Introduction Post-traumatic stress disorder (PSTD) was moved out of anxiety disorders into a distinct category of trauma and trauma-related disorders in the subsequent revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013). The number of symptoms representing PTSD was expanded from 17 to 20 individual symptoms, which were grouped into four-symptom categories. The symptom clusters are of monumental importance in diagnostic algorithms in a way that the symptoms are organized across the different symptom sets that eventually may lead to a variation in PTSD diagnosis, and hence, a change in prevalence rates [ Elhai JD, Miller ME, Ford JD, et al. Posttraumatic stress disorder in DSM-5: estimates of prevalence and symptom structure in a nonclinical sample of college students. J Anxiety Disord. 2012;26(1): 58– 64.

Doi: 10.1016/j.janxdis.2011.08.013 ]. Identification of accurate dimensionality underlying PTSD can help to a better understanding of etiological and maintenance factors strongly tied to PTSD to culminate in developing and evaluating potential clinical interventions. Those of trauma survivors who have experienced at least one re-experiencing symptom (Criterion B), at least one avoidance symptom (Criterion C), at least two symptoms of negative alterations in mood and cognitions (Criterion D) at least one-month of duration ensuing severe functional impairment meet a DSM-5 PTSD diagnosis. Also dissociative subtype was added to the criteria stipulated for PTSD diagnosis [ American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition: DSM-5. Washington ( DC): American Psychiatric; 2013.

Clinical Health Psychology, University College London, Gower Street. Tered PTSD Scale (CAPS; Blake et al., 1995). PTSD-Q = Posttraumatic Stress Disorder Questionnaire; Penn = Penn Inventory for Posttraumatic Stress Disorder; TSQ = Trauma Screening Questionnaire; DRPST = Disaster-Related.

The latent symptom structure of PTSD has been an issue, which has received extensive research interest. Given the importance of the link between the symptom clusters and PTSD diagnosis, understanding the optimal symptom sets best represent PTSD’s underlying dimensionality would allow clinicians to assess whether specific symptom clusters predominate development and the course of the disorder or characterize co-occurrence with other types of disorders as well as in which instances variations occur. Since the initial introduction of PTSD into diagnostic systems in 1980 [ American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-III. Washington ( DC): American Psychiatric; 1980. ], this clinical entity have been officially conceptualized as comprising three symptom groups of re-experiencing, avoidance, and hyper-arousal.

Specifically, the DSM-IV and DSM-IV-TR [ American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington ( DC): American Psychiatric Association; 1994., American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition, text revision (DSM-IV-TR).

Washington ( DC): American Psychiatric Association; 2000. ] built-up 17 symptoms that were separated into 3 symptom clusters have been subjected to extensive factor analysis studies. The two most prominent four-factor latent structure of PTSD symptoms are Emotional Numbing model [ King DW, Leskin GA, King LA, et al. Confirmatory factor analysis of the clinician-administered PTSD Scale: evidence for the dimensionality of posttraumatic stress disorder. Psychol Assess.

1998;10(2): 90– 96. Doi: 10.1037/1040-3590.10.2.90 ] and Dysphoria model [ Simms LJ, Watson D, Doebbeling BN. Confirmatory factor analyses of posttraumatic stress symptoms in deployed and nondeployed veterans of the Gulf War. J Abnorm Psychol. 2002;111(4): 637– 647.

Doi: 10.1037/0021-843X.111.4.637 ], which have extensively investigated and demonstrated to be preferential in comparison to classical three symptom sets of DSM-IV implied model. A more recent conceptualization of the five-factor Dysphoric Arousal model [ Elhai JD, Biehn TL, Armour C, et al. Evidence for a unique PTSD construct represented by PTSD’s D1-D3 symptoms. J Anxiety Disord. 2011;25(3): 340– 345.

Doi: 10.1016/j.janxdis.2010.10.007 ] moved the symptoms of sleeping difficulties, anger, and irritability from hyper-arousal set into dysphoric factor and the remained hypervigilance and exaggerated startle response symptoms were renamed as anxious arousal factor that were extracted from a combination of Emotional Numbing model and Dysphoria model and consistently outperformed Emotional Numbing model and Dysphoria model as well as the DSM-IV implied three-factor structure. The weight of evidence extracted from confirmatory factor analytic studies suggested a superior performance of the model; even though, this model has been largely examined in comparison to the two models with four-factor structures, namely Emotional Numbing model and Dysphoria model based on DSM-IV and DSM-IV-TR [ Armour C. The underlying dimensionality of PTSD in the diagnostic and statistical manual of mental disorders: where are we going? Eur J Psychotraumato. Doi: 10.3402/ejpt.v6.28074 ].

