Clinical Psychology Review 31 (2011) 993–1003

Contents lists available at ScienceDirect

Clinical Psychology Review

Factors of PTSD: Differential specificity and external correlates

Joshua Gootzeit ⁎, Kristian Markon
Department of Psychology, The University of Iowa, USA

a r t i c l e i n f o a b s t r a c t

Article history: Posttraumatic Stress Disorder (PTSD) has been found to be a multidimensional disorder most likely consisting
Received 27 January 2011 of four distinct symptom dimensions. Many studies have investigated the fit of two competing structural
Received in revised form 3 June 2011 models of PTSD (King et al., 1998; Simms et al., 2002). However, little research has been done on the utility
Accepted 8 June 2011
and differential external correlates of these dimensions. Meta-analysis was used to find the correlations
Available online 22 June 2011
between dimensions of PTSD and five external variables (depression, anxiety, panic, substance use, and
Keywords:
trauma history), and multivariate analysis was used to find the unique contributions of each dimension in
Posttraumatic stress predicting each variable. It was found that the Simms et al. (2002) model better divides PTSD symptoms into
Meta-analysis specific and general factors. The relative specificity of each factor is discussed.
Model © 2011 Elsevier Ltd. All rights reserved.
Validity

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 993
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995
2.1. Literature search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995
2.2. Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995
3.1. Zero-order correlations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 996
3.2. Multiple correlations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 996
3.3. Path models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 997
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999
4.1. Predictions and findings regarding the general-dysphoria model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999
4.2. Predictions and findings regarding other models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999
4.3. Summary of our findings and areas for further research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1000
4.4. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001

1. Introduction prevalence is considerably higher among vulnerable populations;

Posttraumatic Stress Disorder (PTSD) is a debilitating anxiety
disorder that develops in response to a severe traumatic event. The
national comorbidity survey replication found that the disorder's 12-
month prevalence rate in a sample of community adults was around
3.5% (Kessler, Chiu, Demler, Merikangas, & Walters, 2005). Its
⁎ Corresponding author at: Department of Psychology, The University of Iowa, 11
Seashore Hall E, Iowa City, IA, 52242-1407, USA. Tel.: + 1 319 335 2406.
E-mail address: joshua-gootzeit@uiowa.edu (J. Gootzeit).
for example, 8.7% of Iraq War veterans meet diagnostic criteria for
PTSD three years after combat exposure (Smith et al., 2008). Veterans
who suffer from PTSD are likely to suffer low quality of life and
impaired interpersonal and occupational functioning (Schnurr,
Lunney, Bovin, & Marx, 2009).
The diagnostic criteria of PTSD in the DSM-III-R and the DSM-IV
include seventeen symptoms divided into the three symptom clusters of
intrusive re-experiencing (5 symptoms), effortful avoidance/emotional
numbing (7 symptoms), and physiological hyperarousal (5 symptoms).
To receive a diagnosis, individuals must show at least one symptom of

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994 J. Gootzeit, K. Markon / Clinical Psychology Review 31 (2011) 993–1003

traumatic intrusions, at least three symptoms of avoidance/numbing, Table 1

and at least two symptoms of hyperarousal. These symptom clusters Possible symptom dimensions of PTSD.

