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Conflict and Health
Published in: Conflict and Health 1/2018

Open Access 01-12-2018 | Research

A factor analytic investigation of DSM-5 PTSD symptoms in a culturally diverse sample of refugees resettled in Australia

Authors: Philippa Specker, Belinda J. Liddell, Yulisha Byrow, Richard A. Bryant, Angela Nickerson

Published in: Conflict and Health | Issue 1/2018

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Abstract

Background

Refugees and asylum-seekers are often exposed to multiple types of potentially traumatic events (PTEs) and report elevated rates of psychological disorders, including posttraumatic stress disorder (PTSD). Considering this, refugee populations merit continued research in the field of traumatic stress to better understand the psychological impact of these experiences. The symptom structure of PTSD underwent a major revision in the recent formulation in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and this reformulation has yet to be comprehensively investigated in the context of PTSD arising from traumatic events experienced by refugees. The current study assessed the construct validity of the DSM-5 PTSD structure in a refugee sample from a variety of cultural backgrounds alongside four alternate models commonly identified in western populations, namely the four-factor Dysphoria model, the five-factor Dysphoric Arousal model, and the six-factor Anhedonia and Externalising Behaviours models.

Methods

A total of 246 refugees settled in Australia were assessed using the Harvard Trauma Questionnaire, to measure exposure to potentially traumatic events (PTEs), and the Posttraumatic Diagnostic Scale, to assess symptoms of PTSD based on DSM-5 criteria. All measures were translated into Arabic, Farsi or Tamil using rigorous translation procedures, or provided in English.

Results

Findings from five confirmatory factor analyses (CFAs) revealed that all models demonstrated acceptable model fit. However, an examination of relative fit revealed that the DSM-5 model provided the poorest fit overall for our sample. Instead, we found preliminary evidence in support of the six-factor Anhedonia model, comprising the symptom clusters of re-experiencing, avoidance, negative affect, anhedonia, dysphoric arousal and anxious arousal, as the superior model for our data.

Conclusions

Our findings offer preliminary support for the applicability of the Anhedonia model to a culturally diverse refugee sample, and contribute to a growing body of studies which indicate that the DSM-5 model may not best represent the symptom structure of PTSD found across non-western conflict-affected populations.
Literature
1.
Lindert J, Carta MG, Schäfer I, Mollica RF. Refugees mental health-a public mental health challenge. Eur J Pub Health. 2016;26:374–5.CrossRef
2.
Office of the United Nations High Commissioner for Refugees [UNHCR]. Global trends report. Geneva: UNHCR; 2016.
3.
Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC int health and human rights. 2015;15:29.
4.
Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365:1309–14.CrossRefPubMed
5.
Steel Z, Chey T, Silove D, Marnane C, Bryant RA, Van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. J Am Med Assoc. 2009;302(5):537–49.CrossRef
6.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Third ed. Washington, DC: American Psychiatric Association Press; 1980.
7.
Armour C, Mullerova J, Elhai JD. A systematic literature review of PTSD's latent structure in the diagnostic and statistical manual of mental disorders: DSM-IV to DSM-5. Clin Psychol Rev. 2016;44:60–74.CrossRefPubMed
8.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth ed. Washington, DC: American Psychiatric Association Press; 2013.
9.
Michalopoulos LM, Unick GK, Haroz EE, Bass J, Murray L, Bolton P. Exploring the fit of western PTSD models across three non-western low- and middle income countries. Traumatology. 2015;21:55–63.CrossRef
10.
Rasmussen A, Smith H, Keller AS. Factor structure of PTSD symptoms among west and central African refugees. J Trauma Stress. 2007;20(3):271–80.CrossRefPubMed
11.
Tay AK, Jayasuriya R, Jayasuriya D, Silove D. Assessing the factorial structure and measurement invariance of PTSD by gender and ethnic groups in Sri Lanka: an analysis of the modified Harvard trauma questionnaire (HTQ). J Anxiety Disord. 2017;47:45–53.CrossRefPubMed
12.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fourth ed. Washington, DC: American Psychiatric Association Press; 1994.
13.
14.
King DW, Leskin GA, King LA, Weathers FW. Confirmatory factor analysis of the clinician-administered PTSD scale: evidence for the dimensionality of posttraumatic stress disorder. Psychol Assess. 1998;10:90–6.CrossRef
15.
Simms LJ, Watson D, Doebbelling BN. Confirmatory factor analyses of posttraumatic stress symptoms in deployed and nondeployed veterans of the Gulf war. J Abnorm Psychol. 2002;111:637–47.CrossRefPubMed
16.
Elhai JD, Biehn TL, Armour C, Klopper JJ, Frueh BC, Palmieri PA. Evidence for a unique PTSD construct represented by PTSD's D1–D3 symptoms. J Anxiety Disord. 2011;25:340–5.CrossRefPubMed
17.
Foa EB, Riggs DS, Gershuny BS. Arousal, numbing, and intrusion: symptom structure of PTSD following assault. Am J Psychiatr. 1995;152:116–20.CrossRefPubMed
18.
King LA, King DW. Latent structure of the Mississippi scale for combat-related post-traumatic stress disorder: exploratory and higher-order confirmatory factor analyses. Assessment. 1994;1:275–91.CrossRef
19.
Taylor S, Kuch K, Koch WJ, Crockett DJ, Passey G. The structure of posttraumatic stress symptoms. J Abnorm Psychol. 1998;107:154–60.CrossRefPubMed
20.
Pietrzak RH, Tsai J, Harpaz-Rotem I, Whealin JM, Southwick SM. Support for a novel five-factor model of posttraumatic stress symptoms in three independent samples of Iraq/Afghanistan veterans: a confirmatory factor analytic study. J Psychiatr Res. 2012;46:317–22.CrossRefPubMed
21.
Liu P, Wang L, Cao C, et al. The underlying dimensions of DSM-5 posttraumatic stress disorder symptoms in an epidemiological sample of Chinese earthquake survivors. J anxiety disord. 2014;28:345–51.CrossRefPubMed
22.
Tsai J, Harpaz-Rotem I, Armour C, Southwick SM, Krystal JH, Pietrzak RH. Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from the National Health and resilience in veterans study. J clin psychiat. 2015;76:546.CrossRef
23.
Cuthbert BN, Kozak MJ. Constructing constructs for psychopathology: the NIMH research domain criteria. J Abnorm Psychol. 2013;122:928–37.CrossRefPubMed
24.
Watson D. Differentiating the mood and anxiety disorders: a quadripartite model. Annu Rev Clin Psychol. 2009;5:221–47.CrossRefPubMed
25.
Watson D, Clark LA, Stasik SM. Emotions and the emotional disorders: a quantitative hierarchical perspective. Int J Clin Health Psychol. 2011;11:429–42.
26.
Armour C, Tsai J, Durham TA, et al. Dimensional structure of DSM-5 posttraumatic stress symptoms: support for a hybrid anhedonia and externalizing behaviors model. J Psychiatr Res. 2015;61:106.CrossRefPubMed
27.
Mordeno IG, Carpio JGE, Nalipay MJN, Saavedra RLJ. PTSD's underlying dimensions in typhoon Haiyan survivors: assessing DSM-5 symptomatology-based PTSD models and their relation to posttraumatic cognition. Psychiatry Q. 2017;88:9.CrossRef
28.
Osterman JE, De Jong JT. Cultural issues and trauma. Handb PTSD Sci pract. 2007;29:425–46.
29.
Hollifield M, Warner TD, Lian N, Krakow B, Jenkins JH, Kesler J, Stevenson J, Westermeyer J. Measuring trauma and health status in refugees: a critical review. JAMA. 2002;288(5):611–21.CrossRefPubMed
30.
Nickerson A, Bryant RA, Silove D, Steel Z. A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clin Psychol Rev. 2011;31:399–417.CrossRefPubMed
31.
Li SSY, Liddell BJ, Nickerson A. The relationship between post-migration stress and psychological disorders in refugees and asylum seekers. Curr Psychiatry Rep. 2016;18:1–9.CrossRef
