Complex trauma, PTSD and complex PTSD in African refugees

Figures & data

Table 1. Comparison of list of items indicated in the ICD-11 International Trauma Questionnaire and items extracted from PCL-5.

ICD-11 International Trauma Questionnaire Cloitre et al., 2015	PCL-5 Weathers et al., 2013
PTSD criteria	PTSD criteria
Re-experiencing (Re)	Re-experiencing (Re)
RE1: Upsetting dreams that replay part of the event or are clearly related to the event	PCL-5 [2]: Repeated, disturbing dreams of the stressful experience
RE2: Powerful images or memories that sometimes come not your mind in which you feel the event is happening again in the same here and now	PCL-5 [3]: Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)
Avoidance (Av)	Avoidance (Av)
AV1: Avoiding internal reminders of the stressful event experience (for example, thoughts, feelings, or physical sensations)	PCL-5 [6]: Avoiding memories, thoughts, or feelings related to the stressful experience
AV2: Avoiding external reminders of the stressful event experience (for example people, places, conversations, objects, activities, or situations)	PCL-5 [7]: Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)
Sense of current threat (Th)	Sense of current threat (Th)
TH1: Being ‘superalert’ or watchful or on guard	PCL-5 [17]: Being ‘superalert’ or watchful or on guard
TH2: Feeling jumpy or easily startled	PCL-5 [18]: Feeling jumpy or easily startled
Disturbances of Self Organization (DSO)	Disturbances of Self Organization (DSO)
Affective Dysregulation (AD)	Affective Dysregulation (AD)
AD1: I react intensely to things that don’t seem to affect other people so much
AD2: When I am upset, it takes me a long time to calm down
AD3: My feelings tend to be easily hurt [Hyper]	PCL-5 [11]: Having strong negative feelings such as fear, horror, anger, guilt, or shame [Hyper]
AD4: I experience episodes of uncontrollable anger [Hyper]	PCL-5 [15]: Irritable behaviour, angry outbursts, or acting aggressively [Hyper]
AD5: I do things that people told me are dangerous or reckless (for example, driving very fast) [Hyper]	PCL-5 [16]: Taking too many risks or doing things that could cause you harm [Hyper]
AD6: I feel numb or emotionally shut down
AD7: I am the kind of person who has difficulty experiencing feelings of pleasure or joy [Deact]	PCL-5 [14]: Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you) [Deact]
AD8: When I am under stress or confronted with reminders of my trauma, I often feel that the world is distant or that the worlds seem different
AD9: When I am under stress or confronted with reminders of my trauma, I often feel outside of my body or feel that there is something strange with me
Negative Self Concept (NSC)	Negative Self Concept (NSC)
NSC1: I feel like a failure
NSC2: I feel worthless	PCL-5 [9]: Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)
NCS3: I often feel ashamed of myself whether it makes sense or not
NSC4: I feel guilty about things I have done or failed to do	PCL-5 [10]: Blaming yourself or someone else for the stressful experience or what happened after it
Disturbed Relation (DR)	Disturbed Relation (DR)
DR1: I feel distant or cut off from other people	PCL-5 [13]: Feeling distant or cut off from other people
DR2: I find it hard to stay emotionally close to people
DR3: I avoid relationships because they end up being too difficult or painful

Table 2. Trauma exposure reported by refugees.

Trauma type	N	%
Torture	97	80,8
Lack of food or water	92	76,7
Imprisonment	77	64,2
Non-sexual assault	72	60,0
Lack of shelter	68	56,7
Murder of one or more strangers	56	46,7
Disappearance or kidnapping	51	42,5
Being close to death	48	40,0
Serious physical injury	42	35,0
Ill health without access to medical care	41	34,2
Murder of a family member or friend	36	30,0
Unnatural death of a family member or friend	29	24,2
Forced separation from family member	25	20,8
Non-sexual assault by a family member or someone you know	22	18,3
Sexual assault by a stranger	19	15,8
Serious accident, fire or explosion	17	14,2
Enforced isolation from others	16	13,3
Life-threating illness	15	12,5
Combat situation	14	11,7
Sexual contact when you were younger than 18 with someone who was 5 or more years older than you	9	7,5
Sexual assault by a family member or someone you know	8	6,7
Brainwashing	6	5,0
Natural disaster	1	0,8

Table 3. Frequencies and percentages of refugees meeting diagnostic criteria for each PTSD and DSO symptom cluster, PTSD and CPTSD diagnosis (N = 120).

		N	%
ICD-11	Re-experiencing	112	93
	Avoidance	116	97
	Sense of threat	87	73
	Affective dysregulation	80	67
	Negative self-concept	62	52
	Disturbed relationships	74	62
	PTSD or CPTSD	82	68
	PTSD	46	38
	CPTSD	36	30
DSM-5	Re-experiencing	115	96
	Avoidance	116	97
	Negative alterations in cognitions and mood	110	92
	Marked alterations in arousal and reactivity	105	88
	PTSD	95	79

Figure 1. Venn diagram representing the distribution of particpants diagnoses according to both DSM-5 and ICD-11 criteria.

Table 4. Frequency, sensitivity, specificity, positive predictive power and negative predictive power of PTSD symptoms in relation to DSM-5 PTSD diagnosis. Sensitivity: The probability of the presence of the symptom when PTSD diagnosis is present. Specificity: The probability of the absence of the symptom when PTSD diagnosis is absent. Positive predictive power: The probability of the presence of PTSD diagnosis when the symptom is present. Negative predictive power: The probability of the absence of PTSD diagnosis when the symptom is absent.

Symptom		Frequency N (%)	Sensitivity	Specificity	Positive predictive power	Negative predictive power
PTSD symptoms
Cluster B: Re-experiencing symptoms
PCL-5 item
1	Repeated, disturbing, and unwanted memories of the stressful experience	110 (91.7%)	0.95	0.20	0.82	0.50
2	Repeated, disturbing dreams of the stressful experience	92 (76.7%)	0.84	0.52	0.87	0.46
3	Suddenly feeling or acting as if the stressful experience were actually happening again	86 (71.7%)	0.79	0.56	0.87	0.41
4	Feeling very upset when something reminded you of the stressful experience	106 (88.3%)	0.96	0.40	0.86	0.71
5	Having strong physical reactions when something reminded you of the stressful experience	100 (83.3%)	0.90	0.44	0.86	0.55
Cluster C: Avoidance
6	Avoiding memories, thoughts, or feelings related to the stressful experience	105 (87.5%)	0.90	0.24	0.82	0.40
7	Avoiding external reminders of the stressful experience	98 (81.7%)	0.86	0.36	0.84	0.41
Cluster D: Negative alterations in cognitions and mood
8	Trouble remembering important parts of the stressful experience	62 (51.7%)	0.57	0.68	0.87	0.29
9	Having strong negative beliefs about yourself, other people, or the world	82 (68.3%)	0.77	0.64	0.89	0.42
10	Blaming yourself or someone else for the stressful experience or what happened after it	77 (64.2%)	0.70	0.60	0.87	0.35
11	Having strong negative feelings such as fear, horror, anger, guilt, or shame	103 (85.8%)	0.94	0.44	0.86	0.65
12	Loss of interest in activities that you used to enjoy	71 (59.2%)	0.69	0.80	0.93	0.41
13	Feeling distant or cut off from other people	76 (63.3%)	0.73	0.72	0.91	0.41
14	Trouble experiencing positive feelings	59 (57.5%)	0.66	0.76	0.91	0.37
Cluster E: Marked alterations in arousal and reactivity
15	Irritable behaviour, angry outbursts, or acting aggressively	69 (57.5%)	0.66	0.76	0.91	0.37
16	Taking too many risks or doing things that could cause you harm	25 (20.8%)	0.26	1.00	1.00	0.26
17	Being ‘superalert’ or watchful or on guard	70 (58.3%)	0.70	0.88	0.96	0.44
18	Feeling jumpy or easily startled	75 (62.5%)	0.74	0.80	0.93	0.44
19	Having difficulty concentrating	85 (70.8%)	0.80	0.64	0.89	0.46
20	Trouble falling or staying asleep	102 (85.0%)	0.93	0.44	0.86	0.61

Table 5. Frequency, sensitivity, specificity, positive predictive power and negative predictive power of CPTSD symptoms in relation to ICD-11 CPTSD diagnosis. Sensitivity: The probability of the presence of the symptom when CPTSD diagnosis is present. Specificity: The probability of the absence of the symptom when CPTSD diagnosis is absent. Positive predictive power: The probability of the presence of CPTSD diagnosis when the symptom is present. Negative predictive power: The probability of the absence of CPTSD diagnosis when the symptom is absent.

