555523

research-article2014

ASMXXX10.1177/1073191114555523AssessmentDemirchyan et al.

Article

Factor Structure and Psychometric

Properties of the Posttraumatic Stress
Disorder (PTSD) Checklist and DSM5 PTSD Symptom Set in a Long-Term
Postearthquake Cohort in Armenia

Assessment
113
The Author(s) 2014
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DOI: 10.1177/1073191114555523
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Anahit Demirchyan1, Armen K. Goenjian2,3, and Vahe Khachadourian1

Abstract
Psychometric properties of the Armenian-language posttraumatic stress disorder (PTSD) ChecklistCivilian version
(PCL-C) and the DSM-5 PTSD symptom set were examined in a long-term cohort of earthquake survivors. In 2012, 725
survivors completed the instruments. Item-/scale-level analysis and confirmatory factor analysis (CFA) were performed
for both scales. In addition, exploratory factor analysis (EFA) was conducted for DSM-5 symptoms. Also, the differential
internal versus external specificity of PTSD symptom clusters taken from the most supported PTSD structural models was
examined. Both scales had Cronbachs alpha greater than .9. CFA of PCL-C structure demonstrated an excellent fit by a
four-factor (reexperiencing, avoidance, numbing, and hyperarousal) model known as numbing model; however, a superior
fit was achieved by a five-factor model (Elhai et al.). EFA yielded a five-factor structure for DSM-5 symptoms with the
aforementioned four domains plus a negative state domain. This model achieved an acceptable fit during CFA, whereas
the DSM-5 criteria-based model did not. The Armenian-language PCL-C was recommended as a valid PTSD screening
tool. The study findings provided support to the proposed new classification of common mental disorders, where PTSD,
depression, and generalized anxiety are grouped together as a subclass of distress disorders. Recommendations were
made to further improve the PTSD diagnostic criteria.
Keywords
posttraumatic stress disorder (PTSD), PTSD ChecklistCivilian version (PCL-C), DSM-5, psychometric properties, factor
structure
The burden of disaster-caused posttraumatic stress disorder
(PTSD) among exposed subjects is substantial worldwide
and the prevalence of PTSD in the areas of natural disasters
varies widely, depending on the intensity of exposure,
degree of human and material loss, availability of support,
and personality traits (Neria, Nandi, & Galea, 2008).
The 1988 Spitak earthquake in Armenia was one of the
worst natural disasters of the 20th century. It produced an
unprecedented high prevalence of PTSD, ranging from 65%
to 95% among different populations of heavily affected
adults and children (Goenjian, 1993; Goenjian et al., 1995;
Pynoos et al., 1993). Two years after the earthquake, a psychopathological investigation was carried out among a geographically stratified subsample of participants from a
large-scale postearthquake cohort study (Armenian et al.,
2000). The authors found that almost half of the population
in the earthquake zone met the criteria for PTSD. The persistence of PTSD symptoms in this population was attributed to the severity of the disaster-associated losses and

long-lasting postdisaster adversities causing persistent

stress (Goenjian et al., 1994).
A follow-up investigation of this subsample was conducted in 2012. As the PTSD diagnostic criteria changed
since the time of the baseline assessment and several new
well-validated self-reporting measures of PTSD, based on
Diagnostic and Statistical Manual of Mental Disorders, 4th
edition (DSM-IV) criteria (American Psychiatric
Association, 2000) were developed, the follow-up study in
2012 applied one of the most widely used PTSD screening
1

American University of Armenia, Yerevan, Armenia

UCLA/Duke University National Center for Child Traumatic Stress,
University of California, Los Angeles, CA, USA
3
Collaborative Neuroscience Network, Garden Grove, CA, USA
2

Corresponding Author:
Anahit Demirchyan, School of Public Health, American University of
Armenia, 40 Marshal Baghramian Avenue, Yerevan 0019, Armenia.
Email: ademirch@aua.am

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Assessment

instruments at the presentthe PTSD ChecklistCivilian

version (PCL-C; Weathers, Litz, Herman, Huska, & Keane,
1993). This instrument was chosen because of its demonstrated favorable psychometric properties in a variety of
populations (Adkins, Weathers, McDevitt-Murphy, &
Daniels, 2008; McDonald & Calhoun, 2010; Ruggiero, Del
Ben, Scotti, & Rabalais, 2003; Wilkins, Lang, & Norman,
2011). It has also been translated and validated for different
ethnic/racial groups (Hem, Hussain, Wentzel-Larsen, &
Heir, 2012; Li et al., 2010; Marshall, 2004; Passos, Figueira,
Mendlowicz, Moraes, & Coutinho, 2012). However, its
operational characteristics have demonstrated considerable
variation across populations and research methods
(McDonald & Calhoun, 2010).
It is well recognized that the internal structure of PTSD,
mirrored in the factor structure of PCL, is an important subject to investigate, as it could shed light on core constructs
representing PTSD, confirm its distinctiveness as a diagnostic unit, contribute to modeling the frequent comorbidity
of PTSD with other mood and anxiety disorders and
improving diagnosis, prevention, and treatment of this condition (Elhai & Palmieri, 2011).
The DSM-IV criteria for PTSD assume a first-order
three-factor model for PCL (i.e., PTSD) with reexperiencing, avoidance/numbing, and hyperarousal domains.
However, there is inadequate empirical evidence for this
latent structure in the literature (Yufik & Simms, 2010).
Studies using different populations and settings suggest
various factor structures for PTSD, including indirect hierarchical four-factor (Wu, Chan, & Yiu, 2008), two-factor
(Passos et al., 2012; Taylor, Kuch, Koch, Crockett, &
Passey, 1998), four-factor with distinct avoidance and
numbing domains (King, Leskin, King, & Weathers, 1998;
Marshall, 2004; Schinka, Brown, Borenstein, & Mortimer,
2007), four-factor with a dysphoria domain (Gauci &
MacDonald, 2012; Palmieri, Weathers, Difede, & King,
2007; Simms, Watson, & Doebbeling, 2002; Yufik &
Simms, 2010), and five-factor (Elhai et al., 2011; Wang et
al., 2011) models. The four-factor models have the most
abundant empirical evidence in populations with various
traumatic exposures, while the recently proposed five-factor model has the advantage of combining these well-supported models into a single better-fitting structure (Elhai
et al., 2011; Wang et al., 2011).
These previous findings indicate the need to investigate
the psychometric properties of PCL with new study populations, especially when applying a translated version of this
instrument. The Armenian-language version of the PCL-C
was first developed and used in this postearthquake cohort.
Thus, the objective of this study was to investigate the psychometric properties of the Armenian-language PCL-C,
including its factor structure, internal consistency, and correlation with measures of related psychopathology.
Additionally, as the new DSM-5 criteria for PTSD were

recently released, we used this opportunity to investigate

the properties of the new set of PTSD symptoms and symptom clusters suggested by DSM-5. A number of recent studies have explored the factor structure of this new symptom
set and mostly supported the dimensions suggested by
DSM-5 PTSD criteria (Biehn et al., 2013; Contractor et al.,
2014; Elhai et al., 2012). Nevertheless, Miller et al. (2013)
emphasized the need of future research examining alternative structural models of DSM-5 PTSD symptom set. Elhai
et al. pointed out the importance of investigating new structural models of PTSD among population groups presenting
a different culture (Elhai et al., 2011). Thus, we felt worthwhile studying the internal structure of the DSM-5 PTSD
criteria in our study population.

Method
Participants
The study participants were a subsample of a cohort study
initiated in 1990 to explore the impact of the 1988 earthquake on survivors health. The cohort consisted of all
employees of the health care services in the earthquake
zone and their family members32,743 individuals in total
(Armenian, Melkonian, Noji, & Hovanesian, 1997). In
1991, a geographically stratified subsample of that cohort
consisting of 1,785 adults (between the ages of 16 and 70)
from areas most affected by the earthquake participated in
the initial phase of the study known as Post Earthquake
Psychopathological Investigation (Armenian et al., 2000;
Armenian et al., 2002). The follow-up phase of this study
was conducted in 2012. The Institutional Review Board of
the American University of Armenia reviewed and approved
the study protocol. Of the original sample (N = 1,785),
information was obtained on 1,487 (83%) individuals, of
which 725 individuals participated in the follow-up assessment. The rest were either dead (N = 309), incapable to participate due to ailments (N = 89), unwilling to participate
(N = 64), or moved out of the country (N = 300).

Measures
We used the self-administered Armenian-language version
of the PCL-C to measure the current status of PTSD in this
study cohort, regardless of the type of traumatic exposure
causing the disease (although the entire sample was directly
exposed to the 1988 earthquake, we used PCL-C to capture
the potential impact of any lifetime traumatic event, not
necessarily the earthquake). The PCL-C consists of 17
items exactly corresponding to the DSM-IV PTSD symptoms. Each item has a 5-point rating scale ranging from 1
(not at all) to 5 (extremely). Thus, the scale yields a cumulative score of 17 to 85. Two methods were suggested to
assess the PTSD status using this scale: (a) computing the

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Demirchyan et al.
cumulative score with a threshold level varying within
broad boundaries (from 30 to 60) in different studies and
populations (McDonald & Calhoun, 2010; Terhakopian,
Sinaii, Engel, Schnurr, & Hoge, 2008) and (b) using a
symptom clusterbased method coinciding with the
DSM-IV criterion B (at least one reexperiencing symptom
of the fiveItems B1 through B5), Criterion C (at least
three avoidance/numbing symptoms of the sevenItems
C1 through C7), and Criterion D (at least two hyperarousal
symptoms of the fiveItems D1 through D5; American
Psychiatric Association, 2000). Some studies used a combination of cumulative score and symptom cluster approach
to achieve better estimates (McDonald & Calhoun, 2010).
However, recent findings suggest that the score-based
approach outperforms the symptom clusterbased approach
in achieving higher diagnostic efficiency (Chiu et al., 2011).
Two members of the research team (AD and VK) translated the PCL-C into Armenian language after several
rounds of forward and backward translations until a full
concordance between the translation and the original instrument was reached. This was followed by pretesting among
a convenience sample of 13 survivors of the 1988 earthquake currently living in the earthquake zone. They were
asked to respond to the scale items taking a note of the language expression and identifying any items they were not
comfortable with or had a difficulty to understand. No such
items were identified. The finalized Armenian-language
PCL-C faithfully reflected the original scale in terms of
both items content/sequence and response options.
After applying the PCL-C, we asked four additional
items on new symptoms introduced by DSM-5 criteria for
PTSD (using the same PCL-C response scale) to be able to
investigate the properties of the new set of symptoms as
well. The latter includes 16 of the 17 PCL items (except C7
item on foreshortened future) and four new items, one of
which reflects reckless/self-destructive behavior, while the
remaining three reflect negative emotional state expressed
by feelings of distorted blame, loss of trust, fear, anger,
guilt, and so on. These four items also passed the rounds of
forward and backward translations and pretesting before
being finalized in Armenian.
According to DSM-5 diagnostic criteria for PTSD,
Criterion B remains unchanged (Items B1-B5), Criterion C
consists of two avoidance items (C1 and C2), Criterion D
combines the remaining four numbing items with the three
new negative emotional state items (D1-D7), and Criterion
E combines the five hyperarousal items with a new item on
reckless/self-destructive behavior (E1-E6), (American
Psychiatric Association, 2013). The item mapping for
PCL-C and DSM-5 symptoms is presented in the online
appendix (http://asm.sagepub.com/supplemental).
To measure the exposure to potentially traumatic
event(s) (DSM-IV Criterion A), a trauma exposure checklist was included in the instrument. This checklist was

modified from the Trauma History Screen (Carlson et al.,

2011), with the purpose to make it relevant to the study
population and feasible to implement. In particular, we
asked about the earthquake exposure of this postearthquake
cohort separately from the other disasters. The checklist
measured the number of times each traumatic event happened, the age when it happened, and the degree of the
emotional distress it caused each time on a 4-point response
scale ranging from 0 (mildly stressful) to 3 (greatly
stressful).
Depression was measured using the validated revised
Armenian-language version (Demirchyan, Petrosyan, &
Thompson, 2011) of the Center for Epidemiologic Studies
Depression Scale (Radloff, 1977). This self-report scale
excluded the four positively worded items (4th, 8th, 12th,
and 16th) from the initial 20-item scale, retaining the
remaining 16 items and the 4-point response scale ranging
from 0 (rarely or none of the time) to 3 (most or all of the
time) with a summed score in a range of 0 to 48. A 12/13
cutoff (proportionate to the 15/16 cutoff commonly recommended for the original 20-item scale) was used to distinguish between nondepressed and possibly depressed
individuals.
Anxiety was measured through the 10-item Anxiety subscale of the Symptom Checklist-90-R, a 90-item multidimensional self-reporting inventory validated as a whole and
for each subscale (Derogatis, 1994). The Anxiety subscale
items had 5-point response scale ranging from 0 (not at all)
to 4 (extremely). The summed score ranged from 0 to 40 and
a 10/11 threshold was used to identify individuals with possible anxiety. The subscale was translated into Armenian
using the same approach of forward and backward translations and pretesting.

Analysis
For both PCL-C and DSM-5 PTSD symptom set, SPSS 11.0
statistical software was used for item-and scale-level analyses, including testing for internal consistency. For PCL-C,
this was followed by confirmatory factor analysis (CFA)
using the AMOS 18 structural equation modeling program
to estimate the fit of the following five most-supported
models (see the online appendix at http://asm.sagepub.com/
supplemental): a model corresponding to the DSM-IV diagnostic criteria (American Psychiatric Association, 2000)
with three first-order intercorrelated factors of reexperiencing, avoidance/numbing, and hyperarousal (Model 1); a
model with four first-order intercorrelated factors of reexperiencing, avoidance (C1-C2), dysphoria (C3-C7; D1-D3),
and anxious arousal (D4-D5; Simms et al., 2002; Model 2);
an indirect hierarchical four-factor (reexperiencing, avoidance, numbing, and hyperarousal) model with a single
higher order factor of PTSD (Wu et al., 2008; Model 3); a
model with four first-order intercorrelated factors

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Assessment

of reexperiencing, avoidance, numbing, and hyperarousal

recommended by King et al. (1998; Model 4); and a model
recommended by Elhai et al. (2011) with five first-order
intercorrelated factors of reexperiencing, avoidance, emotional numbing, dysphoric arousal (D1-D3), and anxious
arousal (Model 5).
Since there is relatively little supporting evidence for the
latent structure of DSM-5 PTSD symptom set in the literature, CFA alone is not recommended for the explorative
detection of its latent structure, as it could provide equal
support to several quite different models (Wittchen, Hofler,
& Merikangas, 1999). For any new sufficiently large symptom set, Hurley et al. (1997) recommended first to explore
its internal structure in one sample using exploratory factor
analysis (EFA) and then confirm it in another sample using
CFA, as replication largely enhances the scientific value of
the findings. In a recent article, Miller et al. (2013) also
highlighted the importance of supplementing CFA with
other statistical methods to investigate the internal structure
of the DSM-5 PTSD symptom set. Thus, following the
approach suggested by MacCallum, Roznowski, Mar, and
Reith (1994), we randomly divided the total sample of 725
cases into half; the first half (363 cases) was used to conduct
EFA and the second half (362 cases) to run CFA.
EFA with principal axis factoring was used to identify
the underlying domains of DSM-5 PTSD symptom set. The
number of extracted factors was determined applying parallel analysis for principal axis factoring using ViSta-7.2.04
statistical software, as parallel analysis was shown to be one
of the most accurate tests for estimating the optimal number
of factors during EFA (Fabrigar, Wegener, MacCallum, &
Strahan, 1999). In addition, Scree test and clinical judgment
were used. Oblique rotation (Promax) was chosen as recommended when the factors are expected to correlate
(Costello & Osborne, 2005). Then, CFA was applied to
compare the DSM-5 criteria-based PTSD structure (Model
1n with four first-order intercorrelated factors of reexperiencing, avoidance, negative cognitive state, and hyperarousal/recklessness) with the EFA-detected structures.
The choice of goodness-of-fit indices was based on the
two-index presentation strategy recommended by Hu and
Bentler (1999). However, to avoid potential shortcomings of
using a combination of two indices, we supplemented the
maximum likelihood (ML)based standardized root mean
square residual (SRMR) with two other indices recommended by this strategy: the ML-based comparative fit
index (CFI), and the root mean square error of approximation (RMSEA), so that all three major clusters of fit indices, each reflecting some unique aspect of the model, are
included (Matsunaga, 2010). The cutoff values used for
these indices as recommended by Hu and Bentler (1999)
were close to 0.08 (or lower) for SRMR, close to 0.95 (or
higher) for CFI, and close to 0.06 (or lower) for RMSEA.
Chi-square testing for differences was used to statistically

compare the nested models fit. Nonnested models were

compared descriptively using Akaike information criterion
(AIC) and expected cross-validation index (ECVI), lower
values of which indicate a better fit of the model (Akaike,
1987; Brown, 2006). The practical significance of the difference between the models with different complexity levels
was also examined using the TuckerLewis Index (TLI), as
this index incorporates a penalty for model complexity. A
TLI difference of 0.01 or more between two competing
models was viewed as indicative of practical significance
(Gignac, 2007). As the assumption for multivariate normality of the data was not violatedall univariate skewness values were less than 2.0 and kurtosis values much less than 7.0
(Curran, West, & Finch, 1996), an ML estimation procedure
was applied. Each item was specified to load on a single factor. For PCL-C, 4.7% (34 cases) and for DSM-5 PTSD
symptom set, 5.1% (37cases) of the sample had missing data
at the item level. All the cases with any missing response at
the item level were excluded from the analysis during EFA
(resulting in 346 valid cases for DSM-5 PTSD symptom set)
and when calculating SRMR during CFA (resulting in 342
valid cases for DSM-5 PTSD symptom set and 691 for PCLC). For all the other fit indices, the cases with up to 14 missing values (720 for PCL-C and 360 for DSM-5 PTSD
symptom set) were maintained in the data set.
Finally, to investigate the construct validity of the PTSD
scales, we examined the correlation of PTSD and its domain
scores with the scores of lifetime trauma (LT) and the
closely related psychopathologies of anxiety and depression. Stegers Z test (i.e., Williamss T test) was used to
identify significant differences between these correlations
(Steiger, 1980). As the underlying domains of PTSD differ
in their specificity to PTSD, some (e.g., reexperiencing,
avoidance) being more closely related to it whereas others
(e.g., numbing, hyperarousal) reflecting the general distress
common to other mood and anxiety disorders, and since the
Simms et al. dysphoria scale is believed to be the most complete representation of general distress bridging PTSD with
depression and anxiety (Gootzeit & Markon, 2011; Simms
et al., 2002; Watson, 2005), we used symptom dimensions
taken from different structural models of PTSD to correlate
with the external constructs and to compare their differential internal versus external specificity.

