Testing the validity of ICD-11 PTSD and CPTSD among refugees in treatment using latent class analysis
DOI:
https://doi.org/10.7146/torture.v29i3.115367Keywords:
PTSD, Complex PTSD, ICD-11, International Trauma QuestionnaireAbstract
Introduction: The WHO has proposed posttraumatic stress (PTSD) and Complex PTSD (CPTSD) trauma-related ‘sibling’-disorders in ICD-11. The proposal has received support from research among clinical and community samples alike but only few studies have tested the validity of these disorders in a sample of refugees using the International Trauma Questionnaire especially designed for assessment of ICD-11 PTSD and CPTSD.
Methods: Latent class analysis was used to test the validity of the ICD-11 PTSD and CPTSD distinction in a heterogeneous group of 284 highly symptomatic refugees registered for treatment at a Danish treatment-center.
Results: A two-class solution fit the data best. One group reported elevated levels of PTSD-symptoms and symptoms of affective dysregulation, and one group reported elevated levels of symptoms corresponding to CPTSD. The CPTSD group was considerably larger than the PTSD-group.
Discussion: The current study supports the ICD-11 distinction between PTSD and CPTSD in a sample of treatment-seeking refugees. The assistance of interpreters was needed for some of the participants which affected the reliability of the assessment.
Conclusion: The ICD-11 proposal for PTSD and CPTSD is supported in a heterogenous sample of refugees using the ITQ.
References
Akaike, H. (1987). Factor analysis and AIC. In: Selected Papers of Hirotugu Akaike (pp. 371-386). New York: Springer.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
Ben-Ezra, M., Karatzias, T., Hyland, P., Brewin, C.R., Cloitre, M., Bisson, J.I., Roberts, N.P., Lueger-Schuster, B., & Shevlin, M. (2018). Posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as per ICD-11 proposals: A population study in Israel. Depression and Anxiety, 35 (3), 264-274. doi: 10.1002/ da.22723
Bogic, M., Njoku, A., & Priebe, S. (2015). Longterm mental health of war-refugees: a systematic literature review. BMC International Health and Human Rights, 15(1), 29. doi: 10.1186/s12914-015-0064-9
Brewin, C.R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R.A., … Reed, G.M. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 1-15. doi: 10.1016/j.cpr.2017.09.001
Briggs, S. R., & Cheek, J. M. (1986). The role of factor analysis in the development and evaluation of personality scales. Journal of Personality, 54(1), 106-148.
Buhmann, C., Mortensen, E. L., Nordentoft, M., Ryberg, J., & Ekstrøm, M. (2015). Follow-up study of the treatment outcomes at a psychiatric trauma clinic for refugees. Torture, 25(1), 1-16. doi: https://doi.org/10.7146/torture.v25i1.109505
Burri A., & Maercker A. (2014). Differences in prevalence rates of PTSD in various European countries explained by war exposure, other trauma and cultural value orientation. BMC Research Notes, 7, 407. doi:10.1186/1756-0500-7-407
Carta, M.G., Bernal, M., Hardoy, M.C., & Haro- Abad, J.M. (2005). Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1). Clinical Practice and Epidemiology in Mental Health, 1, 13-29. doi: 10.1186/1745-0179-1-13
Cloitre, M., Courtois, C. A., Ford, J. D., Green, B. L., Alexander, P., Briere, J., ... Van der Hart, O. (2012). The ISTSS expert consensus treatment guidelines for complex PTSD in adults. Retrieved from https://www.istss.org/ ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSDUpdated- 060315.pdf
Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4, 20706. doi: 10.3402/ejpt.v4i0.20706
Cloitre, M., Garvert, D.W., Weiss, B., Carlson, E.B., & Bryant, R.A. (2014). Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis. European Journal of Psychotraumatology, 5, 25097.
Cloitre, M., Roberts, N., Bisson, J.I., & Brewin, C.R., (2013). Self-Report Community Version 1.0. Translated by Elklit, A.(2015). Unpublished manuscript.
Cloitre, M., Shevlin, M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta Psychiatrica Scandinavia, 138(6), 536-546. doi: 10.1111/acps.12956
Competence Centre for Transcultural Psychiatry (2015). Tidlig intervention kan være nøglen til behandling af svær patientgruppe. [Early intervention might be key to treating a challenging patient-group] Retrieved from: https://www.psykiatri-regionh.dk/presse-og-nyt/ pressemeddelelser-og-nyheder/Nyheder-ogpressemeddelelser/ Sider/Tidlig-interventionkan- være-nøglen-til-behandling-af-sværpatientgruppe.aspx.
DIGNITY. (2019). Fakta om tortur | DIGNITY - Dansk Institut Mod Tortur. [Facts about torture| DIGNITY – Danish Institute Against Torture] Retrieved from: https://dignity.dk/dignitysarbejde/fakta-om-tortur/
Ditlevsen, D. N., & Elklit, A. (2010). The combined effect of gender and age on post-traumatic stress disorder: do men and women show differences in the lifespan distribution of the disorder? Annals of General Psychiatry, 9(1), 32. doi: 10.1186/1744-859X-9-32
Elklit, A., Nørregaard, J., Tibor, B. (1997). Traumatisering hos unge bosniske flygtninge i Danmark. [Traumatization among young Bosnian refugees in Denmark] Psykologisk Pædagogisk Rådgivning, 34, 3-18.
Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. The Lancet, 365(9467), 1309-1314. doi: 10.1016/S0140-6736(05)61027-6
Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. (2008). Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies (2nd ed.). New York, NY: Guilford.
Frost, R., Hyland, P., McCarthy, A., Halpin, R., Shevlin, M., & Murphy, J. (2019). The complexity of trauma exposure and response: Profiling PTSD and CPTSD among a refugee sample. Psychological Trauma: Theory, Research, Practice, and Policy, 11(2), 165. doi: 10.1037/tra0000408.
Geiser, C. (2010). Data analysis with Mplus. New York: Guilford Press.
Gil, T., Calev, A., Greenberg, D., Kugelmass, S., & Lerer, B. (1990). Cognitive functioning in posttraumatic stress disorder. Journal of Traumatic Stress, 3(1), 29-45. doi: https://doi.org/10.1002/jts.2490030104
Grossman, E. S., Hoffman, Y. S., Shrira, A., Kedar, M., Ben-Ezra, M., Dinnayi, M., & Zivotofsky, A. Z. (2019). Preliminary evidence linking complex-PTSD to insomnia in a sample of Yazidi genocide survivors. Psychiatry Research, 271, 161-166. doi: 10.1016/j.psychres.2018.11.044.
Harlacher, U., Polatin, P., Buhmann, C. B., Nordentoft, M., Ekstroem, M., Lohmann, J. C., & Mortensen, E. L. (2016) Comment and response to the commentary. Torture Journal, 26(1), 5-5.
Hecker, T., Huber, S., Maier, T., & Maercker, A. (2018). Differential Associations Among PTSD and Complex PTSD Symptoms and Traumatic Experiences and Postmigration Difficulties in aCulturally Diverse Refugee Sample. Journal of
Traumatic Stress, 31(6), 795-804. doi: 10.1002/jts.22342.
Hoffman, Y. S., Grossman, E. S., Shrira, A., Kedar, M., Ben‐Ezra, M., Dinnayi, M., ... & Zivotofsky, A. Z. (2018). Complex PTSD and its correlates amongst female Yazidi victims of sexual slavery living in post‐ISIS camps. World Psychiatry, 17(1),
doi: 10.1002/jts.22342.
Hyland, P., Ceannt, R., Daccache, F., Daher, R. A., Sleiman, J., Gilmore, B., ... & Vallières, F. (2018).Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable within a treatment-seeking sample of Syrian refugees living in Lebanon? Global Mental Health, 5. doi: 10.1017/gmh.2018.2.
Hyland, P., Murphy, J., Shevlin, M., Vallières, F., McElroy, E., Elklit, A., ... & Cloitre, M. (2017a). Variation in post-traumatic response: the role of trauma type in predicting ICD-11 PTSD and CPTSD symptoms. Social Psychiatry and Psychiatric Epidemiology, 52(6), 727-736. doi:10.1007/s00127-017-1350-8.
Hyland, P., Shevlin, M., Brewin, C.R., Cloitre, M., Downes, A.J., Jumbe, S., … Roberts, N.P. (2017b). Validation of post-traumatic stress disorder (PTSD) and complex PTSD using the International Trauma Questionnaire. Acta
Psychiatrica Scandinavica, 136, 313–322. doi:10.1111/acps.12771
Hyland, P., Shevlin, M., Elklit, A., Murphy, J., Vallières, F., Garvert, D. W., & Cloitre, M. (2017c). An assessment of the construct validity of the ICD-11 proposal for complex posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 9(1), 1. doi: 10.1037/tra0000114.
Hyland, P., Shevlin, M., Fyvie, C., & Karatzias, T. (2018). Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in DSM-5 and ICD-11: Clinical and Behavioral Correlates. Journal of Traumatic Stress, 31, 174–180. doi:10.1002/jts.22272.
Karatzias, T., Cloitre, M., Maercker, A., Kazlauskas, E., Shevlin, M., Hyland, P., … Brewin, C. R. (2017). PTSD and Complex PTSD: ICD-11 updates on concept and measurement in the UK, USA, Germany and Lithuania. European Journal of Psychotraumatology, 8, 1418103. doi.org/10.1080/20008198.2017.1418103
Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Roberts, N., Shevlin, M., ... & Mason-Roberts, S. (2019). Psychological interventions for ICD-11 complex PTSD symptoms: systematic review and meta-analysis. Psychological Medicine, 1-15. doi:10.1017/S0033291719000436.
Karatzias T., Shevlin M., Fyvie C., Hyland P., Efthymiadou E., Wilson D., … Cloitre M. (2016). An initial psychometric assessment of an ICD-11 based measure of PTSD and complex PTSD (ICD-TQ): Evidence of construct validity. Journal of Anxiety Disorders, 44, 73–79. doi: 10.1016/j.janxdis.2016.10.009.
Knefel, M. & Lueger-Schuster, B. (2013). An evaluation of ICD-11 PTSD and complex PTSD criteria in a sample of adult survivors of childhood institutional abuse. European Journal of Psychotraumatology, 4, 22608.
Lo, Y., Mendell, N. R., & Rubin, D. B. (2001). Testing the number of components in a normal mixture. Biometrika, 88(3), 767-778.
Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., Reed, G. M., Van Ommeren, M. … Saxena, S. (2013a). Proposals for mental disorders specifically associated with stress in the ICD-11. Lancet, 381, 1683-1685. doi: 10.1016/S0140- 6736(12)62191-6
Maercker, A., Brewin, C. R., Cloitre, M., Van Ommeren, M., Jones, L. M., Humayan, A. … Reed, G. M. (2013b). Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry, 12 (3).
Maercker A., Forstmeier S., Wagner B., Glaesmer H., & Brähler E. (2008). Posttraumatische Belastungsstörungen in Deutschland. Ergebnisse einer gesamtdeutschen epidemiologischen Untersuchung [Post-traumatic stress disorder in Germany. Results of a nationwide epidemiological study]. Nervenarzt, 79, 577–586.doi: doi.org/10.1007/s00115-0082467-5
McElroy, E., Shevlin, M., Murphy, S., Roberts, B., Makhashvili, N., Javakhishvili, J., ... & Hyland, P. (2019). ICD-11 PTSD and complex PTSD: structural validation using network analysis. World Psychiatry: Official Journal of the World Psychiatric Association (WPA)18(2), 236-237. doi: 10.1002/wps.20638.
McFarlane, C.A., & Kaplan, I. (2012). Evidence based psychological interventions for adult survivors of torture and trauma: A 30-year review. Transcultural Psychiatry, 49 (3–4), 539–567. doi: 10.1177/1363461512447608
McLachlan, G.J., & Peel, D. (2000). Finite Mixture Models. New York: Wiley
Muthén, L.K. & Muthén, B.O. (2018). Mplus User’s Guide (version 8.1). Los Angeles, CA: Muthén & Muthén.
Murphy S., Elklit A., Dokkedahl S., & Shevlin M. (2016). Testing the validity of the proposed ICD-11 PTSD and complex PTSD criteria using a sample from Northern Uganda. European Journalof Psychotraumatology, 7(1), 32678. doi: 10.3402/ejpt.v7.32678.
Murphy, J., Houston, J. E., & Shevlin, M. (2007). Principles and applications of latent class analysis in psychological research. The Irish Journal of Psychology, 28(1-2), 87-96.
Nickerson, A., Cloitre, M., Bryant, R. A., Schnyder, U., Morina, N., & Schick, M. (2016). The factor structure of complex posttraumatic stress disorder in traumatized refugees. European Journal of Psychotraumatology, 7(1), 33253. doi:10.3402/ejpt.v7.33253.
Nylund, K.L., Asparouhov, T., & Muthén, B.O. (2007). Deciding on the number of classes in latent class analysis and growth mixture modeling: A Monte Carlo simulation study. Structural Equation Modeling, 14, 535-569.
O’Donnell, M. L., Schaefer, I., Varker, T., Kartal, D., Forbes, D., Bryant, R. A., ... & Felmingham, K. (2017). A systematic review of person-centered approaches to investigating patterns of trauma exposure. Clinical Psychology Review, 57, 208-225. doi: 10.1016/j.cpr.2017.08.009.
