An initial psychometric assessment of an ICD-11 based measure of PTSD and complex PTSD (ICD-TQ): Evidence of construct validity

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.

Development of the complex trauma screener: A brief measure of ICD-11 PTSD and complex PTSD

The purpose of this study was to develop the Complex Trauma Screener (CTS), a brief screener (seven items) of the ICD-11 trauma disorders that can be used in "quick-paced" facilities. We examined the factor structure of the CTS in two separate samples: civilian college students (N = 823) and military veterans (N = 130) who reported exposure to at least one traumatic event. Confirmatory factor analyses (CFAs) supported two highly-correlated factors (post-traumatic stress disorder [PTSD] and Disturbances in Self-Organization [DSO]) that loaded on the ICD-11-consistent items. The model fit indices indicated good to excellent model fit in both samples, and the internal consistencies for the scales were borderline to good (α = 0.68-0.86). Supplementary analyses supported the gender invariance of the CFA model in the civilian student sample, as well as convergent (with another trauma inventory) and discriminant validity (with borderline disorder features, depression, and mania) of the CTS in both samples. The CTS is, to our knowledge, the shortest instrument designed to measure the ICD-11 trauma disorders and is ideal for "fast-paced" facilities that have significant assessment time restraints. The CTS is, therefore, is a psychometrically-validated instrument that can help mental health professionals efficiently screen adults for ICD-11 trauma disorders.

Digital-Based Interventions for Complex Post-Traumatic Stress Disorder: A Systematic Literature Review

Research has shown that complex post-traumatic stress disorder (cPTSD) differs from post-traumatic stress disorder (PTSD) on core symptoms relating to the individual's sense of self, and this has driven the need for treatment approaches to address these specific features of cPTSD. The COVID-19 pandemic has led to the increased use of digital-based interventions (DBIs) to treat mental illnesses, including trauma-related disorders. However, while evidence for the use of DBIs for PTSD has previously been synthesized, the current review is the first synthesis of research on the use of DBIs for cPTSD. A systematic search of Scopus, PsychINFO, and EBSCOhost was conducted, using search terms targeting "cPTSD" and "DBIs," to identify research on the use of DBIs to treat cPTSD symptoms. Ten papers were identified, which provided preliminary evidence for the efficacy of DBIs to reduce cPTSD symptoms. Further, DBIs were reported as acceptable by individuals with a history of complex trauma. The paper also provides insight into the therapeutic approaches adopted, digital modalities utilized, safety measures included, and whether/to what degree support was provided. While DBIs show promise for treating cPTSD, there is substantial room for advancement of the empirical evidence base for these approaches. Both clinical and research-based recommendations are provided separately.

Gender, sex and complex PTSD clinical presentation: a systematic review

Background: Post-traumatic stress disorder (PTSD) prevalence and clinical presentation reportedly vary with gender and/or sex. Equivalent complex PTSD (CPTSD) research is in its relative infancy and to date no systematic review has been conducted on this topic.Objective: To systematically review the literature and provide a narrative addressing the question of whether gender and/or sex differences exist in CPTSD prevalence and clinical presentation.Method: Embase, PsycINFO, PTSDpubs, PubMed, Web of Science, EThOS and Google Scholar were searched. Twelve papers were eligible for inclusion. Data were extracted and synthesised narratively.Results: Four themes were identified: (i) the reporting of gender and/or sex; (ii) index trauma; (iii) CPTSD prevalence rates; and (iv) CPTSD clinical presentation. Findings were mixed. Nine papers reported prevalence rates: eight found no gender and/or sex differences; one found higher diagnostic rates among women and/or females. Four papers reported clinical presentation: one reported higher cluster-level scores among women and/or females; two used single gender and/or sex samples; and one found higher scores in two clusters in men and/or males. Most papers failed to report in gender- and/or sex-sensitive ways.Conclusions: Gender- and sex-sensitive research and clinical practice is needed. Awareness in research and clinical practice is recommended regarding the intersect between identity and the experience and expression of complex trauma.

Responding to concerns related to the measurement of ICD-11 complex posttraumatic stress disorder using the International Trauma Questionnaire

BACKGROUND

A recent study in this journal by Frewen et al. (2023) provided a critical analysis of the most widely used measure of ICD-11 Complex Posttraumatic Stress Disorder (CPTSD), the International Trauma Questionnaire (ITQ). The article was a thoughtful review and gave voice to several widely held concerns about the nature of CPTSD as it is represented in ICD-11 and measured by the ITQ. The primary concern expressed by Frewen et al. was that the symptom profile of ICD-11 CPTSD, as represented in the ITQ, is too simple and fails to provide adequate coverage of the construct.

OBJECTIVE

Despite its quality, the article included several misunderstandings about the nature of ICD-11 CPTSD, and the function of the ITQ, that we wish to clarify.

PARTICIPANTS

Not applicable.

SETTING

Not applicable.

RESULTS

In this article, we provide a description of what ICD-11 PTSD and CPTSD are, a review of the process that led to their inclusion in ICD-11, how the ITQ was developed and refined to measure these constructs. We then provide responses to several of the most important concerns raised by Frewen et al. CONCLUSIONS: We highlight the clinical utility of the ICD-11 descriptions of PTSD and CPTSD and discuss how the ITQ can be used as part of a suite of clinical assessments to accurately describe and understand common experiences of psychological distress that often result from exposure to traumatic life events.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Measuring post-traumatic stress disorder and complex post-traumatic stress disorder using the International Trauma Questionnaire: results from a Hungarian clinical and non-clinical sample

Background: The 11th revision of the International Classification of Diseases (ICD-11) simplified the description of post-traumatic stress disorder (PTSD) and also introduced a new trauma-related diagnosis called complex post-traumatic stress disorder (CPTSD). CPTSD is linked to earlier, prolonged interpersonal trauma, and is characterized by a broader range of symptoms, in addition to the core PTSD symptoms. The International Trauma Questionnaire (ITQ) has been developed to assess the new diagnostic criteria.Objectives: The primary aim of our study was to test the factor structure of the ITQ in a clinical and a non-clinical Hungarian sample. We also examined whether the degree of traumatization or the type of trauma experienced was associated with meeting the criteria for PTSD or CPTSD, or with the severity of PTSD or disturbances in self-organization (DSO) symptoms, in both samples.Method: A trauma-exposed heterogeneous clinical sample (N = 176) and a non-clinical sample (N = 229) filled out the ITQ and a modified version of the Life Events Checklist (LEC-5). The factor structure of the ITQ was tested by examining the model fit of seven competing confirmatory factor analysis models.Results: A two-factor second-order model with a second-order PTSD factor (measured by three first-order factors) and a DSO factor (measured directly by six symptoms) had the best fit to the data in both samples if an error correlation was allowed between negative self-concept items. Those in the clinical group who reported more interpersonal and childhood trauma experienced more PTSD and DSO symptoms. Also, there were significant, positive, and weak associations between the total number of different traumas and PTSD and DSO factor scores in both samples.Conclusion: ITQ was found to be a reliable tool to differentiate between PTSD and CPTSD, two related but distinct constructs in a clinical and a non-clinical trauma-exposed sample in Hungary.

Expert international trauma clinicians’ views on the definition, composition and delivery of reintegration interventions for complex PTSD

Background: Research has previously distinguished between complex post-traumatic stress disorder (CPTSD) and PTSD, with the former including a range of disturbances in self-regulatory capacities in addition to difficulties associated with PTSD. Clinical guidelines have previously recommended a phase-based approach for the treatment of CPTSD, yet the final 'reintegration' phase of treatment has been overlooked in research, with limited evidence into its value and effectiveness, and inconsistencies in its definitions and understanding.Objective: We set out to define and determine the key principles of 'reintegration' and to specify the components and method of delivery of treatment.Method: Leading national and international clinical and academic experts in CPTSD were interviewed and asked about their views of how 'reintegration' should be defined, its role in the treatment of CPTSD, what it should be composed of, the key principles of its delivery, and how it should be evaluated. We analysed transcripts of the interviews following the principles of Codebook Thematic Analysis.Results: We conducted 16 interviews with leading national and international experts with at least 10 years' experience of treating people with CPTSD. Themes derived from our analysis demonstrated that while the definition and composition of reintegration varied greatly between experts, the key principles in its delivery were consistent across all experts.Conclusions: The results of this study lay the foundation for a framework of what reintegration is and how it can be used in, but also highlight the need for more research to be conducted on the role of reintegration in the treatment of CPTSD. Consensus for the definition and composition of reintegration is still yet to be reached. Possible measures for evaluating reintegration should also be explored in the future.

The relationship between multiple traumatic events and the severity of posttraumatic stress disorder symptoms – evidence for a cognitive link

Background: Previous research has shown that multiple traumatic experiences cumulatively increase the risk for the development of severe symptoms of posttraumatic stress disorder (PTSD). Yet, little is known about the specific psychological mechanism through which this increased risk comes about.Objective: In the present study, we examined a possible cognitive link between multiple traumatic events and PTSD symptom severity through dysfunctional cognitions and expectations.Methods: A sample of patients with a diagnosed PTSD (N = 70; M_Age= 42.06; 82% female) and high symptom burden (IES-R M = 79.24) was examined. On average, patients had experienced 5.31 different traumatic events. In a structural equation model, we tested the hypothesis that the relationship between multiple traumatic experiences and PTSD symptom severity is mediated through dysfunctional general cognitions and dysfunctional situation-specific expectations. General trauma-related cognitions were assessed with the Posttraumatic Cognition Inventory (PTCI) and trauma-related situational expectations were assessed with the Posttraumatic Expectations Scale (PTES).Results: The direct effect of the number of traumatic events on PTSD symptom severity was non-significant. Instead, as hypothesised, there was evidence for a significant indirect effect via dysfunctional general cognitions and situation-specific expectations.Conclusions: The current results further specify the cognitive model of PTSD by indicating that the relationship between the number of traumatic events and PTSD symptom severity is mediated through dysfunctional cognitions and expectations. These findings emphasise the importance of focused cognitive treatment approaches that seek to modify dysfunctional cognitions and expectations in people with multiple traumatic experiences.

What are the predictive variables that increase the risk of developing a complex trauma? A meta-analysis

In 2018, Complex Post Traumatic Stress Disorder (CPTSD) was officially recognized as a distinct syndrome in the International Classification of Diseases, 11th Revision (ICD-11). This recognition aimed to differentiate between neurotic disorders secondary to stressful situations and somatoform disorders, and disorders specifically associated with stress. The inclusion of CPTSD in the ICD-11 marked the culmination of two decades of research focused on understanding its symptoms, treatments, and risk factors. However, despite the progress made, a comprehensive meta-analysis to elucidate the specific risk factors and impact on the development of CPTSD is still lacking. The objective of this article is to conduct such a meta-analysis. A total of 24 studies were selected for analysis, and the findings revealed several key risk factors associated with the development of CPTSD. The main risk factor identified is having experienced sexual abuse in childhood (k = 12; OR = 2.880). In addition, childhood physical abuse (k = 11; OR = 2.841), experiencing emotional neglect during childhood (k = 5; OR = 2.510), physical abuse throughout life (k = 8; OR = 2.149) and being a woman (k = 13; OR = 1.726) were also significant risk factors.

War-related stressors and ICD-11 (complex) post-traumatic stress disorders in Ukrainian students living in Kyiv during the Russian-Ukrainian war

We estimated the prevalence of war-related stressors (Harvard Trauma Questionnaire-R), risk of ICD-11 posttraumatic stress disorder (PTSD), and complex posttraumatic stress disorder (CPTSD; International Trauma Questionnaire-R) in N = 563 Ukrainian students living in Kyiv, an active war zone between December 2022 and January 2023. Among trauma survivors (n = 381), we used multinomial logistic regression to examine whether different war-related traumatic events and cumulative trauma increased risk for ICD-11-PTSD and CPTSD after controlling for other traumatic events, age, and gender. Nine of ten Ukrainian students (91.5%) reported at least one war-related stressor, one of five (20.8%) reported four or more stressors. War-related combat situations were reported most frequently (59.5%), followed by forced separation from family members (54.5%), lack of shelter (53.3%), and murder or violent death of a family member or friend (15.6%). Rates for probable ICD-11 PTSD and CPTSD were 12.4% and 11.2%, respectively. Sexual violence and cumulative trauma exposure significantly increased the risk of CPTSD compared to other traumatic events. The high proportions of ICD-11-PTSD and CPTSD underscore the psychological burden of Ukrainian students living in an active war zone and the need for trauma-focused interventions for war-affected populations.

The effect of childhood trauma on complex posttraumatic stress disorder: the role of self-esteem

Background: Due to the short time that complex posttraumatic stress disorder (CPTSD) has been an independent diagnosis, few studies have explored the role that self-esteem might play in the relationship between childhood trauma and CPTSD.Objective: The current study aimed to explore the impact of childhood trauma on CPTSD and the role of self-esteem in this relationship.Methods: Study 1 involved a questionnaire survey in which a total of 360 young Chinese adults with childhood trauma participated. Study 2 used experimental research by manipulating short-term self-esteem to explore the effect of self-esteem on CPTSD. A total of 80 young Chinese adults with childhood trauma participated.Results: The results of Study 1 showed that childhood trauma positively predicts adulthood CPTSD, while self-esteem partially mediates the relationship between the two. It also found that self-esteem has a greater mediating effect on the disordered self-organization (DSO) dimension of CPTSD than on the PTSD dimension. In Study 2, participants in the high manipulated-self-esteem group reported fewer CPTSD symptoms than those in the low manipulated-self-esteem group.Conclusion: Overall, this study emphasized the role of self-esteem in CPTSD among individuals with a childhood trauma history. In practice, we provided a potential optimization direction for CPTSD clinical treatment, suggesting a method of self-esteem reconstruction.

Assessment tools for complex post traumatic stress disorder: a systematic review

Appropriate screening tools are required to accurately detect complex post traumatic stress disorder (CPTSD). This systematic review aimed to assess and compare measurement tools. A literature search using key words 'complex post traumatic stress disorder', 'PTSD', and 'assessment' was undertaken on Embase and PsychINFO during February 2022 by two reviewers. Inclusion criteria included full text papers between 2002-2022 which evaluated CPTSD using assessment tools. Exclusion criteria included reviews, editorials, meta-analyses, or conference abstracts. Twenty-two papers met selection criteria. Thirteen studies used the International Trauma Questionnaire (ITQ). Two studies each evaluated CPTSD with the International Trauma Interview (ITI) or Symptoms of Trauma Scale (SOTS). The Developmental Trauma Inventory (DTI), Cameron Complex Trauma Interview (CCTI), Complex PTSD Item Set additional to the Clinician Administered PTSD Scale (COPISAC), Complex Trauma Questionnaire (ComplexTQ), and Scale 8 of the Minnesota Multiphasic Personality Inventory Scale (MMPI) were used by a single study each. The ITQ was the most thoroughly investigated, validated across different populations, and is a convenient questionnaire for screening within the clinical setting. Where self-report measures are inappropriate, the ITI, SOTS, and COPISAC are interview tools which detect CPTSD. However, they require further validation and should be used alongside clinical history and examination.

Risk factors, comorbidity and social impairment of ICD-11 PTSD and complex PTSD in Danish treatment-seeking military veterans

PURPOSE

While a number of studies have investigated risk factors and comorbidities of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) in various trauma exposed samples, few studies have been conducted in military samples. Existing studies with military samples have included rather small samples. The aim of the present study was to identify risk factors and comorbidities of ICD-11 PTSD and CPTSD in a large sample of previously deployed, treatment-seeking soldiers and veterans.

METHODS

Previously deployed, treatment-seeking Danish soldiers and veterans (N = 599), recruited from the Military Psychology Department of the Danish Defense, completed the International Trauma Questionnaire (ITQ), as well as questionnaires of common mental health difficulties, trauma exposure, functioning and demographics. Multivariate multinomial logistic regression analysis explored differences in self-reported exposure to adversity and health outcomes between those meeting ICD-11 criteria for probable PTSD, CPTSD and no trauma disorder.

RESULTS

A total of 13.0% met probable ICD-11 criteria for PTSD and 31.4% for CPTSD. Risk factors for CPTSD (compared to those with no trauma disorder) included exposure to warfare or combat, longer duration since the traumatic event and being single. Those with CPTSD were more likely than those with PTSD or no trauma disorder to endorse symptoms of depression, anxiety, stress, use of psychotropic medication, and suicide attempts.

CONCLUSION

CPTSD is a more common and debilitating condition compared to PTSD in treatment-seeking soldiers and veterans. Further research should focus on testing existing and novel interventions for CPTSD in the military.

Adult Attachment as a Mediator of the Link Between Interpersonal Trauma and International Classification of Diseases (ICD)-11 Complex Posttraumatic Stress Disorder Symptoms Among College Men and Women

Previous research indicates that insecure attachment patterns are associated with interpersonal trauma and posttraumatic symptomatology, and that they mediate various trauma-related symptoms. However, no study to date has examined whether these patterns mediate the link between interpersonal trauma and the newly recognized diagnostic features of complex posttraumatic stress disorder (CPTSD), as published by the World Health Organization (2019) in the 11th version of the International Classification of Diseases (ICD-11). Mediators of CPTSD are important to identify because they can provide a deeper understanding of the condition's etiology. Moreover, if amenable to clinical intervention, they can be targeted to improve treatment effectiveness. The purpose of the present study was to formally test our hypothesis that two underlying dimensions of adult attachment insecurity (i.e., attachment anxiety and avoidance) would mediate the link between interpersonal trauma and ICD-11 CPTSD symptoms. Participants were a culturally diverse sample of 169 college men and women. They completed a modified version of the Life Events Checklist (LEC-5), the revised Experiences in Close Relationships (ECR-R) scale, and the International Trauma Questionnaire (ITQ). Results of path analysis partially supported our hypothesis, indicating that attachment anxiety, but not avoidance, partially mediated the link between interpersonal trauma and PTSD and DSO ("Disturbances in Self-Organization") features of CPTSD. Although longitudinal research is needed, findings suggest that attachment anxiety may contribute to the development and maintenance of CPTSD symptoms following interpersonal trauma. Clinical interventions that help individuals rework and integrate representations of attachment that involve a fear of not being able to access adequate care and protection, and a negative view of self may be particularly useful in ameliorating the symptoms of CPTSD.

Prevalence and predictors of ICD-11 posttraumatic stress disorder and complex PTSD in young people

OBJECTIVE

The prevalence, construct validity, risk factors and psychopathological correlates associated with ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as measured by the International Trauma Questionnaire for Children and Adolescents (ITQ-CA) were assessed in a sample of young people from Northern Ireland.

METHOD

Participants were trauma-exposed 11-19-year-olds (N = 507) who participated in the Northern Ireland Youth Wellbeing Prevalence Survey (YWS-NI, 2020). Factor mixture modelling (FMM) was used to test the latent structure of the ITQ-CA. Risk-factors and psychopathological correlates associated with latent class membership, and ICD-11diagnostic status, were also investigated.

RESULTS

More participants met the ITQ-CA criteria for CPTSD (3.4%, n = 44) than PTSD (1.5%, n = 19). A second-order FMM comprising a 'partial-PTSD class', a 'CPTSD class', a 'DSO class' and a 'low symptom endorsement class' was the best-fitting model. Younger age and cumulative trauma were risk factors for all trauma classes. Female gender and two or more violent traumas were significant predictors of the 'PTSD' and 'CPTSD' classes, while single sexual trauma was a significant predictor of the 'DSO' and 'CPTSD' classes. Two or more sexual traumas was a unique predictor of 'CPTSD class', while two or more vicarious traumas was a unique predictor of 'DSO class'. The 'CPTSD' class displayed the most notable comorbidity.

CONCLUSIONS

Findings indicate that CPTSD may be more prevalent than PTSD in children and young people. Support for the ICD-11 conceptualisation of CPTSD as representing a unique diagnostic construct was supported using FMM, with findings indicating trauma symptom class-specific risk profiles.

French translation and validation of the International Trauma Questionnaire in a Canadian community sample

BACKGROUND

The diagnosis of complex post-traumatic stress disorder (CPTSD) was recently included into the 11th edition of the International Classification of Diseases (ICD-11). Recognizing the need for a brief and specific measure CPTSD symptoms as defined by the ICD-11, Cloitre and her team (2018) developed the original English version of the International Trauma Questionnaire (ITQ). The ITQ is composed of two scales-'post-traumatic stress disorder (PTSD)' and 'disturbances in self-organization' (DSO), respectively subdivided into three subscales. It was found to be psychometrically valid but has yet to be available in French.

OBJECTIVE

The purpose of this study was to provide a French version of the ITQ and to examine its factorial validity, internal consistency, and convergent validity in a French-speaking Canadian sample.

PARTICIPANTS

The sample included 335 French-Canadian adults from the community.

METHODS

The ITQ was translated in French, back translated into English, and deemed equivalent by the original ITQ's author. Participants answered the French version of the ITQ, as well as measures of convergent validity, via phone interview.

RESULTS

Confirmatory factorial analyses revealed that the French ITQ presented the same factor structure as the original ITQ. Composite reliability scores revealed good internal consistency for both scales, and all but one subscale. Pearson's correlation and Steiger's Z test revealed good convergent validity.

CONCLUSION

This study supports the factorial validity, internal consistency, and convergent validity of the French version of the ITQ, suggesting that it is a psychometrically sound measure of CPTSD.