were based primarily on clinicians' rational ideas about PTSD symptom DSM-IV PTSD Models
structure rather than on empirical data (Brett, Spitzer, & Williams, symptoms
DSM-IV King et al. Simms et al.
1988), and the disorder has been controversial from its outset (McNally, 3-factor (1998) (2002)
2003). 4-factor 4-factor
In the 1990s, some exploratory factor analyses (EFAs) were B1. Intrusive thoughts Intrusions Intrusions Intrusions
performed in an attempt to validate these symptom dimensions. of trauma
These analyses showed little agreement, positing four-factor (Keane, B2. Recurrent dreams Intrusions Intrusions Intrusions
1993), three-factor (Foa, Riggs, & Gershuny, 1995; Smith, Redd, of trauma
B3. Flashbacks Intrusions Intrusions Intrusions
DuHamel, Vickberg, & Ricketts, 1999), and two-factor models (Taylor, B4. Emotional reactivity Intrusions Intrusions Intrusions
Kuch, Koch, Crockett, & Passey, 1998). These studies tended to use to trauma cues
small samples, and there was little agreement between them. B5. Physiological reactivity Intrusions Intrusions Intrusions
Although EFAs are useful for finding structure in data, they are not to trauma cues
C1. Avoiding thoughts Avoidance/Numbing Avoidance Avoidance
typically used to test competing factor models. A large number of
of trauma
confirmatory factor analyses (CFAs) has therefore been run to test the C2. Avoiding reminders Avoidance/Numbing Avoidance Avoidance
goodness of fit for various structural models of PTSD. Although some of trauma
early studies tested the fit indices for Taylor et al.'s (1998) two-factor C3. Inability to recall Avoidance/Numbing Numbing Dysphoria
model (Buckley, Blanchard, & Hickling, 1998) and the DSM-IV's three- aspects of trauma
C4. Loss of interest Avoidance/Numbing Numbing Dysphoria
factor model (Cordova, Studts, Hann, Jacobsen, & Andrykowski, 2000), C5. Detachment Avoidance/Numbing Numbing Dysphoria
these studies did not compare the investigated structures to other C6. Restricted affect Avoidance/Numbing Numbing Dysphoria
possible solutions. C7. Sense of foreshortened Avoidance/Numbing Numbing Dysphoria
Recent CFAs have suggested two competing four-factor models of future
D1. Sleep disturbance Hyperarousal Hyperarousal Dysphoria
PTSD, both of which show better fits than other proposed models. The
D2. Irritability Hyperarousal Hyperarousal Dysphoria
first of these models involves splitting the DSM-IV's avoidance/numbing D3. Difficulty Hyperarousal Hyperarousal Dysphoria
cluster into separate factors, creating intrusions, effortful avoidance, concentrating
emotional numbing, and hyperarousal factors (King, Leskin, King & D4. Hypervigilance Hyperarousal Hyperarousal Hypervigilance
Weathers, 1998). The second proposed four-factor model creates a D5. Exaggerated Hyperarousal Hyperarousal Hypervigilance
startle response
separate avoidance factor, expands emotional numbing into a broader
dysphoria factor, and reduces hyperarousal into a more specific
hypervigilance factor, creating the four factors of intrusions, avoidance,
dysphoria, and hypervigilance (Simms, Watson & Doebbelling, 2002). mood disorders have been found to be very comorbid, and to
These two models are summarized in Table 1. Over the last decade, collectively form an “internalizing” cluster of psychopathology
much of the research on the structure of PTSD has focused on which of (Krueger, 1999). Cox, Clara, and Enns (2002) have found that PTSD
these two models provides a better fit. Some studies suggest that the is particularly highly comorbid with Major Depressive Disorder,
King et al. (1998) model is superior (e.g., McDonald et al., 2008; Naifeh, Dysthymic Disorder, and Generalized Anxiety Disorder (GAD). These
Elhai, Kashdan & Grubaugh, 2008), whereas others support the Simms high comorbidities have led some researchers to question the validity
et al. (2002) model (e.g., Boelen, van den Hout, & van den Bout, 2008; of the PTSD diagnosis (Rosen & Lilienfeld, 2008).
Elklit & Shevlin, 2007). Still other studies suggest that one or the other of Mineka, Watson, and Clark's (1998) integrative hierarchical model
these models might be superior depending on the assessment method of anxiety and depression suggests a possible reason for this high
(Palmieri, Weathers, et al., 2007) or the population under investigation comorbidity. This model states that each mood or anxiety disorder
(Elhai et al., 2009). However, in their recent meta-analysis, Yufik and consists of a unique component, or specific factor, and a shared
Simms (2010) suggest that the structure is largely invariant, finding that component, or general factor. Based on their review of the literature,
the Simms et al. (2002) model is superior for a variety of populations they suggest that high negative affect (associated with general distress
and measures of PTSD. or neuroticism) is a general factor across the mood and anxiety
Based on their meta-analysis of the overall fit for the two models, disorders. This model also offers a possible means to evaluate the utility
Yufik and Simms (2010) suggest that PTSD's multi-factor structure of the factor models of PTSD. If some factors represent the shared
indicates that the DSM-5 should include the four symptom clusters of variance among disorders, whereas others are more specific, they can be
intrusions, avoidance, hyperarousal, and dysphoria. They acknowledge, interpreted with these considerations in mind. This information might
however, that both four-factor models fit the data well. also be useful for future revisions of the DSM symptom criteria, allowing
Whereas most structural research that has been done in recent clinicians to emphasize symptom dimensions that are more specific to
years focuses on investigating which structural model provides the PTSD (Spitzer, First, & Wakefield, 2007).
best fit, less research has been done on the clinical utility and external Simms et al. (2002) suggest that their model's dysphoria
validity of a multi-factor model of PTSD. Unlike PTSD, the diagnostic dimension represents this general negative affect factor. They also
criteria for most mood and anxiety disorders in the DSM-IV are not suggest that the intrusions/re-experiencing symptom dimension
broken into separate symptom clusters. For example, individuals are might then represent a factor more specific to PTSD, and that
not required to show symptoms of both negative affect and somatic avoidance and hypervigilance might represent mid-level factors
symptoms of depression to be diagnosed with Major Depressive common to PTSD and the anxiety disorders, although the researchers
Disorder (MDD), despite empirical evidence that these areas did not find that these symptoms were unique predictors of
represent distinct factors of depression (Shafer, 2006). Likewise, a generalized anxiety and panic. They found some evidence that
diagnosis of Obsessive Compulsive Disorder (OCD) does not require dysphoria has a higher correlation with depression than other
symptoms of symmetry, forbidden thoughts, cleaning, and hoarding, dimensions of PTSD, but they did not find such support for avoidance
despite evidence that these areas represent distinct factors of OCD and hypervigilance.
(Bloch, Landeros-Weisenberger, Rosario, Pittenger & Leckman, 2008). Grant, Beck, Marques, Palyo, & Clapp (2008) tested directly
One area in which multiple factors might be helpful is in whether PTSD is distinguishable from MDD and GAD at a factor
explaining and modeling comorbidity. The anxiety and unipolar level, using confirmatory factor analysis. They found that PTSD could
 J. Gootzeit, K. Markon / Clinical Psychology Review 31 (2011) 993–1003
be distinguished from MDD and GAD, and that the intrusions,
avoidance, and hypervigilance factors are best understood as lower-
order factors specific to PTSD. Conversely, the dysphoria factor was not
