Response to the Letter to the Editor regarding ‘The factor structure of complex posttraumatic stress disorder in traumatized refugees’

We are writing in response to the Letter to the Editor by De Jongh and colleagues regarding our article ‘The factor structure of complex posttraumatic stress disorder in traumatized refugees’ (Nickerson et al., 2016). The authors raise several queries about the methodology employed in our study, asserting that ‘there were a number of flaws that we consider as potential threats to both the internal and external validity of the study results and, therefore, compromise confidence in the conclusions of the authors’. We appreciate the opportunity to respond to this Letter, and to correct several errors made in the critique of this and related studies. The first methodological criticism raised by De Jongh and colleagues relates to the assessment of traumatic events the sample may have experienced and of the complex PTSD (CPTSD) diagnosis. They queried whether participants in the current study met criteria for CPTSD, arguing that it was not possible to determine whether participants had experienced an event that was sufficiently traumatic to qualify for the diagnoses of CPTSD and PTSD without conducting clinical interviews. As reported in the manuscript, over 90% of the sample reported having experienced or directly witnessed torture on a self-report measure of trauma exposure. The remaining participants reported having been exposed to a mean of 8.67 (standard deviation = 3.97) types of traumatic events, with a range of 4–15 types of traumas. These events included physical assault, sexual assault and witnessing the murder of family and friends. Thus, all participants in this study had been exposed to one or more events that would meet the definition of traumatic according to the DSM-IV criteria. De Jongh and colleagues have questioned the validity of determining diagnostic status in the absence of clinical interviews. We disagree that this represents ‘improper assessment procedure’. As reported in the article (and as noted by De Jongh and colleagues), we used self-report measures to assess probable diagnostic status. We agree with the authors that future research investigating CPTSD in traumatized refugees could benefit from implementing clinical interviews to determine diagnostic status. De Jongh and colleagues also queried whether CPTSD symptoms in the current sample may have been associated with non-trauma-related stressors, such as those experienced in displacement. We agree with the authors that the significant challenges experienced by refugees in the post-migration environment may exacerbate symptoms of PTSD and CPTSD. In fact, there is a large body of evidence linking post-migration stressors to symptoms of PTSD and other mental health difficulties (Li, Liddell, & Nickerson, 2016; Porter & Haslam, 2005). It is thus likely that symptoms of both PTSD and CPTSD (e.g. feelings of worthlessness, feeling cut-off from others) arising from trauma exposure will be heightened in the post-migration environment. For example, many refugees are separated from family members who remain in peril in the country of origin which might directly contribute to symptoms like nightmares, hypervigilance and feelings of guilt. The likelihood that these symptoms may be heightened by post-migration stressors should not be interpreted as evidence that the CPTSD construct is not applicable to this group; on the contrary, it provides a strong rationale for examining both CPTSD and PTSD in refugee groups. In addition, the authors also suggested that symptom endorsement may have arisen from comorbidity given the use of items from measures designed to assess other psychological constructs (e.g. depression) to index CPTSD. While it is indeed the case that there are similarities between items measured in the current study and symptoms of other disorders such as depression, findings from the current study indicated that the items measuring disturbances in self-organisation loaded onto the affect regulation, self-concept and interpersonal relationships factors as hypothesized. This provided preliminary evidence that the identified symptoms form part of a cohesive construct in traumatized refugees. Such symptoms (e.g. low self-worth) are currently typically recognized by the addition of multiple comorbid disorders. This can lead to the excessive pathologizing of the patient as every new diagnosed disorder brings with it additional peripheral symptoms and creates a challenge to treatment formulation which, to date, remains unresolved. This is reflected in the finding that the majority of trauma-exposed individuals with PTSD have three or more co-morbid diagnoses (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). We propose that CPTSD presents a coherent and streamlined profile of the critical symptoms that frequently occur following exposure to trauma, particularly chronic forms. Future research is needed to examine EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY, 2017 VOL. 8, 1308200 http://dx.doi. org/10.1080/20008198.2017. 1308200