Translation and validation of the Chinese ICD-11 International Trauma Questionnaire (ITQ) for the Assessment of Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD)

Background: Two stress-related disorders have been proposed for inclusion in the revised ICD-11: Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). The International Trauma Questionnaire (ITQ) is a bespoke measure of PTSD and CPTSD and has been widely used in English-speaking countries. Objective: The primary aim of this study was to develop a Chinese version of the ITQ and assess its content, construct, and concurrent validity. Methods: Six mental health practitioners and experts rated the Chinese translated and back-translated items to assess content validity. A sample of 423 Chinese young adults completed the ITQ, the WHO Adverse Childhood Experiences International Questionnaire, and the Hospital Anxiety and Depression Scale. Among them, 31 participants also completed the English and Chinese versions of the ITQ administered in random order at retest. Four alternative confirmatory factor analysis models were tested using data from participants who reported at least one adverse childhood experience (ACE; N = 314). Results: The Chinese ITQ received excellent ratings on relevance and appropriateness. Test-retest reliability and semantic equivalence across English and Chinese versions were acceptable. The correlated first-order six-factor model and a second-order two-factor (PTSD and DSO) both provided an acceptable model fit. The six ITQ symptoms clusters were all significantly correlated with anxiety, depression, and the number of ACEs. Conclusions: The Chinese ITQ generates scores with acceptable psychometric properties and provides evidence for including PTSD and CPTSD as separate diagnoses in ICD-11.

Hyperactivation and hypoactivation affective dysregulation symptoms are integral in complex posttraumatic stress disorder: Results from a nonclinical Israeli sample

OBJECTIVES

The current study sought to further assess the nature of the affect dysregulation (AD) cluster of the International Classification of Diseases-11 (ICD-11) proposal for complex posttraumatic stress disorder (CPTSD) in a nonclinical sample.

METHODS

An online survey sample from Israel (n = 618) completed a disorder-specific measure (International Trauma Questionnaire) of PTSD and CPTSD along with the Life Events Checklist and the World Health Organization Well-Being Index.

RESULTS

Estimated prevalence rates of PTSD and CPTSD were 9.2% and 1.0%, respectively. Confirmatory factor analysis results indicated that AD symptoms are better conceived as two correlated dimensions of hyperactivation and hypoactivation symptoms. Latent class analysis results indicated that CPTSD was clearly distinguishable from PTSD. CPTSD class membership was associated with higher levels of traumatization and poorer psychological well-being scores.

CONCLUSIONS

Findings support the discriminant validity of the ICD-11 proposals for PTSD and CPTSD in a nonclinical sample using a disorder-specific measure. The results provide further evidence that the final symptom profile for CPTSD in ICD-11 should model the AD cluster using both hyperactivation and hypoactivation symptoms.

ICD-11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire

OBJECTIVE

Support for ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing; however, few studies include refugees or examine the clinical utility of PTSD/CPTSD classifications. This study sought to provide the first evaluations of (i) the factor structure of ICD-11 PTSD/CPTSD amongst refugees in the Middle East; and (ii) the clinical utility of the International Trauma Questionnaire (ITQ) to identify PTSD/CPTSD in a humanitarian context.

METHOD

Participants were 112 treatment-seeking Syrian refugees living in Lebanon. Factorial validity was assessed using confirmatory factor analysis (CFA) based on responses to the ITQ. Clinical utility of the ITQ was assessed through semi-structured interviews with six Lebanese psychotherapists.

RESULTS

Complex PTSD (36.1%) was more common than PTSD (25.2%), and no sex or age differences were observed at the prevalence or symptomatic levels. CFA results supported a two-factor higher-order model consistent with ICD-11 PTSD/CPTSD. Qualitative findings indicated that the ITQ is generally positively regarded, with some limitations and suggested modifications noted.

CONCLUSION

This is the first study to support the ICD-11 PTSD/CPTSD amongst refugees in the Middle East and the clinical utility of the ITQ in a humanitarian context. Findings support the growing evidence for the cross-cultural applicability of ICD-11 PTSD/CPTSD.