specific to PTSD, but was best conceptualized as a higher-order
dimension common to all three disorders. Although these conclusions
were based on a single sample (N = 228), they provide some evidence
for differential specificity for the factors of PTSD.
Gros, Simms, and Acierno (2010) further investigated specificity of
PTSD and depression at the symptom level. Using exploratory factor
analysis of PTSD and depression measures, they found that the PTSD
symptoms roughly corresponding to the Simms dysphoria factor and
the King numbing factor were more highly associated with symptoms
of depression than with other symptoms of PTSD. In contrast,
symptoms of intrusions, avoidance, and hyperarousal were more
highly associated with each other than with symptoms of depression.
The results again show evidence that symptoms of PTSD show
differential specificity.
In another study, Elhai, Grubaugh, Kashdan and Frue (2008)
addressed the concern that there is too much overlap between PTSD
and other disorders. While not directly examining the factor structure
of PTSD, they examined an alternative set of diagnostic criteria
(Spitzer et al., 2007), which eliminates symptoms that directly
overlap with other internalizing disorders. These eliminated symp-
toms were comprised of five of the eight symptoms in the dysphoria
dimension. The revised diagnostic criteria therefore include a much
weaker general distress factor. However, comorbidity between PTSD
and other disorders remained unchanged regardless of the criteria
that were used. These results suggest that a multi-dimensional model
of PTSD might be of limited utility. These results were replicated by
Grubaugh, Long, Elhai, Frueh, and Magruder (2010).
Marshall, Schell and Miles (2010) have directly examined the
dysphoria dimension, testing whether the dysphoria symptoms of PTSD
had stronger associations with measures of depression, generalized
anxiety, and general distress. They found that the dysphoria and
nondysphoria dimensions of PTSD are both associated with these
external measures and that there was no evidence of specificity in the
dysphoria factor. They therefore suggested that there is little reason to
differentiate specific and general symptoms of PTSD. These results are
consistent with those of Elhai et al. (2008) suggesting little differential
specificity in a multi-dimensional model of PTSD.
In a review of the literature, Watson (2009) identified several studies
that reported correlations between PTSD symptom dimensions and
depression. He found that, for the King et al. (1998) model of PTSD,
depression is more highly associated with numbing and hyperarousal
than with intrusions and avoidance. For the Simms et al. (2002) model,
the dysphoria dimension showed a stronger relationship with depres-
sion compared to the other factors. These data suggest that the Simms
et al. (2002) model's symptom factors may be superior in separating
specific and general symptoms.
In this paper, we examine the external validity of multidimen-
sional diagnostic criteria for PTSD, across a broad range of external
criteria. Yufik and Simms (2010) have examined the internal validity
of PTSD's latent structure using meta-analysis, and found evidence
that the Simms et al. (2002) dysphoria model best accounts for the
symptom structure across populations and symptom measures.
Although their evidence indicates that such a structure provides a
better fit, meta-analysis has not been used to investigate the extent to
which these symptom dimensions show useful differential specificity
and discriminant validity. Some previous researchers (e.g., Marshall
et al., 2010; Elhai et al., 2008; Grubaugh et al., 2010) have suggested
that a multi-dimensional model of PTSD separating out dysphoria
symptoms is unnecessary, and that dysphoria symptoms do not show
a greater relationship with external correlates or drive comorbidity.
The current study aimed to address this hypothesis by examining the
external correlates of PTSD symptom factors using methods of meta-
analysis.
995
2. Methods
2.1. Literature search
In addition to external correlates of PTSD factors, the magnitude of
the correlations among the factors was investigated for the purpose of
multivariate analysis. Analysis was limited to studies that reported
correlations between PTSD factors and external factors, or among PTSD
factors. Only measures of PTSD that follow the DSM-IV's symptoms were
included in this analysis. When a study included multiple time points,
time 1 data were used. Factor correlations in CFA studies were included
in estimates of the correlations among PTSD dimensions.
Literature searches were conducted on PsycINFO and Google Scholar.
Studies citing the original King et al. (1998) or Simms et al. (2002)
studies were examined for relevant correlations. Other searches (e.g.,
“PTSD factor analysis”) were also conducted. The search was limited to
papers published in English. Unpublished thesis projects indexed on
Google Scholar were included in the search, and unpublished data from
the authors were used in the analyses. No other unpublished studies
were included. In all, 41 relevant studies were identified. Studies were
included if they reported correlations between the King et al. (1998) or
the Simms et al. (2002) factors and external variables, or if they included
correlations among the PTSD factors. Five external variables were
identified whose correlations were reported for both four-factor
models in at least two samples: depression, anxiety, panic, substance
use, and trauma history. These variables were included in the final
analysis.
If a study included multiple measures of the same construct in a
single sample (e.g., Palmieri, Weathers, et al., 2007), the correlations
were averaged before being entered into the meta-analysis. If a study
included correlations for multiple samples (e.g., McDonald et al.,
2008), each sample was coded as a separate study.
Studies included in the meta-analysis are shown in Table 2.
2.2. Procedure
Correlations were aggregated using the Hunter and Schmidt bare
bones method of meta-analysis, using a random effects model (Hunter &
Schmidt, 2004). Heterogeneity of samples was assumed when calcu-
lating estimated effect size variance. A Fisher's Z transformation was not
used. Each individual correlation was weighted by sample size before
being entered into the meta-analysis. Because reliability data do not
exist for some included measures, such as trauma history, correlations
were not corrected for reliability. Correlations corrected for sampling
error, observed standard deviations of the correlations and standard
deviations corrected for sampling error were calculated using formulas
given by Hunter and Schmidt (2004). The meta-analyses were
conducted using software by Schmidt and Le (2004).
To investigate the unique contribution of each factor of PTSD to
external variables, multivariate analyses were conducted using SAS
and Mplus software. Forward multiple regression was conducted for
each model and for each external variable, and the squared multiple
correlation value was calculated for each step to calculate the
percentage of variance accounted for by each model. Path analysis
was conducted to calculate the unique predictive power of each factor
of PTSD, using maximum likelihood estimation. For each path analysis,
in order to calculate confidence intervals, we used the harmonic mean
sample size, based in part on structural equation modeling literature
on how to analyze correlation matrices with differing sample sizes
(Enders & Peugh, 2004).
3. Results
Results of the meta-analyses are shown in Table 3. All correlations
were positive, and, with the exception of the correlation between
avoidance and trauma history, all were statistically significant at
996 J. Gootzeit, K. Markon / Clinical Psychology Review 31 (2011) 993–1003

