Research paperThe structure of ICD-11 PTSD and Complex PTSD in adolescents exposed to potentially traumatic experiences
Introduction
The recently released 11th edition of International Classification of Diseases (ICD-11) included a chapter ‘06: Disorders Specifically Associated with Stress’ (World Health Organization, 2018). Complex post-traumatic stress disorder (CPTSD) was included in ICD-11 as a new trauma-related disorder which could develop following prolonged or reoccurring traumatic experiences (Brewin, 2019). CPTSD, according to the ICD-11, can be diagnosed if a person is trauma-exposed, meets all diagnostic criteria for PTSD (i.e., symptoms of (1) re-experiencing, (2) avoidance, and (3) sense of threat, and functional impairment associated with these symptoms), and has additional symptoms of disorganized self-organization (DSO) from three symptom clusters; (4) affective dysregulation; (5) negative self-concept and (6) disturbances in relationships, plus impairment in functioning associated with these DSO symptoms (World Health Organization, 2018).
Findings from around the world have provided empirical support for the construct validity of ICD-11 PTSD and CPTSD using multiple methodologies including latent class analysis, confirmatory factor analysis (Brewin et al., 2017), and network analysis (Knefel et al., 2019). Research on the epidemiology and construct validity of ICD-11 PTSD and CPTSD has, so far, primarily been conducted with adult populations (e.g., Ben-Ezra et al., 2018; Cloitre et al., 2019; Ho et al., 2019; Hyland et al., 2017; Kazlauskas et al., 2018; Shevlin et al., 2017). These studies have used the International Trauma Questionnaire (ITQ) (Cloitre et al., 2018; Karatzias et al., 2017) to measure symptoms of PTSD/CPTSD, as per the ICD-11 guidelines. Notably, very few studies have assessed the validity of these constructs among children and adolescents.
A recent study in Germany used archival data from 155 children and adolescents and found evidence of separate groups of children and adolescents whose symptoms were consistent with the distinction between PTSD and CPTSD (Sachser et al., 2017). More recently, Haselgruber et al. (2020) analyzed data from 136 Austrian foster adolescents who completed the adult version of the ITQ. Consistent with Sachser et al.’s results, distinct groups of adolescents with PTSD and CPTSD symptoms were identified (Sachser et al., 2017). Additionally, and in line with much of the adult literature (Brewin et al., 2017), the latent structure of the ITQ was best explained by two second-order factors (PTSD and DSO) explaining covariation between six first-order factors (Re-experiencing, Avoidance, Threat, Affective Dysregulation, Negative Self-Concept, and Disturbed Relationships). To facilitate additional research with children and adolescents, a Child and Adolescent version of International Trauma Questionnaire (ITQ-CA) has been developed (Cloitre et al., 2018).
This is the first study to explore the factor structure of the ITQ-CA in a sample of adolescents from the general population. We used confirmatory factor analysis (CFA) to test four alternative models of the latent structure of the ITQ-CA based on findings from previous studies with the ITQ. We hypothesized that the latent structure of the ITQ-CA would be best explained by one of the two models that are consistently supported in the adult ITQ literature: either a correlated six factor model or a two factor higher-order model, both of which capture the distinction between PTSD and DSO symptoms. Second, we hypothesized consistent with the ICD-11 PTSD and CPTSD studies that distinct groups of adolescents would be identified with symptom profiles consistent with the distinction between PTSD and CPTSD.
Section snippets
Participants and procedures
Data for this study was from the first wave of the longitudinal study Stress and Resilience in Adolescence (STAR-A) conducted by the Center for Psychotraumatology at Vilnius University in Lithuania. The STAR-A study was approved by the Ethics Committee for Psychological Research at Vilnius University. The data were collected using self-report measures from adolescents in 15 randomly selected public schools from four different regions across the country in Lithuania between March and June, 2019.
Trauma exposure
Participants reported a mean of 2.66 (SD = 1.73) lifetime traumatic experiences, ranging from one to 13 events. Exposure to one traumatic event was reported by 33.2% (n = 309), 2–3 traumatic experiences were reported by 39.9% (n = 372), 4–5 traumatic experiences were experienced by 20.1% (n = 178), and ≥ 6 experiences were reported by 6.9% (n = 64) of participants. Rates of exposure to each traumatic event, along with sex differences, are presented in Table 2. The most common traumatic
Discussion
To our knowledge, this was the first study to validate ICD-11 PTSD and CPTSD factorial structure in an adolescent population using the International Trauma Questionnaire Child and Adolescent version (ITQ-CA). Our study confirmed findings from the ICD-11 PTSD and CPTSD adult samples factor structure studies (Brewin et al., 2017) indicating a similar factor structure of PTSD and CPTSD among adolescents exposed to potentially traumatic events.
The two CFA PTSD and CPTSD symptom structure models
Limitations
There are several limitations associated with this study that needs to be discussed. This was a cross-sectional study and thus we could not analyze either trajectories of symptom change, nor effects of time since trauma exposure on posttraumatic stress disorders symptoms. As our main measure of PTSD and CPTSD in the study was self-report, we relied on self-report of participants. However, diagnostic interviews for ICD-11 PTSD and CPTSD although in development are not yet available. The study
CRediT authorship contribution statement
Evaldas Kazlauskas: Supervision, Formal analysis, Writing - original draft. Paulina Zelviene: Investigation, Supervision, Data curation. Ieva Daniunaite: Supervision, Data curation. Philip Hyland: Formal analysis. Monika Kvedaraite: Data curation, Formal analysis. Mark Shevlin: Formal analysis. Marylene Cloitre: Supervision, Writing - review & editing.
Declaration of Competing Interest
The authors report no conflicts of interest in this work.
Acknowledgement
This project has received funding from European Social Fund (project No 09.3.3-LMT-K-712-02-0096) under grant agreement with the Research Council of Lithuania (LMTLT).
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