The Complex Trauma Inventory: A Self‐Report Measure of Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder

The work group revising the criteria for trauma‐related disorders in the International Classification of Diseases (ICD‐11) made several changes. Specifically, they simplified the criteria for posttraumatic stress disorder (PTSD) and added a new trauma disorder called complex PTSD (CPTSD). These proposed changes to taxonomy require new instruments to assess these novel constructs. We developed a measure of PTSD and CPTSD (the Complex Trauma Inventory; CTI) according to the proposed domains, creating several items to assess each domain. We examined the factor structure of the CTI in two separate samples of diverse college students (n ₁ = 391; n ₂ = 391) who reported exposure to at least one traumatic event and at least occasional functional impairment. After reducing the original 50 items in the item pool to 20 items, confirmatory factor analyses supported two highly correlated second‐order factors—PTSD and disturbances in self‐organization (DSO)—with PTSD (i.e., reexperiencing, avoidance, sense of threat) and DSO (i.e., affect dysregulation, negative self‐concept, and disturbances in relationships), each loading on three of the six ICD‐11‐consistent first‐order factors, root mean square error of approximation (RMSEA) = .056, 95% confidence interval (CI) [.048, .064], comparative fit index (CFI) = .956, Tucker‐Lewis index (TLI) = .948, standardized root mean square residual (SRMR) = .043, Bayesian information criterion (BIC) = 641.55, χ²(163) = 361.02, p < .001. Internal consistencies for PTSD and DSO were good to excellent (Cronbach's αs = .89 to .92). Supplementary analyses supported the gender invariance of the CFA model, as well as convergent and discriminant validity of the CTI. The validity of the CTI supports the distinction between CPTSD and PTSD. Moreover, the CTI will assist clinicians with diagnosis, symptom tracking, treatment planning, and assessing outcomes.     

Modeling Patterns of Polyvictimization and Their Associations with Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in the Israeli Population

Although evidence is accumulating for the conceptual validity of the ICD‐11 proposal for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD), our understanding of the specificity of trauma‐related predictors is still evolving. Specifically, studies utilizing advanced statistical methods to model the association between trauma exposure and ICD‐11 proposals of traumatic stress and differences in profiles of trauma exposure are lacking. Additionally, time since trauma and a clear memory of the trauma are yet to be examined as predictors of PTSD and CPTSD. We analyzed trauma exposure as reported by a general population sample of Israeli adults (N = 834), using latent class analysis, and the resultant classes were used in regression models to predict PTSD and CPTSD operationalized both dimensionally and categorically. Four distinct groups were identified: child and adult interpersonal victimization, community victimization–male, community victimization–female, and adult victimization. These groups were differentially related to PTSD and CPTSD, with only child and adult interpersonal victimization consistently predicting CPTSD and disturbances in self‐organization. When modeled dimensionally, PTSD was associated with the child and adult interpersonal victimization and adult victimization groups, whereas only the child and adult interpersonal victimization group was predictive of PTSD when operationalized categorically. The roles of time since trauma and a clear memory of the trauma differed across PTSD and CPTSD. These findings support the use of trauma typologies for predicting PTSD and CPTSD and provide important insight into the distribution of trauma exposure in the Israeli population.     

Complex Posttraumatic Stress Disorder Symptom Profiles in Traumatized Refugees

Although it is well documented that exposure to severe, cumulative trauma and postdisplacement stress increases the risk for posttraumatic stress symptom disorder (PTSD), less is known about the representation and predictors of complex PTSD (CPTSD) symptoms in refugee populations. We examined PTSD and CPTSD symptom profiles (co‐occurring PTSD and disturbances in self‐organization [DSO] symptoms) and their premigration, postmigration, and demographic predictors, using latent class analysis (LCA), in a cohort of 112 refugees resettled in Australia. The LCA identified a four‐factor model as the best fit to the data, comprising classes categorized as: (a) CPTSD, exhibiting high levels of PTSD and DSO symptoms (29.5%); (b) PTSD only (23.5%); (c) high affective dysregulation (AD) symptoms (31.9%); and (d) low PTSD and DSO symptoms (15.1%). Membership in the CPTSD and PTSD classes was specifically associated with cumulative traumatization, CPTSD OR = 1.56, 95% CI [1.15, 2.12], and PTSD OR = 1.64, 95% CI [1.15, 2.34]; and female gender, CPTSD OR = 14.18, 95% CI [1.66, 121.29], and PTSD OR = 16.84, 95% CI [1.78, 159.2], relative to the low‐symptom class. Moreover, CPTSD and AD class membership was significantly predicted by insecure visa status, CPTSD OR = 7.53, 95% CI [1.26, 45.08], and AD OR = 7.19, 95% CI [1.23, 42.05]. These findings are consistent with the ICD‐11 model of CPTSD and highlight the contributions of cumulative trauma to CPTSD and PTSD profiles as well as of contextual stress from visa uncertainty to DSO symptom profiles in refugee cohorts, particularly those characterized by AD.     

Examining the Discriminant Validity of Complex Posttraumatic Stress Disorder and Borderline Personality Disorder Symptoms: Results From a United Kingdom Population Sample

Complex posttraumatic stress disorder (CPTSD) was added to the diagnostic nomenclature in the 11th revision of the International Classification of Diseases (ICD‐11). Although considerable evidence exists supporting the construct validity of CPTSD, the distinguishability of CPTSD symptoms from those of borderline personality disorder (BPD) has been questioned. The present study examined the discriminant validity of CPTSD and BPD symptoms among a trauma‐exposed population sample from the United Kingdom (N = 546). Participants completed self‐report measures of CPTSD and BPD symptoms, and their latent structure was assessed using exploratory structural equation modeling (ESEM). A three‐factor model with latent variables reflecting PTSD, disturbances in self‐organization (DSO), and BPD symptoms provided the best fit of the data, χ²(399, N = 546) = 1,650, p < .001; CFI = .944; TLI = .930; RMSEA = .077, 90% CI [.073, .081]. We identified multiple symptoms distinctive to individual constructs (e.g., disturbed relationships and suicidality) as well as symptoms shared across the constructs (e.g., affective dysregulation). The PTSD, β = .24; DSO, β = .23; and BPD, β = .27, latent variables were positively and significantly associated with childhood interpersonal trauma. The current findings support the discriminant validity of CPTSD and BPD symptoms and highlight various phenomenological signatures of each construct as well as demonstrate how these constructs share important similarities in symptom composition and exogenous correlates.     

ICD‐11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in the United States: A Population‐Based Study

The primary aim of this study was to provide an assessment of the current prevalence rates of International Classification of Diseases (11th rev.) posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) among the adult population of the United States and to identify characteristics and correlates associated with each disorder. A total of 7.2% of the sample met criteria for either PTSD or CPTSD, and the prevalence rates were 3.4% for PTSD and 3.8% for CPTSD. Women were more likely than men to meet criteria for both PTSD and CPTSD. Cumulative adulthood trauma was associated with both PTSD and CPTSD; however, cumulative childhood trauma was more strongly associated with CPTSD than PTSD. Among traumatic stressors occurring in childhood, sexual and physical abuse by caregivers were identified as events associated with risk for CPTSD, whereas sexual assault by noncaregivers and abduction were risk factors for PTSD. Adverse childhood events were associated with both PTSD and CPTSD, and equally so. Individuals with CPTSD reported substantially higher psychiatric burden and lower levels of psychological well‐being compared to those with PTSD and those with neither diagnosis.     

Posttraumatic Stress Disorder in Very Young Children: Diagnostic Agreement Between ICD‐11 and DSM‐5

The prevalence of posttraumatic stress disorder (PTSD) in very young children depends on the diagnostic criteria. Thus far, studies have investigated the International Classification of Diseases (11th rev.; ICD‐11) criteria for PTSD only in samples of children older than 6 years of age. The aim of this study was to test the diagnostic agreement between the ICD‐11 and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM‐5) criteria for children who are 6 years old and younger. Caregivers of children aged 3–6 years in foster care in Germany (N = 147) and parents of children aged 1–4 years who had attended a hospital in Switzerland following burn injuries (N  = 149) completed a questionnaire about children's PTSD. Rates of PTSD were calculated according to ICD‐11 (considering a specific and a more general conceptualization of intrusive memories) and DSM‐5 criteria and were compared using McNemar's tests and Cohen's kappa. The proportion of children who met the ICD‐11 criteria was 0.6–25.8% lower than the proportion of PTSD cases according to the DSM‐5 criteria. The diagnostic agreement between each ICD‐11 algorithm and DSM‐5 was moderate, κ = 0.52–0.66. A systematic investigation of adaptions of the ICD‐11 avoidance cluster identified alternative symptom combinations leading to higher agreement with the DSM‐5 requirements. Furthermore, DSM‐5 had higher predictive power for functional impairment than the ICD‐11 algorithms. In conclusion, the findings suggest that the ICD‐11 criteria show less sensitivity in very young children, which can be explained by the more stringent avoidance cluster.     

The Influence of Depressive Symptoms on Suicidal Ideation Among U.S. Vietnam‐Era and Afghanistan/Iraq‐Era Veterans With Posttraumatic Stress Disorder

Major depressive disorder (MDD) co‐occurs frequently with posttraumatic stress disorder (PTSD), and both disorders are linked to suicidal ideation. An emergent literature examines suicidal ideation in U.S. Afghanistan/Iraq‐era veterans. Little research, however, has studied the role of PTSD and comorbid MDD on suicidal ideation across service eras. Therefore, this study aimed to examine the impact of depression on suicidal ideation in Afghanistan/Iraq‐era and Vietnam‐era veterans with PTSD. The sample included 164 Vietnam and 98 Afghanistan/Iraq veterans diagnosed with PTSD at a VA outpatient PTSD Clinic. Using structured interviews, 63% of the Vietnam sample and 45% of the Afghanistan/Iraq sample were diagnosed with comorbid current MDD. Measures included self‐report assessments of PTSD and depressive symptoms and the Personality Assessment Inventory. Results of analyses suggested that in veterans of both eras, PTSD, MDD, and their interaction were significantly related to suicidal ideation (PTSD: η² = .01; MDD: η² = .10; PTSD × MDD: η² = .02). For veterans reporting greater depressive symptoms, there was a stronger relationship between PTSD symptoms and suicidal ideation. These results suggest that veterans from both eras display a similar clinical presentation and highlight the need to consider depressive symptoms when assessing veterans with PTSD. Future research should examine suicidal ideation and behaviors as they change over time in these two cohorts.     

Nonsuicidal Self‐Injury and Borderline Personality Features as Risk Factors for Suicidal Ideation Among Male Veterans With Posttraumatic Stress Disorder

U.S. veterans are at increased risk for suicide compared to their civilian counterparts and account for approximately 20% of all deaths by suicide. Posttraumatic stress disorder (PTSD) and borderline personality features (BPF) have each been associated with increased suicide risk. Additionally, emerging research suggests that nonsuicidal self‐injury (NSSI) may be a unique risk factor for suicidal behavior. Archival data from 728 male veterans with a PTSD diagnosis who were receiving care through an outpatient Veterans Health Administration (VHA) specialty PTSD clinic were analyzed. Diagnosis of PTSD was based on a structured clinical interview administered by trained clinicians. A subscale of the Personality Assessment Inventory was used to assess BPF, and NSSI and suicidal ideation (SI) were assessed by self‐report. Findings revealed that NSSI (58.8%) and BPF (23.5%) were both relatively common in this sample of male veterans with PTSD. As expected, each condition was associated with significantly increased odds of experiencing SI compared to PTSD alone, odds ratios (ORs) = 1.2–2.6. Moreover, co‐occurring PTSD, NSSI, and BPF were associated with significantly increased odds of experiencing SI compared with PTSD, OR = 5.68; comorbid PTSD and NSSI, OR = 2.57; and comorbid PTSD and BPF, OR = 2.13. The present findings provide new insight into the rates of NSSI and BPF among male veterans with PTSD and highlight the potential importance of these factors in suicide risk.     

Loving‐Kindness Meditation for Posttraumatic Stress Disorder: A Pilot Study

Loving‐kindness meditation is a practice designed to enhance feelings of kindness and compassion for self and others. Loving‐kindness meditation involves repetition of phrases of positive intention for self and others. We undertook an open pilot trial of loving‐kindness meditation for veterans with posttraumatic stress disorder (PTSD). Measures of PTSD, depression, self‐compassion, and mindfulness were obtained at baseline, after a 12‐week loving‐kindness meditation course, and 3 months later. Effect sizes were calculated from baseline to each follow‐up point, and self‐compassion was assessed as a mediator. Attendance was high; 74% attended 9–12 classes. Self‐compassion increased with large effect sizes and mindfulness increased with medium to large effect sizes. A large effect size was found for PTSD symptoms at 3‐month follow‐up (d = ?0.89), and a medium effect size was found for depression at 3‐month follow‐up (d = ?0.49). There was evidence of mediation of reductions in PTSD symptoms and depression by enhanced self‐compassion. Overall, loving‐kindness meditation appeared safe and acceptable and was associated with reduced symptoms of PTSD and depression. Additional study of loving‐kindness meditation for PTSD is warranted to determine whether the changes seen are due to the loving‐kindness meditation intervention versus other influences, including concurrent receipt of other treatments.     

Alternative Models of DSM‐5 Posttraumatic Stress Disorder in Portuguese Adolescents Exposed to Trauma and Childhood Adversity

The factor structure of DSM‐5 posttraumatic stress disorder (PTSD) has been extensively debated, with evidence supporting the recently proposed seven‐factor hybrid model. However, few studies examining PTSD symptom structure have assessed the implications of these proposed models on diagnostic criteria and PTSD prevalence. In the present study, we examined seven alternative DSM‐5 PTSD models within a confirmatory factor analysis (CFA), using the Child PTSD Symptom Scale–Self‐Report for DSM‐5 (CPSS‐5). Additionally, we generated prevalence rates for each of the seven models by using a symptom‐based diagnostic algorithm and assessed whether substance abuse, depression, anxiety symptoms, and daily functioning were differentially associated with PTSD depending on the model used to derive the diagnosis. Participants were 317 adolescents aged 13–17 years (M = 15.93, SD = 1.23) who had experienced a DSM‐5 Criterion A trauma and/or childhood adversity. The CFA results showed good fit indices for all models, with the seven‐factor hybrid model presenting the best fit. The rates of PTSD diagnosis varied according to each model. The four‐factor DSM‐5 model presented the highest rate (30.6%), and the seven‐factor hybrid model presented the lowest rate (17.4%). Similar to the CFA analysis, the inclusion criteria for the diagnosis based on the hybrid model also presented the strongest associations with daily functional impairment, odds ratio (OR) = 1.48, 95% CI [1.25, 1.75]; and adverse childhood experiences, OR = 1.46, 95% CI [1.16, 1.82]. Research and clinical implications of these results are discussed, and suggestions for future investigation are presented.     

Complex Posttraumatic Stress Disorder in Patients Exposed to Emotional Neglect and Traumatic Events: Latent Class Analysis

The inclusion of a complex posttraumatic stress disorder (CPTSD) diagnosis in the 11th revision of the International Classification of Diseases reflects growing evidence that a subgroup of individuals with PTSD also suffer from disturbances in emotion regulation, interpersonal skills, and self‐concept, which together are termed “disturbances in self‐organization” (DSO). Although CPTSD is assumed to result from exposure to complex traumatic events, emotional neglect may be an important contributor. This study investigated the presence of CPTSD, defined by endorsement of PTSD and DSO symptoms in a clinical postwar generation sample. The sample consisted of 218 patients who had been exposed to emotional neglect in childhood, a subgroup of whom had also been exposed to potentially traumatic events. Using items from the Harvard Trauma Questionnaire and the Brief Symptom Inventory, a latent class analysis revealed two classes: high endorsement of almost all CPTSD symptoms (n = 83; 38.1%) and low endorsement of all CPTSD symptoms (n = 135; 61.9%). Contrary to our hypothesis, no DSO‐only class was found. The R3step method showed gender and number of traumatic events to be significant predictors of class membership. Compared to the low endorsement class, individuals in the CPTSD class were more likely to be female, p = .013, and to report a higher number of traumatic experiences, p < .001. The potential intermediary role of emotional neglect in the development of DSO and CPTSD is discussed.     

Borderline Personality Disorder and Posttraumatic Stress Disorder at Psychiatric Discharge Predict General Hospital Admission for Self‐Harm

We investigated whether posttraumatic stress disorder (PTSD) was predictor of suicidal behavior even when adjusting for comorbid borderline personality disorder (BPD) and other salient risk factors. To study this, we randomly selected 308 patients admitted to a psychiatric hospital because of suicide risk. Baseline interviews were performed within the first days of the stay. Information concerning the number of self‐harm admissions to general hospitals over the subsequent 6 months was retrieved through linkage with the regional hospital registers. A censored regression analysis of hospital admissions for self‐harm indicated significant associations with both PTSD (β = .21, p < .001) and BPD (β = .27, p < .001). A structural model comprising two latent BPD factors, dysregulation and relationship problems, as well as PTSD and several other variables, demonstrated that PTSD was an important correlate of the number of self‐harm admissions to general hospitals (B = 1.52, p < .01). Dysregulation was associated directly with self‐harm (B = 0.28, p < .05), and also through PTSD. These results suggested that PTSD and related dysregulation problems could be important treatment targets for a reduction in the risk of severe self‐harm in high‐risk psychiatric patients.     

Using Latent Class Analysis to Support the ICD-11 Complex Posttraumatic Stress Disorder Diagnosis in a Sample of Homeless Adults

The 11th revision of the International Classification of Diseases (ICD-11), ratified at the World Health Assembly in May 2019, introduced revised diagnostic guidelines for posttraumatic stress disorder (PTSD) as well as a separate diagnosis of complex PTSD (CPTSD). We aimed to test the new ICD-11 symptom structure for PTSD and CPTSD in a sample of individuals who have experienced homelessness. Experiences of trauma exposure and the associated mental health outcomes have been underresearched in this population. A sample of adults experiencing homelessness (N = 206) completed structured and semi-structured interviews that collected information about trauma exposure and symptoms of PTSD and CPTSD. We conducted a latent class analysis (LCA) using six symptom clusters (three PTSD symptom clusters that are components of CPTSD and three CPTSD symptom clusters). All participants reported trauma exposure, with 88.6% having experienced at least one event before 16 years of age. Four distinct classes of participants emerged in relation to the potential to meet the diagnosis: LCA CPTSD (n = 122, 59.8%), LCA no diagnosis (n = 27: 13.2%), LCA PTSD (n = 33; 16.2%), and LCA disturbance in self-organization (DSO; n = 22; 10.8%). Of note, participants with an ICD-11 CPTSD as well as those with an ICD-11 PTSD diagnosis fell into the LCA CPTSD class. Our findings provide some support for the distinction between CPTSD and PTSD within this population specifically but potentially have broader implications. Clear diagnoses will allow targeted PTSD and CPTSD treatment development.     

The Ending Self‐Stigma for Posttraumatic Stress Disorder (ESS‐P) Program: Results of a Pilot Randomized Trial

Experiences of and concerns about encountering stigma are common among veterans with posttraumatic stress disorder (PTSD). One common and serious consequence is self‐stigma, which is when an individual comes to believe that common negative stereotypes and assumptions about PTSD are true of oneself. The current study was a pilot randomized trial that evaluated the feasibility, acceptability, and preliminary outcomes of the Ending Self‐Stigma for PTSD (ESS‐P) program, a nine‐session group intervention that aims to assist veterans with PTSD learn tools and strategies to address stigma and self‐stigma. Veterans (N = 57) with a diagnosis of PTSD who were receiving treatment in U.S. Veterans Health Administration outpatient mental health programs were recruited. Participants were randomized to either ESS‐P or minimally enhanced treatment as usual and assessed at baseline and after treatment on clinical symptoms, self‐stigma, self‐efficacy, recovery, and sense of belonging. Information on mental health treatment utilization for the 3 months before and after group treatment was also collected. Compared to controls, there was a significant decrease in self‐stigma, d = ?0.77, and symptoms of depression, d = ?0.76, along with significant increases in general and social self‐efficacy, ds = 0.73 and 0.60, respectively, and psychological experience of belonging, d = 0.46, among ESS‐P participants. There were no differences regarding recovery status or changes in treatment utilization. The results of the pilot study suggest that participation in ESS‐P may help reduce self‐stigma and improve self‐efficacy and a sense of belonging in veterans with PTSD.     

Social–Emotional Profiles of PTSD,Complex PTSD,and Borderline Personality Disorder Among Racially and Ethnically Diverse Young Adults: A Latent Class Analysis

The debate around the construct validity of complex posttraumatic stress disorder (CPTSD) has begun to examine whether CPTSD diverges from posttraumatic stress disorder (PTSD) when it co‐occurs with the diagnosis of borderline personality disorder (BPD). The present study (a) examined the construct validity of CPTSD through a latent class analysis of a non–treatment‐seeking sample of young trauma‐exposed adults and (b) characterized each class in terms of trauma characteristics, social emotions (e.g., shame, guilt, blame), and interpersonal functioning. A total of 23 dichotomized survey items were chosen to represent the symptoms of PTSD, CPTSD, and BPD and administered to 197 trauma‐exposed participants. Fit statistics compared models with 2–4 latent classes. The four‐class model showed the best fit statistics and clinical interpretability. Classes included a “high PTSD+CPTSD+BPD” class, characterized by high‐level endorsement of all symptoms for the three diagnoses; a “moderate PTSD+CPTSD+BPD” class, characterized by endorsement of some symptoms across all three diagnoses; a “PTSD” class, characterized by endorsement of the ICD‐11 PTSD criteria; and a “healthy” class, characterized by low symptom endorsement overall. Pairwise comparisons showed individuals in the high PTSD+CPTSD+BPD class to have the highest levels of psychological distress, traumatic event history, adverse childhood experiences, and PTSD symptoms. Shame was the only social emotion to significantly differ between the classes, p = .002, η² = .16. The findings diverge from the literature, indicating an overlap of PTSD, CPTSD, and BPD symptoms in a non–treatment‐seeking community sample. Further, shame may be a central emotion that differentiates between presentation severities following trauma exposure.     

Comorbidity of Posttraumatic Stress Disorder and Depression in Tortured,Treatment‐Seeking Refugees

Comorbid posttraumatic stress disorder (PTSD) and depression is common in refugee groups; however, little is known about the predictors and correlates of comorbidity in treatment‐seeking refugees. Participants in this study were 134 refugees resettled in Switzerland. Most participants were from Turkey, Iran, and Sri Lanka, and 92.7% had been exposed to torture. Self‐report measures were implemented to assess PTSD, depression, mental and physical health‐related quality of life (QoL), as well as pre‐ and postmigration experiences. Findings indicated that approximately half the sample met criteria for PTSD and depression, 33.6% met criteria for depression only, and only 2.2% met criteria for PTSD only. Several variables emerged as predictors of comorbidity in contrast to no diagnosis: female gender, odds ratio (OR ) = 0.17; age, OR = 0.93; time in Switzerland, OR = 1.16; and trauma exposure, OR = 1.19. Postmigration stress was also associated with greater likelihood of comorbidity compared with no diagnosis, OR = 1.32, and a single diagnosis, OR = 1.14. Further, dual diagnosis was associated with significantly poorer mental health‐related and physical health‐related QoL (mental health‐related QoL: dual diagnosis vs. single diagnosis, d = −0.52 and dual diagnosis vs. no diagnosis, d = −1.30; physical health‐related QoL: dual diagnosis vs. single diagnosis, d = −0.73 and dual diagnosis vs. no diagnosis: d = −1.04). Findings indicated that comorbidity was highly prevalent in this sample of treatment‐seeking refugees and was associated with a substantial impairment burden. Psychological interventions for refugees should consider the dual impact of PTSD and depression symptoms to optimally decrease distress and improve QoL in this vulnerable group.     

Gender Differences in Threat Biases: Trauma Type Matters in Posttraumatic Stress Disorder

Women are diagnosed with posttraumatic stress disorder (PTSD) at twice the rate of men. This gender difference may be related to differences in PTSD experiences (e.g., more hypervigilance in women) or types of trauma experienced (e.g., interpersonal trauma). We examined whether attentional threat biases were associated with gender, PTSD diagnosis, and/or trauma type. Participants were 70 civilians and veterans (38 women, 32 men; 41 with PTSD, 29 without PTSD) assessed with the Clinician Administered PTSD Scale for DSM‐IV who completed a facial dot‐probe attention bias task and self‐report measures of psychiatric symptoms and trauma history. Factorial ANOVA and regression models examined associations between gender, PTSD diagnosis, index trauma type, lifetime traumatic experiences, and attentional threat biases. Results revealed that compared to women without PTSD and men both with and without PTSD, women with PTSD demonstrated attentional biases toward threatening facial expressions, d = 1.19, particularly fearful expressions, d = 0.74. Psychiatric symptoms or early/lifetime trauma did not account for these attentional biases. Biases were related to interpersonal assault index traumas, η_p² = .13, especially sexual assault, d = 1.19. Trauma type may be an important factor in the development of attentional threat biases, which theoretically interfere with trauma recovery. Women may be more likely to demonstrate attentional threat biases due to higher likelihood of interpersonal trauma victimization rather than due to gender‐specific psychobiological pathways. Future research is necessary to clarify if sexual assault alone or in combination with gender puts individuals at higher risk of developing PTSD.     

Salivary Cortisol Lower in Posttraumatic Stress Disorder

Altered cortisol has been demonstrated to be lower in those with posttraumatic stress disorder (PTSD) in most studies. This cross‐sectional study evaluated salivary cortisol at waking and 30 minutes after, and at bedtime in 51 combat veterans with PTSD compared to 20 veterans without PTSD. It also examined the relationship of cortisol to PTSD symptoms using 2 classifications: the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM‐IV; American Psychiatric Association, 1994) and the more recent 4‐factor classification proposed for DSM‐5. The PTSD group had lower cortisol values than the control group, F(6, 69) = 3.35, p = .006. This significance did not change when adding age, body mass index, smoking, medications affecting cortisol, awakening time, sleep duration, season, depression, perceived stress, service era, combat exposure, and lifetime trauma to the model. Post hoc analyses revealed that the PTSD group had lower area‐under‐the‐curve ground and waking, 30 min, and bedtime values; the cortisol awakening response and area‐under‐the‐curve increase were not different between groups. The 4‐factor avoidance PTSD symptom cluster was associated with cortisol, but not the other symptom clusters. This study supports the finding that cortisol is lower in people with PTSD.     

A Comparison of DSM‐5 and DSM‐IV Diagnostic Criteria for Posttraumatic Stress Disorder in Traumatized Refugees

The aim of this study was to compare the prevalence rate and factor structure of posttraumatic stress disorder (PTSD) based on the diagnostic criteria of the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV; DSM‐5; American Psychiatric Association, 1994, 2013) in traumatized refugees. There were 134 adult treatment‐seeking, severely and multiply traumatized patients from various refugee backgrounds were assessed in their mother tongue using a computerized set of questionnaires consisting of a trauma list, the Posttraumatic Diagnostic Scale, and the new PTSD items that had been suggested by the DSM‐5 Task Force of the American Psychiatric Association. Using DSM‐IV, 60.4% of participants met diagnostic criteria for PTSD; using DSM‐5, only 49.3% fulfilled all criteria (p < .001). Confirmatory factor analysis of DSM‐IV and DSM‐5 items showed good and comparable model fits. Furthermore, classification functions in the DSM‐5 were satisfactory. The new Cluster D symptoms showed relatively high sensitivity, specificity, positive predictive power, and negative predictive power. The DSM‐5 symptom structure appears to be applicable to traumatized refugees. Negative alterations in cognitions and mood may be especially useful for clinicians, not only to determine the extent to which an individual refugee is likely to meet criteria for PTSD, but also in providing targets for clinical intervention.