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The relation between change in reports of traumatic events and symptoms of psychiatric distress
The Relation Between Change in Reports of Traumatic Events and Symptoms of Psychiatric Distress Grace Wyshak,
Ph.D.
Abstract: This study examines change in the reporting of trauma events in relation to the reporting of severity of symptoms of psychiatric distress among refugees from Southeast Asia. Patients (N = 30) from a specialized clinic were interviewed on two occasions using a questionnaire which includes inquiry about traumatic events and about psychiatric symptoms. The changes in responses to the questionnaire, administered twice, 1 week apart, were assessed. In accord with other studies, results indicated that the number of trauma events reported correlates positively with severity of symptoms (r = 0.533, p = 0.002). Severity of symptoms of psychiatric distress increased slightly from time 1 to time 2 for 23 of the 30 symptoms. The reporting of trauma events varied between time 1 and time 2; the correlation coefficient ranged from 0.23 to 0.90, with a median 0.62 for the 17 trauma events. The important new finding is that of an inverse relation between total symptom score and the percent change in the reporting of trauma events on two occasions (r = -0.478, p = 0.009). Findings suggest that clinicians and researchers should give attention to variability in recall of traumatic events and reexamine the emphasis placed on the memory of traumatic events in the treatment of Posttraumatic Stress Disorder.
Introduction Southeast Asian refugees report a multitude of traumatic experiences, including rape and torture; these trauma stories influence psychiatric treatment approaches to these patients. In the present paper we report findings, based on a trauma ques-
Departments of Population and International Health and Biostatistics, Harvard School of Public Health and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts Address reprint requests to: Dr. G. Wyshak, Department of Population and International Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115.
tionnaire relating to symptoms of depression, anxiety, and posttraumatic stress disorder among Southeast Asian refugees; viz., an inverse association has been observed between symptom scores and change in the reporting of traumatic events. Variability in reporting traumatic events may have important implications for the understanding and treatment of patients suffering from severe trauma. Previous work in a specialized psychiatric clinic (the Indochinese Psychiatric Clinic; IPC) serving Indochinese refugees [l-5] revealed that the Cambodian patients were more highly traumatized than the other two groups. Cambodian widows reported a mean of 17.1 traumatic experiences, including 3.5 torture experiences. The Laotians reported a mean of 10.7 traumatic experiences, including 1.2 torture experiences; the Vietnamese 2.1 and 0.3, respectively. In previous work, we found that major affective disorder was the most prominent diagnosis for each ethnic group: 57% (12/21) of the Cambodians, 92% (12/13) of the Laotians, and 11% (2/18) of the Vietnamese were diagnosed as having posttraumatic stress disorder, with or without other diagnoses. In this paper we examine the relation between trauma experiences and the severity of symptoms of psychological distress.
Methods The study instrument which has been denoted as the Trauma Questionnaire was developed by the staff of the IPC which is part of St. Elizabeth’s Hospital, a general hospital in Boston, and has been described in detail elsewhere [6]. Briefly, the quesGeneral Hospital
290 ISSN 0163-8343/94/$7.00
Psychiatry 16, 290-297, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Traumatic Events and Psychiatric Symptoms tionnaire consists of three sections: basic sociodemographic data, questions about traumatic experiences, and questions about current symptoms. Linguistic equivalence for each item of the questionnaire was established for the three Southeast Asian languages-Cambodian, Vietnamese, and Laotian. The questionnaire was administered by IPC bicultural clinicians of the same ethnic group as the subject and in the subject’s native language. The 30 symptoms in the questionnaire relate to the Posttraumatic Stress Disorder (PTSD) diagnostic criteria of DSM-III-R [7] as follows: Questions 1, 2, and 3 relate to criterion B, a persistent reexperiencing of the traumatic event. Questions 4, 5, 11, 12, 19, 20, and 22 relate to criterion C, a persistent avoidance of circumstances and responses similar to those of the trauma event. Questions 6, 7, 8, 9, 10, and 23 relate to criterion D, persistent anxiety or heightened arousal. Question 13 about selfblame and question 21 about hopelessness are similar to items in the Hopkins Symptom Checklist [2]. The remaining 12 items (14-18 and 24-30) are unique to the trauma questionnaire. The trauma questionnaire in its present form consists of the following: 1. Sociodemographic data 2. 17 questions on whether the patient experienced, witnessed, or heard about the following trauma/torture events: Lack of food or water :: Ill health without access to medical care Lack of shelter Imprisonment Serious injury Torture Brainwashing Rape or sexual abuse i. Enforced isolation from others Being close to death j. k. Forced separation from family members 1. Murder of family or friend m. Unnatural death of family or friend n. Murder of stranger or strangers Lost or kidnapped 0. Combat situation P* Any other situation that was very frighten9. ing or you felt your life was in danger.
