Complex Posttraumatic Stress Disorder Symptom Profiles in Traumatized Refugees

(Complex) PTSD in Ukrainian refugees: Prevalence and association with acts of war in the Danish refugee cohort (DARECO)

BACKGROUND

The Russian invasion of Ukraine has driven millions of Ukrainians away from their homes. Among these, the majority have likely experienced war-related potentially traumatic events, and some will experience symptoms of posttraumatic stress disorder (PTSD). The aims of the study are to estimate the prevalence of PTSD and Complex PTSD (CPTSD) in displaced Ukrainians and examine associations between war- and other potentially traumatic exposures and (C)PTSD.

METHODS

Questionnaires were distributed to all registered adult Ukrainians (18+) who arrived in Denmark between February 24th 2022 and February 15th 2023 (N = 18,389). We estimate the prevalence of war exposures, other potentially traumatic exposures, and (C)PTSD. In logistic regression analyses, we test if exposure to war and other potentially traumatic events are associated with PTSD and CPTSD.

RESULTS

The final sample size was 6993 (38.0 %). Responders were more likely to be female and younger than non-responders. Prevalence of PTSD and CPTSD was 15.9 % and 13.5 %, respectively. Female gender, high education, and loss of a relative due to the war were associated with (C)PTSD. Direct and indirect exposure to war and combat was related to PTSD but not CPTSD, while exposure to war prior to the 2022 invasion was related to CPTSD but not PTSD.

LIMITATIONS

The study is cross-sectional and based on self-report.

CONCLUSION

Close to one third of the sample fulfill the criteria of PTSD or CPTSD. War exposures are differentially related to PTSD and CPTSD. The findings illustrate that trauma-related psychopathology is a pertinent problem in displaced Ukrainians.

The impact of age-related differences in emotion dysregulation on refugee mental health and social outcomes

The refugee experience is typically characterized by exposure to numerous premigration traumatic events and postmigration stress in the resettlement environment. Refugees' experiences can lead to elevated rates of psychopathology, including posttraumatic stress disorder (PTSD) and depression. Emotion regulation is a key mechanism contributing to mental health outcomes among refugees. This study examined the impact of age on the association between emotion regulation and critical social outcomes relevant to refugee resettlement, such as social engagement and functional impairment. Participants were 1,081 Arabic-, Farsi-, Tamil- and English-speaking adult refugees. Premigration trauma exposure, postmigration stressors, PTSD symptoms, depressive symptoms, emotion regulation, social engagement, and functional impairment were measured. A series of hierarchical regression and Poisson regression analyses revealed emotion dysregulation as a significant predictor of functional impairment, β = .36, p < .001, and social engagement, Exp B = 0.99, p = .002. A significant interaction between age and emotion dysregulation was associated with both PTSD, β = .05, p = .048 and depressive symptoms, β = .06, p = .010, suggesting a stronger positive association between emotion dysregulation and both PTSD and depressive symptom severity for older individuals. Postmigration stressor exposure, emotion dysregulation, and older age are important factors that may negatively impact social engagement and functional impairment in the resettlement environment. Additionally, higher levels of trauma exposure may negatively impact social engagement. These findings have implications for public health and social services in the context of resettled refugee communities.

Examining the clinical validity of the global psychotrauma screen in refugees

Introduction

The Global Psychotrauma Screen (GPS) is a brief transdiagnostic screener that covers a broad range of trauma-related disorders as well as risk factors known to influence the course of symptoms.

Methods

We analyzed data from African war refugees in Australia (n = 70), including the GPS, the Structured Clinical Interview for DSM-5 Disorders (SCID-5), the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and the Brief Resilience Scale (BRS).

Results

Using the Youden's J Index to examine the clinical validity of the GPS subscales measuring PTSD, dissociation, depression, and generalized anxiety disorder (GAD), we found that a PTSD subscale score of 3 or higher, and a depression and dissociation subscale score of 1 or higher, was optimally efficient for detecting a probable diagnosis (Youden's J = 0.76, J = 0.72, and J = 0.90, respectively) with high sensitivity and specificity. We were unable to test the GPS clinical validity for GAD due to the low GAD occurrence. The GPS resilience item was not related to the total score (r = 0.02), indicating low convergent validity for resilience. Risk factors, including current stressors and childhood trauma history, were related to more severe GPS symptom scores, while lack of resilience, social support, and history of mental illness were not.

Conclusion

We conclude that the GPS may be a useful screening tool for PTSD, depression, and the dissociative subtype in refugees.

Multiple trauma exposure and psychopathology in Syrian refugees living in Turkey: A latent class analysis

BACKGROUND

After the Syrian civil war, millions of Syrian refugees migrated to neighboring countries, with the majority settling in Turkey. The prevalence of mental disorders is notably higher among refugee populations. However, prior research on Syrian refugees have mostly used variable-centred approaches which have known limitations. Thus, the present study sought to examine the occurrence and co-occurrence of traumatic experiences among Syrian refugees living in Turkey using latent class analysis (LCA). Additionally, this study aimed to identify the associations between latent class membership and trauma-related psychopathology.

METHODS

Participants included 593 Syrian refugees living in Turkey. LCA was used to identify latent classes of trauma exposure. Demographic predictors of the latent classes were examined and associations with PTSD, CPTSD, depression and anxiety were also explored.

RESULTS

Three latent classes were identified based on trauma exposure; a "multiple traumas" class, "war and human suffering" class, and "low exposure, combat-exposed" class. Odds of PTSD, CPTSD, depression, or anxiety diagnosis did not differ significantly between classes, with the exception of the "multiple traumas" class who were more likely to meet the criteria for anxiety diagnosis compared to the "low exposure" class.

LIMITATIONS

Historic psychiatric symptoms or post-migration stressors could not be accounted for in this study, which may explain the lack of significant differences in most mental health outcomes by trauma exposure class.

DISCUSSION

The latent classes identified in this study correspond with previous research regarding trauma in Syrian refugees. However, this study largely failed to find significant differences in mental health diagnoses between classes. Future research should consider the effect of post-migration stressors in refugee populations, which may play a crucial role in mental health outcomes.

Prevalence, comorbidities, and factors associated with prolonged grief disorder, posttraumatic stress disorder and complex posttraumatic stress disorder in refugees: a systematic review

BACKGROUND

The number of refugees worldwide is at an all-time high with many being exposed to potentially traumatic events and the loss of loved ones. The 11th revision of the International Statistical Classification of Diseases and Related Health Problems now includes prolonged grief disorder and complex posttraumatic stress disorder and revised criteria for posttraumatic stress disorder. An overview of these stress-related disorders among people who have become refugees is therefore needed. Consequently, we conducted a systematic review to determine prevalence rates, comorbidities, and associated factors for each of the disorders.

METHOD

We systematically searched PubMed, Web of Science, and PsycArticles to identify studies that reported prevalence rates, predictors or associated factors, and/or comorbid mental disorders for either (1) prolonged grief disorder, (2) posttraumatic stress disorder, or (3) complex posttraumatic stress disorder among refugees. The selection process followed the PRISMA guidelines.

RESULTS

A total of 36 studies met the inclusion criteria. Most of the studies were of high quality. There was substantial variation in prevalence rates by disorder, with prolonged grief ranging from 6 to 54%, posttraumatic stress disorder ranging from 0.4 to 80%, and complex posttraumatic stress disorder ranging from 3 to 74.6%. Pooled prevalence for posttraumatic stress disorder was estimated at 29.8% in treatment seeking samples and 9.92% in population samples. For complex posttraumatic stress disorder, it was estimated at 57.4% in treatment seeking samples and 7.8% in population samples. Posttraumatic stress disorder was among the most frequent comorbidities for prolonged grief disorder while depressive symptoms were the most frequently occurring co-morbidity across all three disorders. Sociodemographic variables, trauma exposure, and loss characteristics were associated with higher symptom severity. Postmigration living difficulties played an important role in prolonged grief and complex posttraumatic stress disorder.

CONCLUSION

The review revealed substantial differences in prevalence rates between the three studied disorders but underscored a very high prevalence of ICD-11 stress-related disorders among refugees. The identified associated factors point to subgroups that may be particularly at risk and establishes a foundational basis for targeted interventions and potential policy changes. Future research should incorporate longitudinal investigations and emphasize culturally sensitive assessments.

Psychotic and Somatic Symptoms Are Frequent in Refugees With Posttraumatic Stress Disorder: A Narrative Review

OBJECTIVE

In 2021, 89.3 million refugees were vulnerable to posttraumatic stress disorder (PTSD) after exposure to multiple and repeated traumatic experiences. The recent war in Ukraine provoked 7 million refugees to flee their homes. Specific clinical presentations of PTSD in refugee populations may not be familiar to most physicians. The goal of this review is to describe the diagnosis and specific clinical features of PTSD in refugees.

METHODS

This narrative review of 263 articles explores 3 PTSD diagnoses that are frequently described in refugee populations and that have been observed in our clinical practices: complex PTSD, PTSD with psychotic symptoms, and PTSD with somatic symptoms.

RESULTS

While complex PTSD does not seem to be related to individuals' culture and origin, the other 2 diagnoses have been specifically described in refugee populations. PTSD with somatic manifestations appears to be the most frequently described and commonly acknowledged form in refugee populations, whereas PTSD with psychotic symptoms remains more controversial due to its clinical variability and association with comorbid disorders.

CONCLUSIONS

The difficulty of identifying PTSD with psychotic symptoms and PTSD with somatic symptoms in refugee populations may lead to misdiagnosis and explain the moderate effectiveness of care delivered to these populations. Appropriate diagnosis is essential to provide optimal psychiatric care to refugee populations.

The Impact of Complex PTSD on Suicide Risk in Patients with Bipolar Disorder: A Cross-Sectional Study

BACKGROUND

Patients with bipolar disorder (BD) are more likely than the general population to experience traumatic events, particularly during childhood, and these may predict and be a risk factor for the development of complex PTSD (cPTSD). The presence of multiple traumas plays a relevant role from a psychopathological point of view, but little is known about the effect this may have on suicide attempts in patients with BD.

METHODS

A cross-sectional study was conducted comparing socio-demographic and clinical characteristics, recruiting 344 patients diagnosed with BD I and II, screened for the presence (or absence) of cPTSD using the International Trauma Questionnaire (ITQ). Suicide attempts were assessed directly during the clinical interview and from the patient's medical record.

RESULTS

The results emerging from the study indicate that cPTSD can be considered a risk factor for suicide attempts in patients with BD. Furthermore, evidence is provided to support the idea that cPTSD is highly prevalent in patients with BD and is related to a higher psychopathological burden.

CONCLUSIONS

The results recommend an urgent and comprehensive assessment of suicidal risk in patients with comorbidity of both bipolar disorder and cPTSD. There is a crucial demand for early intervention initiatives and proactive prevention strategies to address the intricate intersection of these mental health challenges.

Translation and validation of the Dari International Trauma Questionnaire (ITQ) in Afghan asylum seekers and refugees

Background: The International Trauma Questionnaire (ITQ) is a standardized and validated measure aligned with the 11th version of the International Classification of Diseases (ICD-11) diagnostic criteria to assess post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD). It has been translated into 25 different languages, but is yet to be translated into Dari and validated for use in the Afghan population.Objective: This study aimed (1) to translate and culturally adapt the ITQ for use in Dari; (2) to assess the construct validity and composite reliability of ICD-11 PTSD and CPTSD using the Dari ITQ; and (3) to examine the concurrent, convergent, and discriminant validity of the Dari ITQ.Method: The Dari ITQ was validated through the completion of a set of standardized measures by 305 Afghan asylum seekers and refugees in Austria. Factorial analyses and psychometric properties of the Dari ITQ were assessed using confirmatory factor analysis (CFA), bivariate correlations, and multivariate regression.Results: Asylum seekers showed significantly higher levels of ICD-11 CPTSD symptomatology and probable diagnoses of ICD-11 PTSD, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) PTSD, anxiety, depression, and psychological distress in comparison to refugees. CFA results supported the two-factor second-order model comprised of the PTSD and disturbances in self-organization (DSO) as the best fit to the data. The psychometric adequacy of this model in the Dari ITQ was evidenced by high factor loadings and excellent internal reliability. The Dari ITQ showed satisfactory concurrent, convergent, and discriminant validity.Conclusion: The current study supports the statistical validity and cultural sensitivity of the Dari ITQ in identifying symptoms of ICD-11 PTSD and CPTSD among Afghan asylum seekers and refugees.

Patterns of posttraumatic stress symptoms, their predictors, and comorbid mental health symptoms in traumatized Arabic-speaking people: A latent class analysis

Many people from the Middle East and North Africa (MENA) have experienced traumatic events due to human rights abuses, violence, and conflict in the region, with potential psychological consequences including symptoms of posttraumatic stress and comorbid mental health problems. Yet, little is known about how different posttraumatic stress symptoms unfold in Arabic-speaking people who have experienced diverse traumatic events. This study examined latent classes based on posttraumatic stress symptoms, differences across classes concerning comorbid mental health symptoms and quality of life, and several predictors, including sociodemographic characteristics, social support, and trauma-related characteristics. Participants were 5,140 traumatized Arabic-speaking individuals who had registered for an online intervention. Latent class analysis was conducted to identify distinct classes based on DSM-5 posttraumatic stress symptoms. Multinomial logistic regression was used to analyze predictors of class membership. Differences between classes in severity of posttraumatic stress, depressive, anxiety, and somatoform symptoms, as well as quality of life were examined. Five different latent classes were identified: a general high posttraumatic stress symptom class (43.8%), a high posttraumatic stress symptom-low avoidance class (12.8%), a mixed posttraumatic stress symptom class (20.9%), a high dysphoric-low reexperiencing/avoidance class (14%), and a general low posttraumatic stress symptom class (8.4%). The classes differed in severity of posttraumatic stress, depressive, anxiety and somatoform symptoms, and quality of life. Consistent significant predictors of class membership were gender, social support, cumulative trauma exposure, sexual violence and direct exposure during the most distressing trauma, as well as time since the most distressing trauma. Distinct symptom classes with quantitative and qualitative differences can emerge following exposure to trauma among help-seeking Arabic-speaking people from the MENA region, with gender, social support, and trauma-related characteristics predicting symptom presentation. The results have implications for identifying distressed people and enhancing interventions based on an individual's symptom presentation.

The prevalence, latent structure and psychosocial and cognitive correlates of complex post-traumatic stress disorder in an adolescent community sample

Complex PTSD has received growing attention in recent years. However, the validity, prevalence and risk factors of this diagnosis remain unclear. This study examined PTSD presentations in adolescents using diagnostic criteria and latent class analysis (LCA). It then explored the role of demographics factors, trauma history factors, psychopathology factors and cognitive factors in predicting different PTSD presentations. A cross-sectional data comprising self-report measures of 342 community adolescents (12-15 years) were collected and analysed. 2.3 %, 5.6 % and 10 % of adolescents met the criteria for PTSD, CPTSD and disturbances in self-organisation (DSO) respectively. A three-class model (healthy class, CPTSD class and DSO class) were generated from LCA. Adolescents with CPTSD were most likely to be female and endorsed the most overall trauma types, interpersonal trauma types, depression, anxiety and maladaptive cognitive processes, followed by adolescents with DSO and subsequently healthy adolescents. CPTSD appeared to be a more common presentation than PTSD among community adolescents. The relatively high prevalence of DSO is noteworthy and suggests that DSO is not necessarily accompanied by PTSD. Given the strong associations between CPTSD and cognitive processes implicated in PTSD, CPTSD as a construct might be conceptually similar to PTSD.

Neurofeedback for post-traumatic stress disorder: systematic review and meta-analysis of clinical and neurophysiological outcomes

Background: Posttraumatic stress disorder (PTSD) is a debilitating condition affecting millions of people worldwide. Existing treatments often fail to address the complexity of its symptoms and functional impairments resulting from severe and prolonged trauma. Electroencephalographic Neurofeedback (NFB) has emerged as a promising treatment that aims to reduce the symptoms of PTSD by modulating brain activity.Objective: We conducted a systematic review and meta-analysis of ten clinical trials to answer the question: how effective is NFB in addressing PTSD and other associated symptoms across different trauma populations, and are these improvements related to neurophysiological changes?Method: The review followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. We considered all published and unpublished randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) involving adults with PTSD as a primary diagnosis without exclusion by type of trauma, co-morbid diagnosis, locality, or sex. Ten controlled studies were included; seven RCTs and three NRSIs with a total number of participants n = 293 (128 male). Only RCTs were included in the meta-analysis (215 participants; 88 male).Results: All included studies showed an advantage of NFB over control conditions in reducing symptoms of PTSD, with indications of improvement in symptoms of anxiety and depression and related neurophysiological changes. Meta-analysis of the pooled data shows a significant reduction in PTSD symptoms post-treatment SMD of -1.76 (95% CI -2.69, -0.83), and the mean remission rate was higher in the NFB group (79.3%) compared to the control group (24.4%). However, the studies reviewed were mostly small, with heterogeneous populations and varied quality.Conclusions: The effect of NFB on the symptoms of PTSD was moderate and mechanistic evidence suggested that NFB leads to therapeutic changes in brain functioning. Future research should focus on more rigorous methodological designs, expanded sample size and longer follow-up.

Complex post-traumatic stress disorder: a much needed diagnosis

This commentary conveys appreciation for a recent review of the rates of complex post-traumatic stress disorder (CPTSD) among refugees, describes the relevance of CPTSD to the refugee experience and discusses implications for assessment and treatment, the effective development of which requires collaboration among researchers, clinicians and individuals with lived experience.

The nosographic structure of posttraumatic stress symptoms across trauma types: An exploratory network analysis approach

The nosographic structure of posttraumatic stress disorder (PTSD) remains unclear, and attempts to determine its symptomatic organization have been unsatisfactory. Several explanations have been suggested, and the impact of trauma type is receiving increasing attention. As little is known about the differential impact trauma type in the nosographic structure of PTSD, we explored the nosology of PTSD and the effect of trauma type on its symptomatic organization. We reanalyzed five cross-sectional psychopathological networks involving different trauma types, encompassing a broad range of traumatic events in veterans, war-related trauma in veterans, sexual abuse, terrorist attacks, and various traumatic events in refugees. The weighted topological overlap was used to estimate the networks and attribute weights to their links. Coexpression differential network analysis was used to identify the common and specific network structures of the connections across different trauma types and to determine the importance of symptoms across the networks. We found a set of symptoms with more common connections with other symptoms, suggesting that these might constitute the prototypical nosographic structure of PTSD. We also found a set of symptoms that had a high number of specific connections with other symptoms; these connections varied according to trauma type. The importance of symptoms across the common and specific networks was ascertained. The present findings offer new insights into the symptomatic organization of PTSD and support previous research on the impact of trauma type on the nosology of this disorder.

Distinct trajectories of psychological distress among resettled refugees: Community acceptance predicts resilience while low ingroup social support predicts clinical distress

Refugees can experience elevated levels of psychological distress upon resettlement, although disparate outcomes over time are expected. The current study modeled trajectories of changes in distress over a 5-year period among resettled refugees and sought to explicate post-settlement factors that influence distress over time. A large-scale sample of refugees resettled in Australia (2,399) was tracked over a 5-year period, completing measures of psychological distress at each wave and initial risk and protective factors immediately after resettlement. A latent class growth analysis conducted on distress found four unique classes characterized by (1) resilient levels of distress, (2) consistent clinical distress, (3) recovering levels of distress, and (4) deteriorating distress. Lower perceived discrimination and greater positive context of reception predicted membership to the resilient group and differentiated the recovering and deteriorating groups. Further, lower ingroup social support predicted membership to the clinically distressed group relative to all others. We conclude by echoing calls to strengthen community support for refugees and promote ingroup ties, particularly among those who are the most vulnerable.

The boundaries between complex posttraumatic stress disorder symptom clusters and post-migration living difficulties in traumatised Afghan refugees: a network analysis

BACKGROUND

Psychological distress due to the ongoing war, violence, and persecution is particularly common among Afghan asylum seekers and refugees. In addition, individuals face a variety of post-migration living difficulties (PMLDs). Complex posttraumatic stress symptoms are among the most common mental health problems in this population, and were associated with the overall burden of PMLDs. The complex interplay of posttraumatic symptoms has been investigated from a network perspective in previous studies. However, individuals are embedded in and constantly react to the environment, which makes it important to include external factors in network models to better understand the etiology and maintaining factors of posttraumatic mental health problems. PMLDs are a major risk factor for posttraumatic distress and considering their impact in interventions might improve response rates. However, the interaction of these external factors with posttraumatic psychopathological distress is not yet fully understood. Thus, we aimed to illuminate the complex interaction between PMLDs and CPTSD symptom clusters.

OBJECTIVE

The main objective is the exploration of the network structure and the complex interplay of ICD-11 CPTSD symptom clusters and distinct forms of PMLDs.

METHOD

The symptom clusters of CPTSD and PMLDs were collected within a randomised controlled trial among 93 treatment-seeking Afghan asylum seekers and refugees via a fully structured face-to-face and interpreter assisted interview. Using a network analytical approach, we explored the complex associations and network centrality of the CPTSD symptom clusters and the PMLD factors: discrimination & socio-economical living conditions, language acquisition & barriers, family concerns, and residence insecurity.

RESULTS

The results suggest direct links within and between the constructs (CPTSD, PMLD). Almost all PMLD factors were interrelated and associated to CPTSD, family concerns was the only isolated variable. The CPTSD symptom cluster re-experiencing and the PMLD factor language acquisition & barriers connected the two constructs. Affective dysregulation had the highest and avoidance the lowest centrality.

CONCLUSIONS

Re-experiencing and affective dysregulation have the strongest ties to PMLDs. Thus, these domains might explain the strong association of posttraumatic psychopathology with PLMDs and, consequently, prioritization of these domains in treatment approaches might both facilitate treatment response and reduce burden caused by PMLDs.

Exploring complex-PTSD comorbidity in trauma-exposed Northern Ireland veterans

Background

Complex posttraumatic stress disorder (CPTSD) describes the results of complex, prolonged, and/or inescapable trauma, and is typified by avoidance, re-experiencing, sense of threat, affect dysregulation, negative self-concept, and interpersonal disturbances. Additionally, CPTSD is highly comorbid with other common psychopathologies.

Objectives

A study was conducted in a trauma-exposed UK Armed Forces Veteran population resident in Northern Ireland (N = 638, NI) to determine the prevalence of CPTSD and comorbid associations.

Methods

Data from the Northern Ireland Veterans Health and Wellbeing Study (NIVHWS), including self-report data describing traumatic stress, depression, anxiety, and suicidality, were used in a latent class analysis to identify distinct profiles of symptomology in the sample, and in a multinomial logistic regression to identify comorbidities associated with class membership.

Results

Three distinct classes emerged: a low endorsement 'baseline' class (36%), a 'Moderate Symptomatic' class (27%), and a high endorsement 'Probable CPTSD' class (37%). Both the Moderate Symptomatic and CPTSD classes were predicted by cumulative trauma exposure. Depression was highly comorbid (OR = 23.06 in CPTSD), as was anxiety (OR = 22.05 in CPTSD) and suicidal ideation (OR = 4.32 in CPTSD), with suicidal attempt associated with the CPTSD class (OR = 2.51).

Conclusions

Cases of probable CPTSD were more prevalent than cases of probable posttraumatic stress disorder (PTSD) without Difficulties in Self-Organisation (DSO) symptoms in a UK Armed Forces veteran sample, were associated with repeated/cumulative trauma, and were highly comorbid across a range of psychopathologies. Findings validate previous literature on CPTSD and indicate considerable distress and thus need for support in UK Armed Forces veterans resident in NI.

The validity of ICD-11 PTSD and complex PTSD in North Korean defectors using the International Trauma Questionnaire

Background: The International Trauma Questionnaire (ITQ) is a self-report assessment focused on the core features of Post-Traumatic Stress Disorder (PTSD) and complex Post-Traumatic Stress Disorder (CPTSD). It is consistent with the organizing principles of the 11th revision to the WHO's International Classification of Diseases (ICD-11). Since the 1990s, the number of North Korean defectors (NKD) entering South Korea to escape human rights violations has been increasing rapidly, with 33,815 NKD settled by 2021. The South Korean government faces an important challenge in supporting NKD to successfully adapt and settle in South Korean society. NKD experience various traumatic events during the process of defecting and repatriation. Therefore, it is essential to understand the psychological disorders of NKD, especially PTSD and CPTSD. Objective: This study aimed to test the validity of the ITQ assessment and explore the differences in symptoms and quality of life between PTSD and CPTSD. Method: The study sample comprised 503 trauma-exposed NKD. Confirmatory factor analysis (CFA) and latent class analysis (LCA) were used to evaluate the validity of ITQ. One-way analysis of variances and post-hoc analyses revealed the difference in the Depression and Somatic Symptoms Scale (DSSS) and WHOQOL-BREF results among PTSD and CPTSD symptom LCA classes. Results: The CFA and LCA results supported the ICD-11 conceptualization of PTSD and CPTSD in NKD. The CFA results confirmed that both the first- and second-order models were statistically fit, but for community-dwelling NKD the first-order model had better model fit than the second-order model. The LCA findings revealed a four-class model with 'PTSD', 'CPTSD', 'DSO', and 'low symptom' classes. Compared to the PTSD class, CPTSD class had higher levels of depression and somatic symptoms and a lower quality of life. Conclusion: This study provided evidence that ITQ is a valid tool to assess PTSD or CPTSD in community-dwelling NKD.

Russian Version of the International Trauma Questionnaire: Adaptation and Validation in a Non-Clinical Sample

Purpose. The article presents the results of adaptation and validation of the International Trauma Questionnaire (ITQ) on a Russian sample. The questionnaire measures the symptoms of complex post-traumatic stress disorder (CPTSD), which can develop as a result of exposure to prolonged, repetitive traumatic experiences in the interpersonal sphere. Method. The study was carried out on a non-clinical sample, which included 429 participants who were 18 to 68 years old and who experienced at least one traumatic event in their lives. International Trauma Questionnaire (ITQ), LEC-5 (Life events checklist-5), author’s questionnaire “Emotional abuse”, Symptom Checklist (SCL-90-R) were used in the study. Results. The structure of the questionnaire in the Russian-speaking sample confirmed the two-factor model of complex PTSD, which combines the symptoms of PTSD («Re-experiencing», «Avoidance», «Sense of Threat») and disturbances of Self-organization («Affective Dysregulation», «Negative Self-concept», «Disturbances in Relationships»). Internal consistency of the scale was in the acceptable range. Among those who have experienced at least one traumatic event, 20% met criteria for PTSD (11%) or CPTSD (9%). These data show that respondents with CPTSD have more intense psychopathological symptoms than respondents with PTSD; women show more intense symptoms of CPTSD than men.

Complex post-traumatic stress disorder and post-migration living difficulties in traumatised refugees and asylum seekers: the role of language acquisition and barriers

Background

Numerous traumatic experiences and post-migration living difficulties (PMLDs) increase the risk of developing symptoms of complex post-traumatic stress disorder (CPTSD) among Afghan refugees and asylum seekers, living in Austria. Research has repeatedly associated higher levels of CPTSD with higher levels of PMLDs. Summarizing PMLDs into empirically derived factors might facilitate a further understanding of their interaction with symptom presentation within distinct clusters of CPTSD.

Objective

The current study aimed to investigate homogeneous subgroups of ICD-11 CPTSD and their association with demographic variables, traumatic experiences, and empirically derived factors of PMLDs.

Method

Within a randomized controlled trail (RCT) CPTSD, PMLDs, and traumatic experiences were assessed in a sample of 93 treatment-seeking Afghan refugees and asylum seekers through a fully structured face-to-face and interpreter-assisted interview using the ITQ, the PMLDC, and a trauma checklist. Underlying clusters of CPTSD, superior factors of PMLDs, and their associations were investigated.

Results

In total, 19.4% of the sample met the diagnostic criteria for PTSD and 49.5% for CPTSD. We identified a 2-cluster solution consisting of two distinct subgroups as best fitting: (1) a CPTSD cluster and (2) a PTSD cluster. The multitude of PMLDs was summarized into four superior factors. CPTSD cluster membership was associated with childhood potentially traumatic experience types, and one of four PMLD factors, namely 'language acquisition & barriers'.

Conclusions

The results suggest that not PMLDs in general, but rather specific types of PMLDs, are associated with CPTSD. An assumed bidirectional relationship between these PMLD factors and CPTSD symptoms might lead to a downward spiral of increasing distress, and could be considered in treatment strategies.

Individuals of refugee background resettled in regional and rural Australia: A systematic review of mental health research

INTRODUCTION

The Australian Government aims to increase the number of individuals on humanitarian resettlement visas allocated to regional locations to 50% by the year 2022. A significant issue with this, given the substantive body of research identifying that refugee populations face chronic mental health concerns during resettlement, is the lack of health-related research focusing on the resettlement of individuals of refugee background to rural and regional locations in Australia, especially in the area of mental health.

OBJECTIVE

To provide a foundation for rectifying this omission, this review is the first to synthesise mental health research focusing on individuals of refugee background specifically resettled to rural and regional locations in Australia.

DESIGN

The review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Findings were synthesised using thematic analytic techniques.

FINDINGS

14 relevant studies (3 quantitative, one mixed-method, 10 qualitative) were identified. Findings indicated that individuals of refugee background resettled in rural and regional Australia not only experienced higher levels of psychological distress than the general population but also had significant difficulty and limited options when accessing mental health services. Furthermore, resettlement in rural and regional locations increased the risk of experiencing many interrelated factors associated with adverse mental health outcomes and distress, including very limited access to support services, with the latter being identified as vital for well-being.

CONCLUSION

This review highlights the disparity between the Australian Government's policies and plans regarding regional resettlement, what is happening on the ground, and identifies key gaps in research and practice which must be addressed.

A qualitative investigation of mental health in women of refugee background resettled in Tasmania, Australia

Background

Women of Refugee Background (WoRB) are a highly vulnerable population with complex going mental health needs following resettlement. In Australia, there has been a substantial increase in WoRB being resettled in rural and regional locations. Despite this, no research to date has specifically focused on factors contributing to mental distress in WoRB in regional resettlement locations. The current study aimed to address this gap in literature.

Methods

21 semi-structured qualitative interviews were conducted with WoRB and service providers in regional locations of Tasmania, Australia. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed utilising Braun and Clarke (Qual Res Psychol 3(2):77–101, 2006) framework for conducting thematic analysis.

Results

Thematic analysis revealed that WoRB conceptualised mental health as a pathogenic entity, which significantly influenced their mental health help-seeking behaviours. The findings also highlighted how resettlement to a rural and regional location of Australia may exacerbate many of the factors which contribute to ongoing mental distress in WoRB.

Conclusions

The findings of the current study build upon existing research which indicates the adverse impacts post-migrations stressors can have on the mental health of individuals of refugee background. Furthermore, this study suggests that the current services and supports available to WoRB resettled in regional locations of Australia are inadequate, and under-resources. These findings are discussed in regard to practical and policy implications which should be addressed to better support the mental health of WoRB resettled in rural and regional locations of Australia.

Prevalence of complex post-traumatic stress disorder in refugees and asylum seekers: systematic review

BACKGROUND

Refugees and asylum seekers often report having experienced numerous complex traumas. It is important to understand the prevalence of complex post-traumatic stress disorder (CPTSD), which can follow complex traumas.

AIMS

This systematic review aims to summarise the available literature reporting the prevalence in refugees and asylum seekers of three operationalised definitions of CPTSD: the ICD-11 diagnostic criteria, the ICD-10 criteria (for enduring personality change after catastrophic experience) and the DSM-IV criteria (for disorders of extreme stress not otherwise specified).

METHOD

Six electronic databases were searched for studies reporting the prevalence of CPTSD in adult refugee and/or asylum-seeking samples. Owing to heterogeneity between the studies, a narrative synthesis approach was used to summarise studies. Methodological quality was assessed using the Joanna Briggs Critical Appraisal Checklist for Prevalence Studies. This systematic review has been registered with PROSPERO (registration number CRD42020188422, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=188422).

RESULTS

Systematic searches identified 15 eligible studies, with 10 examining treatment-seeking samples and five using population samples. CPTSD prevalence in treatment-seeking samples was between 16 and 38%. Prevalence in population samples ranged from 2.2 to 9.3% in four studies, with the fifth reporting a much higher estimate (50.9%).

CONCLUSIONS

This review highlights both the high prevalence of CPTSD in treatment samples and the lack of research aiming to establish prevalence of CPTSD in refugee and asylum-seeking populations. Understanding the prevalence of these disabling disorders has implications for policy and healthcare services for the appropriate promotion, planning and provision of suitable treatment and interventions for this highly traumatised population.

Complex post-traumatic stress disorder in asylum seekers and victims of trafficking: treatment considerations

Asylum-seekers experience high levels of traumatic events pre-, post- and during migration. Poly-traumatisation is associated with complex post-traumatic stress disorder (CPTSD), which has not yet been extensively explored in this population. CPTSD is a prevalent and highly disabling disorder in the present population requiring culturally sensitive diagnostic and treatment approaches. In this service evaluation, we evidence the high prevalence of CPTSD in an asylum-seeking sample and its association with greater distress compared with PTSD. We outline the treatment needs of asylum seekers with CPTSD.

The role of migration processes and cultural factors in the classification of personality disorders

Migrants and ethnic minorities are at risk of being under- and overdiagnosed with personality disorders (PDs). A culturally informed approach to the classification of PDs guides clinicians in incorporating migration processes and cultural factors, to arrive at a reliable and valid assessment of personality pathology. In this article, we provide a tentative framework to highlight specific interactions between personality disorders, migration processes, and cultural factors. It is argued that migration processes can merely resemble personality pathology, activate certain (latent) vulnerabilities, and aggravate pre-existing personality pathology. We propose that these migration processes can include manifestations of grief about the loss of pre-migratory psychosocial and economic resources, and the struggle to attain psychosocial and economic resources in the host culture. Moreover, several cultural dimensions are outlined that can either resemble or mask personality pathology. The term "culturally masked personality disorder" is coined, to delineate clinical cases in which cultural factors are overused or misused to rationalize behavioral patterns that are consistently inflexible, distressing, or harmful to the individual and/or significant others, lead to significant impairment, and exceed the relevant cultural norms. Additionally, the role of historical trauma is addressed in the context of potential overdiagnosis of personality disorders in Indigenous persons, and the implications of misdiagnosis in migrants, ethnic minorities, and Indigenous populations are elaborated. Finally, clinical implications are discussed, outlining various diagnostic steps, including an assessment of temperament/character, developmental history, systemic/family dynamics, migration processes, cultural dimensions, and possible historical trauma.