The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD

OBJECTIVE

The purpose of this study was to finalize the development of the International Trauma Questionnaire (ITQ), a self-report diagnostic measure of post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD), as defined in the 11th version of the International Classification of Diseases (ICD-11).

METHOD

The optimal symptom indicators of PTSD and CPTSD were identified by applying item response theory (IRT) analysis to data from a trauma-exposed community sample (n = 1051) and a trauma-exposed clinical sample (n = 247) from the United Kingdom. The validity of the optimized 12-item ITQ was assessed with confirmatory factor analyses. Diagnostic rates were estimated and compared to previous validation studies.

RESULTS

The latent structure of the 12-item, optimized ITQ was consistent with prior findings, and diagnostic rates of PTSD and CPTSD were in line with previous estimates.

CONCLUSION

The ITQ is a brief, simply worded measure of the core features of PTSD and CPTSD. It is consistent with the organizing principles of the ICD-11 to maximize clinical utility and international applicability through a focus on a limited but central set of symptoms. The measure is freely available and can be found in the body of this paper.

Co-occurring internalizing and externalizing psychopathology in childhood and adolescence: a network approach

The network approach suggests that psychopathology arises from complex associations between symptoms and may offer insight into the mechanisms that underpin psychiatric comorbidities. The transition from childhood to adolescence is a key period in the development of psychopathology, yet has rarely been considered from a network perspective. As such, the present study examined the network structure of internalizing and externalizing psychopathology from middle childhood through adolescence using data from the Avon Longitudinal Study of Parents and Children (ALSPAC; n = 4405). Eight DSM-IV disorders were assessed using maternal reports when children were aged 7.5, 10.5 and 14 years. Weighted, undirected networks were estimated and the relative importance of each node was assessed using three common measures of node centrality; strength, betweenness, and closeness. A consistent network structure emerged at all three time points; nodes clustered together in two regions of space broadly reflecting the internalizing and externalizing spectra. Permutation tests supported structural invariance across this developmental period. These spectra were bridged by numerous disorder-level interactions, the most consistent of which was between depression and oppositional defiant disorder (ODD). Furthermore, inspection of the centrality indices indicated that generalised anxiety disorder and ODD were the most central disorders in the networks. These findings demonstrate that symptom/disorder-level interplay and reciprocal influence are plausible mechanisms for the association between internalizing and externalizing psychopathology in childhood/adolescence.

The complexity of trauma exposure and response: Profiling PTSD and CPTSD among a refugee sample

OBJECTIVE

This study investigated the latent dimensional and categorical structure of ICD-11 complex posttraumatic stress disorder (CPTSD) within a refugee sample.

METHOD

A subsample that identified as refugee (n = 308) was selected from the National Epidemiological Survey on Alcohol and Related Conditions. Factor mixture modeling (FMM) was employed to establish the dimensional structure of CPTSD symptomology and the categorical distribution of these dimensions. It was then evaluated whether trauma history could differentiate between the distribution of trauma response profiles.

RESULTS

A correlated 6-factor model with 5 latent classes was the best fitting model. Two classes were characterized by symptom profiles that were consistent with ICD-11 CPTSD and PTSD formulations. The remaining classes were characterized by nonspecific variation across dimensions. CPTSD class membership was predicted by traumas that were predominantly interpersonal in nature (serious neglect, physical assault, and sexual assault), whereas PTSD class membership was predicted by situational traumatic experiences (unarmed civilian in a conflict environment and a serious accident). A distinct dose-response effect was evident between cumulative traumatic exposure and CPTSD class membership.