Following a number of confirmatory analytic studies based on DSM-5 PTSD symptoms since the DSM-5 published in May 2013 [ American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition: DSM-5. Washington ( DC): American Psychiatric; 2013. ], DSM-5 implied four-set of PTSD symptoms have consistently provided adequate fit across populations with various characteristics, but was less likely to be presumed to be optimal as compared to alternative models [ 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. Doi: 10.1016/j.cpr.2015.12.003 ].

The general trend in early factor analytic studies of dimensionality of DSM-5 PTSD symptoms was to compare the DSM-5 implied model to a modified DSM-5 Dysphoria model. Miller [ Miller MW, Wolf EJ, Kilpatrick D, et al. The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in US national and veteran samples. Psychol Trauma: Theory, Res Prac Policy. 2013;5(6): 501– 512.

Doi: 10.1037/a0029730 ] provided evidence for a DSM-5 version of a Dysphoria model that was preferential in a representative community sample and clinical sample of US military veterans. In following a similar vein of the DSM-IV factor analytic research, alternative models of the constellation of the DSM-5’s PTSD symptoms have emerged. To date, several DSM-5 version latent factor structures of PTSD ranging from one to seven factors encompass the DSM-5 implied four-factor model, the DSM-5 modification of the five-factor Dysphoric Arousal model, the six-factor Anhedonia model [ Liu P, Wang L, Cao CQ, 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(4): 345– 351. Doi: 10.1016/j.janxdis.2014.03.008 ], the six-factor Externalizing Behaviors [ Tsai J, Harpaz-Rotem I, Armour C, et al. Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from The National health and resilience in veterans study.

J Clin Psychiat. 2015;76(5): 546– 553. Doi: 10.4088/JCP.14m09091 ], and seven-factor Hybrid model [ 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– 113.

Doi: 10.1016/j.jpsychires.2014.10.012 ]. The six-factor Anhedonia model incorporates the separation of hyper-arousal symptoms into dysphoric and anxious arousal factors into an architecture of DSM-5’s PTSD symptomatology in which the negative alterations in cognitions and mood symptom cluster was divided into negative affect and reduced positive affect or anhedonia [ Liu P, Wang L, Cao CQ, 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(4): 345– 351.

Doi: 10.1016/j.janxdis.2014.03.008 ]. Another proposed six-factor latent dimensional structure of the DSM-5’s PSTD symptomatology was the Externalizing Behaviors model that was also prompted by the Dysphoric Arousal model by catching the hyper-arousal cluster on two separate symptom sets as anxious and dysphoric arousal. The model further divided dysphoric arousal into two symptom sets and moved irritability and self-destructive behavior symptoms from dysphoric arousal factor into externalizing behaviors factor [ Tsai J, Harpaz-Rotem I, Armour C, et al. Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from The National health and resilience in veterans study. J Clin Psychiat. 2015;76(5): 546– 553.

Doi: 10.4088/JCP.14m09091 ]. Finally, the most recent developed model based on DSM-5’s PTSD symptom structure was the seven-factor Hybrid model, extracted from combining the two newly proposed DSM-5 models of anhedonia and externalizing behaviors along with features of the Dysphoric Arousal model. The model included anxious and dysphoric arousal symptoms as distinct symptom sets as per the Dysphoric Arousal model, negative and reduced positive affect (anhedonia) as two separate symptom clusters in accordance with the Anhedonia model, and externalizing behaviors symptom cluster per se comparable to the Externalizing Behaviors model [ 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– 113. Doi: 10.1016/j.jpsychires.2014.10.012 ]. The evidence as to these more distilled symptom clusters has been accumulated and supported that the seven-factor Hybrid model seems to be superior to DSM-5 implied factor structure as well as previously proposed DSM-5 models of PTSD’s latent symptom structure in several studies conducted in largely veterans along with psychiatric patients and community samples varied in trauma experiences. A considerable proportion of this scrutiny has also provided support for the Anhedonia model secondary to the Hybrid model prevailing over the alternative latent factor structures [ Pietrzak RH, Tsai J, Armour C, et al.

Functional significance of a novel 7-factor model of DSM-5 PTSD symptoms: results from The National health and resilience in veterans study. J Affect Disord. 2015;174: 522– 526.

Doi: 10.1016/j.jad.2014.12.007 Wortmann JH, Jordan AH, Weathers FW, et al. Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychol Assess. 2016;28(11): 1392– 1403. Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD Checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychol Assess.

