSD among those diagnosed with BPD. The purpose of this study was to evaluate relationships between PTSD symptom severity and negative affect intensity and affective lability among individuals with BPD. Method: Participants were 67 individuals diagnosed with BPD (79% women; M _age = 38, SD = 10), who reported one or more DSM‐IV PTSD Criterion A events. Results: Hierarchical multiple regression analyses indicated that when examined concurrently with BPD symptom severity, PTSD symptom severity, but not BPD symptom severity, was related to negative affect intensity and affective lability. Re‐experiencing symptoms uniquely predicted affective lability, and hyperarousal symptoms uniquely predicted negative affect intensity, lending additional support to emerging literature linking re‐experiencing and hyperarousal symptoms with emotion dysregulation. Conclusions: PTSD symptom severity among individuals with a BPD diagnosis is related to elevations in emotion dysregulation. It is important to evaluate whether early treatment of PTSD symptoms provided concurrently with BPD treatment leads to enhanced improvements in emotion regulation among individuals with co‐occurring PTSD and BPD. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Confirmatory factor analysis of posttraumatic stress symptoms in Brazilian primary care patients: an examination of seven alternative models

The DSM-IV-TR postulates that PTSD symptoms are organized into 3 clusters. This assumption has been challenged by growing number of factor analytical studies, which tend to favor 4-factor, first-order models. Our objective was to investigate whether the clusters of PTSD symptoms identified in North American and European studies could be replicated in a Brazilian sample composed of 805 primary care patients living in hillside slums. Volunteers were asked to fill out the Brazilian version of the Posttraumatic Stress Disorder Checklist—Civilian Version and a confirmatory factor analysis of this scale was conducted with the software LISREL 8.80. Seven models were tested and a 4-factor, first-order solution including an emotional numbing cluster was found to provide the best fit. Although PTSD has been characterized by some critics as a Western culture-specific disorder lacking universal validity, our results seem to uphold the cross-cultural validity of the 4-factor, first-order model.     

Psychopathology and alexithymia in severe mental illness: the impact of trauma and posttraumatic stress symptoms

Objective To empirically investigate whether or not symptoms of posttraumatic stress disorder (PTSD) are essential for transferring the negative effects of trauma on the severity of severe mental illness (SMI) as recently suggested by an interactive model. Methods About 122 inpatients with either schizophrenia or major affective disorder were administered the Posttraumatic Diagnostic Scale, the Symptom Checklist and the Toronto Alexithymia Scale. Results At least one trauma was reported by 83 participants (68%) and 28 patients (23%) reported symptoms of current PTSD. Those SMI subjects with current PTSD sympoms had significantly more psychopathological distress and alexithymic features than those with a trauma exposure but without PTSD symptoms and those patients without any traumatic experiences. Discussion In line with prior research, our data indicate that patients with SMI have frequently been exposed to traumatic events and that a third suffers from current posttraumatic stress symptoms. Despite some methodological limitations our findings support the interactive model, which posits that a comorbid PTSD increases the symptom severity of SMI. More attention should be directed at assessing trauma and PTSD in SMI patients and at developing therapeutic interventions.     

The rebirth of PTSD: the rise of a new paradigm in psychiatry

Abstract. The new conception of psychological trauma that arose in the 1980s with the definition of PTSD in the DSM-III was a major change compared to the previous traumatic neurosis. While the clinical features were in some way similar, the political and sociological meanings of trauma were absolutely different. At that time, the invention of PTSD was much more the consequence of a broad mutation in mentality that introduced a new moral perspective in trauma studies than of a scientific discovery. In this paper, the author underlines from an anthropological point of view the second turning point that occurred in trauma studies in the mid 1990s when large epidemiological surveys did not confirm the first hypothesis. Readdressing the issues of vulnerability and risk factors that the previous version of PTSD had withdrawn, this second conception raises new epistemological questions that stay unsolved.