CONCLUSION

FMM class profiles distinguished between PTSD and CPTSD symptom formulations. Moreover, class membership was determined by specific trauma-exposure histories. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Distress and worry as mediators in the relationship between psychosocial risks and upper body musculoskeletal complaints in highly automated manufacturing

As a result of changes in manufacturing including an upward trend in automation and the advent of the fourth industrial revolution, the requirement for supervisory monitoring and consequently, cognitive demand has increased in automated manufacturing. The incidence of musculoskeletal disorders has also increased in the manufacturing sector. A model was developed based on survey data to test if distress and worry mediate the relationship between psychosocial factors (job control, cognitive demand, social isolation and skill discretion), stress states and symptoms of upper body musculoskeletal disorders in highly automated manufacturing companies (n = 235). These constructs facilitated the development of a statistically significant model (RMSEA 0.057, TLI 0.924, CFI 0.935). Cognitive demand was shown to be related to higher distress in employees, and distress to a higher incidence of self-reported shoulder and lower back symptoms. The mediation model incorporating stress states (distress, worry) as mediators is a novel approach in linking psychosocial risks to musculoskeletal disorders. Practitioners' Summary With little requirement for physical work in many modern automated manufacturing workplaces, there is often minimal management focus on Work-Related Musculoskeletal Disorders (WRMSDs) as important occupational health problems. Our model provides evidence that psychosocial factors are important risk factors in symptoms of WRMSD and should be managed.

From child maltreatment to ICD-11 complex post-traumatic stress symptoms: The role of emotion regulation and re-victimisation

OBJECTIVE

Complex post-traumatic stress disorder (CPTSD) will be introduced in ICD-11 and comprises symptoms of PTSD and disturbances in self-organisation (DSO). The association of trauma with PTSD and DSO is not yet fully understood. We investigated the path from child maltreatment to PTSD and DSO and examined the mediating role of emotion regulation (ER) and adult interpersonal re-victimisation.

METHOD

Adult patients (N = 193) from a Scottish National Health Service clinic participated in the project. Participants completed measures of life events, ICD-11 PTSD and CPTSD, and ER. Path analysis was used to assess possible direct and indirect effects from childhood trauma on current post-traumatic psychopathology.

RESULTS

Overall results indicate that the path from child maltreatment to PTSD is a direct one, while the path to DSO is indirectly mediated by ER.

CONCLUSIONS

Future research should address the potentially beneficial effect of treatment protocols for CPTSD explicitly aiming at reducing ER difficulties.

Prevalence and predictors of antidepressant prescribing in Northern Ireland

BackgroundAntidepressant prescription rates in the United Kingdom (UK) are among the highest in Western Europe and prescription rates in Northern Ireland (NI) are significantly higher than the rest of the UK. Moreover, while prescription rates are climbing annually, rates of depression are not changing, and evidence suggests that a range of socio-economic and geographical factors may be responsible. ObjectivesThe primary aim was to calculate the rates of antidepressant prescribing for the Northern Ireland population for years 2011 to 2015 and identify significant socio-demographic predictors. Methods (including data)This Administrative Research Centre (Northern Ireland) study linked data from the 2011 census and prescribing records (Enhanced Prescribing Database). The British National Formulary codes was used to identify the four main antidepressant drug types. FindingsResults indicated high levels of antidepressant prescribing for years 2011 to 2015 and significant associations were found with demographic, health, and economic variables. ConclusionsNorthern Ireland has high levels of antidepressant prescribing compared to other parts of the UK and other European countries. This suggests that there is a need to extend the provision of social prescribing, where people can avail of local, non-clinical options to alleviate mental health problems.

Learning Disability and Northern Ireland: Achieving Proportionate Universalism through Administrative Data Research

BackgroundThe Department of Health, Social Services & Public Safety’s policy document ‘Fit and Well – Changing Lives (2012-2022)’ indicates that people with a learning disability (LD) represent one of the most vulnerable and disadvantaged groups in Northern Ireland (NI). Individuals with a LD are more likely to experience major illnesses, to develop them earlier, and die of them sooner, than the general population. Furthermore, the LD population is less likely to get some of the evidence-based annual health checks and treatments they need, and continue to face real barriers in accessing services. At present there is no central register detailing the actual number of individuals with LD in NI. Study aimsThe study is based on research funded by the ESRC SDAI (ES/P002293/1). It involves the analysis of Northern Ireland Mortality Study (NIMS) data to: Establish the socio-demographic characteristics of the LD population; Profile morbidity and comorbidity of health care problems among individuals with LD; and Explore the causes of death among the NI LD community. Results and ConclusionsPreliminary study findings will be available by June 2018. Findings will be of particular interest to a range of government departments, trusts and learning disability support groups.

