ICD-11 PTSD and CPTSD: Implications for the rehabilitation of survivors of torture seeking international protection


  • Aisling Hearns Trinity Centre for Global Health, University of Dublin
  • Philip Hyland School of Psychology, Maynooth University, Maynooth, Co Kildare, Ireland
  • Carin Benninger-Budel OMCT International Secretariat
  • Frederique Vallières Trinity Centre for Global Health, School of Psychology, University of Dublin, Trinity College, 7-9 South Leinster Street, Dublin 2, Ireland.




Torture, ITQ, CPTSD, Asylum Seekers, Refugees


Introduction: Rates of torture are especially high among those seeking asylum, with global estimates of forced migrants having experienced torture exceeding 50%. Torture is the strongest predictor of PTSD amongst refugee populations. This study assesses the construct validity and diagnostic rate of the ICD-11 PTSD and Complex PTSD (CPTSD) within a population of torture survivors seeking asylum in Ireland. It further explores whether this population were more likely to meet the diagnostic criteria for CPTSD than PTSD, and whether any sex differences existed in probable rates of PTSD and CPTSD. Methods: A secondary data analysis of 264 treatment-seeking asylum seekers and refugees who experienced torture or ill-treatment was conducted. Rates of PTSD and CPTSD were assessed using the International Trauma Questionnaire. Findings: A Confirmatory Factor Analysis supported a a six-factor correlated model consisting of re-experiencing (Re), avoidance (Av), threat (Th), affective dysregulation (AD), negative self-concept (NSC), and disturbed relationships (DR), consistent with ICD-11 PTSD and CPTSD. High rates of PTSD (32.4%) and CPTSD (39.6%) were found, with the experience of torture significantly associated to the development of PTSD. No significant difference was found between the sexes. Discussion: This is the first study to investigate the validity of ICD 11 PTSD and CPTSD among torture survivors actively seeking international protection in Europe. Given the high rates of PTSD and CPTSD found among torture survivors, rehabilitation centres for victims of torture should consider CPTSD as part of their assessment and treatment programmes.

Author Biography

Aisling Hearns, Trinity Centre for Global Health, University of Dublin

Correspondence to: hearnsai@tcd.ie


Baker, R., & Basoglu, M. (1992). Psychosocial consequences for tortured refugees seeking asylum and refugee status in Europe.
Basoglu, M. (2006). Little otcome evaluation has been done in torture rehabilitation. British Medical Journal, 2006(333), 1230-1231.
Beiser, M., & Hou, F. (2001). Language acquisition, unemployment and depressive disorder among Southeast Asian refugees: a 10-year study. Social science & medicine, 53(10), 1321-1334.
Beltran, R. O., & Silove, D. . (1999). Expert opinions about the ICD-10 category of enduring personality change after catastrophic experience. . Comprehensive Psychiatry, 40, 396-403. doi:10.1016/S0010-440X(99)90147-5
Ben-Ezra, M., Hyland, P., Karatzias, T., Maercker, A., Hamama-Raz, Y., Lavenda, O., . . . Shevlin, M. (2020). A cross-country psychiatric screening of ICD-11 disorders specifically associated with stress in Kenya, Nigeria and Ghana. European Journal of Psychotraumatology, 11(1), 1720972-1720972. doi:10.1080/20008198.2020.1720972
Brewin, C. R. (2013). “I Wouldn't Start From Here”—An Alternative Perspective on PTSD From the ICD‐11: Comment on Friedman Journal of traumatic stress, 26(5), 557-559.
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. J Trauma Stress, 24(6), 615-627. doi:10.1002/jts.20697
Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., . . . Hyland, P. (2018). The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatr Scand, 138(6), 536-546. doi:10.1111/acps.12956
Courtois, C. A., & Ford, J. D. . (2009). Treating complex traumatic stress disorders: An evidence-based guide. New York: NY: Guilford Press.
Crumlish, N., & Bracken, P. (2011). Mental health and the asylum process. Irish Journal Of Psychological Medicine, 28(2), 57-60. doi:10.1017/S0790966700011447
Crumlish, N., & O'Rourke, K. (2010). A Systematic Review of Treatments for Post-Traumatic Stress Disorder Among Refugees and Asylum-Seekers. In (Vol. 198, pp. 237-251).
de C Williams, A. C., & van der Merwe, J. (2013). The psychological impact of torture. British Journal of Pain, 7(2), 101-106. doi:10.1177/2049463713483596
Foa, E. B., Davidson, J. R. T., Frances, A., Culpepper, L., Ross, R., & Ross, D. . (1999). The expert consensus guideline series: Treatment of posttraumatic stress disorder. Journal of Clinical Psychiatry, 60, 4-76.
Herman, J. (1992). Trauma and recovery: The aftermath of violence--from domestic abuse to political terror: Hachette UK.
Ibrahim, H., & Hassan, C. Q. (2017). Post-traumatic Stress Disorder Symptoms Resulting from Torture and Other Traumatic Events among Syrian Kurdish Refugees in Kurdistan Region, Iraq. Frontiers in psychology, 8, 241-241. doi:10.3389/fpsyg.2017.00241
Jaranson, J., & Quiroga, J. (2011). Chapter:3 Evaluating the services of torture rehabilitation programmes: History and recommendations. Torture Journal, 21(2), 98. Retrieved from http://elib.tcd.ie/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=62525087
Karatzias, T., Hyland, P., Bradley, A., Cloitre, M., Roberts, N. P., Bisson, J. I., & Shevlin, M. (2019). Risk factors and comorbidity of ICD-11 PTSD and complex PTSD: Findings from a trauma-exposed population based sample of adults in the United Kingdom. Depress Anxiety. doi:10.1002/da.22934
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. J Anxiety Disord, 44, 73-79. doi:10.1016/j.janxdis.2016.10.009
Karatzias, T., Shevlin, M., Fyvie, C., Hyland, P., Efthymiadou, E., Wilson, D., . . . Cloitre, M. (2017). Evidence of distinct profiles of Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) based on the new ICD-11 Trauma Questionnaire (ICD-TQ). J Affect Disord, 207, 181-187. doi:10.1016/j.jad.2016.09.032
Kazlauskas, E., Zelviene, P., Daniunaite, I., Hyland, P., Kvedaraite, M., Shevlin, M., & Cloitre, M. (2020). The structure of ICD-11 PTSD and Complex PTSD in adolescents exposed to potentially traumatic experiences. Journal of affective disorders, 265, 169-174. doi:https://doi.org/10.1016/j.jad.2020.01.061
Lie, B. (2002). A 3-year follow-up study of psychosocial functioning and general symptoms in settled refugees. Acta Psychiatr Scand, 106(6), 415-425.
Marsella, A. J., Friedman, M. J., Gerrity, E. T., & Scurfield, R. M. . (1996). Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical applications.
Mollica, R., Caspi-Yavin, Y., & Bagoslu, M. (1992). Overview: The assessment and diagnosis of torture events and symptoms.
Mollica, R. F., & Caspi-Yavin, Y. (1991). Measuring torture and torture-related symptoms. 3(4), 581-587.
Nickerson, A., Bryant, R. A., Silove, D., & Steel, Z. (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clin Psychol Rev, 31(3), 399-417. doi:10.1016/j.cpr.2010.10.004
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. Eur J Psychotraumatol, 7, 33253. doi:10.3402/ejpt.v7.33253
O'Connell M, D. R., Crumlish N. . (2016). Refugees, the asylum system and mental healthcare in Ireland. BJPsych international,, 13, 35-37.
OHCHR. (2004). Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment ("Istanbul Protocol"). "Istanbul Protocol".
OMCT. (2019). New Briefing Report: Protecting Women from Violence through the UN Convention against Torture (CAT). Retrieved from http://www.omct.org/reports-and-publications/2019/06/d25377/
OSCE. (2018). Providing Rehabilitation to Victims of Torture and Other Ill-Treatment. Retrieved from
Pietrzak, M. (2018). Providing Rehabilitation to Victims of Torture and Other Ill-Treatment UNCAT Implementation Tool. 5/2018.
Rembrant, A., Lennard, W., Evert, B., & Geert, S. (2019). Expert medico-legal reports: The relationship between levels of consistency and judicial outcomes in asylum seekers in the Netherlands. Torture Journal, 29(1). doi:10.7146/torture.v29i1.111205
Shevlin, M., Hyland, P., Vallieres, 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 Psychiatr Scand, 137(2), 138-147. doi:10.1111/acps.12840
Toar, M., O'Brien, K. K., & Fahey, T. (2009). Comparison of self-reported health & healthcare utilisation between asylum seekers and refugees: an observational study. BMC public health, 9(1), 214.
UNCAT. (1984). Convention Against Torture and Other Cruel Inhuman or Degrading Treatment or Punishment.
UNCERD. (2011). The Policy of Direct Provision: Concluding observations of the Committee on the Elimination of Racial Discrimination. Retrieved from http://www2.ohchr.org/english/bodies/cerd/docs/co/Ireland_AUV.pdf
UNHCR:Ireland. (2019). Figures at a glance. Retrieved from https://www.unhcr.org/en-ie/
Vaage, A. B., Thomsen, P. H., Silove, D., Wentzel-Larsen, T., Van Ta, T., & Hauff, E. (2010). Long-term mental health of Vietnamese refugees in the aftermath of trauma. 196(2), 122-125.
Vallieres, 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 Psychiatr Scand, 138(6), 547-557. doi:10.1111/acps.12973
van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. J Trauma Stress, 18(5), 389-399. doi:10.1002/jts.20047
Vang, M. L., Nielsen, S. B., Auning-Hansen, M., & Elklit, A. (2019). Testing the validity of ICD-11 PTSD and CPTSD among refugees in treatment using latent class analysis. Torture Journal, 29(3), 27-45.
WHO. (2018). International statistical classification of diseases and related health problems (11th Revision). Retrieved from https://icd.who.int/browse11/l-m/en
Wilson, F. E., Hennessy, E., Dooley, B., Kelly, B. D., & Ryan, D. A. (2013). Trauma and PTSD rates in an irish psychiatric population: A comparison of native and immigrant samples. Disaster health, 1(2), 74-83. doi:10.4161/dish.27366




How to Cite

Hearns, A., Hyland, P., Benninger-Budel, C., & Vallières, F. (2021). ICD-11 PTSD and CPTSD: Implications for the rehabilitation of survivors of torture seeking international protection. Torture Journal, 31(3), 96–112. https://doi.org/10.7146/torture.v32i3.125780