Results
Descriptive Findings
The demographic characteristics of the sample are presented in Table 1. The respondents mean age was 58.4
years (SD = 12.1; range = 39-90 years). The count of
women in the sample was double that of men but women
did not substantially differ from men in basic demographic characteristics. The vast majority of respondents

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Demirchyan et al.
Table 1. Demographic Characteristics of the Sample.
Variable
Age group in years (N = 725)
39-50
51-64
65
Gender (N = 725)
Male
Female
Education (N = 725)
Incomplete secondary
Complete secondary
University or higher
Employment (N = 641)
Employed
Unemployed
Retired
Marital status (N = 725)
Married
Single/divorced
Widowed
Prevalence of psychopathology
PTSDa (N = 691)
Anxiety (N = 706)
Depression (N = 699)
Lifetime traumatic exposure (N = 725)
1988 earthquake
Sudden death of close family/friend
Life-threatening accident
Disaster other than 1988 earthquake
Participation in war
Violence toward oneself

Valid %

218
294
213

30.1
40.6
29.4

233
492

32.1
67.9

53
501
171

7.3
69.1
23.6

325
143
173

48.2
24.8
27.0

508
63
154

70.1
8.7
21.2

104
198
177

15.1
28.0
25.3

724
547
91
63
33
20

99.9
75.4
12.6
8.7
4.6
2.8

Note. N = number of valid responses; PTSD = posttraumatic stress

disorder.
a.Those having a PTSD ChecklistCivilian version score of 50 and more.

had secondary education or higher, almost half were

employed and more than one fourth were retired.
Respondents reported from 1 to 7 potentially traumatic
events during their lifetime with a mean of 2.6 (SD = 1.1)
events. The most endorsed traumatic event was 1988
earthquake, followed by sudden death of close family or
friend (Table 1). The average LT score, calculated as the
sum of traumatic events multiplied by the perceived
stressfulness of each (on a 0-3 scale), was 7.4 (SD = 3.4;
range = 1-19), indicating that the majority of the reported
events were perceived as greatly stressful (mean perceived stressfulness of 2.8).

PCL-C Scale
The average PCL-C cumulative scale score was 36.3
(SD = 13.6). The estimated prevalence of PTSD, based on

threshold 50, was 15.1% (confidence interval [CI] =

12.5% to 17.9%; Table 1). There was no gender difference
in the prevalence of PTSD. Among the other measured
psychopathologies, the prevalence of anxiety was the
highest, 28.0% (CI = 24.8% to 31.5%), followed by
depression, 25.3% (CI = 22.1% to 28.7%). There was no
gender effect for anxiety, whereas for depression the rate
for females was significantly higher than that for males
(28.8% [CI = 24.8% to 33.1%] versus 17.9% [CI = 13.1%
to 23.5%], p = .001).
Table 2 presents the PCL-C item means, measures of
internal consistency, and factor loadings of the best fitting
PCL-C model (Model 5) in CFA. The internal consistency
of the PCL-C Scale as measured by Cronbachs alpha was
.918. Each of the 17 items added to the internal consistency
of the overall scale. Mean itemtotal correlation for the
scale was 0.60 (range = 0.47-0.67). Cronbachs alpha for
the symptom cluster subscales defined by DSM-IV was also
above the acceptable threshold level of .80: .864 for cluster
B symptoms (reexperiencing), .838 for Cluster C symptoms
(avoidance/numbing), and .822 for Cluster D symptoms
(hyperarousal).
CFA with the ML estimation was used to assess the fit of
this and four other recommended models for PCL-C, as
described in the Method section. The goodness-of-fit
indices for all these models are summarized in Table 3. All
the models except Model 1 (based on DSM-IV criteria)
achieved acceptable fits (RMSEA value less than 0.08; CFI
and TLI values greater than 0.90; Hu & Bentler, 1998).
Model 3 achieved close-to-excellent fit, whereas both
Model 4 and Model 5 achieved excellent fits (RMSEA
close to 0.06 and CFI close to 0.95). Chi-square values
were compared between the three nested models (Models
1, 4, and 5), indicating that Model 4 fits the data significantly better than Model 1 (2 = 851.09; p < .001) and
Model 5 fits the data significantly better than Model 4 (2
= 44.67; p < .001). The nonnested models (Models 2 and
3) were compared with each other and with the three nested
models descriptively, using AIC and ECVI values. The differences in these values indicated a better fit of Model 5
compared with Model 3 (AIC = 51.84; ECVI =
0.077), of Model 4 compared with Model 3 ( AIC =
15.17; ECVI = 0.021), of Model 3 compared with
Model 2 ( AIC = 65.64; ECVI = 0.092), and of Model
2 compared with Model 1 ( AIC = 764.28; ECVI =
1.063). Altogether, the five-factor Model 5 emerged as
the best fitting model. However, as the two best-fitting
models (Model 5 and Model 4) had different complexity
levels (Model 5 had fewer degrees of freedom, indicating a
larger number of freely estimated parameters than Model
4), we compared the practical significance of these models
to one another. The difference in the TLI values between
Model 5 and Model 4 was <.01, indicating a lack of practical significance between the fit of these models. Table 2

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Assessment

Table 2. PCL-C Item Means, Corrected ItemTotal Correlations, Cronbachs Alphas if Item Deleted, Standardized Factor Loadings
and Factor Correlations for the Model 5 (Elhai et al., 2011) in CFA.