Table 2 Table 2 (continued)

Studies included in meta-analysis. Study PTSD Other measures N
measure
Study PTSD Other measures N
measure Shelby et al. (2005) PCL – 148
Asmundson et al. PCL CES-D 1822 Shevlin et al. AUDADIS- – 12,467
(2004) sample 1 (2009) IV
Asmundson et al. PSS-SR CES-D 400 Simms et al. (2002) PCL PRIME-MD depression, anxiety and 1896
(2004) sample 2 sample 1 alcohol abuse, trauma history
Asmundson et al. CAPS CES-D 58 Simms et al. (2002) PCL PRIME-MD depression, anxiety and 1799
sample 2 alcohol abuse
(2004) sample 3
Taft et al. (2007) SCID CAGE alcoholism 1168
Asmundson et al. CAPS CES-D 60
(2004) sample 4 Witteveen et al. SRIP SCL-90 depression 833
Baschnagel et al. PDS – 748 (2006) sample 1
(2005) Witteveen et al. SRIP SCL-90 depression 333
Beck et al. (2009) CAPS BDI-II 109 (2006) sample 2
Boelen et al. (2008) PSS-SR SCL-90 depression 347 Wright and CAPS Trauma history questionnaire 227
Carragher et al. CIDI – 2677 Johnson (2009)
Zahradnik et al. PCL – 677
(2010)
(2009)
Cook et al. (2009) PCL PHQ depression 439
Cox et al. (2008) CIDI – 588 Note: AUDIS-IV = Alcohol Use Disorder and Associated Disabilities Interview Schedule;
Declercq et al. DTS Peritraumatic stress questionnaire 125 BDI-II = Beck Depression Inventory II; BAI = Beck Anxiety Inventory; CAGE = Ewing
(2010) alcoholism questionnaire; CAPS = Clinician-Administered PTSD Scale; CES-D = Center
DuHamel et al. PCL – 236 for Epidemiologic Studies Depression Scale; CIDI = Composite International Diagnostic
(2004) Interview; DTS = Davidson Trauma Scale; HTQ = Harvard Trauma Questionnaire;
Elhai et al. (2007) PCL – 215 IDAS = Inventory of Depression and Anxiety Symptoms; PAI = Personality Assessment
Elklit and Shevlin HTQ TSC-33 depression and anxiety 1116 Inventory; PCL = PTSD Checklist; PDS = Posttraumatic Diagnostic Scale; PHQ =
(2007) Patient Health Questionnaire; PRIME-MD = Primary Care Evaluation of Mental
Elklit et al. (2010) HTQ – 973 Disorders; PSS-I = PTSD Symptom Scale-Interview; PSS-SR = PTSD Symptom Scale-
Feuer et al. (2005) CAPS – 272 Self Report; PTSD-Q = Posttraumatic Stress Disorder Questionnaire; SCID = Structured
Flack et al. (2005) PCL Trauma history questionnaire 869 Clinical Interview for DSM-IV; SCL-90 = Symptom Checklist; SRIP = Self-Rating
sample 1 Inventory for PTSD; TSC-33 = Trauma Symptom Checklist.
Flack et al. (2005) PCL Trauma history questionnaire 423
sample 2
Forbes et al. (2005) SCID – 692 p = 0.05. Number of studies for a correlation ranged from 3 to 42, and
Gootzeit (2010) PCL IDAS dyphoria (depression), trauma 408 overall sample sizes ranged from 3196 to 55,774.
sample 1 history
Gootzeit (2010) PCL IDAS dyphoria (depression), trauma 297
sample 2 history 3.1. Zero-order correlations
Gootzeit (2010) PCL IDAS dyphoria (depression), trauma 240
sample 3 history An examination of the King et al. (1998) zero-order correlations
Hetzel-Riggin PTSD-Q – 2378
(Table 4) shows that all four PTSD symptom dimensions are related to
(2009)
Hoyt and Yeater PCL – 278
all five external variables. Numbing and hyperarousal are both more
(2010) sample 1 strongly related to depression and anxiety than are intrusions and
Hoyt and Yeater PCL – 226 avoidance. There is no evidence that avoidance has a unique relationship
(2010) sample 2 with anxiety or that numbing has a unique relationship with depression.
Johnson et al. PSS-I CES-D 225
Hyperarousal is slightly more associated with anxiety than numbing is,
(2007)
King et al. (1998) CAPS – 524 but shows no specificity to anxiety over depression. Hyperarousal and
Mansfield et al. PCL – 15,593 numbing have slightly higher correlations with panic compared with
(2010) intrusions and numbing. Hyperarousal shows the strongest relationship
Marshall et al. PCL PHQ depression 357 with substance use, and intrusions factor shows the strongest
(2010) Sample 1
Marshall et al. PCL SCL-90 depression 413
relationship with trauma.
(2010) Sample 2 The Simms et al. (2002) zero-order correlations (Table 5) also
McDevitt-Murphy CAPS PAI depression, anxiety, alcohol, and 55 demonstrate that all four dimensions of PTSD are related to all external
et al. (2005) drug use variables. Dysphoria is the strongest correlate for every external
McDonald et al. DTS – 814
variable. Hypervigilance has a stronger relationship with anxiety and
(2008) sample 1
McDonald et al. DTS – 320 substance use than intrusions or avoidance do, but does not show this
(2008) sample 2 pattern for panic. Intrusive re-experiencing shows a stronger
McDonald et al. DTS – 313 relationship with trauma than avoidance or hypervigilance do.
(2008) sample 3
Miller et al. (2008) CAPS – 315
Naifeh et al. (2008) PSS-SR CES-D 395
3.2. Multiple correlations
Newton et al. PDS BDI-II, trauma severity 39
(2005) Squared multiple correlations are given in Table 6 for the King et al.
Palmieri and PCL – 1218 (1998) model of PTSD. Hyperarousal is the best predictor of depression
Fitzgerald (2005)
(R2 = 0.4617), anxiety (R2 = 0.3437), panic (R2 = 0.2052), and sub-
Palmieri, Marshall PCL, CAPS BDI-II 2960
and Schell (2007) stance use (R 2 = 0.0330). Numbing adds some small additional
Palmieri, Weathers, HTQ – 490 predictive power for depression (ΔR 2 = 0.0466), anxiety (ΔR 2 =
et al. (2007) 0.0149), and panic (ΔR2 = 0.0182), but adds almost nothing to the
Pietrzak et al. PCL CES, PHQ depression, CAGE alcoholism 272 prediction of substance use (ΔR 2 = 0.0013). The addition of intrusions
(2010)
Pruneau (2008) PCL BDI-II, BAI, PAI alcohol and drug use 314
and avoidance accounts for more than an additional 1% of the variance
Pruneau (2009) PCL – 200 for anxiety, but not for depression, panic, or substance use. Intrusions
Schell et al. (2004) PCL – 413 are the best predictor of trauma history (R2 = 0.0779), with the other
factors adding almost no predictive power (ΔR 2 = 0.0050).
 J. Gootzeit, K. Markon / Clinical Psychology Review 31 (2011) 993–1003 997

Table 3 Table 5
Meta-analysis zero-order correlations. Zero-order correlations for Simms et al. (2002) factors.

