Does PTSD transcend cultural barriers? A study from the Khmer Adolescent Refugee Project

Is factor analysis useful for revising diagnostic criteria for PTSD? A systematic review of five issues ten years after DSM-5

BACKGROUND

Based on factor analysis research, DSM-5 revised the diagnostic criteria for posttraumatic stress disorder (PTSD) by increasing symptom clusters from three to four.

AIMS

To question whether that is an appropriate use of factor analysis.

METHODS

Reviewed the literature on five issues of factor analysis relevant to diagnostic criteria: (1) discovery of factors identical to symptom clusters, (2) consensus about the number of factors in best-fitting models, (3) configural variance between subpopulations to explain inconsistent model results, (4) methods to externally validate factors after discovery, and (5) treatment response of symptom clusters to externally validate factors. Two hundred four articles using DSM-IV or DSM-5 symptoms were included.

RESULTS

Two of four DSM-5 clusters were discovered with exploratory factor analysis. Support for a best-fitting model was inconsistent. Models with the highest number of factors were the best mathematical fit 87% of the time. Subpopulations did not reveal a pattern of configural variance to explain inconsistent findings. External validation of factors relied entirely on questionnaires. A review of 143 randomized controlled trials did not reveal differential treatment response of any symptom cluster.

CONCLUSION

Findings did not support the usefulness of factor analysis because the findings are too disparate to be helpful.

Standardized Suicide Prevention Program for Gatekeeper Intervention of North Korean Defectors in South Korea

OBJECTIVE

North Korean defectors (NKDs) have experienced substantial difficulties during the migration and settlement in South Korea. They have a high prevalence of depression, post-traumatic stress disorder, and suicidal behaviors. The high prevalence of mental disorders among NKDs can lead to a high suicide rate. However, there are no suicide prevention programs for NKDs. This study aims to customize a suicide prevention program with content suitable for NKDs' particular circumstances.

METHODS

A multidisciplinary research team developed this program based on domestic and international gatekeeper training programs for suicide prevention and articles related to suicide prevention.

RESULTS

We developed a multi-part gatekeeper training program, "Suicide CARE for NKDs." In the "Introduction," trainees learn about the need for the program and its importance. In "Careful observation," trainees learn to recognize linguistic, behavioral, and situational signals of suicide risk. In "Active listening," trainees learn how to ask about suicidal thoughts and to listen empathetically. In "Risk evaluation and expert referral," trainees learn to evaluate suicide risk and to connect NKDs with institutes or services.

CONCLUSION

We expect this program to become useful for training gatekeepers to prevent suicide among NKD. A future follow-up study is needed to confirm the efficacy of the program.

The Dimensionality of Proposed DSM-5 PTSD Symptoms in Trauma-Exposed Young Children

A subtype of the posttraumatic stress disorder diagnosis for children 6 years and younger (PTSD-6Y) was introduced in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5). This study utilized confirmatory factor analytic techniques to evaluate the proposed DSM-5 PTSD-6Y factor structure and criterion and convergent validity against competing models. Data for N = 284 (3–6 years) trauma-exposed young children living in New Orleans were recruited following a range of traumas, including medical emergencies, exposure to Hurricane Katrina and repeated exposure to domestic violence. The model was compared to DSM-IV, a 4-factor ‘dysphoria’ model that groups symptoms also associated with anxiety and depression, and alternate 1- and 2- factor models. Convergent validity was established against the Child Behavior Checklist (CBCL). Criterion related validity was established by comparing each model to a categorical rating of impairment. The Dysphoria and PTSD-6Y models offered the better accounts of symptom structure, although neither satisfied minimum requirements for a good fitting model. These two models also only showed small levels of convergence with CBCL dimensions. The 1-factor model offered the most compelling balance of sensitivity and specificity, with the 2-factor model and the Dysphoria model following closely behind. These CFA results do not support the symptom clusters proposed within the DSM-5 for PTSD-6Y. Although a 4-factor Dysphoria model offers a better overall account of clustering patterns (relative to alternate models), alongside acceptable sensitivity and specificity for detecting clinical impairment, it also falls short of being an adequate model in this younger age group.

Psychological morbidity among forcibly displaced children-a literature review

In 2018, nearly 75 million people were displaced from their place of origin of which 20.4 million are considered as refugees. Children constitute over half of this population. A review of the currently available literature regarding the psychological impact of forced displacement on children was performed with the concept examined under three stages of flight: pre-migration, intra-migration and post-migration. The resilience of children despite adversities is explored. Post-traumatic stress disorder (PTSD), depression and anxiety are the most commonly studied effects of forced migration on children. Rates range from 20 to 52.7%, 23 to 44.1% and 38.3 to 69% respectively. PTSD is associated with pre-migration disturbances such as witnessing death or torture of relatives, assaults and separation from family. Intra-migration difficulties relate to the hazardous journey, length of detention, type of facility and failed asylum application. Post-migration difficulties highlighted are insecure asylum status, housing worries, multiple relocations and poor acculturation technique and are more related to depression and anxiety. Despite these challenges and the tremendous horror witnessed, the majority of children report good functionality in their host countries in the long-term. The purpose of this report is to provide an overview of the factors contributing to the manifestation of mental health issues in child refugees as well as to examine mechanisms which enhance successful resettling in the host society. Health and social care providers must understand the complex interplay between the damaging effects of displacement, and the innate protective factors that persecuted children possess. Management should involve a holistic approach that considers children, families and native communities.

Invariance of the Construct of Posttraumatic Stress Disorder: A Systematic Review

We conducted a systematic review of studies that have evaluated invariance of the construct of posttraumatic stress disorder (PTSD) to summarize their conclusions related to invariance/noninvariance and sources of noninvariance. In November 2017, we searched Pubmed, PSYCINFO, PILOTS Web of Science, CINAHL, Medline, and Psychological and Behavioral Science Collection for abstracts and articles with these inclusionary criteria: peer-reviewed, including DSM-IV or DSM-5 PTSD invariance as a main study aim, use of multigroup confirmatory factor analyses, and use of an independent PTSD instrument or module. In total, 45 articles out of 1,169 initially identified abstracts met inclusion criteria. Research assistants then followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to complete a secondary search and independently extract data. Results indicated that DSM-IV dysphoric arousal and DSM-5 hybrid model factors demonstrated the most stability; sources of instability were some intrusion (distress to trauma cues), dysphoria/numbing (traumatic amnesia, foreshortened future, emotional numbness, detachment), and arousal (hypervigilance) items. The PTSD Checklist and PTSD Reaction Index were most often used to assess PTSD in studies investigating its invariance; however, these measures demonstrated partial conceptual equivalence of PTSD across subgroups. Instead, clinician-administered measures demonstrated more conceptual equivalence across subgroups. Age, gender, cultural/linguistic factors, and sample diversity had the least moderating effect on PTSD's symptom structure. Our review demonstrates the need to examine invariance of the PTSD construct following recommended guidelines for each empirical and clinical trial study to draw meaningful multigroup comparative conclusions.

Knowledge and training in paediatric medical traumatic stress and trauma-informed care among emergency medical professionals in low- and middle-income countries

Background: Provision of psychosocial care, in particular trauma-informed care, in the immediate aftermath of paediatric injury is a recommended strategy to minimize the risk of paediatric medical traumatic stress. Objective: To examine the knowledge of paediatric medical traumatic stress and perspectives on providing trauma-informed care among emergency staff working in low- and middle-income countries (LMICs). Method: Training status, knowledge of paediatric medical traumatic stress, attitudes towards incorporating psychosocial care and barriers experienced were assessed using an online self-report questionnaire. Respondents included 320 emergency staff from 58 LMICs. Data analyses included descriptive statistics, t-tests and multiple regression. Results: Participating emergency staff working in LMICs had a low level of knowledge of paediatric medical traumatic stress. Ninety-one percent of respondents had not received any training or education in paediatric medical traumatic stress, or trauma-informed care for injured children, while 94% of respondents indicated they wanted training in this area. Conclusions: There appears to be a need for training and education of emergency staff in LMICs regarding paediatric medical traumatic stress and trauma-informed care, in particular among staff working in comparatively lower income countries.

The latent structure of post-traumatic stress disorder among Arabic-speaking refugees receiving psychiatric treatment in Denmark

BACKGROUND

Refugees are known to have high rates of post-traumatic stress disorder (PTSD). Although recent years have seen an increase in the number of refugees from Arabic speaking countries in the Middle East, no study so far has validated the construct of PTSD in an Arabic speaking sample of refugees.

METHODS

Responses to the Harvard Trauma Questionnaire (HTQ) were obtained from 409 Arabic-speaking refugees diagnosed with PTSD and undergoing treatment in Denmark. Confirmatory factor analysis was used to test and compare five alternative models.

RESULTS

All four- and five-factor models provided sufficient fit indices. However, a combination of excessively small clusters, and a case of mistranslation in the official Arabic translation of the HTQ, rendered results two of the models inadmissible. A post hoc analysis revealed that a simpler factor structure is supported, once local dependence is addressed.

CONCLUSIONS

Overall, the construct of PTSD is supported in this sample of Arabic-speaking refugees. Apart from pursuing maximum fit, future studies may wish to test simpler, potentially more stable models, which allow a more informative analysis of individual items.

Current Psychopathological Symptoms in Children and Adolescents Who Suffered Different Forms of Maltreatment

The aim of the present study is to evaluate the current psychopathological problems of different forms associated with maltreatment on children's and adolescents' mental health. Ninety-five females and ninety males with a mean age of 8.8 years who have suffered in the last six months different forms of abuse (physical, sexual, and emotional) and neglect were included in the study. The current reaction to trauma as directly observed by clinical instruments was examined. Differences in gender, age at the time of medical examination, familial psychiatric disorders, neuropsychiatric status, and type of maltreatment were also taken into account. Results documented that 95.1% of abused children and adolescents developed a psychiatric disorder or a subclinical form of a Posttraumatic Stress Disorder (PTSD). Moreover, our data demonstrate a role for gender, age, and familial psychiatric comorbidity in the current psychopathological problems associated with maltreatment. Overall, our findings can help clinicians make a diagnosis and provide efficient treatment and prevention strategies for child maltreatment and abuse.

A Factor Analysis of PTSD with Latino Samples with Substance Use Disorders

Objective

The Post - Traumatic Stress Disorder (PTSD) factor structure is not a generally agreed upon concept. It has remained controversial and its’ efficacy regarding different trauma presentations is still in question. Therefore, it is imperative that we evaluate different conceptualizations of the PTSD factor structure. This study aims to understand how PTSD is structured when comorbid with Substance Use Disorder (SUD).

Method

We evaluated presentations of PTSD - SUD from a Latino community based sample. This was done using several accepted models of the PTSD factor structure. We then performed an exploratory factor analysis of the factor structure of PTSD when comorbid with SUD.

Results

We found that the factor structure of PTSD - SUD was different from the structure presented in the DSM - IV and other empirically validated structural models.

