Skip to main content Accessibility help

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

  • Jon D. Elhai (a1), Julian D. Ford (a2), Kenneth J. Ruggiero (a3) and B. Christopher Frueh (a4)



Two alternative models of post-traumatic stress disorder (PTSD) appear to represent the disorder's latent structure better than the traditional Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) three-factor PTSD model. The present study examines the impact of using these structural models for the diagnosis of lifetime PTSD while retaining the DSM-IV PTSD's six-symptom diagnostic requirement.


Data were gathered from large-scale, epidemiological datasets collected with adults (National Comorbidity Survey Replication) and adolescents (National Survey of Adolescents). Two alternative, empirically supported four-factor models of PTSD were compared with the DSM-IV three-factor PTSD diagnostic model.


Results indicated that the diagnostic alterations resulted in substantially improved structural validity, downward adjustments of PTSD's lifetime prevalence (roughly 1 percentage point decreases in adults, 1–2.5 percentage point decreases in adolescents), and equivalent psychiatric co-morbidity and sociodemographic associations.


Implications for modifying PTSD diagnostic criteria in future editions of DSM are discussed.


Corresponding author

*Address for correspondence: J. D. Elhai, Ph.D., Disaster Mental Health Institute, The University of South Dakota, 414 East Clark Street – SDU 114, Vermillion, South Dakota57069-2390, USA. (Email:


Hide All
Andrews, G, Peters, L (1998). The psychometric properties of the Composite International Diagnostic Interview. Social Psychiatry and Psychiatric Epidemiology 33, 8088.
APA (2001). Diagnostic and Statistical Manual of Mental Disorders, 4th edn, text revision. American Psychological Association: Washington, DC.
Asmundson, GJG, Stapleton, JA, Taylor, S (2004). Are avoidance and numbing distinct PTSD symptom clusters? Journal of Traumatic Stress 17, 467475.
Broman-Fulks, JJ, Ruggiero, KJ, Green, BA, Kilpatrick, DG, Danielson, CK, Resnick, HS, Saunders, BE (2006). Taxometric investigation of PTSD: Data from two nationally representative samples. Behavior Therapy 37, 364380.
Buckley, TC (2007). PTSD and Vietnam veterans. Science 315, 185.
Cox, BJ, Mota, N, Clara, I, Asmundson, GJG (2008). The symptom structure of posttraumatic stress disorder in the National Comorbidity Replication Survey. Journal of Anxiety Disorders 22, 15231528.
DuHamel, KN, Ostrof, J, Ashman, T, Winkel, G, Mundy, EA, Keane, TM, Morasco, BJ, Vickberg, SMJ, Hurley, K, Burkhalter, J, Chhabra, R, Scigliano, E, Papadopoulos, E, Moskowitz, C, Redd, W (2004). Construct validity of the Posttraumatic Stress Disorder Checklist in cancer survivors: analyses based on two samples. Psychological Assessment 16, 255266.
Elhai, JD, Gray, MJ, Docherty, AR, Kashdan, TB, Kose, S (2007). Structural validity of the Posttraumatic Stress Disorder Checklist among college students with a trauma history. Journal of Interpersonal Violence 22, 14711478.
Elhai, JD, Grubaugh, AL, Kashdan, TB, Frueh, BC (2008). 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 69, 597602.
Elkit, A, Shevlin, M (2007). The structure of PTSD symptoms: A test of alternative models using confirmatory factor analysis. British Journal of Clinical Psychology 46, 299313.
Flora, DB, Curran, PJ (2004). An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data. Psychological Methods 9, 466491.
Frueh, BC, Elhai, JD, Kaloupek, DG (2004). Unresolved issues in the assessment of trauma exposure and posttraumatic reactions. In Posttraumatic Stress Disorder: Issues and Controversies (ed. Rosen, G. M.), pp. 6384. Wiley: New York.
Haro, JM, Arbabzadeh-Bouchez, S, Brugha, TS, De Girolamo, G, Guyer, ME, Jin, R, Lepine, JP, Mazzi, F, Reneses, B, Vilagut, G, Sampson, NA, Kessler, RC (2006). Concordance of the Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health Surveys. International Journal of Methods in Psychiatric Research 15, 167180.
Hays, W (1994). Statistics. Wadsworth: Belmont, CA.
Hu, L, Bentler, PM (1998). Fit indices in covariance structural modeling: Sensitivity to underparameterized model misspecification. Psychological Methods 3, 424453.
Hu, L, Bentler, PM (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling 6, 155.
Kessler, RC (2006). National Comorbidity Survey: Replication (NCS-R), 2001–2003 (computer file). Conducted by Harvard Medical School, Department of Health Care Policy/University of Michigan, Survey Research Center. ICPSR04438-v1. Inter-University Consortium for Political and Social Research: Ann Arbor, MI.
Kessler, RC, Berglund, P, Chiu, WT, Demler, O, Heeringa, S, Hiripi, E, Jin, R, Pennell, BE, Walters, EE, Zaslavsky, A, Zheng, H (2004). The US National Comorbidity Survey Replication (NCS-R): design and field procedures. International Journal of Methods in Psychiatric Research 13, 6992.
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. Archives of General Psychiatry 62, 593602.
Kessler, RC, Ustun, TB (2004). The World Mental Health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatric Research 13, 93121.
Kilpatrick, DG, Acierno, R, Saunders, B, Resnick, HS, Best, CL, Schnurr, PP (2000). Risk factors for adolescent substance abuse and dependence: data from a national sample. Journal of Consulting and Clinical Psychology 68, 1930.
Kilpatrick, DG, Resnick, HS, Freedy, JR, Pelcovitz, D, Resick, P, Roth, S, van der Kolk, B (1998). Posttraumatic stress disorder field trial: evaluation of the PTSD construct – criteria A through E. In DSM-IV Sourcebook (ed. Widiger, T. A., Frances, A. J., Pincus, H. A., Ross, R., First, M. B., Davis, W. and Kline, M.), pp. 804844. American Psychiatric Press: Washington, DC.
Kilpatrick, DG, Saunders, BE (1995). National Survey of Adolescents in the United States (computer file). ICPSR version. Inter-university Consortium for Political and Social Research: Ann Arbor, MI.
Kilpatrick, DG, Saunders, BE (1997). Prevalence and consequences of child victimization. Results from the National Survey of Adolescents: Final report. National Crime Victims Research and Treatment Center: Charleston, SC.
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. Psychological Assessment 10, 9096.
Kline, RB (2004). Principles and Practice of Structural Equation Modeling. Guilford Press: New York.
Krause, ED, Kaltman, S, Goodman, LA, Dutton, MA (2007). Longitudinal factor structure of posttraumatic stress symptoms related to intimate partner violence. Psychological Assessment 19, 165175.
Landis, JR, Koch, GG (1977). The measurement of observer agreement for categorical data. Biometrics 33, 159174.
Long, ME, Elhai, JD (in press). Posttraumatic stress disorder's traumatic stressor criterion: History, controversy, clinical and legal implications. Psychological Injury and Law.
McNally, RJ (2003). Progress and controversy in the study of posttraumatic stress disorder. Annual Review of Psychology 54, 229252.
McWilliams, LA, Cox, BJ, Asmundson, GJG (2005). Symptom structure of posttraumatic stress disorder in a nationally representative sample. Journal of Anxiety Disorders 19, 626641.
Muthén, BO (1984). A general structural equation model with dichotomous, ordered categorical, and continuous latent variable indicators. Psychometrika 49, 115132.
Muthén, BO, Muthén, L (2006). Chi-square Difference Testing Using the Satorra-Bentler Scaled Chi-square. Muthén & Muthén: Los Angeles.
Muthén, LK, Muthén, BO (1998–2007). Mplus User's Guide. Muthén & Muthén: Los Angeles.
Naifeh, JA, Elhai, JD, Kashdan, TB, Grubaugh, AL (2008). The PTSD Symptom Scale's latent structure: an examination of trauma-exposed medical patients. Journal of Anxiety Disorders 22, 13551368.
Palmieri, PA, Marshall, GN, Schell, TL (2007 a). Confirmatory factor analysis of posttraumatic stress symptoms in Cambodian refugees. Journal of Traumatic Stress 20, 207216.
Palmieri, PA, Weathers, FW, Difede, J, King, DW (2007 b). Confirmatory factor analysis of the PTSD Checklist and the Clinician-Administered PTSD Scale in disaster workers exposed to the World Trade Center Ground Zero. Journal of Abnormal Psychology 116, 329341.
Raftery, AE (1995). Bayesian model selection in social research. Sociological Methodology 25, 111163.
Rosen, GM, Lilienfield, SO (2008). Posttraumatic stress disorder: an empirical evaluation of core assumptions. Clinical Psychology Review 28, 837868.
Rosen, GM, Spitzer, RL, McHugh, PR (2008). Problems with the post-traumatic stress disorder diagnosis and its future in DSM V. British Journal of Psychiatry 192, 34.
Saul, AL, Grant, KE, Carter, JS (2008). Post-traumatic reactions in adolescents: how well do the DSM-IV PTSD criteria fit the real life experience of trauma exposed youth? Journal of Abnormal Child Psychology 17, 277289.
Schafer, JL, Graham, JW (2002). Missing data: our view of the state of the art. Psychological Methods 7, 147177.
Schinka, JA, Brown, LM, Borenstein, AR, Mortimer, JA (2007). Confirmatory factor analysis of the PTSD Checklist in the elderly. Journal of Traumatic Stress 20, 281289.
Simms, LJ, Watson, D, Doebbeling, BN (2002). Confirmatory factor analyses of posttraumatic stress symptoms in deployed and nondeployed veterans of the Gulf War. Journal of Abnormal Psychology 111, 637647.
Slade, T, Watson, D (2006). The structure of common DSM-IV and ICD-10 mental disorders in the Australian general population. Psychological Medicine 36, 15931600.
Spitzer, RL, First, MB, Wakefield, JC (2007). Saving PTSD from itself in DSM-V. Journal of Anxiety Disorders 21, 233241.
Watson, D (2005). Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V. Journal of Abnormal Psychology 114, 522536.
Wirth, RJ, Edwards, MC (2007). Item factor analysis: current approaches and future directions. Psychological Methods 12, 5879.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed