Factor structure of the International Trauma Questionnaire in UK
         Armed Forces veterans residing in Northern Ireland
         Armour, C., Robinson, M., & Ross, J. (2021). Factor structure of the International Trauma Questionnaire in UK
         Armed Forces veterans residing in Northern Ireland. European Journal of Psychotraumatology, 12(1), [1924954].
         https://doi.org/10.1080/20008198.2021.1924954
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                     European Journal of Psychotraumatology
                     ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/zept20
                Factor structure of the International Trauma
                Questionnaire in UK Armed Forces veterans
                residing in Northern Ireland
                Cherie Armour, Martin Robinson & Jana Ross
                To cite this article: Cherie Armour, Martin Robinson & Jana Ross (2021) Factor structure of the
                International Trauma Questionnaire in UK Armed Forces veterans residing in Northern Ireland,
                European Journal of Psychotraumatology, 12:1, 1924954, DOI: 10.1080/20008198.2021.1924954
                To link to this article:  https://doi.org/10.1080/20008198.2021.1924954
                      © 2021 The Author(s). Published by Informa
                      UK Limited, trading as Taylor & Francis
                      Group.
                      Published online: 17 Jun 2021.
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                  EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 
                  2021, VOL. 12, 1924954 
                  https://doi.org/10.1080/20008198.2021.1924954
                  BASIC RESEARCH ARTICLE
                  Factor structure of the International Trauma Questionnaire in UK Armed Forces 
                  veterans residing in Northern Ireland
                  Cherie Armour        , Martin Robinson         and Jana Ross
                  Stress Trauma and Related Conditions (STARC) Research Lab, School of Psychology, Queen’s University Belfast, Belfast, Northern 
                  Ireland, UK
                     ABSTRACT                                                                                                  ARTICLE HISTORY 
                     Background: Complex Posttraumatic Stress Disorder (C-PTSD) was recently included in the                   Received 7 January 2021  
                     revised  International  Classification  of  Diseases  (ICD-11)  by  the  World  Health  Organization      Revised 12 April 2021  
                     (WHO, 2018). C-PTSD is a new trauma related disorder which may develop after prolonged                    Accepted 22 April 2021 
                     and multiple exposures to trauma. It is a sister disorder of PTSD and is further characterized by         KEYWORDS 
                     symptomatology of disorganized self-organization (DSO). To qualify for the diagnosis, indivi-             Complex PTSD; factor 
                     duals must first meet the diagnostic criteria for PTSD, then report DSO symptoms and func-                analysis; veterans; military; 
                     tional  impairment.  A  body  of  work  is  emerging  which  has  focused  on  the  underlying            UK Armed Forces
                     dimensionality of C-PTSD across both adult and more recently adolescent populations from                  PALABRAS CLAVE 
                     differing index trauma groups and from across several nations and cultures. However, few                  TEPT Complejo; Análisis 
                     studies have been conducted in populations exposed to combat trauma despite the obvious                   Factorial; veteranos; Milicia; 
                     prolonged and multiple nature of their trauma histories.                                                  Fuerzas Armadas del Reino 
                     Objective: To contribute to emerging evidence of the factor structure of ICD-11 C-PTSD in                 Unido
                     a novel population.
                     Methods: This is the first factor analytic study to explore C-PTSD in a sample of UK Armed                关键词 
                     Forces veterans residing in Northern Ireland (N = 732). C-PTSD was measured via the ITQ and               复杂性PTSD; 因子分析; 退 
                     we utilized CFA to assess the fit of 7 competing models.                                                  伍军人; 军队; 英国武装部 
                     Results: Based on established CFA fit indices, a correlated, first order, 6-factor model of C-PTSD,       队
                     representing 3 PTSD and 3 DSO symptom groupings, was deemed to provide superior fit to the                HIGHLIGHTS
                     data  compared to 6  alternative  C-PTSD  models.  The  superiority  of  the  model  was  further         • This is the first factor ana-
                     supported by statistical comparisons of competing C-PTSD models. All factor loadings (0.866–-              lytic study to explore 
                     0.998) and inter-factor correlations (.746-.975) of the optimally fitting model were statistically         C-PTSD in a sample of UK 
                     significant and high.                                                                                      Armed Forces veterans 
                     Conclusion:  These  results  provide  support  for  the  construct  validity  of  ICD-11  C-PTSD  in       residing in Northern 
                     a unique sample of Armed Forces veterans residing in Northern Ireland.                                     Ireland. 
                                                                                                                               • A correlated, first order, 
                                                                                                                                6-factor model of C-PTSD, 
                                                                                                                                was deemed to provide 
                     Estructura Factorial del Cuestionario Internacional de Trauma en                                           superior fit to the data 
                     Veteranos de las Fuerzas Armadas del Reino Unido que residen en                                            compared to 6 alternative 
                                                                                                                                C-PTSD models. 