Conclusion

The factor structure of PTSD may need to include a separate structure when PTSD is comorbid with SUD. Cultural differences when structuring the PTSD diagnosis should also be considered.

Confirmatory factor analyses of DSM-5 posttraumatic stress disorder symptoms in psychiatric samples differing in Criterion A status

We examined the symptom structure of posttraumatic stress disorder (PTSD), as defined by American Psychiatric Association (2013. Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed.). Washington, DC: Author). DSM-5 introduced notable changes to PTSD criteria, and the structural impact of these changes is unclear. We conducted confirmatory factor analyses comparing seven commonly investigated or recently proposed PTSD models in a large sample of interviewed psychiatric outpatients reporting a Criterion A trauma (n = 310) or a sub-threshold (non-Criterion A) stressful life event (n = 284). A novel six-factor dysphoria model and recently proposed seven-factor hybrid model outperformed other models and fit the data equally well in both groups. Our results suggest equal fit for both models, although the six-factor model is more parsimonious. These results have implications for research regarding the mechanisms underlying and the treatments targeting PTSD.

Familial separations, coping styles, and PTSD symptomatology in resettled refugee youth

Youth from refugee backgrounds have been found to experience high rates of posttraumatic stress disorder (PTSD), even after years of resettlement. The present study sought to investigate how familial separations and coping styles act as correlates of PTSD symptoms in resettled refugee youth (N = 50). Participants (Mage = 16.63; range: 12-21) completed self-report questionnaires assessing PTSD symptoms and their use of coping styles, and engaged in a semi-structured interview designed by the authors to investigate their resettlement and adaptational experiences in Australia. Youth who were separated from immediate family members demonstrated significantly more PTSD symptoms than their counterparts, and there was a relationship between avoidant coping and PTSD, although this diminished once the confound between scales was controlled for. This study found evidence for the integrity of the family unit as a correlate of PTSD in refugee youth, but no evidence of a relationship between coping style and family separations.

Posttraumatic symptom structure across age groups

The applicability of diagnostic criteria of Posttraumatic Stress Disorder to the pediatric population has been a focus of much debate (e.g., Carrion, Weems, Ray, & Reiss, 2002 ), informing changes in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5). The current study examined the factor structure of posttraumatic distress among adult versus pediatric samples using confirmatory factor analysis. The analysis was performed on the DSM-IV-adherent Posttraumatic Diagnostic Scale (Foa, Cashman, Jaycox, & Perry, 1997 ) and Child Posttraumatic Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001 ). The sample included 378 adult and 204 child and adolescent victims of diverse single-event traumas. A series of models based on previous findings and DSM-IV specification were evaluated. A 4-factor model (Intrusions, Avoidance, Dysphoria, and Hyperarousal), similar to the DSM-5 model, best fit the data among adults, and a different 4-factor model (Intrusion, Avodiance, Numbing, and Hyperarousal) best fit the data among children and adolescents. Despite some similarity, the posttraumatic symptom profiles of pediatric and adult samples may differ. These differences are not fully incorporated into the DSM-5, and warrant further examination.

Do gender and age moderate the symptom structure of PTSD? Findings from a national clinical sample of children and adolescents

A substantial body of evidence documents that the frequency and intensity of posttraumatic stress disorder (PTSD) symptoms are linked to such demographic variables as female sex (e.g., Kaplow et al., 2005) and age (e.g., Meiser-Stedman et al., 2008). Considerably less is known about relations between biological sex and age with PTSD's latent factor structure. This study systematically examined the roles that sex and age may play as candidate moderators of the full range of factor structure parameters of an empirically supported five-factor PTSD model (Elhai et al., 2011). The sample included 6591 trauma-exposed children and adolescents selected from the National Child Traumatic Stress Network's Core Data Set. Confirmatory factor analysis using invariance testing (Gregorich, 2006) and comparative fit index difference values (Cheung and Rensvold, 2002) reflected a mixed pattern of test item intercepts across age groups. The adolescent subsample produced lower residual error variances, reflecting less measurement error than the child subsample. Sex did not show a robust moderating effect. We conclude by discussing implications for clinical assessment, theory building, and future research.

Assessing children's disaster reactions and mental health needs: screening and clinical evaluation

OBJECTIVE

To present a framework for assessing children's disaster reactions and mental health needs.

METHODS

We reviewed the relevant literature and clinical experience to identify information on assessment approaches in children and to construct an assessment framework based on disaster exposure.

RESULTS

Child disaster mental health assessment includes 2 components-screening and clinical evaluation-but these have not been fully explicated or distinguished in the literature. Screening can be used to assess large numbers of children across exposure groups. Clinical evaluation is appropriate for children who are directly exposed to a disaster, for those whose family members and (or) close associates are directly exposed, and for those who are identified through screening as being at risk for psychiatric disturbance. Clinical evaluation includes a full diagnostic assessment (posttraumatic stress disorder and other disorders) with the goals of identifying psychopathology, determining the need for clinical care, and guiding intervention planning and referral. Children with psychiatric conditions should be referred to treatment, while those with psychological distress but without psychiatric illness may benefit from psychosocial interventions.

CONCLUSIONS

Screening is appropriate to identify children at risk for psychiatric disturbance who will need further evaluation to determine diagnosis. Screening should not be used to dictate treatment decisions. Children who screen positive for psychiatric risk should receive a full clinical evaluation. Children determined to be suffering from psychiatric disorders should receive, or be referred for, formal treatment. Children without psychiatric disorders may benefit from psychosocial interventions.

Mental health approaches to child victims of acts of terrorism

It has long been recognized that human beings exposed to severe stress may develop psychological symptoms. With recent terrorist acts around the world including the New York City World Trade Center September 11, 2001 atrocity, there has been a growing interest in the specific impact of terrorist acts on the victims and witnesses. One area that has received less study is the specific impact on children. This paper reviews some of the general effects of traumatic stress on children and the history of the research in this area including a specific discussion of post-traumatic stress disorder in children. This is followed by a review of how children might react to the trauma of a terrorist attack differentiating between three different subgroups of children (preschool age children, school-age children, and adolescents). Then there is a review of what a comprehensive evaluation of childhood victims of terrorism should entail. Finally, treatment modalities that have been shown to be effective are reviewed.

Psychometric properties of the child PTSD checklist in a community sample of South African children and adolescents

OBJECTIVE

The current study assessed the basic psychometric properties of the Child PTSD Checklist and examined the structure of symptoms of posttraumatic stress disorder (PTSD) in a large sample of South African youth.

METHODOLOGY

The checklist was completed by 1025 (540 male; 485 female) South African youth (aged between 10 and 19 years). The factor structure of the scale was assessed with a combination of confirmatory and exploratory techniques. Internal consistencies for the full scale and all subscales were evaluated with Cronbach's alpha and McDonald's omega. Validity was assessed by comparing PTSD scores obtained by children who had and had not experienced a traumatic event, and by examining associations between total PTSD scores and known correlates of PTSD.

RESULTS

Scores on the Child PTSD Checklist clearly discriminated between youth who had experienced a traumatic event and those who had not. Internal consistencies for the full scale (and all subscales) were acceptable to good and hypothesized correlations between PTSD, depression, anxiety, somatic symptoms, and age were observed. Two of the reported fit statistics for the tripartite DSM-IV-TR model of PTSD did not meet traditional criteria and further exploratory analyses revealed a four-factor structure (broadly consistent with Simms and colleagues' Dysphoria Model of PTSD symptoms) which provided a better fit to the observed data.

CONCLUSION

Given the continued use of the Child PTSD Checklist in South Africa, findings offer an important first step in establishing the reliability and validity of the checklist for use with South African youth. However, further evaluation of the checklist in South African samples is clearly required before conclusions regarding its use as diagnostic tool in this context can be made.

The validity of the DSM-IV PTSD criteria in children and adolescents: a review

OBJECTIVE

DSM-V is on its way and doubts have been raised regarding the validity of pediatric PTSD. It is the goal of the current review to critically review the empirical literature on PTSD in youth.

METHOD

A search of PsycINFO, PubMed and reference lists was conducted. Empirical information considered relevant regarding the validity of the criteria was collected.

RESULTS/CONCLUSIONS

The validity of the symptom criteria and clusters varies, with the Avoidance/Numbing cluster outperforming the Re-experiencing-and Arousal cluster. Factor analytic findings suggest that Arousal criterion D4 should be placed within the Re-experiencing cluster, and that the Avoidance/Numbing cluster should be split up. Some non-DSM-IV PTSD symptoms, among which guilt, have considerable validity in trauma-exposed youth and their inclusion in DSM-V PTSD should be considered. As for preschool children, alternative criteria are recommended that are more developmentally sensitive.

Ethnic Differences in Symptoms of Post-traumatic Stress after the Exxon Valdez Oil Spill

Introduction:

Previous studies have reported ethnic differences in the prevalence of post-traumatic stress disorder (PTSD), but the reasons for these differences remain unclear.

Hypothesis:

Ethnic differences in the prevalence of PTSD may reflect ethnic differences in (1) exposure to traumatic events; (2) appraisal of such event as traumatic; and (3) culturally-determined responses to standardized diagnostic instruments, reflecting differences in cultural meanings associated with physical symptoms and idioms of distress.

Methods:

Ethnic differences in risk factors and factor structures of PTSD symptoms were examined in 188 Alaskan Natives and 371 Euro-Americans exposed to the Exxon-Valdez oil spill in 1989.

Results:

High levels of social disruption were associated with PTSD one year after the oil spill in both ethnic groups. However, low family support, participation in spill clean-up activities, and a decline in subsistence activities were significantly associated with PTSD in Alaskan Natives, but not in Euro-Americans. Factor analysis of the Diagnostic Interview Schedule PTSD subscale revealed five factors for both ethnic groups. However, the items comprising these factors were dissimilar.

Conclusions:

These results suggest that social disruption is sufficiently traumatic to be associated with symptoms of post-traumatic stress, but that a diagnosis of PTSD must take into consideration local interpretations of these symptoms.

Anthropological discourses on the globalization of posttraumatic stress disorder (PTSD) in post-conflict societies

Posttraumatic stress disorder (PTSD) is a construct that has moved far beyond its origins in Veterans Administration hospitals after the Vietnam War. It is now commonly used in post-conflict societies by humanitarian agencies and researchers. This article looks at the ever-growing expansion of PTSD and reviews medical anthropologists' critiques of this cross-cultural dissemination of Western psychiatric knowledge. The article also reviews post-conflict ethnographies and their results, which often highlight a mismatch between local priorities and the psycho-social services being provided by outside agencies. Finally, the author highlights interventions that are currently being undertaken by humanitarian agencies in an attempt to bridge psychiatric expertise and local forms of healing. Although PTSD is a useful construct for conceptualizing the experience of those who have suffered traumatic events, it does not lend itself to universal cross-cultural application and should be cautiously applied in post-conflict societies.