Variable 1 Variable 2 K N rc SD robs SD rc 1 2 3 4

Intrusions Anxiety 7 6346 0.396 0.071 0.064 1. Intrusions –

Intrusions Avoidance 42 55,774 0.769 0.126 0.125 2. Avoidance 0.769 –
Intrusions Depression 19 12,491 0.495 0.113 0.108 3. Dysphoria 0.730 0.738 –
Intrusions Dysphoria 16 44,486 0.730 0.114 0.114 4. Hypervigilance 0.678 0.625 0.707 –
Intrusions Hyperarousal 36 35,106 0.725 0.120 0.119 5. Depression 0.495 0.442 0.736 0.502
Intrusions Hypervigilance 15 32,019 0.678 0.113 0.113 6. Anxiety 0.396 0.333 0.583 0.494
Intrusions Numbing 35 35,065 0.694 0.134 0.133 7. Panic 0.403 0.321 0.468 0.372
Intrusions Panic 4 4310 0.403 0.056 0.050 8. Substance Use 0.133 0.097 0.184 0.168
Intrusions Substance 6 5664 0.133 0.051 0.035 9. Trauma 0.279 0.186 0.347 0.201
Intrusions Trauma 10 4877 0.279 0.072 0.057
Avoidance Anxiety 7 6346 0.333 0.058 0.049
Avoidance Depression 22 14,792 0.442 0.100 0.094
Avoidance Dysphoria 16 44,486 0.738 0.128 0.128 3.3. Path models
Avoidance Hyperarousal 35 35,066 0.666 0.137 0.136
Avoidance Hypervigilance 15 32,019 0.625 0.134 0.134 Structural equation modeling was used to explore in greater detail
Avoidance Numbing 35 35,064 0.683 0.152 0.151
the unique predictive power of each dimension of PTSD. Figs. 1–5 show
Avoidance Panic 4 4310 0.321 0.064 0.058
Avoidance Substance 5 4336 0.097 0.049 0.027 the path models for depression, anxiety, panic, substance use, and
Avoidance Trauma 9 4837 0.186 0.114 0.105 trauma history. The path model for depression (Fig. 1) demonstrates
Numbing Anxiety 6 5230 0.542 0.051 0.044 that the King model's hyperarousal (β = 0.417) and numbing
Numbing Depression 18 12,726 0.673 0.083 0.079 (β = 0.443) dimensions are about equally good predictors of depression,
Numbing Hyperarousal 35 35,066 0.800 0.121 0.120
whereas the Simms model's dysphoria dimension (β = 0.887) accounts
Numbing Panic 4 4310 0.443 0.059 0.054
Numbing Substance 4 4064 0.167 0.017 0.000 for nearly all of the variance in depression scores. There is some
Numbing Trauma 8 4564 0.173 0.047 0.019 evidence that avoidance has a negative relationship with depression
Hyperarousal Anxiety 6 5230 0.586 0.045 0.038 after taking other factors of PTSD into account.
Hyperarousal Depression 14 9986 0.679 0.074 0.070
The path model for anxiety (Fig. 2) shows that the King model's
Hyperarousal Panic 4 4310 0.453 0.057 0.051
Hyperarousal Substance 5 5392 0.182 0.040 0.019
hyperarousal dimension (β = 0.492) is that model's best predictor of
Hyperarousal Trauma 9 4605 0.219 0.070 0.054 anxiety, whereas numbing (β = 0.281) also shows unique positive
Dysphoria Anxiety 3 4811 0.583 0.046 0.043 predictive power. The Simms model's dysphoria dimension (β = 0.626)
Dysphoria Depression 11 10,188 0.736 0.072 0.070 is that model's best predictor of anxiety, while hypervigilance
Dysphoria Hypervigilance 15 32,019 0.707 0.143 0.143
(β = 0.221) also shows unique predictive power. As with depression,
Dysphoria Panic 4 4310 0.468 0.059 0.053
Dysphoria Substance 3 3967 0.184 0.051 0.044 avoidance showed a negative relationship with anxiety after controlling
Dysphoria Trauma 5 3196 0.347 0.089 0.081 for other dimensions of PTSD.
Hypervigilance Anxiety 3 4811 0.494 0.035 0.029 The path model for panic (Fig. 3) shows that the King model's
Hypervigilance Depression 11 10,188 0.502 0.089 0.084
hyperarousal dimension (β = 0.229), numbing dimension (β = 0.217),
Hypervigilance Panic 4 4310 0.372 0.079 0.075
Hypervigilance Substance 3 3967 0.168 0.032 0.017
and intrusions dimension (β = 0.172) show unique positive predictive
Hypervigilance Trauma 5 3196 0.201 0.075 0.065 power for panic. The Simms model's dysphoria dimension (β = 0.409) is
the strongest predictor of panic, with intrusions (β = 0.192) and
Note: K = Number of studies; N = Total sample size; rc = Correlation corrected for
sampling error; SD robs = Observed standard deviation of correlation; SD rc = Standard hypervigilance (β = 0.053) showing some positive predictive power.
deviation of correlation corrected for sampling error. Once again, avoidance has a negative relationship with the external
variable after controlling for other dimensions of PTSD.
The path model for substance use (Fig. 4) shows that the King
Squared multiple correlations are given in Table 7 for the Simms model's hyperarousal dimension (β = 0.146) is the best predictor,
et al. (2002) model of PTSD. Dysphoria is the best predictor of all
external variables (Depression: R 2 = 0.5417; Anxiety: R 2 = 0.3404;
Panic: R 2 = 0.2190; Substance Use: R 2 = 0.0338; Trauma: R 2 = Table 6
Squared multiple correlations for King et al. (1998) model of PTSD.
0.1204). During the second step, avoidance accounts for an additional
2% of the variance for depression and anxiety, and an additional 1% of Dependent variable Predictors R2
the variance for trauma history. During the third step, hypervigilance Depression Arous 0.4617
accounts for an additional 2% of anxiety, while the intrusions factor Arous, Numb 0.5083
accounts for an additional 1% of trauma history. Arous, Numb, Avoid 0.5166
Arous, Numb, Avoid, Intrus 0.5168
Anxiety Arous 0.3437
Arous, Numb 0.3586
Arous, Numb, Avoid 0.3742
Arous, Numb, Avoid, Intrus 0.3745
Table 4 Panic Arous 0.2052
Zero-order correlations for King et al. (1998) factors. Arous, Numb 0.2234
Arous, Numb, Intrus 0.2288
1 2 3 4
Arous, Numb, Intrus, Avoid 0.2333
1. Intrusions – Substance Use Arous 0.0330
2. Avoidance 0.769 – Arous, Numb 0.0343
3. Numbing 0.694 0.683 – Arous, Numb, Avoid 0.0364
4. Hyperarousal 0.725 0.666 0.800 – Arous, Numb, Avoid, Intrus 0.0367
5. Depression 0.495 0.442 0.673 0.679 Trauma Intrus 0.0779
6. Anxiety 0.396 0.333 0.542 0.586 Intrus, Avoid 0.0798
7. Panic 0.403 0.321 0.443 0.453 Intrus, Avoid, Arous 0.0811
8. Substance Use 0.133 0.097 0.167 0.182 Intrus, Avoid, Arous, Numb 0.0829
9. Trauma 0.279 0.186 0.173 0.219
Note: Intrus = Intrusions; Avoid = Avoidance; Numb = Numbing; Arous = Hyperarousal.
998 J. Gootzeit, K. Markon / Clinical Psychology Review 31 (2011) 993–1003