                     Irlanda del Norte                                                                                         • These results provide sup-
                     Antecedentes: El Trastorno de Estrés Postraumático Complejo (TEPT-C) fue recientemente                     port for the construct 
                     incluido  en  la  revisión  de  la  Clasificación  Internacional  de  Enfermedades  (CIE-11)  por  la      validity of ICD-11 C-PTSD.
                     Organización Mundial de la Salud (OMS, 2018). EL TEPT-C es un nuevo trastorno relacio-
                     nado con el trauma que puede desarrollarse posterior a exposición prolongada y múltiple 
                     a  traumas.  Es  un  trastorno  hermano  del  TEPT,  y  se  caracteriza  además  por  su 
                     sintomatología de desorden en la auto-organización (DSO por sus siglas en inglés). Para 
                     calificar  para  este  diagnóstico,  los  individuos  deben  cumplir  primero  con  criterios  para 
                     TEPT, y luego reportar síntomas de DSO y deterioro funcional. Un cúmulo de trabajo está 
                     emergiendo,  y  se  ha  concentrado  en  la  dimensionalidad  subyacente  del  TEPT-C  en 
                     poblaciones de adultos y más recientemente en adolescentes, diferenciándolas de grupos 
                     de  trauma  índice  y  en  numerosas  naciones  y  culturas.  Sin  embargo,  se  han  realizado 
                     pocos  estudios  en  poblaciones  expuestas  a  trauma  de  combate  pese  a  la  naturaleza 
                     obviamente prolongada y múltiple de sus historias de trauma.
                     Objetivo: Contribuir a la evidencia emergente de la estructura factorial del TEPT-C de la CIE-11 
                     en una población nueva.
                     Métodos: Este es el primer estudio analítico factorial en explorar el TEPT-C en una muestra de 
                     Veteranos de las Fuerzas Armadas del Reino Unido que residen en Irlanda del Norte (N=732). El 
                     TEPT-C fue medido mediante el ITQ (Cuestionario Internacional de Trauma por sus siglas en 
                     inglés) y se utilizó análisis factorial confirmatorio (CFA por sus siglas en inglés) para evaluar el 
                     ajuste de 7 modelos en competencia.
                     Resultados: Basado en lo establecido por los índices de ajustes, un modelo de 6 factores 
                     correlacionado y de primer orden representando 3 agrupaciones de síntomas de TEPT y 3 
                  CONTACT Cherie Armour      c.armour@qub.ac.uk    School of Psychology, Queen’s University Belfast, David Keir Building, 18-30 Malone Road, Belfast 
                  BT9 5BN, Northern Ireland, UK
                  © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. 
                  This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which 
                  permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
                 2       C. ARMOUR ET AL.
                    agrupaciones de síntomas de DSO, fue encontrado que probó un ajuste superior a los datos 
                    comparado con los 6 modelos alternativos de TEP-C. La superioridad del modelo fue respal-
                    dada además por comparación estadística de los modelos en competencia de TEPT-C. Todas las 
                    cargas  factoriales  (0.866-0.998)  y  correlaciones  inter-factoriales  (.746-.975)  del  modelo  con 
                    ajuste óptimo fueron estadísticamente significativas y altas.