Distinguishing PTSD, complex PTSD, and borderline personality disorder using exploratory structural equation modeling in a trauma-exposed urban sample

There is debate about the validity of the complex posttraumatic stress disorder (CPTSD) diagnosis and whether disturbances in self-organization (DSO) in CPTSD can be differentiated from borderline personality disorder (BPD). How PTSD is defined may matter. The present study used exploratory structural equation modeling (ESEM) to replicate and extend prior work by including two models to examine how PTSD (ICD-11, DSM-5), DSO, and BPD symptoms relate. Participants (N = 470; 98.1% women; 97.7% Black) were recruited from medical clinics within an urban hospital. PTSD, CPTSD, and BPD were assessed using semi-structured interviews and trauma-related avoidance, aggressive behavior, and anxious attachment were assessed using self-report measures. ESEM models of PTSD, DSO, and BPD symptoms were run. We found a three-factor ESEM model of CPTSD (ICD-11 PTSD and DSO symptoms) and BPD symptoms best fit the data and found support for discriminant validity between factors across trauma-related avoidance, aggressive behavior, and anxious attachment. For DSM-5 PTSD, a two-factor ESEM model was best-fitting (PTSD and DSO/BPD). The findings demonstrate clear distinguishing and overlapping features of ICD-11 PTSD, CPTSD, and BPD and the necessity to consider the diagnostic structure of PTSD in determining the additive value of CPTSD as a distinct construct.

Testing alternative models and predictive utility of the Death Anxiety Inventory-Revised: A COVID-19 related longitudinal population based study

The beginning of the COVID-19 pandemic had a profound effect on all aspects of daily life and triggered a swell of anxiety across the world. Some suggest this emotional response to the pandemic can be explained through death anxiety (DA), a transdiagnostic dimension associated with numerous psychological disorders. However, it remains unclear as to whether DA is a unidimensional or multidimensional construct. The primary aim of this study was to examine the underlying structure of the Death Anxiety Inventory-Revised (DAI-R; Tomás-Sábado et al., 2005) and assess its associations with mental health and demographic variables during the COVID-19 pandemic. To achieve these aims, we utilized data from Waves 1 (N = 2205: collected between March 23 and March 28, 2020) and 2 (N = 1406: collected between April 22 and May 1, 2020) of the COVID-19 Psychological Research Consortium (C19PRC), a multi-wave nationally representative study. Results showed that a 4-factor model provided the best fit to the data compared to a unidimensional and 4-factor second-order model. Further analyses showed that DA at Wave 1 was positively associated with somatic symptoms, paranoia, depression, anxiety, and traumatic stress symptoms at Wave 2, supporting previous research that suggests that the fear of death is predictive of psychopathology. Significantly, the factor labelled ‘Thoughts about Death’ at Wave 1 was the strongest predictor of the five main psychological variables at Wave 2, after statistically controlling for the other latent variables. These findings highlight the transdiagnostic nature of DA and support this important diagnostic construct becoming a measure of mental health more generally within the population. It is hoped that this research will shine a light on those suffering from DA and become a catalyst for increased therapeutic intervention, funding, and research in this area.

Testing both affordability-availability and psychological-coping mechanisms underlying changes in alcohol use during the COVID-19 pandemic

Two theoretical perspectives have been proffered to explain changes in alcohol use during the pandemic: the ‘affordability-availability’ mechanism (i.e., drinking decreases due to changes in physical availability and/or reduced disposable income) and the ‘psychological-coping’ mechanism (i.e., drinking increases as adults attempt to cope with pandemic-related distress). We tested these alternative perspectives via longitudinal analyses of the COVID-19 Psychological Consortium (C19PRC) Study data (spanning three timepoints during March to July 2020). Respondents provided data on psychological measures (e.g., anxiety, depression, posttraumatic stress, paranoia, extraversion, neuroticism, death anxiety, COVID-19 anxiety, intolerance of uncertainty, resilience), changes in socio-economic circumstances (e.g., income loss, reduced working hours), drinking motives, solitary drinking, and ‘at-risk’ drinking (assessed using a modified version of the AUDIT-C). Structural equation modelling was used to determine (i) whether ‘at-risk’ drinking during the pandemic differed from that recalled before the pandemic, (ii) dimensions of drinking motives and the psychosocial correlates of these dimensions, (iii) if increased alcohol consumption was predicted by drinking motives, solitary drinking, and socio-economic changes. The proportion of adults who recalled engaging in ‘at-risk’ drinking decreased significantly from 35.9% pre-pandemic to 32.0% during the pandemic. Drinking to cope was uniquely predicted by experiences of anxiety and/or depression and low resilience levels. Income loss or reduced working hours were not associated with coping, social enhancement, or conformity drinking motives, nor changes in drinking during lockdown. In the earliest stage of the pandemic, psychological-coping mechanisms may have been a stronger driver to changes in adults’ alcohol use than ‘affordability-availability’ alone.

Posttraumatic stress disorder, complex PTSD and subtypes of loneliness among older adults

OBJECTIVES

Research examining the relationship between loneliness and Complex Posttraumatic Stress Disorder (CPTSD) is scarce, particularly among older adults. CPTSD includes the core symptoms of PTSD along with additional symptoms reflecting "disturbances in self-organisation" (DSO). This study examined the cross-sectional relationships between loneliness (emotional and social loneliness) and CPTSD symptoms (i.e., PTSD and DSO symptoms) in older adults.

METHODS

Structural equation modelling was used to examine these relationships in a nationally representative sample of US adults aged 60-70 years (n = 456).

RESULTS

Controlling for covariates, emotional loneliness was associated with PTSD (β = 0.31) and DSO (β = 0.57) symptoms whereas social loneliness was only associated with DSO symptoms (β = 0.25). The model explained 35.0% of the variance in PTSD symptoms and 71.3% in DSO symptoms.

CONCLUSION

These findings have important implications for treating and understanding PTSD/CPTSD and their correlates among older adults.

ICD-11 Posttraumatic Stress Disorder and Complex PTSD Among Hospital Medical Workers in China: Impacts of Wenchuan Earthquake Exposure, Workplaces, and Sociodemographic Factors

BACKGROUND

Previous studies address posttraumatic stress disorder (PTSD) following disasters as a public health issue. However, few studies investigate the long-term effect of disaster exposure on PTSD among hospital medical workers (HMWs).

OBJECTIVES

This study aimed to study the prevalence of ICD-11 PTSD and complex PTSD (CPTSD) among exposed and non-exposed HMWs 11 years after the Wenchuan earthquake in China, to identify the factors associated with PTSD and CPTSD scores, and to examine the factor structures of PTSD and CPTSD models.

METHODS

A cross-sectional study was conducted using a self-administered online questionnaire. Two thousand fifty-nine valid samples were collected from four hospitals in 2019. Descriptive statistical analysis, multivariate regression models, and confirmatory factor analysis (CFA) were performed.

RESULTS

The prevalence of PTSD and CPTSD was 0.58 and 0.34%, respectively. The unexposed group reported higher PTSD and CPTSD scores than the exposed group. The type of workplace and marital status were significantly associated with the PTSD and CPTSD scores of HMWs. The CFA results indicate that both the correlated first-order model and the correlated two-layer model were a good fit to explain the structure of PTSD and CPTSD.

CONCLUSION

These findings suggest that few HMWs who were exposed to the Wenchuan earthquake suffered from PTSD or CPTSD 11 years following the disaster. However, psychological support was still necessary for all HMWs, especially for unmarried HMWs who were Working in smaller hospitals. Further research is required to analyze mental health status using ICD-11 PTSD and CPTSD to provide ongoing evidence to help HWMs cope effectively with the challenges of future disasters.

Protocol of a feasibility trial for an online group parenting intervention with an integrated mental health component for parent refugees and asylum-seekers in the United Kingdom: (LTP + EMDR G-TEP)

OBJECTIVES

Conflicts expose families to a range of factors that could have a negative impact upon parental mental health which in turn leads to poor growth and development of children. Early support can improve parental mental health and parenting behaviours but currently, there is a lack of evidence on parenting interventions for forcibly displaced populations. This study aims to deliver an online parenting intervention with a mental health component for refugee and asylum-seeker parents to evaluate its feasibility and acceptability.