0.726
Table 7
Squared Multiple Correlations for Simms et al. (2002) Model of PTSD. 0.694 0.666

2
Dependent Variable Predictors R 0.769 0.683 0.800
Depression Dys 0.5417
Intrusions Avoidance Numbing Hyperarousal
Dys, Avoid 0.5638
Dys, Avoid, Intrus 0.5640
Dys, Avoid, Intrus, Vig 0.5640
Anxiety Dys 0.3404
Dys, Avoid 0.3610
Dys, Avoid, Vig 0.3837
Dys, Avoid, Vig, Intrus 0.3837 Anxiety
Panic Dys 0.2190
Dys, Intrus 0.2271
Dys, Intrus, Avoid 0.2357
Dys, Intrus, Avoid, Vig 0.2369
Substance Use Dys 0.0338
Dys, Avoid 0.0371 Avoidance Dysphoria
Intrusions Hypervigilance
Dys, Avoid, Vig 0.0416
Dys, Avoid, Vig, Intrus 0.0418 0.769 0.738 0.707
Trauma Dys 0.1204
Dys, Avoid 0.1310 0.730 0.625
Dys, Avoid, Intrus 0.1416
Dys, Avoid, Intrus, Vig 0.1468 0.678

Note: Intrus = Intrusions; Avoid = Avoidance; Dys = Dysphoria; Vig = Hypervigilance. Fig. 2. Path analysis using King et al. (1998) factors (top) and Simms et al. (2002)
factors (bottom) to predict anxiety. 95% confidence intervals shown.

with numbing (β = 0.084) showing some unique positive predictive

power. The Simms model's dysphoria dimension (β = 0.188) is that
model's best predictor of substance use, with hypervigilance
(β = 0.093) also showing some unique positive predictive power.
For the Simms model, the unique relationship between avoidance and
the external variable is again negative.
The path model for trauma history (Fig. 5) shows that the King
model's intrusions dimension (β = 0.313) is that model's best
predictor, with hyperarousal (β = 0.096) showing some unique
positive predictive power. The Simms model's dysphoria dimension
(β = 0.443) is that model's best predictor of substance use, with
intrusions (β = 0.208) showing some unique predictive power. The
remaining dimensions are negative predictors of trauma history, with
the Simms model's avoidance dimension having the most strongly
negative predictive power.
The relative utility of the dysphoria dimension and a combined
nondysphoria dimension was also examined (Table 8). The multiple
correlation between dysphoria and the remaining dimensions of PTSD
was high (R = 0.814). Dysphoria showed a higher correlation with all
external variables compared with the combined nondysphoria factors'
correlations. Structural equation modeling was also used to model
dysphoria and nondysphoria's relationships with these external
variables (Fig. 6). Dysphoria continued to be the best predictor for
every variable even after collapsing nondysphoria dimensions.
Dysphoria had strong predictive power for depression (β = 0.863),
whereas nondysphoria did not (β = −0.156). Dysphoria was also a
strong predictor of anxiety (β = 0.519) compared with nondysphoria
(β = 0.079). Dysphoria was the better predictor of panic (β = 0.362),
but nondysphoria showed some unique predictive power (β = 0.130).
Neither dysphoria (β = 0.128) nor nondysphoria (β = 0.068) was a
strong predictor of substance use. Dysphoria (β = 0.344) was a strong
predictor of trauma history, whereas nondysphoria (β = 0.004) is not.
In order to determine the whether the differences between the
paths for each model are significant, Root Mean Square Error of
Approximation (RMSEA) values were calculated for the models in
which all weights were fixed at the same value. When all four
dimensions of the King model were assumed to have equal

0.726 0.726
0.694 0.666 0.694 0.666

0.769 0.683 0.800 0.769 0.683 0.800

Intrusions Avoidance Numbing Hyperarousal Intrusions Avoidance Numbing Hyperarousal

Depression Panic

Intrusions Avoidance Dysphoria Hypervigilance Intrusions Avoidance Dysphoria Hypervigilance

0.769 0.738 0.707 0.769 0.738 0.707

0.730 0.625 0.730 0.625

0.678 0.678

Fig. 1. Path analysis using King et al. (1998) factors (top) and Simms et al. (2002) Fig. 3. Path analysis using King et al. (1998) factors (top) and Simms et al. (2002)
factors (bottom) to predict depression. 95% confidence intervals shown. factors (bottom) to predict panic. 95% confidence intervals shown.
 J. Gootzeit, K. Markon / Clinical Psychology Review 31 (2011) 993–1003 999

0.726
Table 8
0.694 0.666 Multiple correlations for Simms et al. (2002) dysphoria and nondysphoria factors.

0.769 0.683 0.800 1 2

1. Dysphoria –
Intrusions Avoidance Numbing Hyperarousal
2. Nondysphoria 0.814 –
3. Depression 0.736 0.547
4. Anxiety 0.583 0.502
5. Panic 0.468 0.425
6. Substance Use 0.184 0.173
7. Trauma 0.347 0.284
Subst.Use

models, in terms of their psychopathology correlates. The current

study aimed to investigate the relative specificity of each PTSD
symptom dimension, and to determine whether the King et al. (1998)
Intrusions Avoidance Dysphoria Hypervigilance
or the Simms et al. (2002) dimensions better account for the
comorbidity between PTSD and other psychological problems.
0.769 0.738 0.707
4.1. Predictions and findings regarding the general-dysphoria model
0.730 0.625

0.678 If the Simms model's dysphoria dimension represents Mineka

Fig. 4. Path analysis using King et al. (1998) factors (top) and Simms et al. (2002)
factors (bottom) to predict substance use. 95% confidence intervals shown.
predicative power, the RMSEA values were 0.166 for depression, 0.147
for anxiety, 0.069 for panic, 0.038 for substance use, and 0.062 for
trauma history. When all four dimensions of the Simms model were
assumed to have equal predictive power, the RMSEA values were
0.225 for depression, 0.160 for anxiety, 0.086 for panic, 0.045 for
substance use, and 0.102 for trauma history. When unconstrained, all
models had an RMSEA value of 0. Restricting the four dimensions of
each model to have equal associations therefore resulted in
significantly poor fit of the models, especially for the Simms model.
The results of these constraint tests suggest that the factors of the
Simms model are more differentiated in their patterns of associations
with external variables than the King model.
4. Discussion
Several studies have investigated the relative fit of the King et al.
(1998) and the Simms et al. (2002) models of PTSD. Comparatively
few, however, have examined the external validity of these two
0.726
0.694 0.666
0.769 0.683 0.800
Intrusions Avoidance Numbing
Trauma
et al.'s (1998) general factor, it would be expected to have the
strongest relationship with depression, anxiety, and panic compared
with other symptom dimensions of PTSD. Simms et al. (2002)
speculate that intrusions are specific to PTSD, whereas avoidance
and hypervigilance are mid-level dimensions common to the anxiety
disorders. If this hypothesis is true, intrusions would be expected to
have comparatively less overlap with depression, anxiety, and panic,
and to have greater overlap with trauma history, whereas hypervi-
gilance and avoidance would be expected to have stronger relation-
ships with anxiety and panic than with depression. Mineka et al.
(1998) have suggested that negative emotionality/dysphoria may also
underlie the comorbidity between the internalizing disorders and
externalizing disorders such as substance abuse. For this reason,
dysphoria may be expected to have a stronger relationship with
substance use problems compared with other symptom dimensions.
In path analyses involving the Simms et al. (2002) symptom
dimensions (Figs. 1–5), dysphoria was the strongest predictor of all
external variables, with hypervigilance showing some additional
positive predictive power for anxiety and substance use. Intrusions
showed some additional positive predictive power for trauma history,
whereas avoidance was consistently a negative predictor of all
external variables after controlling for other factors of PTSD. These
results support the hypothesis that dysphoria is a general factor,
hypervigilance is a mid-level factor, and intrusive re-experiencing is a
specific factor of PTSD; they do not support the hypothesis that
avoidance is a mid-level factor.
In order to determine whether differences in predictive power
between the factors of PTSD were significant, RMSEA values were
Hyperarousal
calculated for models in which all factors of PTSD were assumed to
have equal patterns of associations with external variables. With the
exception of substance use (RMSEA = 0.045), none met traditional
criteria for good fit (RMSEA b 0.05) under this constraint. These
findings suggest that the predictive differences between factors are
important.