PCL-C items
B1. Intrusive thoughts
B2. Nightmares
B3. Flashbacks
B4. Emotional reactivity
B5. Physical reactivity
C1. Avoidance in thoughts
C2. Avoidance of reminders
C3. Amnesia for aspects
C4. Loss of interest
C5. Feeling distant
C6. Emotionally numb
C7. Foreshortened future
D1. Sleep disturbance
D2. Irritability
D3. Difficulty concentrating
D4. Hypervigilance
D5. Exaggerated startle
PCL-C Scale (17 items)
Factor correlations
Reexperiencing
Avoidance
Numbing
Dysphoric arousal

SD

Corrected item
total correlation

Cronbachs
if item deleted

2.81
1.89
2.03
3.12
2.49
2.27
2.27
1.60
2.33
1.87
1.57
1.86
2.45
1.75
2.03
1.98
1.95
36.28

1.21
1.21
1.23
1.36
1.33
1.30
1.31
1.06
1.27
1.17
1.02
1.18
1.36
1.09
1.15
1.16
1.15
13.55

0.63
0.60
0.64
0.62
0.67
0.57
0.59
0.47
0.65
0.63
0.56
0.59
0.59
0.51
0.63
0.65
0.65
0.60a

0.912
0.913
0.912
0.913
0.911
0.914
0.914
0.916
0.912
0.912
0.914
0.913
0.913
0.915
0.912
0.912
0.912
0.918b

Model 5 (Elhai et al., 2011) factor loadings,

CFA with ML estimation
R

DA

0.77
0.71
0.75
0.75
0.75
0.92
0.95
0.49
0.73
0.77
0.72
0.71
0.68
0.65
0.77

0.54

0.66
0.51

0.68
0.43
0.82

AA

0.76
0.75

0.76
0.54
0.77
0.89

Note: CFA = confirmatory factor analysis; PTSD = posttraumatic stress disorder; PCL-C = PTSD ChecklistCivilian version; R = reexperiencing; A =
avoidance; N = numbing; DA = dysphoric arousal; AA = anxious arousal.
a.Mean itemtotal correlation.
b.Cronbachs for the scale.

Table 3. Goodness-of-Fit Indices of the Five PCL and Three DSM-5 Models in Confirmatory Factor Analysis With Maximum
Likelihood Estimation.

PCL models (n = 720)

1. PCL three-factor (criteria)a
2. PCL four-factor Dysphoria
3. PCL four-factor higher order
4. PCL four-factor Numbing
5. PCL five-factor (Elhai et al., 2011)
DSM-5 models (n = 360)
1n. DSM-5 four-factor (criteria)a
2n. DSM-5 five-factor (EFA)b
2n. DSM-5 five-factor (EFA)b with
Item E2 removed

df

SRMR (n = 691)

CFI

TLI

RMSEA

ECVI

AIC

1295.94
525.66
464.02
444.85
400.18

116
113
115
113
109

0.064
0.048
0.048
0.046
0.043

0.810
0.934
0.944
0.947
0.953

0.749
0.910
0.925
0.928
0.934

0.119
0.071
0.065
0.064
0.061

1.953
0.890
0.798
0.777
0.726

1403.94
639.66
574.02
558.85
522.18

691.40
446.60
361.36

164
160
142

0.069
0.057
0.055

0.860
0.924
0.939

0.821
0.900
0.918

0.095
0.071
0.066

2.294
1.634
1.380

823.40
586.61
495.36

Note. PTSD = posttraumatic stress disorder; PCL-C = PTSD ChecklistCivilian version; SRMR = standardized root mean squared residual; CFI =
comparative fit index; RMSEA = root mean square error of approximation; TLI = TuckerLewis index; AIC = Akaike information criterion; ECVI =
expected cross-validation index; EFA = exploratory factor analysis.
a.Based on corresponding DSM diagnostic criteria for PTSD.
b.Suggested by exploratory factor analysis with extraction of five factors based on parallel analysis and interpretability.

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Demirchyan et al.
Table 4. DSM-5 PTSD Item Means, Corrected ItemTotal Correlations, Cronbachs Alphas if Item Deleted, and Factor Loadings of
DSM-5 PTSD Symptom Set Identified through EFA With Promax Rotation.
DSM-5 PTSD factor structure: Model 2n (principal
axis factoring with Promax rotation, N = 346)
DSM-5 PTSD symptoms

SD

B1. Intrusive thoughts

2.80 1.21
B2. Nightmares
1.89 1.21
B3. Flashbacks
2.03 1.22
B4. Emotional reactivity
3.12 1.36
B5. Physical reactivity
2.50 1.33
C1. Avoidance in thoughts
2.27 1.30
C2. Avoidance of reminders 2.27 1.31
D1. Amnesia for aspects
1.59 1.04
D5. Loss of interest
2.33 1.27
D6. Feeling distant
1.87 1.17
D7. Emotionally numb
1.56 1.01
E6. Sleep disturbance
2.45 1.36
E1. Irritability
1.75 1.08
E5. Difficulty concentrating
2.03 1.15
E3. Hypervigilance
1.98 1.16
E4. Exaggerated startle
1.95 1.15
E2. Self-destructiveness
1.09 0.47
D2. Negative beliefs
1.29 0.76
D3. Distorted blame
1.50 0.96
D4. Negative emotions
1.66 1.08
DSM-5 symptom set
39.91 14.42
Factor correlations in EFA
2. Hyperarousal
3: Avoidance
4: Negative state
5: Numbing

Corrected item Cronbachs if

total correlation item deleted
0.61
0.61
0.64
0.61
0.66
0.58
0.59
0.48
0.62
0.62
0.55
0.58
0.52
0.62
0.66
0.65
0.42
0.51
0.45
0.60
0.58b

.914
.914
.914
.914
.913
.915
.915
.917
.914
.914
.916
.915
.916
.914
.913
.913
.919
.917
.917
.915
.919c

Factor
1: R
0.84a
0.71
0.78
0.73
0.49
0.06
0.01
0.04
0.17
0.05
0.03
0.03
0.10
0.08
0.03
0.22
0.04
0.18
0.14
0.09

Factor
2: H

Factor
3: A

Factor 4:
NS

Factor
5: N

0.01
0.09
0.15
0.11
0.28
0.02
0.07
0.06
0.21
0.26
0.05
0.59
0.81
0.71
0.68
0.42
0.15
0.07
0.07
0.02

0.04
0.06
0.12
0.09
0.13
1.04
0.88
0.25
0.16
0.06
0.05
0.10
0.17
0.06
0.04
0.06
0.17
0.10
0.01
0.05