2016;28(11): 1379– 1391. Doi: 10.1037/pas0000254 Zelazny K, Simms LJ.

Confirmatory factor analyses of DSM-5 posttraumatic stress disorder symptoms in psychiatric samples differing in criterion A status. J Anxiety Disord. 2015;34: 15– 23. Doi: 10.1016/j.janxdis.2015.05.009 Wang L, Zhang LM, Armour C, et al. Assessing the underlying dimensionality of DSM-5 PTSD symptoms in Chinese adolescents surviving the 2008 Wenchuan earthquake. J Anxiety Disord.

2015;31: 90– 97. Doi: 10.1016/j.janxdis.2015.02.006 – Carragher N, Sunderland M, Batterham PJ, et al.

Discriminant validity and gender differences in DSM-5 posttraumatic stress disorder symptoms. J Affect Disord. 2016;190: 56– 67.

Doi: 10.1016/j.jad.2015.09.071 ]. The Clinician-Administered PTSD Scale (CAPS; [ Blake DD, Weathers FW, Nagy LM, et al. The development of a clinician-administered PTSD Scale. J Trauma Stress. 1995;8(1): 75– 90. Doi: 10.1002/jts., Blake DD, Weathers FW, Nagy LM, et al. A clinician rating scale for assessing current and lifetime PTSD: The CAPS–1.

Behavior Therapist. 1990;13: 187– 188. ]) is the most widely used measure as a clinician-rated scale and has been recognized as the gold standard for PTSD assessment in terms of PTSD status and symptom severity [ Weathers FW, Keane TM, Davidson JRT. Clinician-administered PTSD Scale: a review of the first ten years of research. Depress Anxiety.

2001;13(3): 132– 156. Doi: 10.1002/da.1029, Elhai JD, Gray MJ, Kashdan TB, Franklin CL. Which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects?: a survey of traumatic stress professionals. J Trauma Stress.

2005;18(5): 541– 545. Doi: 10.1002/jts.20062 ]. The accumulation of empirical evidence has supported excellent psychometric properties of the CAPS that has been used in a range of research conducted across a wide variety of populations with variation in type of trauma exposure. The CAPS has excellent reliability with good temporal stability, internal, and inter-rater consistency. The CAPS also has good convergent and discriminant validity, diagnostic utility, and sensitivity to clinical change [ Weathers FW, Keane TM, Davidson JRT.

Clinician-administered PTSD Scale: a review of the first ten years of research. Depress Anxiety. 2001;13(3): 132– 156. Doi: 10.1002/da.1029 ]. The CAPS have been evolved and modified to the CAPS for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (CAPS-5; [ Weathers FW, Blake DD, Schnurr PP, et al. Clinician-administered PTSD Scale for DSM-5 (CAPS-5).

Boston ( MA): National Center for PTSD; 2013. ]) based on the recent revisions to PTSD symptoms made in DSM-5.

Adhering to factor analytic procedures, to date, a vast body of research has utilized the CAPS as well as PTSD Checklist (PCL; [ Weathers FW, Litz B, Herman D, et al. The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. The Annual Convention of the International Society for Traumatic Stress Studies; 1993; San Antonio. ]) to examine and identify true dimensionality of PTSD symptoms; as the same was true for more recently proposed PTSD models representing the DSM-5’s latent symptom structure that were mostly measured by the PTSD Checklist for DSM-5 (PCL-5) [ Weathers FW, Litz BT, Keane TM, et al. The PTSD Checklist for DSM–5 (PCL-5).

Boston ( MA): National Center for PTSD; 2013. One previous scrutiny relying on DSM-IV PTSD models provided empirical evidence that factor analytic solutions representing the latent symptom structure of PTSD may differ due to measures used in assessment. The Dysphoria model provided superior fit to data measured by PCL; contrarily, the Numbing model provided superior fit to data measured by CAPS [ Palmieri PA, Weathers FW, Difede J, et al. Confirmatory factor analysis of the PTSD Checklist and the clinician-administered PTSD Scale in disaster workers exposed to the world trade center ground zero. J Abnorm Psychol. 2007;116(2): 329– 341.

