Academic journal article European Journal of Psychotraumatology

The Factor Structure of Complex Posttraumatic Stress Disorder in Traumatized Refugees

Academic journal article European Journal of Psychotraumatology

The Factor Structure of Complex Posttraumatic Stress Disorder in Traumatized Refugees

Article excerpt

The World Health Organization has proposed substantial changes to the diagnostic category of "disorders associated with stress" in the 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11). The Working Group for Trauma- and StressRelated Disorders has suggested "sibling" diagnoses of posttraumatic stress disorder (PTSD) and the newly added complex PTSD (CPTSD) (Maercker et al., 2013b). Both of these require the individual to have been exposed to a traumatic event, from which he or she can be diagnosed with either PTSD or CPTSD. PTSD is diagnosed when one of two possible symptoms is exhibited in each of the following categories: reexperiencing of the traumatic event, avoidance of internal or external reminders of the event, and hyperarousal. Accordingly, PTSD symptoms are specifically related to the traumatic event and represent a predominantly fear-based response (Hyland et al., 2016). CPTSD is diagnosed when, in addition to meeting criteria for PTSD, trauma survivors exhibit disturbances in self-organization (DSO) by endorsing at least one of two possible symptoms in the categories of affective regulation, self-concept and interpersonal relations (Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013; Maercker et al., 2013a, 2013b). In contrast to PTSD symptoms, DSO symptoms represent more pervasive changes in functioning across contexts (Hyland et al., 2016). While CPTSD has been proposed as a diagnostic category for ICD-11, considerable debate continues regarding the distinctiveness of the construct of CPTSD. CPTSD was excluded from the Diagnostic and Statistical Manual, 5th edition, following the argument of some commentators that the symptoms of CPTSD can be accommodated within the framework of existing definitions of PTSD (Resick et al., 2012). This assertion stems from the expansion of the diagnosis of PTSD in the DSM-5 to encompass symptoms such as self-blame, negative beliefs about the self and feeling alienated from others (American Psychiatric Association, 2013). The breadth of the DSM-5 PTSD diagnosis (Galatzer-Levy & Bryant, 2013) and the heterogeneity in potential clinical presentation afforded by these criteria (Cloitre, 2016) is in contrast to the ICD-11 constructs of PTSD and CPTSD which propose only six symptoms for the diagnosis of PTSD, with an additional six symptoms to meet criteria for CPTSD. Accordingly, the ICD-11 criteria may have benefits in terms of greater parsimony and usability in low-resource settings and reduced overlap with existing diagnoses (i.e., mood and anxiety disorders) (Maercker et al., 2013a), but still facilitates the distinction of symptom profiles that have been demonstrated to be readily observable by clinicians across cultural groups (Keeley et al., 2016).

CPTSD is considered to be especially likely to occur following exposure to repeated, prolonged, interpersonal trauma exposure. Consistent with this, there is growing evidence from research in western settings supporting the validity of this disorder with individuals exposed to sustained interpersonal trauma (Perkonigg et al., 2015), institutional abuse (Knefel, Garvert, Cloitre, & LuegerSchuster, 20152015), childhood abuse (Cloitre, Garvert, Weiss, Carlson, & Bryant, 2014), and people seeking treatment following exposure to a range of trauma types (Cloitre et al., 2013). While CPTSD was originally formulated to describe distinctive psychological responses arising from events where an individual is under the sustained and coercive control of a perpetrator (i.e., torture) (Herman, 1992), there has been scarce examination of CPTSD in individuals from non-western countries who have been exposed to persecution, mass trauma, and torture. It has been suggested that CPTSD and related constructs may be particularly relevant to these groups given the repeated and prolonged interpersonal trauma to which they are typically exposed (de Jong, Komproe, Spinazzola, van der Kolk, & van Ommeren, 2005; Morina & Ford, 2008; Palic & Elklit, 2014). …

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