METHODS

This is a single-arm trial without a control group. The trial aims to recruit 14 refugee and asylum-seeker parents into an Online Learning Through Play and Eye Movement Desensitization and Reprocessing Group Traumatic Episode Protocol (LTP + EMDR G-TEP). The intervention will be delivered by trained research team members using online platforms.

RESULTS

The participants' sense of parenting competence, symptoms of traumatic stress, anxiety and depression will be measured at baseline and post-intervention. Semi-structured interviews at post-intervention will also be conducted.

DISCUSSION

This study will assess the feasibility and inform the design of a future randomized controlled trial which aims to evaluate the effectiveness of LTP + EMDR G-TEP intervention for parent refugees and asylum-seekers with young children.

Suicidal Histories in Adults Experiencing Psychological Trauma: Exploring Vulnerability and Protective Factors

OBJECTIVE

This study aimed to identify vulnerability and protective factors for suicidal histories among adults experiencing psychological trauma.

METHOD

Adults seeking treatment for psychological trauma (N = 113) completed self-report questionnaires measuring childhood trauma history, self-concept, relational functioning, emotion regulation, living arrangements, employment status, marital status, and suicidal history. Independent samples t-tests were used to determine variables on which those with and without suicidal histories differed significantly. These variables were then entered into a binary logistic regression model to identify factors which independently distinguished between those with and without a suicidal history.

RESULTS

Univariate differences were found for childhood emotional abuse (CEA), childhood emotional neglect (CEN), emotion deactivation, and employment status, with those in the suicidal history group scoring higher on all of these. CEA (OR = 1.13, 95% CI = 1.01-1.27) and employment status (OR = 4.12, 95% CI = 1.23-13.73) remained significant predictors of suicidal status in the multivariable logistic regression.

CONCLUSIONS

CEA was an independent vulnerability factor for suicidal risk, highlighting the need for clinicians to assess exposure to such trauma in those presenting with proximal traumatic experiences. Being in employment was an independent protective factor against suicidal risk, highlighting the importance of social buffers or networks when faced with traumatic situations.

The Italian Version of the International Trauma Questionnaire: Symptom and Network Structure of Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder in a Sample of Late Adolescents Exposed to a Natural Disaster

The 11th revision of the International Classification of Diseases has endorsed substantial changes in Post-Traumatic Stress Disorder (PTSD) and has introduced Complex PTSD (cPTSD). The objective of this study was to assess the symptom and network structure of PTSD and cPTSD using the International Trauma Questionnaire- Italian version (ITQ) and the prevalence of PTSD and cPTSD in a community sample of late adolescents enriched with exposure to a destructive earthquake. A 1,010 high school students participated to the study. Confirmatory Factor Analysis supports that a six first-order correlated factors was the best fitting model of ICD-11 PTSD/cPTSD. The network analysis supports a clear separation between core PTSD symptoms and disturbances in self-organization (DSO) symptoms, avoidance, and negative self-concept were the most central items. The prevalence of PTSD and cPTSD was 9.11 and 4.06%, respectively. Female participants reported higher rates of both PTSD and cPTSD. This is the first study to report on ICD-11 PTSD and cPTSD rates on an Italian adolescence community sample. Consistent with other community samples, we found higher rates of PTSD compared to cPTSD. The results confirmed the factorial validity of the ITQ. The network structure highlights the importance of negative self-concept in cPTSD and avoidance in PTSD.

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.

Confirmatory factor analysis of the Clinician-Administered PTSD Scale (CAPS-5) based on DSM-5 vs. ICD-11 criteria

INTRODUCTION

Many studies have investigated the latent structure of the DSM-5 criteria for posttraumatic stress disorder (PTSD). However, most research on this topic was based on self-report data. We aimed to investigate the latent structure of PTSD based on a clinical interview, the Clinician-Administered PTSD Scale (CAPS-5).

METHOD

A clinical sample of 345 participants took part in this multi-centre study. Participants were assessed with the CAPS-5 and the Posttraumatic Stress Disorder Checklist (PCL-5). We evaluated eight competing models of DSM-5 PTSD symptoms and three competing models of ICD-11 PTSD symptoms.

RESULTS

The internal consistency of the CAPS-5 was replicated. In CFAs, the Anhedonia model emerged as the best fitting model within all tested DSM-5 models. However, when compared with the Anhedonia model, the non-nested ICD-11 model as a less complex three-factor solution showed better model fit indices.

DISCUSSION

We discuss the findings in the context of earlier empirical findings as well as theoretical models of PTSD.

Validation of the International Trauma Interview (ITI) for the Clinical Assessment of ICD-11 Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD) in a Lithuanian Sample

BACKGROUND

The 11^th revision of the International Classification of Diseases (ICD-11) includes a new diagnosis of complex posttraumatic stress disorder (CPTSD). The International Trauma Interview (ITI) is a novel clinician-administered diagnostic interview for the assessment of ICD-11 PTSD and CPTSD.

OBJECTIVE

The aim of this study was to evaluate the psychometric properties of the ITI in a Lithuanian sample in relation to interrater agreement, latent structure, internal reliability, as well as convergent and discriminant validity.

METHOD

In total, 103 adults with a history of various traumatic experiences participated in the study. The sample was predominantly female (83.5%), with a mean age of 32.64 years (SD = 9.36). For the assessment of ICD-11 PTSD and CPTSD, the ITI and the self-report International Trauma Questionnaire (ITQ) were used. Mental health indicators, such as depression, anxiety, and dissociation, were measured using self-report questionnaires. The latent structure of the ITI was evaluated using confirmatory factor analysis (CFA). In order to test the convergent and discriminant validity of the ITI we conducted a structural equation model (SEM).

RESULTS

Overall, based on the ITI, 18.4% of participants fulfilled diagnostic criteria for PTSD and 21.4% for CPTSD. A second-order two-factor CFA model of the ITI PTSD and disturbances in self-organization (DSO) symptoms demonstrated a good fit. The associations with various mental health indicators supported the convergent and discriminant validity of the ITI. The clinician-administered ITI and self-report ITQ had poor to moderate diagnostic agreement across different symptom clusters.

CONCLUSION

The ITI is a reliable and valid tool for assessing and diagnosing ICD-11 PTSD and CPTSD.

Item response model validation of the German ICD-11 International Trauma Questionnaire for PTSD and CPTSD

Background

In the 11th revision of the International Classification of Diseases (ICD-11) posttraumatic stress disorder (PTSD) and the complex variant (CPTSD) were newly conceptualised. The International Trauma Questionnaire (ITQ) was developed as a brief self-report measure to screen for both disorders. The English original version has been rigorously tested and presents convincing psychometric properties. The aim of the current study was to validate the German version by means of item response theory (IRT).

Method

This is a secondary analysis of a representative, trauma-exposed adult sample from the German general population (N = 500). 1- and 2-parameter logistic IRT models (i.e. examination on an item level), diagnostic rates and confirmatory factor analyses were calculated.

Results

All items showed good model fit and acceptable to good performance aligning with the items of the English original except for item C1 (Long time to calm down) which had a high endorsement rate and a low discriminatory power yielding low information gain. CPTSD diagnostic rate of 3.2% was lower than in comparable literature. Confirmatory factor analysis deemed the six first-order, two second-order factors model superior.