A systematic literature review of factor analytic and mixture models of ICD-11 PTSD and CPTSD using the International Trauma Questionnaire

The 11th version of the International Classification of Diseases (ICD-11; WHO, 2018) describes two distinct trauma related disorders, Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). This review aims to summarise and synthesize evidence from factor analytic and mixture modelling studies that have investigated the latent structure of the International Trauma Questionnaire. A systematic search of PsycInfo, Web of Science, Scopus and Pubmed databases was conducted to identify relevant articles. Thirty-three studies met the inclusion criteria for this systematic review. The latent structure of the ITQ was best represented by two models; a correlated six-factor model (Re-experiencing, Avoidance, Threat, Affect Dysregulation, Negative Self Concept, and Disturbed Relationships) and a two-factor second-order model (PTSD and Disturbances in Self-Organization). Mixture model studies consistently identified distinct classes representing those displaying PTSD and CPTSD symptoms. Numerous studies demonstrated support for the factorial and discriminant validity of PTSD and CPTSD when analysed in conjunction with other variables. Overall, support was found for the conceptual coherence of PTSD and CPTSD as empirically distinguishable disorders, as measured by the ITQ. The available evidence demonstrates that the ITQ is a valid measure of ICD-11 PTSD and CPTSD. Recommendations for future research are included.

Factor structure and symptom classes of ICD-11 complex posttraumatic stress disorder in a South Korean general population sample with adverse childhood experiences

BACKGROUND

Adverse childhood experiences (ACE) are known as risk factors for poor adulthood mental health, including ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). While many studies focused on the association of ACE and CPTSD, examining variant symptom patterns related to ACE is lacking.

OBJECTIVE

This study aimed to identify the factorial validity of the ICD-11 CPTSD and its distinctive symptom classes in Korean adults with ACE from a representative community sample and examine the risk factors and clinical symptoms that distinguish the CPTSD symptom classes.

METHODS

We conducted a cross-sectional retrospective study with the International Trauma Questionnaire data from 800 adult general population with ACE histories. A confirmatory factor analysis, latent class analysis, analysis of variance and multinomial logistic regression were conducted.

RESULTS

Results of confirmatory factor analysis supported a six-factor correlation model, while a two-factor higher-order model with PTSD and disturbances in self-organization (DSO) as correlated constructs also showed excellent fit. A latent class analysis identified six classes, including a distinctive ICD-11 CPTSD and PTSD, additionally a DSO with sense of threat, a DSO, an emotion dysregulation, and a low symptom class, showing distinguished features in ACE patterns, lifetime trauma, depression, somatization, panic disorder, and subtypes of dissociation.

CONCLUSIONS

The factorial and discriminant validity of ICD-11 CPTSD for Korean ACE survivors were confirmed. Recognizing the pervasive impact of patterns of ACEs and lifetime trauma would be helpful in access to and delivery of appropriate mental health services. Variation in symptom presentations of CPTSD and the role of dissociation should be of concern, that it may bring complicated life outcomes to people with ACEs.

Validation of posttraumatic stress disorder (PTSD) and complex PTSD in Chinese children as per the ICD-11 proposals using the International trauma questionnaire

Background: Given that the validity of applying complex posttraumatic stress disorder (CPTSD) in nonclinical children remains unclear. Objectives: The current study aimed to explore the factor structure, discriminant validity, and risk factors of ICD-11 posttraumatic stress disorder (PTSD) and CPTSD using the International Trauma Questionnaire. Methods: A total of 3478 trauma-exposed Chinese children aged 9-12 years were included in this study. All participants were assessed for PTSD and CPTSD using the International Trauma Questionnaire (ITQ). Confirmatory factor analysis (CFA) was conducted to explore the factor structure of CPTSD in a sample of Chinese children. Latent class analysis (LCA) was employed to evaluate the discriminant validity of CPTSD symptoms. Multinomial logistic regression analyses determined associations between the different classes and traumatic events. Results: The CFA results showed that the first-order six-factor model was identified as the best-fitting model in Chinese children aged 9-12 years. Four different classes, CPTSD symptoms, PTSD symptoms, disturbances in self-organization (DSO) symptoms, and a low symptom class were found by LCA. Both prolonged interpersonal trauma and other types of trauma were risk factors for the CPTSD class and the PTSD class. Conclusions: The results of this study partially support the factorial validity and strongly support the discriminant validity of the ICD-11 proposals for PTSD and CPTSD in Chinese children, supporting the conceptualization of PTSD and CPTSD as sibling diagnoses based on the ICD-11. However, findings suggest the need for careful consideration of identified trauma types in the ICD-11 proposals.

Prevalence, predictors and associations of complex post-traumatic stress disorder with common mental disorders in refugees and forcibly displaced populations: a systematic review

Background: The inclusion of complex post-traumatic stress disorder (CPTSD) in ICD-11 represents a turning point for the field of traumatic stress, with accumulative evidence of this disorder in refugees and displaced populations. Objective: The objectives of this systematic review are to examine, in refugee and displaced populations: 1) the prevalence of CPTSD; 2) factors contributing to CPTSD; and 3) and associations between CPTSD and other common mental disorders including: PTSD, depression, anxiety and somatisation. Method: We followed the Joanna Briggs Institute Methodology for Systematic Reviews. Papers published in English language were included, with date of publication between 1987 and June 2019. We searched six relevant databases: MEDLINE, PsycINFO, Embase, Scopus, CINAHL, and PILOTS, and the grey literature. We included observational studies with prevalence data on CPTSD. Results: 19 articles met all inclusion criteria. Quality assessment was performed on each included study using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. Based on this, 13 moderate and high-quality studies were included in our narrative synthesis. The included studies reported prevalence of CPTSD in refugees and displaced populations ranging from 2% to 86%. Conclusions: Reasons for the wide variation in prevalence may include contextual and geographical differences, the influence of post-migration difficulties, and sample population characteristics such as treatment seeking versus general population. We found higher prevalence rates (range: 16-82%) in more studies with treatment seeking samples, followed by convenience and snowball samples (40-51%), and lower rates in more studies utilising random sampling techniques (2-86%). Consistent with the broader literature, the studies in our review supported an association for complex post-traumatic stress disorder with prolonged, repeated trauma, and post-migration living difficulties, with the latter association being specific to refugee and displaced populations. Further research on this construct in this population group, including effective treatments, is required.

ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD among organized violence survivors in modern South Korean history of political oppression

BACKGROUND AND OBJECTIVES

Construct and discriminant validity of the ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) has been examined worldwide. However, little is known about CPTSD in Korean population who are suffering with long-term responses of organized violence in their context.

DESIGN

This study conducted a cross-sectional survey to assess the construct and discriminant validity of the ICD-11 PTSD and CPTSD using the Korean International Trauma Questionnaire (ITQ) among organized violence survivors of past political oppression (from 1940s to 2010s) in South Korea.

METHOD

A total of 236 survivors and families completed the survey including the ITQ. A confirmatory factor analysis and a multinomial logistic regression were conducted.

RESULTS

A second-order eight-factor, the ICD-11 CPTSD model, best described the structure of CPTSD. Compared to the non-diagnosed group, having above median score of cumulative trauma was a risk factor for PTSD [Odds ratio (OR) = 3.18] and CPTSD (OR = 3.27). Having above median score of cumulative social stressors increased the risk of CPTSD, relative to PTSD (OR = 4.84), and to the non-diagnosed group (OR = 7.79).

CONCLUSIONS

The ITQ seemed applicable to the Korean culture, showing a valid construct and meaningfully distinguishing ICD-11 PTSD and CPTSD.

Evidence for the coherence and integrity of the complex PTSD (CPTSD) diagnosis: response to Achterhof et al., (2019) and Ford (2020)

This letter to the editor responds to a recent EJPT editorial and following commentary which express concerns about the validity of the ICD-11 complex PTSD (CPTSD) diagnosis. Achterhof and colleagues caution that latent profile analyses and latent class analyses, which have been frequently used to demonstrate the discriminative validity of the ICD-11 PTSD and CPTSD constructs, have limitations and cannot be relied on to definitively determine the validity of the diagnosis. Ford takes a broader perspective and introduces the concept of 'cPTSD' which describes a wide ranging set of symptoms identified from studies related to DSM-IV, DSM-V and ICD-11 and proposes that the validity of the ICD-11 CPTSD is in question as it does not address the multiple symptoms identified from previous trauma-related disorders. We argue that ICD-11 CPTSD is a theory-driven, empirically supported construct that has internal consistency and conceptual coherence and that it need not explain nor resolve the inconsistencies of past formulations to demonstrate its validity. We do agree with Ford and with Achterhof and colleagues that no one single statistical process can definitively answer the question of whether CPTSD is a valid construct. We reference several studies utilizing many different statistical approaches implemented across several countries, the overwhelming majority of which have supported the validity of ICD-11 as a unique construct. We conclude with our own cautions about ICD-11 CPTSD research to date and identify important next steps.

New findings questioning the construct validity of complex posttraumatic stress disorder (cPTSD): let's take a closer look

This commentary provides a broader context for interpreting evidence from Latent Class and Latent Profile analyses on complex posttraumatic stress disorder (CPTSD) that was provided in a recent contribution to the European Journal of Psychotraumatology. These data analytic strategies are not alone sufficient to test the construct validity of CPTSD. They base their conclusion on the empirical finding of substantial variation in latent models obtained with different analytic procedures and interpretations of the fit of different latent models, as well as interesting additional evidence of dispersion when individual patients' symptom counts and symptom severity scores on PTSD and CPTSD are examined. However, the results of their analyses actually do provide support for one feature of construct validity, demonstrating discriminant validity by showing a consistent differentiation between PTSD and CPTSD (with expectable variation in both PTSD and CPTSD severity level by persons). Even in a sample of patients diagnosed with PTSD, there may be a Disorders of Self Organization (DSO) sub-group with low PTSD symptom severity. More detailed examination of which DSO symptoms and sub-domains characterize the DSO sub-group and the CPTSD sub-group is needed in order to clarify the nature of the DSO/CPTSD construct. Other analyses needed to fully test construct validity also are described.

Commentary on the Special Section on Complex PTSD: Still Going Strong After All These Years

Posttraumatic stress disorder (PTSD) is inherently complex, yet a growing evidence base indicates that a complex variant (CPTSD) can be distinguished from classic PTSD based on evidence of clinically significant affect, interpersonal, and self/identity dysregulation. This Commentary to the Journal of Traumatic Stress special section on CPTSD reviews the results of four new studies that empirically tested the structure, traumatic stressor antecedents, and construct validity of CPTSD in relation to PTSD and borderline personality disorder (BPD). Based on these and prior empirical findings, a reconceptualization of PTSD, CPTSD, and BPD as posttraumatic threat, betrayal, and rejection disorders, respectively, is proposed. Implications for treatment of trauma survivors are discussed in relation to articles in this special section, which describe a modular framework for CPTSD treatment and an innovative attachment and self-regulation focused on the redesign of a traditional outpatient mental health clinic.

Introduction to the Special Section on Complex Posttraumatic Stress Disorder (CPTSD): The Evolution of a Disorder

The inclusion of complex posttraumatic stress disorder (CPTSD) in the 11th revision of the International Classification of Diseases is an important development in the field of psychotraumatology. Complex PTSD was developed as a response to a clinical need to describe difficulties commonly associated with exposure to traumatic stressors that are predominantly of an interpersonal nature. With this special section, we bring attention to this common condition following exposure to traumatic stressors that only recently has been designated an official diagnosis. In this introduction, we review the history of CPTSD as a new condition and we briefly introduce the papers for the special section in the present issue of the Journal of Traumatic Stress. It is our hope that the work presented in the special section will add to an ever-expanding evidence base. We also hope that this work inspires further research on the cultural validity of CPTSD, its assessment, and treatment.