Doi: 10.1037/0021-843X.116.2.329 ]. The central focus on this present study was to examine psychometric properties of the Turkish version of the CAPS-5 in clinical samples compared to the healthy controls. We adhered to confirmatory factor analysis (CFA) procedure, a robust method of model validation, to examine and identify the best dimensional structure fit to the current data based on several models representing latent symptom structure of PTSD that have been widely studied in the literature. The PTSD factor structures we tested herein were the one-factor model, the DSM-5 implied four-factor model, the five-factor Dysphoria model, the six-factor Anhedonia model, the six-factor Externalizing Behaviors model, and the seven-factor Hybrid model. We examined these models using CFAs for the CAPS-5, a clinician interview and PCL-5, a self-report measure separately. We hypothesized that the Hybrid model alongside with either Anhedonia model or Externalizing Behaviors model or both would provide superior fit to alternative latent factor structures of DSM-5’s PTSD symptoms for both measures of PTSD for DSM-5. The participants were asked to fill up the LEC-5 and to elect the most distressing traumatic event within the questions that bothered them during the past month.

The clinician interviews as to PTSD were relied on the index trauma for each participant and they were prompted the index trauma to bear in mind while answering subsequent questions. In the sample, the index trauma endorsements measured by the LEC-5 were “natural disaster” ( n = 25, 27.78%), “sudden violent death” ( n = 23, 25.56%), “transportation accident” ( n= 19, 21.11%), “sexual assault” ( n = 10, 11.11%), “physical assault” ( n = 9, 10.00%), and other unwanted sexual experiences ( n = 4, 4.44%). Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition The CAPS-5 is the gold standard assessment of PTSD status [ Weathers FW, Blake DD, Schnurr PP, et al. Clinician-administered PTSD Scale for DSM-5 (CAPS-5).

Boston ( MA): National Center for PTSD; 2013. The measure was demonstrated to have excellent psychometric properties with good inter-rater reliability, validity, and reliability [ Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD Checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychol Assess. 2016;28(11): 1379– 1391.

Doi: 10.1037/pas0000254 ] (see, Appendix 1). PTSD Checklist for DSM-5 The PCL-5 is a 20-item self-report questionnaire designed to assess symptoms of PTSD based on DSM-5 [ Weathers FW, Litz BT, Keane TM, et al. The PTSD Checklist for DSM–5 (PCL-5). Boston ( MA): National Center for PTSD; 2013. For each symptom, participants are asked to rate severity on a scale ranging from 0 ( not at all) to 4 ( extremely) that is indicative of distress having experienced in regard to index trauma during the past month. The Turkish version of the PCL-5 was demonstrated to have good psychometric properties [ Boysan M, Ozdemir PG, Ozdemir O, et al.

Psychometric properties of the Turkish version of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5). Bulletin of Clinical Psychopharmacology. ] (see, Appendix 2). Dissociative Experiences Scale (DES) The DES is a 28-item self-report measure of dissociative experiences [ Carlson EB, Putnam FW.

An update on the Dissociative Experiences Scale. 1993;6: 16– 27. Participants are asked to rate the items on an 11-point scale, ranging from 0 to 100. The Turkish version of the scale was validated by Yargic et al. [ Yargic LI, Tutkun H, Sar V.

The reliability and validity of the Turkish version of the Dissociative Experiences Scale. 1995;8: 10– 13. Beck Depression Inventory (BDI) The BDI consists of 21 items measuring severity of depression symptoms [ Beck AT, Rush J, Shaw BF, et al. Cognitive therapy of depression. New York ( NY): Guildford Press; 1979.

Each item is rated on a scale ranging from 0 to 3, yielding a total scale score of 0‒63. The Turkish version of the scale was demonstrated to have good reliability and validity [ Hisli N. The validity and reliability of the Beck Depression Inventory among university students. Turkish J Psychol. 1989;7: 3– 13. Beck Anxiety Inventory (BAI) This 21-item questionnaire measures severity of physiological symptoms of anxiety [ Beck AT, Brown G, Epstein N, et al. An inventory for measuring clinical anxiety: psychometric properties.

J Consult Clin Psych. 1988;56(6): 893– 897. Doi: 10.1037/0022-006X.56.6.893 ]. Each item is asked to be rated on a five-point scale, ranging 0‒3. Total scores range from 0 to 63. The Turkish version of the instrument was demonstrated to have good reliability and validity [ Ulusoy M, Erkmen H, Sahin N.

Turkish version of the beck anxiety inventory psychometric properties. J Cogn Psychother.

1998;12(2): 163– 172. Descriptive statistics and item descriptive statistics for the measures Descriptive characteristics of the sample are presented in. Then, we began analyzing descriptive and item descriptive statistics for the measures. The mean PCL-5 Global score was 34.62 (SD = 23.98).

Internal consistency of CAPS-5 sub-scales and PCL-5 Global and sub-scales were excellent (Cronbach’s α were greater than 0.87 for the CAPS and greater than 0.90 for the PCL-5). We also detected excellent internal consistency for the psychometric measures of dissociation, depression and anxiety that are used to assess convergent validity of the CAPS-5.

Corrected item-total correlations for both CAPS-5 and PCL-5 were demonstrated to have values above and beyond than expected. Spearman’s inter-item correlation coefficients fell in the suggested range [ Clark LA, Watson D. Constructing validity: basic issues in objective scale development. Psychol Assess. 1995;7(3): 309– 319. Doi: 10.1037/1040-3590.7.3.309 ], all these internal measure of consistency of which were indicative of construct validity of these measures.

Using McNemar test [ Selvin S. Statistical analysis of epidemiologic data. Oxford: Oxford University Press; 2004.

], 15-day re-test reliability of the CAPS-5 was assessed in a sub-sample of 45 participants consisting of 14 controls, 16 patients with depression, and 15 patients with PTSD. Sub-scales of the CAPS-5 revealed excellent temporal stability over two weeks that symptom endorsement for the PTSD clusters did not statistically significantly differ in later assessment ( p >0.05) (). Concurrent validity To examine the differences in endorsement of PTSD symptoms across groups, we conducted two-proportions Z-test. We found that patients with PTSD had statistically significantly greater proportion of PTSD symptom endorsement in all symptom clusters ranging from B to G cluster compared to either healthy controls or patients with depressive disorder ( p.

To explore the concurrent validity of PTSD diagnosis based on the CAPS-5 assessment, we run a multivariate analysis of covariance (MANCOVA) in which four sub-scales of the PCL-5 (re-experiencing, avoidance, negative alterations, and hyper-arousal), dissociative experiences, depression and anxiety were dependent variables. As can be seen in, we compared scale scores across three groups after adjusting for age, gender, education, physical illness, previous psychiatric diagnosis, and family psychopathology. We observed that multivariate differences of MANCOVA across three groups were statistically significant (Wilk’s λ = 0.424; F(14, 148) = 5.654; p. Of the seven models separately derived for the CAPS-5 and PCL-5 data, Externalizing Behaviors and Hybrid models revealed best fit either to the CAPS-5 or PCL-5 data; even though DSM-5 implied four-factor model fit indices were within the acceptable range according to guidelines [ Hu L, Bentler PM.

Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equat Model: A Multidis J. 1999;6: 1– 55.

Doi: 10.10 ]. Using AIC [ Akaike H.

A new look at the statistical model identification. IEEE Trans Automat Contr. 1974;19(6): 716– 723. Doi: 10.1109/TAC.19 ] and scaled chi-square difference test [ Bryant FB, Satorra A. Principles and practice of scaled difference chi-square testing. Struct Equat Model: A Multidis J.

2012;19(3): 372– 398. Doi: 10.101.2012.687671 ], we compared two models separately for the CAPS-5 and PCL-5 data. We found unsubstantial differences between Externalizing Behaviors and Hybrid models of PTSD symptoms, respectively (scaled χ 2 diff (6) = 8.482; p = 0.205 and scaled χ 2 diff (6) = 4.233 p = 0.645). However, Externalizing Behaviors model revealed lowest AIC values on both the CAPS-5 and PCL-5 data which can be interpreted as the optimal model for both PTSD screening instruments. Findings are presented in and. Signal detection analysis represents the diagnostic utility analyses for the CAPS-5, which were examined in the current study. Initially, we ran receiver operating characteristics (ROC) analyses to assess the ability of the CAPS-5 and PCL-5 scores to correctly identify and distinguish PTSD patients from patients with depression and controls.

The analysis revealed a strong ROC curve for the PCL-5 total scores (area under the curve = 0.87 p. Discussion The endeavor to identify the correct constellations of PTSD symptoms within homogenous symptom clusters in order to provide the best diagnostic algorithm to aid in the development of interventions for targeted treatments should be continued.

The newly proposed Anhedonia model, Externalizing Behaviors model and Hybrid model as to PTSD symptoms represented in the DSM-5 provide new opportunities for to extensions and refinement of theoretical considerations and implications that a more parsimonious latent structure of PTSD may exist. Nevertheless, PTSD latent structure research has largely drawn on measures of DSM-IV and DSM-5 PTSD symptoms rather than true PTSD structure. The aim of this present study was to examine the latent structure of the PTSD in clinical and non-clinical samples in Turkey. Seven latent models of PTSD drawn upon the DSM-IV and DSM-5 were explored. Confirmatory factor analytic examination of these models supported the Externalization Behaviors model as well as Hybrid model of PTSD either relying on the PCL-5 or CAPS-5 data. We observed significant overlaps between findings with respect to the PCL-5 or CAPS-5 solutions. Our results were indicative of that the CAPS-5 as well as PCL-5 is a psychometrically sound instrument in assessing PTSD diagnostic status and symptom severity in clinical population.