Childhood Adversity and Traumatic Disorders: A self-report and Danish linkage study

BackgroundAccurate assessment of childhood adversity is fundamental in understanding risk and resilient factors that can inform appropriate intervention and prevention strategies. Different statistical and methodological approaches (e.g., prospective, selfreported data) have been used to assess pathways and outcomes associated with childhood adversity, however, each is limited in a number of ways. ObjectivesLinking administrative data to population-based studies provides a powerful tool to overcome some of the challenges in trauma research and permits the estimation of temporally ordered models of risk. The current study seeks to assess the effect of childhood adversity on a diagnosis of traumatic disorder (TD). MethodsData were collected from a Danish national study in 2008/2009. A sample of 4,718 young adults were randomly selected from the birth cohort of children born in 1984. Structured interviews were conducted on 2,980 participants. This data was then linked with parental data (including 4 years prior to birth of child) and a ICD 10 diagnosis of a TD using information from the Danish registries. FindingsHierarchical regression analysis was used to examine parental risk factors, self-reported child maltreatment, experiencing violence in young adulthood and risk of a TD diagnosis at age 28. Findings indicated the dominant factor associated with TD was self-reported PTSD symptoms at age 24 (OR =3.82); followed by a parental mental health diagnosis (OR = 2.80). Being of female gender (OR = 2.42) and experiencing violence in young adulthood (OR = 1.94) also increased risk of a TD diagnosis. ConclusionThis study highlights the benefits of incorporating administrative data with self-report data to provide a more nuanced understanding of childhood adversity across different developmental stages. These findings have important conceptual and methodological implications and may be useful in informing future trauma studies.

Distress, Impairment and the Extended Psychosis Phenotype: A Network Analysis of Psychotic Experiences in an US General Population Sample

It has been proposed that subclinical psychotic experiences (PEs) may causally impact on each other over time and engage with one another in patterns of mutual reinforcement and feedback. This subclinical network of experiences in turn may facilitate the onset of psychotic disorder. PEs, however, are not inherently distressing, nor do they inevitably lead to impairment. The question arises therefore, whether nondistressing PEs, distressing PEs, or both, meaningfully inform an extended psychosis phenotype. The current study first aimed to exploit valuable ordinal data that captured the absence, occurrence and associated impairment of PEs in the general population to construct a general population based severity network of PEs. The study then aimed to partition the available ordinal data into 2 sets of binary data to test whether an occurrence network comprised of PE data denoting absence (coded 0) and occurrence/impairment (coded 1) was comparable to an impairment network comprised of binary PE data denoting absence/occurrence (coded 0) and impairment (coded 1). Networks were constructed using state-of-the-art regularized pairwise Markov Random Fields (PMRF). The severity network revealed strong interconnectivity between PEs and nodes denoting paranoia were among the most central in the network. The binary PMRF impairment network structure was similar to the occurrence network, however, the impairment network was characterized by significantly stronger PE interconnectivity. The findings may help researchers and clinicians to consider and determine how, when, and why an individual might transition from experiences that are nondistressing to experiences that are more commonly characteristic of psychosis symptomology in clinical settings.

Sex differences in PTSD symptoms: A differential item functioning approach

OBJECTIVE

Evidence has suggested there are sex differences in posttraumatic stress disorder (PTSD) symptom expression; however, few studies have assessed whether these differences are due to measurement invariance. This study aimed to examine sex differences in PTSD symptoms based on the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) using differential item functioning (DIF).

METHOD

Confirmatory factor analysis was conducted on the DSM-5 model of PTSD, followed by a multiple indicators multiple causes (MIMIC) model to examine possible DIF using the PTSD Checklist for DSM-5. Data were analyzed from a Malaysian adolescent sample (n = 481) of which 61.7% were female, with a mean age of 17.03 years.