0.04
0.08
0.09
0.08
0.04
0.00
0.02
0.18
0.08
0.08
0.04
0.07
0.13
0.12
0.13
0.22
0.38
0.62
0.72
0.63

0.06
0.09
0.14
0.11
0.06
0.04
0.03
0.28
0.35
0.51
0.92
0.03
0.04
0.07
0.00
0.09
0.15
0.08
0.15
0.05

.70
.52
.50
.48

.49
.57
.63

0.37
0.47

0.51

Note. PTSD = Posttraumatic stress disorder; EFA = exploratory factor analysis; R = reexperiencing; H = hyperarousal; A = avoidance; NS = negative
state; N = numbing.
a.The highest loading for each variable is boldfaced and underlined.
b.Mean itemtotal correlation.
c.Cronbachs for the scale.

demonstrates standardized factor loadings and factor intercorrelations of Model 5 ranging from 0.43 to 0.89, with the
highest correlation (0.89) observed between the two arousal
factors, which was significantly higher than the next highest correlation observed between dysphoric arousal and
numbing (0.89 vs. 0.82, Z = 6.4, p < .01). The numbing
factor in this model was highly correlated with the arousal
factors (0.82 for dysphoric and 0.77 for anxious arousal),
whereas the avoidance factor was relatively weakly correlated with the arousal factors (0.43 and 0.54, respectively)
and the numbing factor (0.51).

DSM-5 PTSD Symptom Set

Overall, the internal consistency of the DSM-5 PTSD
symptom set was comparable to that of the PCL-C Scale

(Table 4). It had similar Cronbachs (.919) and slightly

lower mean itemtotal correlation (0.58, range = 0.420.66). Nineteen of the 20 items (except Item E2 on reckless/self-destructive behavior) added considerably to the
internal consistency of the scale (Table 4). Item E2 had
the lowest itemtotal correlation (0.42) and the lowest
mean value (1.09). All four symptom clusters defined by
DSM-5 criteria had acceptable internal consistency
(Cronbachs > .8).
EFA (principal axis factoring) was carried out on a random half of the data set to identify the latent structure of the
20-item DSM-5 PTSD symptom set. Four eigenvalues were
greater than one and the scree test suggested four-five factors, whereas the parallel analysis clearly indicated five
eigenvalues being higher than the stimulated random samples mean eigenvalue, with the sixth eigenvalue slightly

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Assessment

Table 5. Intercorrelations of Selected PTSD Construct Scores and Their Correlations (Pearson Correlation Coefficients) With
Depression, Anxiety, and Lifetime Trauma Scores.
N = 691
PCL dimensions
Reexperiencing
Avoidance
Numbing (King)
Hyperarousal (King)
Dysphoria (Simms)
Anxious arousal (Simms)
Negative state
Depression
Anxiety
Lifetime trauma

PCL scorea

0.68
0.54
0.70
0.72
0.71
0.72
0.56
0.56
0.57
0.21

0.49
0.58
0.63
0.62
0.61
0.45
0.43
0.44
0.21

0.48
0.42
0.47
0.44
0.37
0.23
0.31
0.12

0.68
NAb
0.60
0.51
0.50
0.45
0.13

NA
NA
0.53
0.60
0.64
0.19

0.68
0.53
0.59
0.55
0.17

AA

0.52
0.47
0.57
0.16

NS

0.38
0.43
0.11

Depression

Anxiety

0.62
0.17

0.12

Note. PCL = posttraumatic stress disorder (PTSD) Checklist; R = reexperiencing; A = avoidance; N = King numbing; H = King hyperarousal; D =
Simms dysphoria; AA = Simms anxious arousal; NS = negative state (sum of the four new items on negative emotional and behavioral state included in
DSM-5). All correlations are significant at p < .01 level (two-tailed).
a.Correlations between PCL score and its domain scores are corrected for overlap.
b.Dimensions that share variables are not shown and reflected as NA.

over that mean. Of the tested three EFA factor solutions with
extraction of four, five, and six factors, the five-factor solution (Model 2n, Table 4) achieved the best clinical interpretability. Its first and third factors corresponded to the DSM-5
symptom clusters B (B1-B5) and C (C1; C2), respectively.
However, its second factor loaded high on the five hyperarousal items (E1; E3-E6), the fourth factor on the four
newly introduced negative state items (E2; D2-D4), and the
fifth factor on the four numbing items (D1; D5-D7). After
the rotation, all these five factors were strongly inter-correlated, with the highest correlation observed between hyperarousal and reexperiencing (0.70), followed by that between
hyperarousal and numbing (0.63), and the lowest correlation
(0.37) between avoidance and negative state (Table 4).
The fifth numbing factor of this model demonstrated
signs of instability: two (D1 and D5) of the four numbing
items had loadings of 0.35 or less and it broke up into two
factors when forcing a six-factor solution. Thus, we reexamined the PTSD factor structure with inclusion of the item
on foreshortened future (the C7 item of the DSM-IV criteria,
which was removed from DSM-5 criteria) to check whether
it would improve the stability of this factor. With the inclusion of this item the same factor structure of PTSD was
revealed, and the numbing domain became more stable
four of the five items had loadings 0.50 and higher (only
Item D1 had a loading of 0.33, which was still higher than
that in the DSM-5 criteria-based model).
During CFA conducted on the other random half of the
data set, the EFA-derived five-factor model (Model 2n)
achieved acceptable fit (RMSEA value <0.08; CFI and
TLI values >0.90), as shown in Table 3, whereas the
model based on DSM-5 symptom clusters (Model 1n)
failed to achieve acceptable fit. The considerable differences between AIC and ECVI values of these models

( AIC = 236.79; ECVI = 0.66) indicated better fit

for the EFA-derived five-factor model. Removal of the
Item E2 (reckless/self-destructive behavior) from the
scale further improved the fit indices of the EFA-derived
five-factor model (Table 3).