32.
Palmieri PA, Marshall GN, Schell TL. Confirmatory factor analysis of posttraumatic stress symptoms in Cambodian refugees. J Trauma Stress. 2007;20(2):207–16.CrossRefPubMed
33.
Tay AK, Rees S, Chen J, Kareth M, Silove D. The structure of post-traumatic stress disorder and complex post-traumatic stress disorder amongst west Papuan refugees. BMC psychiatry. 2015;15:111.CrossRefPubMedPubMedCentral
34.
Vindbjerg E, Carlsson J, Mortensen EL, Elklit A, Makransky G. The latent structure of post-traumatic stress disorder among Arabic-speaking refugees receiving psychiatric treatment in Denmark. BMC psychiatry. 2016;16:309.CrossRefPubMedPubMedCentral
35.
Vinson GA, Chang Z. PTSD symptom structure among west African war trauma survivors living in African refugee camps: a factor-analytic investigation. J Trauma Stress. 2012;25(2):226–31.CrossRefPubMed
36.
Schnyder U, Müller J, Morina N, Schick M, Bryant RA, Nickerson A. A comparison of DSM-5 and DSM-IV diagnostic criteria for posttraumatic stress disorder in traumatized refugees. J Trauma Stress. 2015;28:267–74.CrossRefPubMed
37.
38.
Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard trauma questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992;180(2):111–6.CrossRefPubMed
39.
Foa EB, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale. Psychol Assess. 1997;9:445–51.CrossRef
40.
Preacher KJ, Coffman DL. Computing power and minimum sample size for RMSEA [computer software]. Available from http://​quantpsy.​org/​ (2006, May) Accessed 18 Jan 2018.
41.
Muthén LK, Muthén BO. Mplus user's guide. 8th ed. Los Angeles: Muthén & Muthén; 2017.
42.
Flora DB, Curran PJ. An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data. Psychol Methods. 2004;9:466–91.CrossRefPubMedPubMedCentral
43.
44.
Brown TA. Confirmatory factor analysis for applied research. New York: Guilford Press; 2006.
45.
Steiger JH. EzPATH: causal modelling. Evanston, IL: SYSTAT; 1989.
46.
47.
Tucker LR, Lewis C. A reliability coefficient for maximum likelihood factor analysis. Psychometrika. 1973;38:1–10.CrossRef
48.
Kline RB. Principles and practice of structural equation modeling. 3rd ed. New York: Guilford Press; 2010.
49.
Yu CY. Evaluating cutoff criteria of model fit indices for latent variable models with binary and continuous outcomes. Los Angeles: University of California, Los Angeles; 2002.
50.
51.
Marsh HW, Hau K, Balla JR, Grayson D. Is more ever too much? The number of indicators per factor in confirmatory factor analysis. Multivar Behav Res. 1998;33:181–220.CrossRef
52.
Armour C, Carragher N, Elhai JD. Assessing the fit of the dysphoric arousal model across two nationally representative epidemiological surveys: the Australian NSMHWB and the United States NESARC. J anxiety disord. 2013;27:109–15.CrossRefPubMed
53.
Armour C, Raudzah Ghazali S, Elklit A. PTSD's latent structure in Malaysian tsunami victims: assessing the newly proposed dysphoric arousal model. Psychiatry Res. 2013;206:26–32.CrossRefPubMed
54.
Pietrzak RH, Feder A, Schechter CB, et al. Dimensional structure and course of post-traumatic stress symptomatology in world trade center responders. Psychol Med. 2014;44:2085–98.CrossRefPubMed
55.
Wang R, Wang L, Li Z, Cao C, Shi Z, Zhang J. Latent structure of posttraumatic stress disorder symptoms in an adolescent sample one month after an earthquake. J Adolesc. 2013;36:717–25.CrossRefPubMed
56.
Watson D. Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V. J Abnorm Psychol. 2005;114:522–36.CrossRefPubMed
57.
Forbes D, Lockwood E, Elhai JD, et al. An evaluation of the DSM-5 factor structure for posttraumatic stress disorder in survivors of traumatic injury. J anxiety disord. 2015;29:43–51.CrossRefPubMed
58.
Forbes D, Fletcher S, Parslow R, et al. Trauma at the hands of another: longitudinal study of differences in the posttraumatic stress disorder symptom profile following interpersonal compared with noninterpersonal trauma. J clin psychiatry. 2012;73:372–6.CrossRefPubMed
59.
Miller MW, Wolf EJ, Kilpatrick D, et al. The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in U.S. national and veteran samples. Psychol TraumaTheo Res, Prac Pol. 2013;5:501–12.
60.
Cohen J. Safe in our hands?: a study of suicide and self-harm in asylum seekers. J Forensic Legal Med. 2008;15:235–44.CrossRef
61.
Patel N, Hodes M. Violent deliberate self-harm amongst adolescent refugees. Euro Child Adolescent Psychiatry. 2006;15:367–70.CrossRef
62.
Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD checklist (PCL). Behav Res Ther. 1996;34:669–73.CrossRefPubMed
63.
Hinton DE, Lewis-Fernandez R. The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5. Depress Anxiety. 2011;28:783–801.CrossRefPubMed
64.
World Health Organization. The ICD-10 classification of mental and Behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.
65.
Maercker A, Brewin CR, Bryant RA, et al. Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry. 2013;12:198–206.CrossRefPubMedPubMedCentral
Metadata
Title
A factor analytic investigation of DSM-5 PTSD symptoms in a culturally diverse sample of refugees resettled in Australia
Authors
Philippa Specker
Belinda J. Liddell
Yulisha Byrow
Richard A. Bryant
Angela Nickerson
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Conflict and Health / Issue 1/2018
Electronic ISSN: 1752-1505
DOI
https://doi.org/10.1186/s13031-018-0155-z

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