RESULTS

The results indicated the presence of DIF for 2 of 20 PTSD criteria. Females scored significantly higher on emotional cue reactivity (B4), and males reported significantly higher rates of reckless or self-destructive behavior (E2) while statistically controlling for the latent variables in the model. However, the magnitude of these item-level differences was small.

CONCLUSION

These findings indicate that despite the presence of DIF for 2 DSM-5 symptoms, this does not provide firm support for nonequivalence across sex. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Correlates of a general psychopathology factor in a clinical sample of childhood sexual abuse survivors

BACKGROUND

Childhood sexual abuse (CSA) increases risk for most psychiatric disorders. There is evidence that the structure of psychopathology can be explained by a number of latent dimensions of psychopathology including a 'General Psychopathology' (P) factor. The objective of the current study was to provide the first assessment as to whether P is identifiable, and what its correlates might be in a clinical sample.

METHODS

An adult, clinical sample of Danish CSA survivors (N = 420) was assessed using the Millon Clinical Multiaxial Inventory-III. Confirmatory factory analysis (CFA) was used to assess the latent structure of nine psychiatric disorders, and structural equation modelling (SEM) was used to determine correlates of the best-fitting dimensional model.

RESULTS

CFA results favoured a bifactor model including three specific dimensions of psychopathology, "Internalizing", "Externalizing", and "Thought Disorder", and a bi-factor "P". A SEM model that included ten predictors was a good fit to the data and explained 55% of variance in 'P'. The 'P' factor was significantly associated with emotional coping, negative self-worth, traumatic life events, and anxious attachments.

LIMITATIONS

Psychiatric disorders were assessed using self-report measures, and the sample was predominately female.

CONCLUSIONS

Results provide initial evidence of P in a clinical sample and several unique correlates of this factor were identified.

Alternative models of DSM-5 PTSD: Examining diagnostic implications

The factor structure of DSM-5 posttraumatic stress disorder (PTSD) has been extensively debated with evidence supporting the recently proposed seven-factor Hybrid model. However, despite myriad studies examining PTSD symptom structure few have assessed the diagnostic implications of these proposed models. This study aimed to generate PTSD prevalence estimates derived from the 7 alternative factor models and assess whether pre-established risk factors associated with PTSD (e.g., transportation accidents and sexual victimisation) produce consistent risk estimates. Seven alternative models were estimated within a confirmatory factor analytic framework using the PTSD Checklist for DSM-5 (PCL-5). Data were analysed from a Malaysian adolescent community sample (n = 481) of which 61.7% were female, with a mean age of 17.03 years. The results indicated that all models provided satisfactory model fit with statistical superiority for the Externalising Behaviours and seven-factor Hybrid models. The PTSD prevalence estimates varied substantially ranging from 21.8% for the DSM-5 model to 10.0% for the Hybrid model. Estimates of risk associated with PTSD were inconsistent across the alternative models, with substantial variation emerging for sexual victimisation. These findings have important implications for research and practice and highlight that more research attention is needed to examine the diagnostic implications emerging from the alternative models of PTSD.

Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in DSM-5 and ICD-11: Clinical and Behavioral Correlates

The American Psychiatric Association and the World Health Organization provide distinct trauma-based diagnoses in the fifth edition of the Diagnostic and Statistical Manual (DSM-5), and the forthcoming 11th version of the International Classification of Diseases (ICD-11), respectively. The DSM-5 conceptualizes posttraumatic stress disorder (PTSD) as a single, broad diagnosis, whereas the ICD-11 proposes two "sibling" disorders: PTSD and complex PTSD (CPTSD). The objectives of the current study were to: (a) compare prevalence rates of PTSD/CPTSD based on each diagnostic system; (b) identify clinical and behavioral variables that distinguish ICD-11 CPTSD and PTSD diagnoses; and (c) examine the diagnostic associations for ICD-11 CPTSD and DSM-5 PTSD. Participants in a predominately female clinical sample (N = 106) completed self-report scales to measure ICD-11 PTSD and CPTSD, DSM-5 PTSD, and depression, anxiety, borderline personality disorder, dissociation, destructive behaviors, and suicidal ideation and self-harm. Significantly more people were diagnosed with PTSD according to the DSM-5 criteria (90.4%) compared to those diagnosed with PTSD and CPTSD according to the ICD-11 guidelines (79.8%). An ICD-11 CPTSD diagnosis was distinguished from an ICD-11 PTSD diagnosis by higher levels of dissociation (d = 1.01), depression (d = 0.63), and borderline personality disorder (d = 0.55). Diagnostic associations with depression, anxiety, and suicidal ideation and self-harm were higher for ICD-11 CPTSD compared to DSM-5 PTSD (by 10.7%, 4.0%, and 7.0%, respectively). These results have implications for differential diagnosis and for the development of targeted treatments for CPTSD.

Posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as per ICD-11 proposals: A population study in Israel

BACKGROUND

The current study sought to advance the existing literature by providing the first assessment of the factorial and discriminant validity of the ICD-11 proposals for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in a nationwide level.

METHODS

A nationally representative sample from Israel (n = 1,003) using a disorder-specific measure (ITQ; International Trauma Questionnaire) in order to assess PTSD and CPTSD along with the Life Events Checklist and the World Health Organization Well-Being Index.

RESULTS

Estimated prevalence rates of PTSD and CPTSD were 9.0 and 2.6%, respectively. The structural analyses indicated that PTSD and disturbances in self-organization symptom clusters were multidimensional, but not necessarily hierarchical, in nature and there were distinct classes that were consistent with PTSD and CPTSD.

CONCLUSIONS

These results partially support the factorial validity and strongly support the discriminant validity of the ICD-11 proposals for PTSD and CPTSD in a nationally representative sample using a disorder-specific measure; findings also supported the international applicability of these diagnoses. Further research is required to determine the prevalence rates of PTSD and CPTSD in national representative samples across different countries and explore the predictive utility of different types of traumatic life events on PTSD and CPTSD.

A comparison of DSM-5 and ICD-11 PTSD prevalence, comorbidity and disability: an analysis of the Ukrainian Internally Displaced Person's Mental Health Survey

OBJECTIVE

Recently, the American Psychiatric Association (DSM-5) and the World Health Organization (ICD-11) have both revised their formulation of post-traumatic stress disorder (PTSD). The primary aim of this study was to compare DSM-5 and ICD-11 PTSD prevalence and comorbidity rates, as well as the level of disability associated with each diagnosis.

METHOD

This study was based on a representative sample of adult Ukrainian internally displaced persons (IDPs: N = 2203). Post-traumatic stress disorder prevalence was assessed using the PTSD Checklist for DSM-5 and the International Trauma Questionnaire (ICD-11). Anxiety and depression were measured using the Generalized Anxiety Disorder Scale and the Patient Health Questionnaire-Depression. Disability was measured using the WHO Disability Assessment Schedule 2.0.

RESULTS

The prevalence of DSM-5 PTSD (27.4%) was significantly higher than ICD-11 PTSD (21.0%), and PTSD rates for females were significantly higher using both criteria. ICD-11 PTSD was associated with significantly higher levels of disability and comorbidity.

CONCLUSION

The ICD-11 diagnosis of PTSD appears to be particularly well suited to identifying those with clinically relevant levels of disability.

Training the next generation of psychotraumatologists: COllaborative Network for Training and EXcellence in psychoTraumatology (CONTEXT)

In this paper we present a description of the Horizon2020, Marie Skłodowska-Curie Action funded, research and training programme CONTEXT: COllaborative Network for Training and EXcellence in psychoTraumatology. The three objectives of the programme are put forward, each of which refers to a key component of the CONTEXT programme. First, we summarize the 12 individual research projects that will take place across three priority populations: (i) refugees and asylum seekers, (ii) first responders, and (iii) perpetrators and survivors of childhood and gender-based violence. Second, we detail the mentoring and training programme central to CONTEXT. Finally, we describe how the research, together with the training, will contribute towards better policy, guidelines, and practice within the field of psychotraumatology.