Conclusion

Measurement and factorial validity of the German version of the ITQ was confirmed. The German translation matches the English original in most psychometric properties and can thus be used for research and clinical practice.

Examining the factor structure of ICD-11 posttraumatic stress disorder (PTSD) and complex-PTSD among prison staff exposed to potentially traumatic experiences

The recently released 11th edition of the International Classification of Diseases (ICD-11) classifies posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as distinct, yet related, disorders within the spectrum of trauma and stress-related disorders. This study aimed to explore the construct validity of the International Trauma Questionnaire (ITQ), a measure of ICD-11 PTSD and CPTSD symptoms among prison governors (i.e., wardens in the U.S. and Canada). Trauma-exposed prison governors (N = 409) aged 26 to 82 years (M = 50.04, SD = 7.97) provided their data online anonymously. Confirmatory factor analyses were performed to evaluate the construct validity of ITQ scores. When using the five-point item response scale, our five first-order factor model produced the best fit to the data; however, when using a dichotomous item scale, the first-order two-factor PTSD and disturbances of self-organization (DSO) model produced the best fit to the data. These results indicate that item-coding and estimation methods can significantly impact conclusions about the best-fitting model for this measure among trauma-exposed prison governors.

ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in treatment seeking veterans: risk factors and comorbidity

PURPOSE

Emerging evidence suggests that ICD-11 CPTSD is a more common condition than PTSD in treatment seeking samples although no study has explored risk factors and comorbidities of PTSD and CPTSD in veteran populations. In this study, risk factors and comorbidity between veterans meeting criteria for PTSD or CPTSD using the ICD-11 International Trauma Questionnaire (ITQ) were explored.

METHODS

A sample of help-seeking veterans who had been diagnosed with a mental health difficulty (n = 177) was recruited. Participants completed a range of mental health and functioning measures. Multinomial logistic regression analysis was conducted to explore differences in the above factors between participants meeting case criteria for PTSD, CPTSD or another mental health disorder.

RESULTS

Those with CPTSD appeared to have taken longer to seek help, reported higher rates of childhood adversity and more experiences of emotional or physical bullying during their military careers. Further, participants with CPTSD reported a greater burden of comorbid mental health difficulties including high levels of dissociation, anger, difficulties related to moral injury and common mental health difficulties and greater degree of impairment including social isolation, sleep difficulties and impaired functioning.

CONCLUSIONS

Considering that CPTSD is a more debilitating condition than PTSD, there is now an urgent need to test the effectiveness of new and existing interventions in veterans with CPTSD.

The international trauma questionnaire (ITQ) measures reliable and clinically significant treatment-related change in PTSD and complex PTSD

Background: The International Trauma Questionnaire (ITQ) is a validated measure that assesses ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). An important task is to determine whether the ITQ is an appropriate evaluative measure for clinical trials. Objective: To assess the psychometric properties of the ITQ in the context of treatment and determine if the ITQ measures reliable and clinically significant change over the course of a psychosocial intervention. Method: Analyses were based on data from an online skills training programme delivered to 254 U.S. Veterans. Reliability and validity of the ITQ scores were assessed at baseline. Changes in symptom scores and probable diagnostic rates were compared at pre-, mid- and post-treatment. A reliable change index (RCI) score was computed to classify participants as improved, unchanged, or worsened. The PCL-5 was used as a comparison measure. Results: Baseline concurrent and factorial validity was similar to previous studies. Internal consistency at each assessment was excellent and comparable to the PCL-5. Decline in symptoms from pre-to-post-treatment was significant for PTSD and CPTSD symptom profiles. Rate of probable disorder (PTSD or CPTSD) declined significantly from pre-treatment to post-treatment. Pre-to-post treatment declines exceeded the critical RCI values for the ITQ. Clinically significant changes were observed where most participants improved, some stayed the same, and few worsened. The performance of the ITQ was consistent with the PCL-5 regarding sensitivity to change. Conclusion: This study provides the first demonstration that the ITQ measures reliable and clinically significant treatment-related change of ICD-11 PTSD and CPTSD symptoms.

Argentinean Adaptation and Psychometric Properties of the Emotion Regulation Questionnaire (ERQ)

The Emotion Regulation Questionnaire (ERQ) is a self-report measure designed to assess the two most widely studied strategies of Gross' model: cognitive reappraisal and expressive suppression. Even though there are two Spanish adaptations of the ERQ, region-specific linguistic factors and dialects must also be considered when adapting a test for another country in order to ensure equivalent evaluations across cultures. The present work developed an Argentinean adaptation of the ERQ. Additionally, the study evaluated its psychometric properties and associations with theoretically related constructs. Study 1 consist of the translation the ERQ into Argentinean Spanish and the analysis of its internal structure and reliability in a sample of 2957 participants. The results supported a two-factor structure with good data fit, adequate factor loadings, and good test-retest reliability and internal consistency. Expected age and gender differences in the use of reappraisal and suppression were also observed. Study 2 analyzed the external validity (concurrent and convergent) of the ERQ adaptation in a sample of 2160 participants. Theory-consistent associations were found with emotion regulation mechanisms, anxiety, depression, and personality traits. In summary, the findings support the validity of a new ERQ adaptation and its use in Argentina.

Complex PTSD and borderline personality disorder

BACKGROUND

This article builds on a previous review (Ford and Courtois, Borderline Personal Disord Emot Dysregul 1:9, 2014) which concluded that complex posttraumatic stress disorder (cPTSD) could not be conceptualized as a sub-type of either PTSD or BPD. Recent research is reviewed that extends and clarifies the still nascent understanding of the relationship between cPTSD and BPD.

MAIN BODY

The circumscribed formulation of adult cPTSD that has been developed, validated, and included in the 11th Edition of the International Classification of Diseases has spurred research aimed at differentiating cPTSD and BPD both descriptively and empirically. A newly validated Developmental Trauma Disorder (DTD) syndrome for children and adolescents provides a basis for systematic research on the developmental course and origins of adult cPTSD and BPD. This review summarizes recent empirical findings regarding BPD, PTSD, and cPTSD in terms of: (1) prevalence and comorbidity; (2) clinical phenomenology; (3) traumatic antecedents; (4) psychobiology; (5) emotion dysregulation; (6) dissociation; and (7) empirically supported approaches to clinical assessment and psychotherapeutic treatment.

CONCLUSION

The evidence suggests that PTSD, cPTSD, and BPD are potentially comorbid but distinct syndromes. A hypothesis is advanced to stimulate scientific research and clinical innovation defining and differentiating the disorders, positing that they may represent a continuum paralleling the classic conceptualization of the stress response, with dissociation potentially involved in each disorder.