                    Conclusión: Estos resultados aportan sustento a la validez del constructo TEPT-C del CIE-11 en 
                    una muestra única de veteranos de las Fuerzas Armadas que residen en Irlanda del Norte
                    居住在北爱尔兰的英国武装部队退伍军人中国际创伤问卷的因子结构
                    背景: 世界卫生组织 (WHO, 2018) 最近将复杂性创伤后应激障碍 (C-PTSD) 纳入了修订版《国 
                    际疾病分类》 (ICD-11) °  C-PTSD是一种新的创伤相关疾病, 可能在长期和多次创伤暴露后发 
                    展° 它是PTSD的姐妹疾病, 其特征还在于自组织障碍 (DSO) 的症候学° 要满足诊断条件, 个人 
                    必须首先满足PTSD的诊断标准, 然后报告DSO症状和功能损伤 大量工作集中在来自不同指 
                                                                                       ° 
                    数创伤组以及来自不同国家和文化的成年群体和更近期的青少年群体中, C-PTSD的潜在维 
                    度 但是, 但很少有研究在遭受战争创伤的群体中进行, 尽管其创伤史具有明显的长期性和 
                       ° 
                    多重性, ° 
                    目的: 为一个新群体中ICD-11 C-PTSD因子结构的新兴证据做出贡献° 
                    方法: 这是第一个对居住在北爱尔兰 (N = 732) 的英国武装部队退伍军人样本中C-PTSD进行 
                    因子分析的研究 C-PTSD由ITQ测量, 我们利用CFA评估了7种竞争模型的拟合度
                                      °                                                                  ° 
                    结果: 根据已确立的CFA拟合指数, 与6个替代C-PTSD模型相比, 表征3个PTSD和3个DSO症状 
                    组合的C-PTSD的相关一阶6因子模型被认为对数据拟合度更高 竞争性C-PTSD模型的统计比 
                                                                                       ° 
                    较进一步支持了该模型的优越性 最佳拟合模型的所有因子负荷 (0.866-0.998) 和因子间相 
                                                        ° 
                    关 (.746-.975) 在统计上均显著且很高
                                                            ° 
                    结论: 这些结果为居住于北爱尔兰的武装部队退伍军人的独特样本中ICD-11 C-PTSD的构建 
                    效度提供了支持
                                      ° 
                 1. Introduction                                                      symptoms  of  PTSD  and  DSO  must  correspond  to 
                 The 11th revision of the International Classification of             functional  impairment  (WHO,  2018).  Notably,  the 
                 Disease (ICD-11; World Health Organisation [WHO],                    most recent edition of the Diagnostic and Statistical 
                 2018)  included  a  new  chapter  titled  ‘Disorders                 Manual  of  Mental  Disorders  (DSM-5;  American 
                 Specifically Associated with Stress’. Within this chapter            Psychiatric  Association,  2013)  chose  not  to  include 
                 was  the  inclusion  of  Complex  Post-traumatic  Stress             C-PTSD as a new disorder within its nomenclature 
                 Disorder  (C-PTSD).  The  concept  of  C-PTSD  is                    given view that C-PTSD as a concept lacked valid and 
                 regarded as owing its origins to the seminal work of                 reliable assessments (at the time the DSM-5 was being 
                 Judith Herman (1992). Herman posited that PTSD was                   revised) and based on the strict criteria required for 
                 not sufficient in its nosology to capture the true multi-            the inclusion of any additional disorders (Friedman, 
                 faceted symptomatology expressed by individuals who                  2013; Resick et al., 2012).
                 had experienced prolonged and sustained traumatic life                  Mirroring  the  factor  analytic  research  that  has 
                 events; particularly those which had occurred in early               focused on the underlying dimensionality of PTSD in 
                 and formative years. The development of C-PTSD in                    the  DSM  (see  Armour,  Mullerova,  &  Elhai,  2016), 
                 response to prolonged and multiple traumatic events                  albeit to a much lesser extent, there has been a recent 
                 has  been  further  supported  in  recent  years  (Brewin            academic focus on identifying which factor analytic 
                 et  al.,  2017;  Cloitre  et  al.,  2019).  Hyland,  Karatzias,      model  of  C-PTSD  best  represents  the  constructs 
                 Shevlin,  Cloitre,  and  Ben-Ezra  (2020)  in  comparing             dimensionality (Brewin et al., 2017; Gilbar, Hyland, 
                 PTSD  and  C-PTSD  rates  across  studies  using  data               Cloitre, & Dekel, 2018; Hyland, Shevlin, Brewin, et al., 
                 from  several  countries,  concluded  that  CPTSD  may               2017;  Hyland  et  al.,  2016;  Kazlauskas  et  al.,  2020; 
                 occur as frequently (e.g. in US & Ireland) or indeed to              Knefel  &  Lueger-Schuster,  2013;  Mordeno,  Nalipay, 
                 a greater extent than PTSD (e.g. in the UK).                         &  Mordeno,  2019;  Nickerson  et  al.,  2016;  Shevlin 
                    C-PTSD,  as  specified  in  ICD-11,  requires  that               et al., 2018). Within the extant literature several com-
                 trauma exposed individuals first meet the diagnostic                 peting models have been specified and estimated ran-
                 criteria for PTSD (characterized in ICD-11 by three                  ging from a unidimensional model through to a model 
                 symptom groupings of Re-experiencing,  Avoidance,                    comprising 7 latent factors. The sum of models speci-
                 and  a  Heightened  Sense  of  Threat),  in  addition  to            fied  also  comprise  of  a  mixture  of  first  and  second 
                 reporting at least one symptom from the three symp-                  order models (see Kazlauskas et al., 2020; Mordeno 
                 tom  groups  of  Disturbances  in  Self-Organization                 et al., 2019).
                 (DSO – comprising symptom groupings of Affective                        Noting that the ICD-11 is utilized worldwide (and 
                 Dysregulation, Negative Self-Concept, and Difficulties               far more extensively than the DSM nomenclature) and 
                 in  Sustaining  Interpersonal  Relationships).  Both  the            is  specifically  designed  to  be  applicable  and  valid