Measurement and documentation of complex PTSD in treatment seeking traumatized refugees: Ph.D. thesis

The aim of the thesis is to study complex traumatization and its measurement in treatment seeking traumatized refugees. Historically there have been repeated attempts to create a diagnosis for complex posttraumatic stress disorder (complex PTSD) to capture the more diverse, trauma related symptoms and personality dysfunction following extreme traumatization. Importantly, patterns of severe traumatic exposure in refugees may represent a group vulnerable to complex PTSD. However, there are currently only a few validated psychiatric measures for the assessment of traumatized refugees, which are limited to measuring symptoms of PTSD, anxiety, and depression. This renders documentation, measurement, and treatment of possible complex traumatic adaptations in traumatized refugees very difficult.
The thesis comprises two studies using different measures and different samples. The first study investigated complex traumatization as Disorders of Extreme Stress Not Otherwise Specified (DESNOS). The first article from this study demonstrated that DESNOS in a clinical sample of refugees, primarily resembled the Schizotypal, and Paranoid personality disorders (PD), when compared to Axis I and Axis II syndromes on self-report measures. A total of 34% of the refugee clinical convenience sample (n = 116) met the criteria for DESNOS, and 32% were estimated to have one of the two PD. Furthermore, Axis-II pathology and DESNOS was observed in traumatized refugees even when there was no presence of childhood maltreatment (which is considered a predominant risk factor for DESNOS and PD). However, there was also overlap between DESNOS and Axis I syndromes – specifically, depression, dissociation, somatization and PTSD. It was therefore concluded, that categorization of DESNOS in refugees under either Axis I or Axis II depends on the overall level of functional impairment and the chronicity of their symptoms. In the second article, 30% of the treatment seeking refugees from the clinical sample had pathological dissociation 16 years after their exposure to war trauma. - This makes monitoring and treatment of dissociation in the traumatized refugees an important challenge.
The second study in the thesis examined the proposed diversity of psychiatric morbidity in complex PTSD using a global psychiatric measure –the Health of Nation Outcome Scales (HoNOS). Article 3 showed that a group of consecutive refugees outpatients from a Danish specialized clinic (N = 448) had higher levels of global psychiatric impairment than the most inpatients with well-defined diagnoses (e.g. schizophrenia, dementia, addiction, affective, anxiety, and personality disorders). Furthermore, the traumatized refugees had a diverse HoNOS profile characterized by over-all high problems with psychiatric morbidity and functional impairment. This over-all high HoNOS profile was un-characteristic of the diagnostically well- defined inpatient groups. Through the use of Rasch analysis, a revised 10-item Refugee HoNOS was developed in article 4. The revised measure displayed good psychometric properties for assessing global, psychiatric impairment in treatment seeking traumatized refugees. Regarding the investigation of complex traumatization, the unidimensionality of the HoNOS in the Rasch model is currently unique to traumatized refugees. It is assumed to be related to the diverse, overall-high HoNOS impairment profile of the traumatized refugees and hence the “complexity” of their condition. Although the thesis explores complex traumatization using different measures, all studies are consistent with the notion of diverse morbidity, indicated by Axis I and Axis II comorbidity, and dissociation. Furthermore the psychiatric morbidity is coupled with high levels of functional impairment. All this renders monitoring of only PTSD, anxiety, and depression in treatment seeking refugees imprecise and probably insufficient for the purposes of treatment implementation and treatment monitoring.