Consistent with our expectations, both measures of PTSD mapping onto DSM-5 definition had good internal consistency and temporal stability across a two-week period. CAPS-5 PTSD diagnosis satisfied in distinguishing patients with PTSD from either patients with depressive disorder and healthy controls. Both the CAPS-5 and PCL-5 scores demonstrated very good convergent validity in regard to the relations with anxiety, depression, and dissociation which can be attributable to excellent construct validity of these assessment tools. Consistent with the literature [ 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. Doi: 10.1016/j.cpr.2015.12.003 ], we observed that DSM-5 implied four-symptom cluster model of PTSD fit the data adequately. However, CAPS-5 data, in parallel with PCL-5 data, best fit to the six-factor model of Externalizing Behaviors and seven-factor Hybrid model of PTSD which incorporates key features of six-factor models of Externalizing Behaviors and Anhedonia that is composed of re-experiencing, avoidance, negative affect, Anhedonia, externalizing behaviors, and anxious and dysphoric arousal symptom clusters. On the other hand, in comparison to Hybrid model, Externalizing Behaviors model provided superior fit to the both CAPS-5 and PCL-5 data. In an extensive review of latent structure of PTSD symptoms, Armour [ 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. Doi: 10.1016/j.cpr.2015.12.003 ] reported that factor analytic studies have generally been conclusive on that the recently proposed four-factor DSM-5 PTSD model has been found to be a good representation of PTSD’s latent structure; while there has been increasingly accumulating evidence supporting six- and seven-factor models of PTSD latent structure that seem to be preferential in comparison to alternative models and DSM-5 PTSD factor structure may need further revisions. Due to the factor analytic studies of PTSD’s latent factor structure DSM-5 Numbing model revealed adequate fit in a majority of research, in three studies the model demonstrated better fit to the data than alternative models [ Elhai JD, Miller ME, Ford JD, et al. Posttraumatic stress disorder in DSM-5: estimates of prevalence and symptom structure in a nonclinical sample of college students. Sony Ericsson Xperia Pc Companion Free Download. J Anxiety Disord.

2012;26(1): 58– 64. Doi: 10.1016/j.janxdis.2011.08.013, Contractor AA, Durham TA, Brennan JA, et al. DSM-5 PTSD’s symptom dimensions and relations with major depression’s symptom dimensions in a primary care sample.

Psychiat Res. 2014;215(1): 146– 153. Doi: 10.1016/j.psychres.2013.10.015, Biehn TL, Elhai JD, Seligman LD, et al. Underlying dimensions of DSM-5 posttraumatic stress disorder and major depressive disorder symptoms. Psychol Inj Law. 2013;6(4): 290– 298.

Doi: 10.1007/s12207-013-9177-4 ]. In the PTSD literature, there has been a long debate whether Dysphoria model or Numbing model better represents latent factor structure of post-traumatic symptoms.

DSM-5 Numbing model generally outperformed Dysphoria models of PTSD symptom structure [ Liu P, Wang L, Cao CQ, 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(4): 345– 351. Doi: 10.1016/j.janxdis.2014.03.008, Tsai J, Harpaz-Rotem I, Armour C, et al.

Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from The National health and resilience in veterans study. J Clin Psychiat.

2015;76(5): 546– 553. Doi: 10.4088/JCP.14m09091, Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD Checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychol Assess. 2016;28(11): 1379– 1391. Doi: 10.1037/pas0000254, Contractor AA, Durham TA, Brennan JA, et al. DSM-5 PTSD’s symptom dimensions and relations with major depression’s symptom dimensions in a primary care sample.

Psychiat Res. 2014;215(1): 146– 153.

Doi: 10.1016/j.psychres.2013.10.015 – Hafstad GS, Dyb G, Jensen TK, et al. PTSD prevalence and symptom structure of DSM-5 criteria in adolescents and young adults surviving the 2011 shooting in Norway. J Affect Disord. 2014;169: 40– 46.

