Application of Western models of posttraumatic stress disorder in Nepal: Confirmatory factor analysis in earthquake survivors and in spinal cord injury patients

Posttraumatic stress disorder (PTSD) is often diagnosed by counting the number of symptoms experienced in specified symptom clusters, as outlined by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) of mental illness. However, PTSD measurement tools and this method of diagnosing and treating PTSD, even in non-Western countries, is based on Western concepts of the underlying factor structure. While some research has suggested that PTSD is a disorder found in Western, or “WEIRD” (White, Educated, Industrialized, Rich, and Democratic) countries and it may not translate to non-Western cultural contexts, other research has documented PTSD in a variety of non-Western countries including India, China, and the Philippines. We examined if the underlying factor structure of PTSD was evident in another non-Western context—in Nepal. We translated and back-translated the PTSD Checklist Specific Stress Version (PCL-S), adapting it for use with populations with low literacy affected by two life changing traumas. We then tested a series of theoretical models of PTSD across two different trauma samples—in survivors of the 2015 earthquake (N=392) and in people who experienced a life-changing spinal cord injury (N=163). Using confirmatory factor analysis, we found some evidence that PTSD symptoms appear to map onto Western factors, with evidence of the four-factor Dysphoria model (Re-experiencing, Avoidance, Dysphoria, and Hyperarousal symptoms) in both populations, and demonstrating scalar invariance across samples. However, exploratory factor analyses suggested a different underlying structure. Further, measurement invariance testing suggested gendered responses to PTSD items. The results demonstrate PTSD symptoms in this non-Western context somewhat fit hypothesized Western concepts of PTSD but point to a holistic approach to diagnosing PTSD in such contexts, as opposed to using clusters or PTSD cut-offs