Symptom		Frequency N(%)	Sensitivity	Specificity	Positive predictive power	Negative predictive power
PTSD symptoms
PCL-5 item
Re-experiencing symptoms
3	Suddenly feeling or acting as if the stressful experience were actually happening again	86 (71.7%)	0,92	0,37	0,38	0,91
2	Repeated, disturbing dreams of the stressful experience	92 (76.7%)	0,92	0,30	0,36	0,89
Avoidance
6	Avoiding memories, thoughts, or feelings related to the stressful experience	105 (87.5%)	0,89	0,13	0,30	0,73
7	Avoiding external reminders of the stressful experience	98 (81.7%)	0,94	0,24	0,35	0,91
Arousal
17	Being ‘superalert’ or watchful or on guard	70 (58.3%)	0,86	0,54	0,44	0,90
18	Feeling jumpy or easily startled	75 (62.5%)	0,89	0,49	0,43	0,91
Disturbances in self-organization
Affect dysregulation
11	Having strong negative feelings such as fear, horror, anger, guilt, or shame (Hyper)	103 (85.8%)	1.00	0.20	0.35	1.00
15	Irritable behaviour, angry outbursts, or acting aggressively (Hyper)	69 (57.5%)	0.89	0.56	0.46	0.92
16	Taking too many risks or doing things that could cause you harm (Hyper)	25 (20.8%)	0.50	0.92	0.72	0.81
14	Trouble experiencing positive feelings (Deact)	69 (57.5%)	0.94	0.58	0.49	0.96
Negative self-concept
9	Having strong negative beliefs about yourself, other people, or the world	82 (68.3%)	0.94	0.43	0.41	0.95
10	Blaming yourself or someone else for the stressful experience or what happened after it	77 (64.2%)	0.94	0.49	0.44	0.95
Interpersonal problems
13	Feeling distant or cut off from other people	76 (63.3%)	1.00	0.52	0.47	1.00

Table 6. Fit indices for LCA (N = 120). Note: AIC, Akaike Information Criterion; BIC, Bayesian Information Criterion; sample size-adjusted BIC; BLRT, Bootstrap likelihood ratio test; Best-fitting model in bold.

Classes	log-likelihood	AIC	BIC	BLRT (p)
1	−365,755	743,509	760,234	-
2	−335,754	697,508	733,745	<0,001
3	−334,321	708,642	764,392	0,352
4	−332,602	719,204	794,466	0,425
5	−328,953	725,905	820,680	0,728

Figure 2. Profile plot based on the best-fitting two-class solution from the LCA.

Table 7. Multinomial logistic regression results predicting PTSD and CPTSD class membership (N = 120).

	Univariate		Multivariate
Predictor variables	OR (95% CI)	p-value	OR (95% CI)	p-value
Legal status	1.233 (0.253–8.895)	0.807	1.039 (0.181–8.627)	0.967
Gender (M)	0.589 (0.157–1.808)	0.384	0.599 (0.13–2.284)	0.474
Age (years)	1.028 (0.969–1.096)	0.380	1.023 (0.953–1.104)	0.539
Years of education (years)	0.944 (0.871–1.02)	0.151	0.921 (0.831–1.013)	0.099
Time spent in Italy (months)	1.004 (0.963–1.052)	0.846	0.995 (0.947–1.048)	0.842
Number of trauma type	0.981 (0.875–1.103)	0.846	0.995 (0.947–1.048)	0.842
Employment	1.486 (0.608–3.846)	0.396	1.443 (0.531–4.126)	0.480

Table 8. Linear regression (R² = 0.107) results predicting 20 items PCL-5 score.

	Univariate		Multivariate
Predictor variables	Estimate	p-value	Estimate	p-value
Legal Status	−4.196	0.428	−1.054	0.846
Gender (M)	−5.627	0.113	−5.956	0.135
Age (years)	0.177	0.347	0.215	0.325
Years of education (years)	−0.348	0.168	−0.227	0.421
Time spent in Italy (months)	−0.261	0.059	−0.320	0.035*
Number of trauma	0.541	0.134	0.215	0.612
Employment	−0.414	0.883	−0.259	0.930

Cloitre, M., Roberts, N. P., Bisson, J. I., & Brewin, C. R. (2015). The International Trauma Questionnaire (ITQ). Unpublished Measure.

 Google Scholar

Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD.

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