Confirmatory factor analysis of posttraumatic stress symptoms in Brazilian primary care patients: an examination of seven alternative models

The DSM-IV-TR postulates that PTSD symptoms are organized into 3 clusters. This assumption has been challenged by growing number of factor analytical studies, which tend to favor 4-factor, first-order models. Our objective was to investigate whether the clusters of PTSD symptoms identified in North American and European studies could be replicated in a Brazilian sample composed of 805 primary care patients living in hillside slums. Volunteers were asked to fill out the Brazilian version of the Posttraumatic Stress Disorder Checklist-Civilian Version and a confirmatory factor analysis of this scale was conducted with the software LISREL 8.80. Seven models were tested and a 4-factor, first-order solution including an emotional numbing cluster was found to provide the best fit. Although PTSD has been characterized by some critics as a Western culture-specific disorder lacking universal validity, our results seem to uphold the cross-cultural validity of the 4-factor, first-order model.

PTSD in children and adolescents: toward an empirically based algorithma

In considering potential revisions for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), describing developmental influences on symptomatic expression is a high priority. This review presents a number of options and preliminary recommendations to be considered for DSM-V. Research conducted in the past 15 years is reviewed that pertains to expressions of posttraumatic stress disorder (PTSD) symptoms in preschool and school age children and in adolescents. This research has attempted to determine the usefulness of the DSM-IV criteria for PTSD in children and adolescents. Based on the studies of preschool children, evidence supports two sets of suggestions: first, we suggest that developmental manifestations are warranted in A-D criteria of PTSD; and second, we suggest that a developmental preschool PTSD subtype is warranted that lowers the C threshold from three to one symptom. For school-age children and young adolescents, the evidence is more limited. Nevertheless, there is also evidence suggesting that modifications in PTSD criteria A-D, including fewer Cluster C symptoms, may facilitate accurate diagnosis in this age group.

The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5

BACKGROUND

There is considerable debate about the cross-cultural applicability of the posttraumatic stress disorder (PTSD) category as currently specified. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds. This review examines various types of cross-cultural validity of the PTSD criteria as defined in DSM-IV-TR, and presents options and preliminary recommendations to be considered for DSM-5.

METHODS

Searches were conducted of the mental health literature, particularly since 1994, regarding cultural-, race-, or ethnicity-related factors that might limit the universal applicability of the diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria for DSM-5.

RESULTS

Substantial evidence of the cross-cultural validity of PTSD was found. However, evidence of cross-cultural variability in certain areas suggests the need for further research: the relative salience of avoidance/numbing symptoms, the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms. This review also indicates the need to modify certain criteria, such as the items on distressing dreams and on foreshortened future, to increase their cross-cultural applicability. Text additions are suggested to increase the applicability of the manual across cultural contexts: specifying that cultural syndromes-such as those indicated in the DSM-IV-TR Glossary-may be a prominent part of the trauma response in certain cultures, and that those syndromes may influence PTSD symptom salience and comorbidity.

CONCLUSIONS

The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

PTSD, depression and anxiety among former abductees in Northern Uganda

BACKGROUND

The population in Northern Uganda has been exposed to extreme levels of traumatic stress and thousands abducted forcibly became rebel combatants.

METHODS

Using structured interviews, the prevalence and severity of posttraumatic stress disorder (PTSD), depression and anxiety was assessed in 72 former abducted adults, 62 of them being former child soldiers.

RESULTS

As retrospective reports of exposure to traumatic stress increased, anxiety and PTSD occurrence increased (r = .45). 49% of respondents were diagnosed with PTSD, 70% presented with symptoms of depression, and 59% with those of anxiety. In a multiple linear regression analysis four factors could best explain the development of PTSD symptoms: male respondents (sex) living in an IDP-Camp (location) with a kinship murdered in the war (family members killed in the war) and having experienced a high number of traumatic events (number of traumatic events) were more likely to develop symptoms of PTSD than others. In disagreement to a simple dose-response-effect though, we also observed a negative correlation between the time spent with the rebels and the PTSD symptom level.

CONCLUSIONS

Former abductees continue to suffer from severe mental ill-health. Adaptation to the living condition of rebels, however, may lower trauma-related mental suffering.

Understanding the experiences and emotional needs of unaccompanied asylum-seeking adolescents in the UK

For adolescents who flee to the UK seeking asylum, the experience of leaving their home country puts them at risk of developing mental health problems. Although there is a research base exploring the mental health of asylum-seeking children and adolescents who arrive with their families, there is in contrast very little focusing on the mental health needs of children and adolescents who arrive in the UK alone. There has been ongoing debate about whether current theoretical models for understanding reactions to trauma and loss are helpful in supporting unaccompanied asylum-seeking children and adolescents with complex psychological and social issues as a result of fleeing their home countries. This article draws on young people's own understanding of their experiences of seeking asylum in the UK using a qualitative semi-structured interview. It attempts to develop a more contextually relevant understanding of their emotional reactions to adversity and to consider the sorts of support required. Interpretative Phenomenological Analysis was used to provide an in-depth understanding of six young asylum seekers' experiences, exploring themes of loss, negotiating a new life, psychological distress and the process of adjustment. Psychological interventions and future service provision for this group are discussed.

Adolescent posttraumatic stress disorder: an examination of factor structure reliability in two national samples

A four-factor structure of posttraumatic stress disorder (PTSD) has been proposed for DSM-V based on empirical evidence that it is superior to the three-factor DSM-IV structure. However, most studies reveal multiple structures fit the data well in adolescent samples, and high factor correlations have been reported. Within two national samples of adolescents, we tested eight PTSD factor structures, which have never been compared in a single study. Confirmatory factor analyses (CFA) of PTSD symptoms were conducted in two national samples of adolescents: the National Survey of Adolescents (NSA; N = 4023) and the NSA-Replication (NSA-R; N = 3614). CFA revealed that all models provided very good fit to both samples (RMSEAs = .021-.039), though the one-factor model can be rejected, and correlations between factors were high (rs = .80-1.0). Potential interpretations of these findings include: (1) the indicators (i.e., symptoms) need refinement; or (2) relevant symptoms have yet to be identified.

Trauma rehabilitation for war-affected persons in northern Uganda: a pilot evaluation of the EMPOWER programme

OBJECTIVES. This study evaluated the impact of a culturally sensitive cognitive behaviour therapy (CBT)-based intervention (the EMPOWER programme) for war-affected persons in northern Uganda. DESIGN. The study conducted a pilot evaluation with a convenience sample of participants from internally displaced persons (IDPs) camps (i.e., a treatment camp and waitlist control camp). This was done to avoid treatment effects spreading from the intervention to control conditions. METHODS. A total of 202 participants (N= 90 treatment participants and N= 112 control participants) were included as a convenience sample. The Acholi Psychosocial Assessment Instrument (APAI), a culturally appropriate measure of psychosocial functioning, was administered to participants residing in two IDP camps at pre-treatment, post-treatment, and at 3-month follow-up. Participants in the treatment camp received the EMPOWER programme--a culturally sensitive CBT-based intervention teaching emotional resiliency and promoting forgiveness. RESULTS. Participants in the treatment condition reported (a) significantly lower scores on the depression-like syndromes and the anxiety-like syndrome and (b) significantly more prosocial behaviours, than participants in the control condition. CONCLUSIONS. The results of this study provide initial support for the application of structured CBT interventions in war-affected areas, illustrating that the EMPOWER programme could be utilized by humanitarian agencies to address the psychosocial needs of war-affected displaced persons.

Posttraumatic stress disorder symptom structure in injured children: functional impairment and depression symptoms in a confirmatory factor analysis

OBJECTIVE

To examine the factor structure of posttraumatic stress disorder (PTSD) symptoms in children and adolescents who have experienced an acute single-incident trauma, associations between PTSD symptom clusters and functional impairment, and the specificity of PTSD symptoms in relation to depression and general distress.

METHOD

Examined PTSD symptom structure in two samples of children (8 to 17 years of age) assessed an average of 6 months after unintentional injury: (1) a combined dataset of 479 children assessed with a PTSD symptom checklist, and (2) a sample of 204 children assessed via a standardized clinical interview. We evaluated the fit of six alternative models for the factor structure of PTSD symptoms, and the association of PTS symptom clusters with indicators of functional impairment. We then evaluated three models for the structure of PTSD and depression symptoms jointly, to examine specificity of PTSD versus general distress or mood symptoms.

RESULTS

In both samples, the DSM-IV 3-factor model fit the data reasonably well. Two alternative four-factor models fit the data very well: one that separates effortful avoidance from emotional numbing, and one that separates PTSD-specific symptoms from general emotional distress. Effortful avoidance and dysphoria symptoms were most consistently associated with impairment. The best-fitting model for PTSD and depression symptom clusters had three factors: PTSD-specific, depression-specific, and general dysphoria symptoms.

CONCLUSIONS

The DSM-IV model for PTSD symptom categories was a reasonable fit for these child data, but several alternative models fit equally well or better, and suggest potential improvements to the current diagnostic criteria for PTSD in children.

The PTSD symptom scale's latent structure: an examination of trauma-exposed medical patients

Several studies have employed confirmatory factor analysis (CFA) to evaluate the latent structure of posttraumatic stress disorder (PTSD) assessment measures among various trauma-exposed populations. Findings have generally failed to support the current three-factor DSM-IV PTSD conceptualization, demonstrating the need to consider alternative models. The present study used CFA to evaluate seven models, including intercorrelated and hierarchical versions of two models with the most empirical support. Data were utilized from a heterogeneous trauma-exposed sample of general medical patients (n=252). Based on several indices, the three-factor DSM-IV PTSD model was shown to be inferior to alternative models. The strongest support was found for an intercorrelated four-factor model, separating avoidance and numbing symptoms into distinct factors. Validity for this model was partially supported by divergent relations between factors and external variables. Implications of the results are discussed, and a framework is proposed for resolving discrepant findings in the PTSD CFA literature.

The structure of post-traumatic stress disorder symptoms in three female trauma samples: a comparison of interview and self-report measures

Empirical research increasingly suggests that post-traumatic stress disorder (PTSD) is comprised of four factors: re-experiencing, avoidance, numbing, and hyperarousal. Nonetheless, there remains some inconsistency in the findings of factor analyses that form the bulk of this empirical literature. One source of such inconsistency may be assessment measure idiosyncrasies. To examine this issue, we conducted confirmatory factor analyses of interview and self-report data across three trauma samples. Analyses of the interview data indicated a good fit for a four-factor model across all samples; analyses of the self-report data indicated an adequate fit in two of three samples. Overall, findings suggest that measure idiosyncrasies may account for some of the inconsistency in previous factor analyses of PTSD symptoms.

Post-traumatic reactions in adolescents: how well do the DSM-IV PTSD criteria fit the real life experience of trauma exposed youth?