Correlations Between PTSD Domains and

External Constructs
Table 5 demonstrates the correlations between selected
PTSD domain scores and the scores of depression, anxiety,
and lifetime trauma. We included in this table PTSD constructs based on the two structural models most supported
in the literatureKing et al. (1998) numbing model and
Simms et al. (2002) dysphoria model. Thus, we looked at
the correlations between depression, anxiety, lifetime
trauma, and the following PCL-based PTSD domains: reexperiencing, avoidance, numbing (King), hyperarousal
(King), dysphoria (Simms), anxious arousal (Simms). In
addition, we included the domain of negative state, containing the DSM-5-introduced symptoms of negative alterations
in cognition and mood and the reckless/self-destructive
behavior, and behaving as a distinct construct in our study.
All the observed correlations between these constructs
and external variables were statistically significant at p <
.01 level (two-tailed). All PTSD domains were highly intercorrelated. For the King et al. (1998) constructs, the highest
correlation was observed between hyperarousal and numbing (0.68), followed by that between hyperarousal and reexperiencing (0.63). For the Simms et al. (2002) constructs,
the highest correlation was detected between dysphoria and
anxious arousal (0.68), followed by that between dysphoria
and reexperiencing (0.62). For both models, the correlations between avoidance and the other constructs (varying

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Demirchyan et al.
between 0.42 and 0.49) were significantly weaker than the
weakest correlation (0.58) observed between other PCL
domains (for the lowest difference, Z = 2.9, p < .01).
All the PTSD domains (including negative state) correlated with PCL score (corrected for overlap) significantly
more than with depression and anxiety, demonstrating ability to discriminate between PTSD and external psychopathology (Z > 3.4, p < .01). It is noteworthy that avoidance
and reexperiencing correlated with the other PTSD constructs significantly stronger than with external psychopathology (Z > 7.4, p < .01), whereas hyperarousal and
dysphoria domains correlated more with depression and
anxiety than with avoidance (Z > 2.3, p < .05). Numbing
and negative state were in-between correlating with avoidance and external psychopathology almost equally.
Anxiety and depression were highly intercorrelated and
correlated equally highly with the PCL score. Both correlated highly with hyperarousal/dysphoria, moderately with
numbing, reexperiencing, negative state, and least with
avoidance. Interestingly, hyperarousal (King et al., 1998)
and dysphoria (Simms et al., 2002) correlated equally
highly with depression (0.60 and 0.59, respectively), while
hyperarousal correlated higher with anxiety, than dysphoria
did (0.64 vs. 0.55, Z = 5.7, p < .01). Of the PTSD constructs,
anxious arousal and avoidance were more related to anxiety
than depression (Z = 3.7, p < .01 for anxious arousal and Z
= 2.5, p < .05 for avoidance). The other constructs were
almost equally related to both (the differences were insignificant). The lifetime trauma score had low to moderate
correlation with PTSD score (0.21), a higher correlation
with reexperiencing than with avoidance (Z = 2.4, p < .05)
and numbing (Z = 2.3, p < .05). The correlation of both
anxiety and depression with trauma exposure was significant but lower (the difference was significant for anxiety,
Z = 2.8, p < .01, while insignificant for depression).

Discussion
In this study, we investigated the psychometric properties
and the factor structures of the Armenian-language translation of PCL-C and the DSM-5 PTSD symptom set in a
cohort of earthquake survivors. As a whole, PCL-C demonstrated good psychometric properties. This study compared
five models of PCL-C factor structure that received strong
support in different studies (Elhai et al., 2011; Gauci &
MacDonald, 2012; King et al., 1998; Palmieri et al., 2007;
Simms et al., 2002; Wang et al., 2011; Wu et al., 2008; Yufik
& Simms, 2010). Of the models tested, only the three-factor
model reflecting the DSM-IV criteria for PTSD demonstrated unacceptable fit to the data. The King et al. (1998)
four-factor numbing model, which differed from the
DSM-IV criteria-based structure only in the separation of
the avoidance/numbing domain into two distinct domains
of avoidance (C1-C2) and numbing (C3-C7), reached a

close-to-excellent fit. However, the five-factor intercorrelated model (Elhai et al., 2011) provided a superior fit to the
data. This model differed from the King et al. (1998) numbing model only in the separation of the Hyperarousal
domain into two subdomainsdysphoric arousal (Items
D1-D3) and anxious arousal (Items D4 and D5). Consistent
with the observation by Wang et al. (2011), this model
bridged the two most-supported factor structures of PTSD,
the King et al. (1998) four-factor numbing model and the
four-factor dysphoria model developed by Simms et al.
(2002). The dysphoria domain introduced by this model is
believed to best capture the symptoms of PTSD that are the
reflection of a general negative affect inherent to other distress disorders, whereas the other PTSD domains are less
clearly related to these disorders (Simms et al., 2002).
Of note, in an experimental study dysphoria model fit
best when the data were collected about a specific traumatic
event, while the numbing model fit best when the traumatic
exposure was not specified (Elhai et al., 2009). This is consistent with the present findings, as we did not specify any
traumatic event but asked the participants to think of the
worst event they had ever experienced when completing the
survey.
In the study by Wang et al. (2011), the numbing model fit
better in an earthquake survivor sample, while the dysphoria model fit better in a violent riot victim sample, suggesting that the conflicting results may be, among other factors,
due to differences in the type of traumatic exposure. This
observation is also consistent with our results: The numbing
model fit better than the dysphoria model in our cohort of
earthquake survivors, more than half of which (54.1%)
reported having in mind the earthquake in 1988 while
answering the PTSD items.
Both the four-factor dysphoria model and the five-factor
model contain two two-item factors (avoidance and anxious
arousal), which is a shortcoming, because the factors with
only two items are underidentified and thus inherently
unstable (Warner, 2008). Also, although the five-factor
model demonstrated the best fit to the data, the difference
between the fit indices of this model and the four-factor
numbing model lacked practical significance. The two new
arousal factors, dysphoric and anxious arousal, introduced
by this model, were much more closely related to each other
than to the remaining factors. The strength of correlation
between these factors (close to 0.90) raised a question
whether these two arousal factors were actually distinct.
Armour et al. (2012) also observed very high correlation
(0.97) between the two arousal factors of the five-factor
model in a primary care patient sample, and expressed a
concern that this strength of correlation could be a sign of
multicollinearity despite the model being statistically superior to the King et al. numbing model. Considering other
examples of the same phenomenon either between dysphoric and anxious arousal or between dysphoric arousal