Palic, S. (2013). Measurement and Documentation of Complex PTSD in Treatment Seeking Traumatized Refugees. University of Southern Denmark: Doctoral dissertation. doi: 10.1016/j. psychres.2016.10.062
Palic, S., & Elklit, A. (2011). Psychosocial treatment of posttraumatic stress disorder in adult refugees:a systematic review of prospective treatment outcome studies and a critique. Journal of Affective Disorders, 131 (1-3), 8-23. doi: 10.1016/j.psychres.2016.10.062.
Palic, S., Zerach, G., Shevlin, M., Zeligman, Z., Elklit, A., Solomon, Z. (2016). Evidence of complex posttraumatic stress disorder (CPTSD) across populations with prolonged trauma of varying interpersonal intensity and ages of exposure. Psychiatry Research, 246, 692-699.
Ramaswamy, V., DeSarbo, W. S., Reibstein, D. J., & Robinson, W. T. (1993). An empirical pooling approach for estimating marketing mix elasticities with PIMS data. Marketing Science, 12(1), 103-124.
Schwarz, G.E. (1978). Estimating the dimension of a model. The Annals of Statistics, 6(2), 461–464.
Sclove, S. L. (1987). Application of model-selection criteria to some problems in multivariate analysis. Psychometrika, 52(3), 333-343.
Shevlin, M., Hyland, P., Vallières, F., Bisson, J., Makhashvili, N., Javakhishvili, J., ... & Roberts, B. (2018). A comparison of DSM‐5 and ICD‐11 PTSD prevalence, comorbidity and disability: an analysis of the Ukrainian Internally Displaced Person’s Mental Health Survey. Acta Psychiatrica Scandinavica, 137(2), 138-147. doi: 10.1111/acps.12840.
Shrira, A., Mollov, B., & Mudahogora, C. (2019). Complex PTSD and intergenerational transmission of distress and resilience among Tutsi genocide survivors and their offspring: A preliminary report. Psychiatry Research, 271, 121-123. doi: 10.1016/j.psychres.2018.11.040.
Silove, D., Rees, S., Mohsin, M., Tam, N., Kareth, M., & Tay, A. K. (2018). Differentiating ICD-11 complex post-traumatic stress disorder from other common mental disorders based on levels of exposure to childhood adversities, the traumas of persecution and postmigration living difficulties among refugees from West Papua. British Journal of Psychiatry Open, 4(5), 361-367. doi: 10.1192/bjo.2018.49.
Slobodin, O., & de Jong, J.T.V.M. (2015). Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy? International Journal of Social Psychiatry, 61 (1) 17–26. doi: 10.1177/0020764014535752
Tam, S. Y., Houlihan, S., & Melendez-Torres, G.J. (2017). A systematic review of longitudinal risk and protective factors and correlates for posttraumatic stress and its natural historyin forcibly displaced children. Trauma, Violence, & Abuse, 18(4), 377-395. doi: 10.1177/1524838015622437.
Tay, A. K., Rees, S., Chen, J., Kareth, M., & Silove, D. (2015). The structure of post-traumatic stress disorder and complex post-traumatic stress disorder amongst West Papuan refugees. BMC Psychiatry, 15, 111. doi: 10.1186/s12888-015-04803.
Tay, A. K., Rees, S., Tam, N., Kareth, M., & Silove, D. (2018). Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua. Psychological Medicine, 1-9. doi: 10.1017/S0033291718002027.
Tolin, D. F., & Foa, E. B. (2008). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Trauma: Theory, Research, Practice, and Policy, S (1), 37-85.
Turrini, G., Purgato, M., Ballette, F., Nosè, M., Ostuzzi, G., & Barbui, C. (2017). Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. International Journal of Mental Health Systems, 11(1), 51. doi: 10.1186/s13033-017-0156-0.
UNHCR. (2018). Global trends. Forced displacement in 2017. United Nations. US Dept. of Health and Human Service. (2019). Survivors of Torture Program. Retrieved from https://www.acf.hhs.gov/orr/programs/survivorsof-torture
Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., ... & Hyland, P. (2018). ICD‐11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire. Acta Psychiatrica Scandinavica, 138(6), 547-557. doi:10.1111/acps.12973
Yuan, K. H., & Bentler, P. M. (2000). Three likelihood‐based methods for mean and covariance structure analysis with nonnormal missing data. Sociological Methodology, 30(1),165-200.
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