This study examined the structure and symptom specific patterns of post traumatic distress in a sample of 1,581 adolescents who reported exposure to at least one traumatic event. Symptom reporting patterns are consistent with past literature in that females reported more symptoms than males and older youth reported more symptoms than did their younger peers. Young people reporting exposure to exclusively violent type traumas were also found to be more likely to endorse symptoms than peers exposed exclusively to non violent type traumas. Confirmatory factor analysis provided stronger support for a four-factor model of PTSD than either the DSM-IV model or an alternate model. Further examination of the four factor model revealed gender differences in factor loadings with small to moderate effect sizes for recurrent, distressing memories, flashbacks, restricted affect, difficulty remember details, detachment, limited future orientation, hypervigilance and startle symptoms. Differences in factor loadings with the four factor model were also noted between younger and older adolescents, with medium to large effect sizes on the arousal items. In contract, comparison of the factor loadings revealed only small differences between youth exposed exclusively to violent traumatic stressors and those exposed exclusively to non violent traumatic stressors, suggesting relative similarity between these two groups.

Post-traumatic stress disorder symptom clusters in Turkish child and adolescent trauma survivors

This study identified post-traumatic stress disorder (PTSD) symptom clusters in Turkish children and adolescents who experienced the 1999 Marmara Earthquake, which was classified as one of the world's six deadliest earthquakes in the 20th century. Two hundred ninety three children and adolescents (152 females and 141 males between the ages of 8 and 15) living in Izmit, the epicenter of the earthquake, participated in this study. The Post-Traumatic Stress Disorder Reaction Index for Children (CPTSD-RI) was administered to assess PTSD symptoms. A confirmatory factor analysis (CFA), using data from the CPTSD-RI, was conducted to determine whether the DSM-IV-TR symptom structure of PTSD was valid in Turkish children and adolescents. The CFA model supported the three-symptom cluster model. Limitations and implications for future research studies are included in the discussion.

The Body Remembers: Somatic Symptoms in Traumatized Khmer

Cambodians experienced genocide from 1975 to 1979 and ensuing civil war until 1993.

PURPOSE

Are Khmer with a history of trauma who present to a general medical clinic with unexplained physical symptoms more likely than the general population to harbor psychiatric symptoms?

METHODS

Subjects were drawn from a Phnom Penh clinic and the surrounding neighborhood. All subjects completed the Stressful Life Events Screening Questionnaire (SLESQ) and the PRIMEMD. Clinic patients with unexplained physical complaints were compared with neighborhood nonpatients. All individuals reporting trauma during the Pol Pot regime were compared to those reporting no such trauma; and those reporting exposure to domestic violence were compared to those without such exposure.

FINDINGS

There is an increased incidence of traumatic events, depressive symptoms, general anxiety symptoms, and panic symptoms in the clinical group as compared to the control group. Survivors of genocide-associated trauma reported more somatic complaints and panic symptoms, while survivors of domestic violence had an increased incidence of depressive symptoms, general anxiety symptoms, and panic symptoms.

CONCLUSION

Clinicians should consider the possibility of trauma-related psychological distress in patients who present with undiagnosable physical complaints.

Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma

BACKGROUND

Increasingly clinicians are being asked to assess and treat young refugees, who have experienced traumatic events due to war and organised violence. However, evidence-based guidance remains scarce.

METHOD

Published studies on the mental health difficulties of refugee children and adolescents, associated risk and protective factors, as well as effective interventions, particularly those designed to reduce war-related post-traumatic stress disorder (PTSD) symptoms, were identified and reviewed. The findings are summarised.

RESULTS

Young refugees are frequently subjected to multiple traumatic events and severe losses, as well as ongoing stressors within the host country. Although young refugees are often resilient, many experience mental health difficulties, including PTSD, depression, anxiety and grief. An awareness of relevant risk and protective factors is important. A phased model of intervention is often useful and the need for a holistic approach crucial. Promising treatments for alleviating symptoms of war-related PTSD include cognitive behavioural treatment (CBT), testimonial psychotherapy, narrative exposure therapy (NET) and eye movement desensitisation and reprocessing (EMDR). Knowledge of the particular needs of unaccompanied asylum-seeking children (UASC), working with interpreters, cross-cultural differences, medico-legal report writing and the importance of clinician self-care is also necessary.

CONCLUSION

More research is required in order to expand our limited knowledge base.

Screening for PTSD among Somali adolescent refugees: psychometric properties of the UCLA PTSD Index

This study presents the psychometric properties for the UCLA Posttraumatic Stress Disorder Index among a sample of Somali adolescents. Data were derived from a sample of English-speaking Somali adolescent refugees between the ages of 12 and 19 years (n=76). The UCLA PTSD Index showed good reliability (Cronbach's alpha=.85). Convergent validity was assessed through bivariate correlations with the Depression Self Rating Scale (r=.72, p<.001) and the War Trauma Screening Scale (r=59, p<.001). Results suggest that the UCLA PTSD Index may be a reliable and valid screening tool for PTSD symptoms for use with Somali adolescent refugees.

Initial physiological responses and perceived hyperarousal predict subsequent emotional numbing in pediatric injury patients

The present study tested the hypothesis that acute posttraumatic hyperarousal would lead to the development of emotional numbing (EN) symptoms in a pediatric injury population. Eighty-two youths aged 8-18 years were recruited from the emergency department of a Midwestern children's hospital. Heart rate was recorded from emergency medical services reports and a 12-hour urine collection was initiated upon admission. Six weeks and 6 months later, depression and PTSD symptoms were assessed. Initial heart rate and urinary cortisol levels predicted 6-week and 6-month EN after controlling for concurrent depression, avoidance, and reexperiencing symptoms and 6-week hyperarousal symptoms. These findings provide empirical support for prior hypotheses concerning the development of PTSD symptoms over time.

Validity of PTSD in a sample of refugee children: can a separate diagnostic entity be justified?

The objective of this study was to examine the construct validity of PTSD in a sample of refugee children from the Middle East-- more specifically, to assess whether associations between traumatic events and specific PTSD symptoms were more outspoken than (1) the associations of PTSD symptoms with non-traumatic exposures, and (2) the associations of violent exposures with symptoms other than PTSD-symptoms. Parents of 311 refugee children from the Middle East were interviewed concerning their children's traumatic experiences and mental health symptoms. The specific PTSD symptoms did not cluster in a factor analysis. The PTSD symptom complex was significantly predicted not only by violent exposures (mother tortured, OR 8.2, p < 0.005; father disappeared OR 3.2, p < 0.05) but also by indicators of family interaction and parents' occupational situation. The two identified violent exposures had significant independent associations with a series of symptoms including symptoms other than those of PTSD (r(s) ranging from 0.25 to 0.44, p < 0.001). Thus it does not seem sufficient to focus solely on PTSD symptomatology when assessing the mental health needs of refugee children.

Multisample cross-validation of a model of childhood posttraumatic stress disorder symptomatology

This study is the latest advancement of our research aimed at best characterizing children's posttraumatic stress reactions. In a previous study, we compared existing nosologic and empirical models of PTSD dimensionality and determined the superior model was a hierarchical one with three symptom clusters (Intrusion/Active Avoidance, Numbing/Passive Avoidance, and Arousal; Anthony, Lonigan, & Hecht, 1999). In this study, we cross-validate this model in two populations. Participants were 396 fifth graders who were exposed to either Hurricane Andrew or Hurricane Hugo. Multisample confirmatory factor analysis demonstrated the model's factorial invariance across populations who experienced traumatic events that differed in severity. These results show the model's robustness to characterize children's posttraumatic stress reactions. Implications for diagnosis, classification criteria, and an empirically supported theory of PTSD are discussed.

Predictive validity in a prospective follow-up of PTSD in preschool children

OBJECTIVE

To examine the predictive validity of an alternative to the DSM-IV for diagnosing posttraumatic stress disorder (PTSD) in preschool children and prospectively explore the course of PTSD symptomatology.

METHOD

Sixty-two traumatized children, ages 20 months through 6 years, were assessed three times in 2 years with caregiver diagnostic interviews.

RESULTS

PTSD diagnosis at visit 1 significantly predicted degree of functional impairment 1 and 2 years later and predicted PTSD diagnosis 2 years later but not 1 year later. The lack of 1-year diagnostic continuity may be explained by children with new traumas. Unexpectedly, overall PTSD symptoms did not remit over time, regardless of community treatment; however, reexperiencing symptoms decreased and avoidance/numbing symptoms increased with time, with avoidance/numbing symptoms increasing at a faster rate in children with PTSD at visit 1. The previous finding that arousal may cause emotional numbing was not replicated. Significantly more children were functionally impaired at visits 2 (48.9%) and 3 (74.3%) than were diagnosed with PTSD (23.4% and 22.9%, respectively).

CONCLUSIONS

This study demonstrates predictive validity for the alternative method of diagnosing PTSD in preschool children. The unremitting course of PTSD symptomatology in preschool children and rates of impairment that are higher than rates of diagnosis indicate the need for efficacious treatment.

Mismatch of posttraumatic stress disorder (PTSD) symptoms and DSM-IV symptom clusters in a cancer sample: exploratory factor analysis of the PTSD Checklist-Civilian Version

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994a) conceptualization of posttraumatic stress disorder (PTSD) includes three symptom clusters: reexperiencing, avoidance/numbing, and arousal. The PTSD Checklist-Civilian Version (PCL-C) corresponds to the DSM-IV PTSD symptoms. In the current study, we conducted exploratory factor analysis (EFA) of the PCL-C with two aims: (a) to examine whether the PCL-C evidenced the three-factor solution implied by the DSM-IV symptom clusters, and (b) to identify a factor solution for the PCL-C in a cancer sample. Women (N = 148) with Stage II or III breast cancer completed the PCL-C after completion of cancer treatment. We extracted two-, three-, four-, and five-factor solutions using EFA. Our data did not support the DSM-IV PTSD symptom clusters. Instead, EFA identified a four-factor solution including reexperiencing, avoidance, numbing, and arousal factors. Four symptom items, which may be confounded with illness and cancer treatment-related symptoms, exhibited poor factor loadings. Using these symptom items in cancer samples may lead to overdiagnosis of PTSD and inflated rates of PTSD symptoms.

Are avoidance and numbing distinct PTSD symptom clusters?

We present the conceptual basis and empirical evidence for considering avoidance and numbing as distinct posttraumatic stress disorder (PTSD) symptom clusters. The majority of data from factor analytic studies supports the position that avoidance and numbing are distinct symptom clusters. As well, the available data suggest that (a) different treatment modalities have differential effects on reducing avoidance but not numbing, (b) patients with more severe pretreatment numbing have poorer treatment outcomes, (c) avoidance and numbing have different patterns of correlation with depression, and (d) they have different correlations with physiological indices of attention. We conclude that avoidance and numbing are distinct PTSD symptom clusters. This distinction has implications for revising current diagnostic criteria. The recognition of this distinction may lead to advances in understanding and treating PTSD.