Doi: 10.1016/j.jad.2014.06.055 ]; while some studies provided support for Dysphoria model and two studies could not find differences between these models [ Armour C, Contractor AA, Palmieri PA, et al. Assessing latent level associations between PTSD and dissociative factors: is depersonalization and derealization related to PTSD factors more so than alternative dissociative factors? Psychol Inj Law.

2014;7(2): 131– 142. Doi: 10.1007/s12207-014-9196-9, 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. Doi: 10.1016/j.janxdis.2014.11.004 ]. On the other hand, in comparison to four-factor models, five-, six, or seven-factor models provided preferential fit [ Liu P, Wang L, Cao CQ, 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(4): 345– 351.

Doi: 10.1016/j.janxdis.2014.03.008 – 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– 113. Doi: 10.1016/j.jpsychires.2014.10.012, Hafstad GS, Dyb G, Jensen TK, et al. PTSD prevalence and symptom structure of DSM-5 criteria in adolescents and young adults surviving the 2011 shooting in Norway. J Affect Disord.

2014;169: 40– 46. Doi: 10.1016/j.jad.2014.06.055, Gentes EL, Dennis PA, Kimbrel NA, et al. DSM-5 posttraumatic stress disorder: factor structure and rates of diagnosis.

J Psychiatr Res. 2014;59: 60– 67.

Doi: 10.1016/j.jpsychires.2014.08.014 ]. It was the central focus of this study to examine the psychometric properties of the Turkish version of the CAPS-5. Even though the results from the current data were promising, certain limitations should be considered. Our sample size was relatively small. Our findings should be warranted via cross-validation of our results in larger clinical and non-clinical samples. Second, we replicated a cut-off criteria of 47 for a tentative PTSD diagnosis previously suggested by Boysan [ Boysan M, Ozdemir PG, Ozdemir O, et al. Psychometric properties of the Turkish version of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5).

Bulletin of Clinical Psychopharmacology. Vendor Es Mucho Mas Pdf Viewer here. ], our cut-off value was excessively greater than the critical values reported in previous studies [ Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD Checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychol Assess.

2016;28(11): 1379– 1391. Doi: 10.1037/pas0000254, Hoge CW, Riviere LA, Wilk JE, et al. The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: a head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD Checklist.

Lancet Psychiat. 2014;1(4): 269– 277.

Doi: 10.1016/S2215-035-4 ]. Further studies should be performed in larger and qualitatively different samples in order to find a more reliable critical value for PTSD diagnosis or verify current cut-off criteria for the Turkish version of the PCL-5. Until a more reliable refinement and extension of our results researchers can use two cut-off values of 33 and 47.

The CAPS-5 is a clinician-administered assessment tool and a gold standard for PTSD diagnosis. However, inter-rater agreement reliability between testers, a crucial point for clinical interview measures, was not assessed.

Inter-rater agreement reliability for the CAPS-5 should be warranted in further studies. Lastly, translations of the CAPS-5 and PCL-5 were conducted by experienced clinicians but a certified translation by authorized translators under the license of international institutions was not implemented. Therefore, this point should be taken into consideration during utilization of these scales in relatively more sensitive areas of use such as forensic assessment. Despite the limitations of this study, our findings provide evidence that both the Turkish versions of the CAPS-5 and PCL-5 have sound psychometric properties.

Socio-demographic characteristics of the sample. Age (Mean, SD) 29.01 8.99 Psychiatric diagnosis Control ( N,%) 30 33.33% Depression ( N,%) 30 33.33% PTSD ( N,%) 30 33.33% Sex Male ( N,%) 50 55.56% Female ( N,%) 40 44.44% Marital status Single ( N,%) 60 66.67% Married ( N,%) 30 33.33% Education Elementary ( N,%) 27 30.00% High school ( N,%) 15 16.67% University ( N,%) 48 53.33% Physical illness ( N,%) 17 18.89% Prior psychiatric illness ( N,%) 20 22.22% Family psychopathology ( N,%) 24 26.67%. Descriptives and item statistics of the measures. Note: N = 90; α = internal consistency; McNemar ( p)= 15-day interval re-test McNemar χ 2 test with 1 degree of freedom (probability of significance); Rjt = corrected item-total correlations (range); inter-item r = Spearman inter-item correlations (range); M = mean; SD = standard deviation; M range (items) = item means (range); SD range (items) = item standard deviations (range); CAPS-5 = Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition; PCL-5 = PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition. Two-proportions Z-test comparisons of DSM-5 implied PTSD symptom clusters endorsement, PTSD status, dissociative and delayed PTSD status across groups according to CAPS-5 assessment. Psychiatric diagnosis Control ( n = 30) Depression ( n = 30) PTSD ( n = 30) Control vs.

