This entire article is available in PDF format to paid subscribers (certain restrictions apply).
If you have not already registered for Full Text Access to The Journal, then visit our registration page.

Refining Posttraumatic Stress Disorder Diagnosis: Evaluation of Symptom Criteria With the National Survey of Adolescents

Julian D. Ford, PhD; Jon D. Elhai, PhD; Kenneth J. Ruggiero, PhD; and B. Christopher Frueh, PhD

Objective: To compare the prevalence estimates, comorbidity rates, and structural validity of a revised symptom criteria set for the diagnosis of posttraumatic stress disorder (PTSD) with those of the DSM-IV criteria in a representative community sample of adolescents.

Method: Cross-sectional data from the National Survey of Adolescents, a 1995 household probability sample of 4,023 adolescents aged 12-17 years, were examined. DSM-IV PTSD symptoms were assessed with a modification of the National Women's Study PTSD module. Three- and 4-factor DSM-IV models were compared to a 2-factor PTSD model that deleted symptoms potentially overlapping with depression or other anxiety disorders. Comorbidity was assessed using DSM-IV criteria for major depressive episodes and substance use disorders.

Results: PTSD prevalence varied across models (ie, 5.2%-8.8%, lifetime; 3.2%-5.7%, past 6 months). When the 2-factor model was used with a proportionate symptom threshold, lifetime PTSD prevalence was comparable to that with the 3-factor DSM-IV model, and major depressive episode comorbidity was reduced by 9%-14%. Comorbidity with substance use disorders was comparable across models. Structural validity, tested with confirmatory factor analyses, showed that the 2-factor model and a 4-factor DSM-IV model were superior to the DSM-IV 3-factor model.

Conclusion: Compared to the DSM-IV 3-factor PTSD model, a 2-factor model that removed depression and anxiety symptoms and used a proportionate symptom threshold may produce comparable lifetime PTSD prevalence estimates, reduced PTSD-depression comorbidity, and superior structural validity (comparable to a 4-factor PTSD model) when applied to community samples of adolescents. Further research on PTSD structure and diagnosis with adolescents is warranted.


(J Clin Psychiatry 2009;70(5):748-755. Online Ahead of Print April 21, 2009. doi:10.4088/JCP.08m04692)

Received September 9, 2008; accepted December 18, 2008. From the Department of Psychiatry, University of Connecticut Medical School, Farmington (Dr Ford); Disaster Mental Health Institute, Department of Psychology, University of South Dakota, Vermillion (Dr Elhai); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, and Center for Disease Prevention and Health Interventions for Diverse Populations, Ralph H. Johnson VA Medical Center, Charleston, SC (Dr Ruggiero); and The Menninger Clinic and Department of Psychiatry, Baylor College of Medicine, Houston, Texas, and Department of Psychology, University of Hawaii, Hilo (Dr Frueh).

Work on this article was partially supported by a grant from the Department of Justice Office of Juvenile Justice and Delinquency Programs CT-52525-JS2 (Dr Ford, principal investigator).

The authors report no competing or financial interests regarding this article.

Corresponding author and reprints: Julian D. Ford, PhD, Department of Psychiatry MC1410, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06032 (e-mail: