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Symptom structure of PTSD and co-morbid depressive symptoms – a network analysis of combat veteran patients

Published online by Cambridge University Press:  27 August 2019

Amit Lazarov*
Department of Psychiatry, Columbia University Irving Medical Center and New York State Psychiatric Institute, New York, NY, USA School of Psychological Sciences, Tel-Aviv University, Tel-Aviv, Israel
Benjamin Suarez-Jimenez
Department of Psychiatry, Columbia University Irving Medical Center and New York State Psychiatric Institute, New York, NY, USA
Ofir Levi
Division of Mental Health, Medical Corps, Israel Defense Forces, Israel Social Work Department, Ruppin Academic Center, Emek Hefer, Israel Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel
Daniel D. L. Coppersmith
Department of Psychology, Harvard University, Cambridge, MA, USA Section on Developmental Affective Neuroscience, National Institute of Mental Health, Bethesda, MD, USA
Gadi Lubin
Division of Mental Health, Medical Corps, Israel Defense Forces, Israel The Jerusalem Mental Health Center, Eitanim-Kfar Shaul, Israel
Daniel S. Pine
Section on Developmental Affective Neuroscience, National Institute of Mental Health, Bethesda, MD, USA
Yair Bar-Haim
School of Psychological Sciences and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
Rany Abend
Section on Developmental Affective Neuroscience, National Institute of Mental Health, Bethesda, MD, USA
Yuval Neria
Departments of Psychiatry and Epidemiology, Columbia University Irving Medical Center and New York State Psychiatric Institute, New York, NY, USA
Author for correspondence: Amit Lazarov, E-mail:



Despite extensive research, symptom structure of posttraumatic stress disorder (PTSD) is highly debated. The network approach to psychopathology offers a novel method for understanding and conceptualizing PTSD. However, extant studies have mainly used small samples and self-report measures among sub-clinical populations, while also overlooking co-morbid depressive symptoms.


PTSD symptom network topology was estimated in a sample of 1489 treatment-seeking veteran patients based on a clinician-rated PTSD measure. Next, clinician-rated depressive symptoms were incorporated into the network to assess their influence on PTSD network structure. The PTSD-symptom network was then contrasted with the network of 306 trauma-exposed (TE) treatment-seeking patients not meeting full criteria for PTSD to assess corresponding network differences. Finally, a directed acyclic graph (DAG) was computed to estimate potential directionality among symptoms, including depressive symptoms and daily functioning.


The PTSD symptom network evidenced robust reliability. Flashbacks and getting emotionally upset by trauma reminders emerged as the most central nodes in the PTSD network, regardless of the inclusion of depressive symptoms. Distinct clustering emerged for PTSD and depressive symptoms within the comorbidity network. DAG analysis suggested a key triggering role for re-experiencing symptoms. Network topology in the PTSD sample was significantly distinct from that of the TE sample.


Flashbacks and psychological reactions to trauma reminders, along with their strong connections to other re-experiencing symptoms, have a pivotal role in the clinical presentation of combat-related PTSD among veterans. Depressive and posttraumatic symptoms constitute two separate diagnostic entities, but with meaningful between-disorder connections, suggesting two mutually-influential systems.

Original Articles
Copyright © Cambridge University Press 2019

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This work reflects equal contribution of the first three authors


This work reflects equal contribution of the two senior authors


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