Depression Control vs. PTSD Depression vs. PTSD n% n% n% Z p Z p Z p Cluster B (re-experiencing) 12 40.00 8 26.67 30 100.00 1.11 0.268 −6.71 1 month 7 23.33 7 23.33 30 100.00 0.00 1.000 −9.93.

MANCOVA comparisons of PCL-5 sub-scale scores, DES, BDI, and BAI across groups a. Psychiatric diagnosis Control ( n = 30) Depression ( n = 30) PTSD ( n = 30) Mean SD Mean SD Mean SD F df p η 2 Post hoc PCL-5 b 9.40 9.73 38.67 20.30 55.80 10.89 37.679 2.80.

Notes: N = 90; PTSD = Post-traumatic Stress Disorder; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition; DES = Dissociative Experiences Scale; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory. ABonferroni multiple comparison test was used to perform pairwise comparisons. BUsing one-way ANCOVA, PCL-5 mean total scores were compared after controlling for age, sex, education, physical illness, prior psychiatric illness, and family psychopathology across groups. CUsing MANCOVA, scale scores were compared across groups after controlling for age, sex, education, physical illness, prior psychiatric illness, and family psychopathology.

Pearson’s product-moment correlation coefficients. 1 2 3 4 5 6 7 8 9 10 11 1. Re-experiencing 0.94 ** 3. Avoidance 0.86 ** 0.82 ** 4. Negative alterations 0.97 ** 0.88 ** 0.79 ** 5. Hyper-arousal 0.95 ** 0.85 ** 0.77 ** 0.90 ** 6.

Cluster B (re-experiencing) 0.67 ** 0.64 ** 0.61 ** 0.65 ** 0.61 ** 7. Cluster C (avoidance) 0.57 ** 0.52 ** 0.57 ** 0.54 ** 0.52 ** 0.86 ** 8. Cluster D (negative alterations) 0.73 ** 0.67 ** 0.66 ** 0.72 ** 0.68 ** 0.89 ** 0.85 ** 9.

Cluster E (hyper-arousal) 0.69 ** 0.65 ** 0.63 ** 0.67 ** 0.66 ** 0.87 ** 0.80 ** 0.92 ** 10. DES 0.72 ** 0.63 ** 0.60 ** 0.73 ** 0.71 ** 0.57 ** 0.48 ** 0.61 ** 0.57 ** 11. BDI 0.81 ** 0.71 ** 0.68 ** 0.80 ** 0.79 ** 0.58 ** 0.53 ** 0.68 ** 0.62 ** 0.77 ** 12. BAI 0.74 ** 0.70 ** 0.63 ** 0.69 ** 0.75 ** 0.49 ** 0.45 ** 0.55 ** 0.50 ** 0.73 ** 0.77 **. Item mapping for confirmatory factor analytic models. CAPS-5 CFA model results.

Factor structure model Number of factors S–B χ 2 df p RMSEA SRMR CFI TLI AIC 1 PTSD Factor 1 219.70 170 0.006 0.057 0.047 0.99 0.99 299.70 DSM-5 4 201.75 164 0.024 0.051 0.046 0.99 0.99 293.75 Dysphoria 4 193.48 164 0.058 0.045 0.046 1.00 1.00 285.48 Dysphoric Arousal 5 185.07 160 0.085 0.042 0.046 1.00 1.00 285.07 Externalizing behaviors 6 172.01 155 0.166 0.035 0.043 1.00 1.00 282.01 Anhedonia 6 179.35 155 0.088 0.042 0.044 1.00 1.00 289.35 Hybrid 7 167.43 149 0.144 0.037 0.041 1.00 1.00 289.43. PCL-5 CFA model results. Factor structure model Number of factors S–B χ 2 df p RMSEA SRMR CFI TLI AIC 1 PTSD Factor 1 226.79 170 0.002 0.061 0.045 0.99 0.99 306.79 DSM-5 4 179.23 164 0.020 0.032 0.041 1.00 1.00 271.23 Dysphoria 4 179.96 164 0.187 0.033 0.041 1.00 1.00 271.96 Dysphoric arousal 5 169.63 160 0.286 0.026 0.039 1.00 1.00 269.63 Externalizing behaviors 6 150.71 155 0.582 0.000 0.036 1.00 1.00 260.71 Anhedonia 6 166.12 155 0.260 0.028 0.038 1.00 1.00 276.12 Hybrid 7 147.71 149 0.510 0.000 0.035 1.00 1.00 269.71.