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 ICD-11 PTSD and DSO using the International Trauma Questionnaire in five clinical samples recruited in Denmark

Background: The 11^th version of the International Classification of Diseases (ICD-11) revised the diagnosis of Posttraumatic Stress Disorder (PTSD) and introduced Complex PTSD as a sibling disorder to PTSD. As the Danish Health Authorities will implement the ICD-11 in 2022, it is more relevant than ever to introduce a measure that enables the identification of ICD-11 PTSD and CPTSD. Objective: The primary aim of the present study was to test the construct validity of the ICD-11 conceptualization of PTSD and DSO in five clinical samples using translated versions of the International Trauma Questionnaire (ITQ). Method: Data from existing studies of adult survivors of sexual abuse (n = 385), women in shelters (n = 147), psychiatric outpatients endorsing an ICD-10 diagnosis of PTSD (n = 111), a heterogenous sample of psychiatric outpatients (n = 178) and refugees and torture survivors (n = 385) was used for the current study. Confirmatory factor analyses were conducted to test the internal structure of the ITQ, and regression models were conducted to test the convergent and discriminant validity of the factor solutions for each sample. Results: Findings supported the ICD-11 formulation of PTSD and disorders in self-organization (DSO) as a representation of the latent structure of the ITQ across five Danish clinical samples. Uniquely for women in shelters, however, the model displayed an unacceptable fit. A revised operationalization of re-experiencing proved a better fit when 'recurrent nightmares' was exchanged with symptoms of intense emotional reactions to reminders of the trauma for women in shelter as well as ICD-10 PTSD psychiatric outpatients. Conclusion: This study supports the use of a Danish translated version of the ITQ to assess symptoms of ICD-11 PTSD and DSO for the introduction of ICD-11 in 2022. Future research is needed to further explore the operationalization of re-experiencing across different trauma exposed populations.

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.

Working in the Field of Complex Psychological Trauma: A Framework for Personal and Professional Growth, Training, and Supervision

The aim of this article is to explore the positive and negative impacts of working therapeutically in complex psychological trauma (CPT), particularly the field of gender-based violence (GBV) and childhood sexual abuse (CSA), from the clinicians' perspective. The focus was on the prospect of positive gains and growth for therapists. Twenty-one clinicians (n = 21; counselors/psychotherapists and psychologists) from National Health Service (NHS) specialist trauma services, a community mental health team, and specialist sexual assault counseling organization participated. Interpretative phenomenological analysis (IPA) was utilized to conduct single one-off interviews and analysis. Six themes were identified: Called to the work; Connection, Separation, and Oneness; Into and out of the darkness; Chaos into meaning; Reparation not repetition; and Expansion and growth. The first "Therapist Led Framework of Growth in Trauma Work" is presented. Vicarious posttraumatic growth (VPTG) was a key finding, with CPT therapists experiencing a "challenge/benefit/change" growth process. Adoption of actively relational strategies to enhance clinicians' growth process through trauma work is being proposed. The benefits of conceptualizing both the positive and negative impacts of such work for supervision, training, shaping the formal curricula, service management, and continuing professional development (CPD) are being discussed. The need for good practice guidelines on self-care internationally is highlighted.

Foster children's complex psychopathology in the context of cumulative childhood trauma: The interplay of ICD-11 complex PTSD, dissociation, depression, and emotion regulation

BACKGROUND

Foster children experience maltreatment at exceptionally high rates with increased risk to develop ICD-11 complex posttraumatic stress disorder (CPTSD). While rates of comorbidity between CPTSD and various disorders are high, the interplay between constituent aspects of psychopathology is not clearly understood. No study used network analysis to model the interplay between these aspects as potentially maintaining a stable condition of psychopathology, and research on the etiology and maintenance of CPTSD in children is especially scarce.

METHODS

Altogether, 208 Austrian foster children completed a set of standardized measures, resulting in a final sample of N = 122 foster children meeting the inclusion criteria. Experiences of childhood trauma, ICD-11 CPTSD, depression, dissociation, adaptive, and maladaptive emotion regulation were assessed. Following an exploratory approach, analyses were conducted using latent single indicator factor scores in two network models.

RESULTS

Domains of CPTSD, PTSD and disturbances in self-organization (DSO), evidenced as most central factors in children's complex psychopathology. Including cumulative childhood trauma did not influence the connectedness of factors in any relevant way. Shortest direct paths from cumulative childhood trauma to CPTSD included dissociation (PTSD) and adaptive emotion regulation (DSO) as mediating factors.

LIMITATIONS

Results are based on a small sample of highly-traumatized foster children, potentially limiting current findings' generalizability.

CONCLUSIONS

CPTSD identified as central in children's complex psychopathology, while the role of childhood trauma seems stronger for the onset than the maintenance of such psychopathology. The current network revealed central disorders and distinct mediating factors as important targets for treatment strategies and future research.

Validation of the Danish International Trauma Questionnaire for posttraumatic stress disorder in chronic pain patients using clinician-rated diagnostic interviews

Background: The estimated prevalence rate of comorbid posttraumatic stress disorder (PTSD) is high in trauma-exposed chronic pain patients. At the same time, self-report measures of PTSD tend to be over-inclusive within this specific population due to the high symptom overlap resulting in potential false positives. There is a need for an updated PTSD screening tools with a proper validation against clinical interviews according to the recently published 11^th revision of the World Health Organization's International Classification of Diseases (ICD-11). Objective: The present study aimed to validate the Danish International Trauma Questionnaire (ITQ) PTSD part in a sample of trauma-exposed chronic pain patients. Method: The ITQ was validated using a clinician-rated diagnostic interview of ICD-11 PTSD among chronic pain patients exposed to accident or work-related trauma (N = 40). Construct validity, concurrent and discriminant validity was investigated using confirmatory factor analyses (CFA) and correlation analysis, respectively. Three CFA models of ITQ PTSD part were tested in a sample of trauma-exposed chronic pain patients (N = 1,017) and a subsample of chronic pain patients exposed to accident or work-related trauma only (n = 367). Results: Diagnostic consistency between the six ICD-11 PTSD symptoms derived from the ITQ and the clinical interview (κ = .59) and the overall accuracy of the scale (AUC = .90) were good. The Danish ITQ showed excellent construct, concurrent and discriminant validity. The ICD-11 three factor PTSD model had excellent fit in both the full sample and the subsample of traffic and work-related accidents. Conclusions: The results indicate that the ITQ also has good psychometric properties in patients with chronic pain.

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.

Complex PTSD in survivors of intimate partner violence: risk factors related to symptoms and diagnoses

BACKGROUND

In 2018, the World Health Organization proposed a new diagnosis entitled Complex Posttraumatic Stress Disorder (CPTSD) in the ICD-11. It is a diagnosis that encompasses the classic symptoms of PTSD, along with symptoms of disturbances in self-organization (DSO). Although this disorder has been studied in several countries and populations, research on the population of women survivors of intimate partner violence (IPV) is scarce.

OBJECTIVES

1) To analyse the prevalence of CPTSD and PTSD according to ICD-11 criteria; 2) To analyse the associations between CPTSD symptomatology and severity of violence, level of fear, resilience and strategies of emotion regulation; 3) To analyse which risk factors (severity of violence, level of fear, resilience and strategies of emotion regulation) may differ between female survivors with CPTSD or PTSD.

METHOD

162 women IPV survivors who completed a socio-demographic and violence-related interview, as well as questionnaires to assess PTSD and CPTSD, severity of violence, resilience and emotion regulation strategies.

RESULTS

The results showed a higher prevalence of CPTSD (39.50%), compared to PTSD (17.90%). Moreover, a high level of fear was related to re-experiencing in the here and now, avoidance, current sense of threat and disturbances in relationships. Low levels of resilience and maladaptive emotion regulation strategies such as expressive suppression were related to affective dysregulation, negative self-concept and disturbances in relationships. Finally, the results showed that maladaptive emotion regulation strategies differentiated between meeting CPTSD and PTSD criteria in women survivors of IPV.

CONCLUSION

The findings of this study indicated that CPTSD was twice as prevalent as PTSD within the sample. Moreover, maladaptive emotion regulation strategy as expressive suppression was the main variable related to experiencing CPTSD, in contrast to PTSD. These findings may have important implications for the design of specific treatments aimed at women survivors of IPV, who also suffer CPTSD.