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Assessment

and numbing, combined with the lack of differential associations between these highly correlated factors and external psychopathology, they concluded that in certain
populations, the four-factor models may be less problematic
and more parsimonious than the five-factor model (Armour
et al., 2012). Thus, practically, the five-factor model did not
provide considerably more value than the King et al. (1998)
four-factor numbing model.
Both these best-fitting models indicated the need for
grouping the numbing and avoidance symptoms into different clusters in the PTSD diagnostic criteria, especially considering that these two factors were relatively weakly
interrelated. The numbing factor was more closely related
to the hyperarousal than to the avoidance symptoms, a finding well supported by other studies (King et al., 1998;
Marshall, 2004; Palmieri et al., 2007; Passos et al., 2012;
Schinka, Brown, Borenstein, & Mortimer, 2007). Also, the
distinct-from-avoidance nature of numbing was reflected in
the pattern of their relationship with depression. Numbing
strongly correlated with depression, whereas avoidance
only weakly, as noted in other studies as well (Asmundson,
Stapleton, & Taylor, 2004; King et al., 1998).
The PCL score highly correlated with anxiety and
depression scores, which in their turn were highly intercorrelated. The correlation coefficients between PTSD and
these two psychopathologies were practically equal (0.57
and 0.56, respectively), which is consistent with the reports
about the similarity of these disorders, serving as a basis for
some researchers to propose a new classification of common mental disorders, where PTSD, dysthymic disorder,
major depression, and generalized anxiety are grouped
together as a diagnostic subclass of distress disorders
instead of being divided into two separate classes of mood
and anxiety disorders (Cox, Clara, & Enns, 2002; Slade &
Watson, 2006; Watson, 2005, 2009).
Although the King et al. (1998) numbing model fit the
data better than the Simms et al. (2002) dysphoria model in
the current study, we felt worthwhile to look at the patterns
of correlations of the factors of both numbing and dysphoria
models with the external variables of depression, anxiety,
and lifetime trauma to see whether the dysphoria model
demonstrated superior ability of discriminating between
external and internal constructs, than the numbing model did
(Gootzeit & Markon, 2011). In a meta-analysis, Gootzeit
and Markon (2011) compared these two models, and showed
that although the hyperarousal and numbing dimensions of
the King et al. (1998) model were strongly related to depression and anxiety, the dysphoria dimension of the Simms et
al. (2002) model was a stronger predictor of both anxiety
and depression, and even, trauma history. Our findings did
not support this evidence. We found that hyperarousal factor
(King et al., 1998) correlated with the external variables
equally/more than dysphoria factor (Simms et al., 2002) did,
meaning that it captured general distress equally/better in

this study. Nevertheless, our findings are consistent with the

findings of Miller et al. (2010). They also did not find an
evidence for better discriminant validity of Simms et al. dysphoria factor relative to the King et al. hyperarousal factor in
relation with external constructs (Miller et al., 2010).
As expected, both the PCL-C scale score and its domain
scores correlated significantly with the LT score. This finding is consistent with other studies showing a positive relationship between the number and/or severity of traumatic
exposures and the PCL score (Chiu et al., 2011; Keen,
Kutter, Niles, & Krinsley, 2008). Of the examined PTSD
constructs, the strongest relationship was observed between
reexperiencing and LT, closely followed by that between
hyperarousal (King) and LT, indicating that despite the low
convergent validity of the hyperarousal (King) domain, it
still belongs to PTSD.
Overall, the findings of this study confirm the well-recognized need of separating the avoidance/numbing domain
into two distinct domains: avoidance and numbing. Ideally,
at least one new item should be added to the avoidance
domain to ensure its stability. The construct of hyperarousal
should be further investigated to find ways to reduce its heterogeneity and to increase its ability to discriminate between
PTSD and other anxiety/affect disorders.
The DSM-5 criteria for PTSD address some shortcomings of the previous one. Most important, the avoidance and
numbing domains are separated. Also, the newly introduced
items on negative alterations in cognition and mood showed
specificity to PTSD. However, the combination of these
items with the numbing items did not receive empirical support, as the negative emotion/behavior items constituted a
separate factor in EFA, which correlated with hyperarousal
more tightly than with numbing. The removal of the item on
foreshortened future from the PTSD diagnostic criteria
increased the instability of the numbing domain. The heterogeneity of the hyperarousal domain was even increased
with inclusion of the item on reckless/self-destructive
behavior, as it reduced the internal consistency of this subscale. Miller et al. (2013) also found that the reckless/selfdestructive behavior symptom did not cohere well with the
remaining symptoms of hyperarousal and suggested eliminating it from the core diagnostic criteria of PTSD.
The CFA supported the EFA-identified five-factor structure of the DSM-5 PTSD symptom set in this study with
reexperiencing, avoidance, numbing, hyperarousal factors
similar to that of the King et al. (1998) numbing model plus
a new factor of negative state consisting of the new symptoms of negative cognition/mood and behavior. Indeed, the
DSM-5 criteria-based solution failed to achieve acceptable
fit in reflecting the latent structure of PTSD.
The main limitation of the current study was its reliance
on self-report measures without clinical interview data.
Because of this, the study did not measure the criterion
validity of the Armenian-language PCL-C to suggest an

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Demirchyan et al.
efficient cutoff score to diagnose PTSD among Armenian
population. However, this study has a number of practical
and theoretical implications. It suggests that the Armenianlanguage PCL-C behaves very similarly to the original
English-language instrument. Thus, this scale can be recommended as a valid tool for measuring PTSD symptoms in the
Armenian population. Studying this unique population with
its cultural specificity and traumatic exposure, the study provided good evidence for the cross-cultural validity of both
the PCL-C and the PTSD structural models. The intercorrelated five-factor model best captured the latent structure of
the Armenian PCL-C. However, the four-factor numbing
model could also, more than adequately, serve as a sound
representation of the underlying constructs of PTSD. DSM-5
diagnostic criteria for PTSD could be improved by treating
the three new negative emotion items as a separate domain,
eliminating the item on reckless/self-destructive behavior
and keeping the item on foreshortened future.
Acknowledgments
The authors are grateful to Dr. Byron Crape for his thorough
review and feedback on the article.

Declaration of Conflicting Interests

The authors declared no conflicts of interest with respect to the
research, authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
Turpanjian Family Educational Foundation supported this study.

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