4.2. Predictions and findings regarding other models

Because King et al. (1998) do not discuss the relative specificity of

Intrusions Avoidance Dysphoria Hypervigilance their symptom dimensions, a priori hypotheses are difficult to make for
their model. Because intrusions and avoidance are common to both
0.769 0.738 0.707 models, it was hypothesized that intrusions will be specific to PTSD,
showing a strong relationship to trauma history, whereas avoidance will
0.730 0.625
show a stronger relationship with anxiety than with depression.
0.678
Because numbing and hyperarousal both include symptoms of general
Fig. 5. Path analysis using King et al. (1998) factors (top) and Simms et al. (2002) distress, they should both show strong relationships with depression,
factors (bottom) to predict trauma history. 95% confidence intervals shown. anxiety, and panic. It is possible that numbing, including symptoms of
1000 J. Gootzeit, K. Markon / Clinical Psychology Review 31 (2011) 993–1003
0.814
Dysphoria Nondysphoria Dysphoria
Depression
0.814
Dysphoria Nondysphoria
Subst.Use
Fig. 6. Path analysis using Simms et al. (2002) dyphoria and nondysphoria factors to predict external variables. 95% confidence intervals shown.
anhedonia, will show a stronger relationship with depression, whereas
hyperarousal, including symptoms of anxious arousal, will show a
stronger relationship with anxiety and panic, but this is speculation. It is
also expected that numbing and hyperarousal will show a stronger
relationship with substance use than intrusions and avoidance, again
due to their nonspecific symptoms.
Path analysis involving the King et al. (1998) model suggests that
numbing and hyperarousal both represent general distress, with
hyperarousal showing some additional specificity to anxiety and
substance use. The intrusions factor was the best predictor of trauma
history, with none of the other factors being strong positive predictors
for this variable. Avoidance was consistently a weak negative
predictor for all external variables after taking the other factors
of PTSD into account. These results support the hypothesis that
numbing and hyperarousal are general factors, whereas intrusive re-
experiencing is specific to PTSD; they do not support the hypothesis
that avoidance is a mid-level factor.
As with the Simms model, RMSEA values were calculated for models
in which all factors of PTSD were assumed to have equal weight. Again,
only the prediction of substance use (RMSEA = 0.038) was well
predicted when these restrictions were put in place. These findings
suggest that the differences between the factors are important.
Further analyses were conducted to test Marshall et al.'s (2010)
conclusion that PTSD's dysphoria and nondysphoria symptoms are
equally associated with general distress. These researchers suggested
that dysphoria shows stronger associations largely because it includes
more symptoms than some of the other dimensions and that, since
dysphoria shows no unique relationship with general distress
compared with a combined nondysphoria dimension, there is no
reason to separate these symptoms into dimensions. Although the
dysphoria and nondysphoria symptoms in this study were highly
correlated, the dysphoria dimension showed higher correlations with
all external variables (Table 8). Moreover, dysphoria showed an
ability to predict depression and anxiety above and beyond the
nondysphoria symptoms (Figs. 6–10). Interestingly, dysphoria was
also superior in predicting trauma history compared with the
theoretically more specific nondysphoria symptoms. Neither dimen-
sion was able to strongly predict substance use problems, and neither
was clearly superior to the other in predicting this variable.
4.3. Summary of our findings and areas for further research
This meta-analysis confirms that the dysphoria dimension repre-
sents a general factor common to PTSD, anxiety, and depression.
0.814 0.814
Nondysphoria Dysphoria Nondysphoria
Anxiety Panic
0.814
Dysphoria Nondysphoria
Trauma
These findings are consistent with Grant et al.'s (2008) conclusion
that the dysphoria dimension is not specific to PTSD. Some
researchers (e.g., Spitzer et al., 2007) have suggested eliminating
PTSD symptoms that overlap with other disorders from the next
edition of the DSM. However, this study has found that the dysphoria
dimension has the strongest relationship with trauma history of any
of the dimensions that were investigated. These findings suggest that
the dysphoria symptoms are an important part of the overall
construct of PTSD, and likely provide important clinical information.
Given the relatively high likelihood that traumatized individuals will
develop MDD or GAD (Grant et al., 2008), there is some obvious value
in measuring this general factor.
Overall, the Simms et al. (2002) model seems better able to
separate specific and general variance; whereas dysphoria clearly
represents the general factor in this model, the King et al. (1998)
model separates this general factor into two components: numbing
and hyperarousal. Both factors are equally able to predict depression,
with hyperarousal showing some specificity to anxiety. The same
pattern is found for substance use; however, the Simms model's
hypervigilance factor also shows some predictive power for substance
use, suggesting that the comorbidity between PTSD and substance use
is not due to a single shared distress factor. The hypervigilance factor
may in this case represents the hyperactivity associated with
impulsivity and externalizing problems. However, the results for
substance use are based on relatively few studies compared to the
results for depression and anxiety, and should be interpreted with
caution. In addition, models in which the factors of PTSD were
assumed to have equal predictive power were still able to adequately
predict substance use problems. Given the high levels of comorbidity
between PTSD and substance use disorders (Brady, Back, & Coffey,
2004), this is an area that warrants future study. In general, the King
model's hyperarousal dimension seems to be a better representation
of the general factor than numbing is.
The finding that factors of Simms et al. (2002) model are more
differentiated than those of the King et al. (1998) model is also
supported by the RMSEA values for the constrained versions of each
model. Constraining the models such that each factor is assumed to
have equal predictive power resulted in higher RMSEA values for the
Simms model than for the King model. Because the King model is less
differentiated, it is less affected by these constraints.
These results are relevant to the upcoming DSM-5 revisions. The
DSM-5's proposed diagnostic criteria for PTSD divides an expanded
set of symptoms into four dimensions, following the King et al. (1998)
four-factor model (Frueh, Elhai, & Acierno, 2010). Although it had
 J. Gootzeit, K. Markon / Clinical Psychology Review 31 (2011) 993–1003
been suggested that symptoms overlapping with depression be
eliminated (Spitzer et al., 2007), the proposed criteria actually expand
PTSD's numbing factor (now called “negative alterations in cognitions
and mood”), including persistent distorted blame of oneself or others
and a pervasive negative emotional state. The DSM-IV's hyperarousal
factor (now called “alterations in arousal and reactivity”) will likewise
be expanded, including a symptom of reckless or self-destructive
behavior. Given our findings, it seems unlikely that these dimensions
will parsimoniously represent specific and general components of
PTSD. According to our analyses, both the proposed negative
cognitions/mood dimension and the proposed arousal dimension
are likely general factors; as such their inclusion in DSM-5 may
actually decrease distinctions between PTSD and depression or other
internalizing syndromes.
Another noteworthy finding in this study is that avoidance was a
consistent negative predictor of all external variables after accounting
for other factors of PTSD, especially when the symptoms are divided
using the Simms model. This finding is inconsistent with the
hypothesis that avoidance is a mid-level factor that is associated
with anxiety. This factor's lack of positive predictive power may be
due to its small size, consisting only of two symptoms. However,
hypervigilance also consists only of two symptoms, and showed
unique overlap with anxiety and substance use.
Because zero-order correlations between avoidance and the
external variables of interest are positive, avoidance does not appear
to be a unitary construct. Rather, it appears to be divided into a
general subfactor, which overlaps with the other factors of PTSD and is
positively associated with external psychopathology variables, and a
specific subfactor, which is negatively associated with external
psychopathology variables. One possibility is that the specific
subfactor is associated with high levels of behavioral activation.
Avoidance is thought to play a critical role in the maintenance of PTSD
symptoms, and the reduction of avoidance is a major goal of
treatment (Foa, Hembree, & Rothbaum, 2007); a better understanding
of this factor's nature would therefore be helpful.
Finally, this study's findings are relevant to the treatment of PTSD.
Gros et al. (2010) have suggested that, given the overlap between
PTSD and depression, therapies designed for depression, such as
behavioral activation, should be included in treatment protocols for
PTSD. Our results show that nonspecific distress is an important
component of PTSD, and is highly associated with trauma history.
Treatments that target this nonspecific distress may therefore be
helpful to include in future treatment protocols. For example, Gros
et al. (2010) argue that behavioral activation, which targets
depression and general distress, would be a useful supplement to
therapies that specifically target PTSD symptoms.
4.4. Limitations
Important limitations of this study should be noted. First, the
meta-analysis was limited to PTSD measures that closely follow the
DSM-IV symptoms. Because the DSM was not written with these
structural models in mind, avoidance and hypervigilance are poorly
modeled compared to intrusions, numbing, hyperarousal, and
dysphoria. For this reason, this study may understate the predictive
power of these two constructs. Future studies should use instruments
that better model these dimensions. However, despite these concerns,
there exists a robust literature examining the structure of PTSD, and
this literature has informed work on the disorder's DSM-5 criteria.
Given that PTSD is operationally defined by these symptoms, and
given the heavy emphasis on using a multi-factor model for diagnostic
purposes, an understanding of these factors is important.
Second, the current meta-analysis aggregates different measures
that are thought to measure the same construct. This may be
particularly problematic for measures of trauma history. Most of the
studies cited used their own idiosyncratic instruments to measure
1001
trauma history and trauma severity. The ability to replicate these
results may therefore be limited due to instrument-specific variations.
The DSM-IV's criterion A for PTSD offers one possible standardized
method for assessing trauma history, and examining the relationship
between criterion A and the dimensions of PTSD across a variety of
samples would be an important follow-up.
Third, this study includes findings from a variety of different
populations, including military and civilian populations. A recent
meta-analysis by Yufik and Simms (2010) suggests that the structure
of PTSD is relatively invariant across populations. However, other
studies (e.g., Elhai et al., 2009) have found differences. It remains
possible that systematic differences across the included populations
may have influenced our results.
Finally, this study did not include a variety of potentially
interesting external variables due to limitations in the literature.
The relationships between PTSD dimensions and a variety of DSM-IV
diagnoses would be a potentially fruitful line of investigation to
expand this study's conclusions.
5. Conclusions
Amidst studies testing the relative fit for competing factor models
of PTSD, it is important to ask how these factors relate to external
constructs. This study supports the Simms, et al. model's interpreta-
tion of dysphoria in PTSD as a general factor that accounts for much of
the overlap between PTSD and other disorders, whereas intrusive re-
experiencing is a dimension that shows specificity to PTSD. While
these findings should be supplemented with investigations of other
external clinical constructs, they shed important light on the utility of
these dimensional models.
Acknowledgments
We would like to thank David Watson, Lee Anna Clark, Michael
O'Hara, and Daniel Tranel for their helpful comments on earlier drafts
of this manuscript.
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