Reintegration interventions for CPTSD: a systematic review

BACKGROUND

Clinical guidelines recommend a phase-based approach to treatment for complex post-traumatic stress disorder (CPTSD), yet little is known about what interventions are being offered and which may be effective in the final 'reintegration' phase.

OBJECTIVE

To systematically review literature on reintegration interventions for CPTSD, describing the nature and effectiveness of interventions.

METHOD

We searched four electronic databases (Medline, PsycINFO, Embase, and PTSDpubs) for interventions aiming to facilitate reintegration for participants with probable CPTSD. We had two aims: firstly, to describe the interventions and secondly, to describe their effectiveness as measured through measures of reintegration, PTSD and/or disturbances in self-organization (DSO), or qualitative data describing changes experienced. Results are presented using narrative synthesis.

RESULTS

Fifteen studies met our inclusion criteria. Interventions included yoga, exercise, use of service dogs, residential treatment, education, self-defence and patient research involvement. Overall study quality was low, as assessed by critical appraisal tools. Of the six studies including a control group, two reported a statistically significant improvement in the measure of reintegration between the intervention and control group, four studies reported a statistically significant difference in the measure of PTSD symptoms, but none reported any significant differences between intervention and control groups in DSO. Of all eight quantitative studies, three reported a statistically significant difference in the reintegration measure pre- to post-intervention for the intervention group, five a statistically significant improvement in the measure of PTSD symptoms, and three a significant difference in the DSO measure. From eight studies reporting qualitative date we synthesized themes into eight categories, within which facilitation of connection with others was the most commonly reported benefit.

CONCLUSIONS

The interventions outlined may facilitate reintegration, however, research in this area is still in its infancy and quality research is lacking. Further research is needed to establish whether reintegration interventions enhance treatment for CPTSD.

Factor structure of the International Trauma Questionnaire in UK Armed Forces veterans residing in Northern Ireland

Background: Complex Posttraumatic Stress Disorder (C-PTSD) was recently included in the revised International Classification of Diseases (ICD-11) by the World Health Organization (WHO, 2018). C-PTSD is a new trauma related disorder which may develop after prolonged and multiple exposures to trauma. It is a sister disorder of PTSD and is further characterized by symptomatology of disorganized self-organization (DSO). To qualify for the diagnosis, individuals must first meet the diagnostic criteria for PTSD, then report DSO symptoms and functional impairment. A body of work is emerging which has focused on the underlying dimensionality of C-PTSD across both adult and more recently adolescent populations from differing index trauma groups and from across several nations and cultures. However, few studies have been conducted in populations exposed to combat trauma despite the obvious prolonged and multiple nature of their trauma histories. Objective: To contribute to emerging evidence of the factor structure of ICD-11 C-PTSD in a novel population. Methods: This is the first factor analytic study to explore C-PTSD in a sample of UK Armed Forces veterans residing in Northern Ireland (N = 732). C-PTSD was measured via the ITQ and we utilized CFA to assess the fit of 7 competing models. Results: Based on established CFA fit indices, a correlated, first order, 6-factor model of C-PTSD, representing 3 PTSD and 3 DSO symptom groupings, was deemed to provide superior fit to the data compared to 6 alternative C-PTSD models. The superiority of the model was further supported by statistical comparisons of competing C-PTSD models. All factor loadings (0.866-0.998) and inter-factor correlations (.746-.975) of the optimally fitting model were statistically significant and high. Conclusion: These results provide support for the construct validity of ICD-11 C-PTSD in a unique sample of Armed Forces veterans residing in Northern Ireland.

A combined individual and group-based stabilization and skill training intervention versus treatment as usual for patients with long lasting posttraumatic reactions receiving outpatient treatment in specialized mental health care – a study protocol for a randomized controlled trial

Background

Suffering linked to previous interpersonal trauma is common among patients in mental health care. Diagnostic labels may vary, but the clinical picture is often characterized by long-lasting and complex psychological and somatic symptoms, subjective distress and reduced quality of health and life. A substantial proportion of patients do not recover after individual treatment in ordinary specialized mental healthcare settings, despite the proven usefulness of individual trauma-specific treatments. The therapeutic factors that arise in group settings, such as normalization, shame reduction and corrective relational experiences, may be particularly useful for trauma survivors. However, evidence in support of group treatment for trauma survivors is scarce. This study aims to test whether combining a novel group intervention to individual treatment is superior to conventional individual out-patient treatment in an ordinary community mental health hospital.

Methods

In a single-site, non-blinded, randomized controlled trial (RCT), the effect of a combined group-based stabilization and skill-training (SST) intervention added to individual treatment will be compared to conventional treatment (treatment as usual, TAU) alone. Participants (N = 160) with ongoing and long-lasting reactions related to known adverse life events from the past will be recruited among patients at general outpatient clinics in a community mental health centre at St. Olav’s University Hospital, Trondheim, Norway. Following baseline assessment and randomization, participants will complete follow-up measures at 4, 8, 13 and 19 months post-baseline. The primary outcome is personal recovery (The questionnaire about the process of recovery , QPR). Secondary outcomes include (1) self-reported symptoms of posttraumatic stress, general mental and somatic health symptoms, well-being, functional impairment and client satisfaction, (2) immunological and endocrine response measured in blood samples and (3) national registry data on occupational status, use of mental health services and pharmacological treatment. Additionally, mechanisms of change via posttraumatic cognitions will be examined.

Discussion

The addition of a group-based intervention to individual treatment for trauma survivors might prove to be an efficient way to meet the need of long-lasting high-intensity treatment in a large group of patients in mental health care, thereby reducing their suffering and increasing their psychosocial functioning.

Trial registration

ClinicalTrials.gov: NCT03887559. Registered on 25 March 2019.

Indirect effects of PTSD and complex PTSD in the relationship of polyvictimization with intimate partner violence victimization and perpetration among men in mandated treatment

Background: Polyvictimization is associated with posttraumatic stress disorder (PTSD), severe impairment, and re-victimization, including due to intimate partner violence (IPV), but polyvictmization's role in the perpetration of IPV is less clear. Objective: To examine the indirect effect of PTSD and complex PTSD in the relationship between polyvictimization and IPV perpetration. Method: Polyvictims were identified by cluster analysis of self-reported lifetime victimization history data in a random national sample (N = 234) of men at 66 clinical treatment centers for domestic violence perpetrators in Israel. Results: Four sub-groups were identified: low exposure to abuse and physical neglect (C1, N = 105), and three polyvictim sub-groups characterized by multiple forms of past exposure to neglect and verbal abuse (C2, N = 38), to verbal and physical abuse without neglect (C3, N = 46), or to neglect and both verbal and physical abuse (C4, N = 28). Participants also were characterized as having low exposure to traumatic events across the lifespan (cluster L5, N=156), or high exposure to traumatic events across the lifespan (cluster L6, N=78). Complex PTSD symptoms had an indirect effect in the relationship between membership in the C3 and C4 polyvictimization clusters (β=.45, p<.05, β=.60, p<.05; respectively) and severity of psychological IPV victimization, as well as between C3 polyvictimization cluster membership and severity of psychological IPV perpetration (β=.32, p<.05). In contrast, PTSD symptoms had no indirect effect in any relationship between cluster membership and IPV outcomes. High lifetime trauma exposure also was directly associated with sexual IPV victimization. Conclusions: Complex PTSD may be a mechanism linking polyvictimization to the severity of both IPV victimization and perpetration. Clinical implications are discussed.