L-. ;. E:
Responses were coded according to yes/no for experienced, witnessed, or heard about the events of experienced, witnessed, or and combinations heard about.
3. 30 symptoms that the patient was bothered by in the past week based on a 4-point scale: l-not at all, 2-a little, 3-quite a bit, 4xtremely. 1. Recurrent thought or memories of the most hurtful or terrifying events 2. Feeling as though the event is happening again 3. Recurrent nightmares 4. Feeling detached or withdrawn from peo5. 6. 7. 8. 9. 10.
ple Unable to feel emotions Feeling jumpy, easily startled Difficulty concentrating Trouble sleeping Feeling on guard Feeling irritable or having outbursts
of an-
ger 11. Avoiding activities that remind you of the most traumatic or hurtful event parts of the most 12. Inability to remember traumatic or hurtful events 13. Blaming yourself for things that have happened 14. Feeling guilty for having survived 15. Feeling ashamed of the hurtful or traumatic events that have happened to you 16. Spending time thinking about why these events happened to you 17. Feeling that people do not understand what happened to you 18. Difficulty performing work or daily tasks 19. Avoiding thoughts or feelings associated with the traumatic or hurtful events 20. Less interest in daily activities 21. Hopelessness 22. Feeling as if you don’t have a future 23. Sudden emotional or physical reaction when reminded of the most hurtful or traumatic events 24. Feeling as if you are going crazy 25. Feeling that you are the only one who has suffered these events 26. Feeling others are hostile towards you 27. Feeling that you have no one to rely on 28. Finding out or being told by other people that you have done something you cannot remember 29. Feeling as if you are split into two people, and one of you is watching what the other is doing 30. Feeling that someone has betrayed you.
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Subjects The questionnaire was administered to 30 patients-10 each of Cambodians, Vietnamese, and Laotians-by bicultural clinicians on two occasions 1 week apart. All were patients at the IPC and are members of larger patient groups served at this clinic. DSM-III-R diagnoses were made by IPC staff western psychiatrists and bicultural teams on the basis of semistructured interviews after the subject had received a minimum of 3 months of treatment. Participation consisted of responding to the three parts of the Trauma Questionnaire, and a psychiatric interview.
Statistical Methods Pearson correlations were computed for determining the associations between traumatic events and symptoms of psychiatric distress. The “test-retest” reliability, concordance of response on the two occasions, was assessed using the Kappa statistic. Trauma events were analyzed based on experienced, witnessed, heard-about (full scale), and a dichotomous scale-experienced/not experienced. Percent change in trauma events was defined as the total number of changes in the reporting of trauma events (experienced/not experienced) from time 1 to time 2 divided by the sum of the trauma events at time 2. This method controls (normalizes) for the number of trauma events reported.
Results The characteristics of the study sample and symptoms of psychological distress are presented in Table 1. For the entire sample of 30,40% were males,
Table 1. Characteristics
with mean age of 44.3 2 SD 10.7; 56.7% had a diagnosis of PTSD with or without other psychiatric diagnoses; and 56.7% had diagnoses of major affective disorder with or without other psychiatric diagnoses; other diagnoses included schizophrenia, personality disorder, organic brain syndrome, and others. On average, subjects arrived in the U.S. in 1982 and became clinic patients in 1985-86 (the means and SDS are in Table 1). Eighty percent were married or widowed. Seventy-three percent had less than 6 years of schooling. Only 10% were employed and in unskilled occupations; the remainder were on Supplemental Security Income (SSI), refugee assistance, or Aid to Families with Dependent Children (AFDC). English skills were good among 13%, fair for 47%, and poor for 40%; 30% reported current attendance in English as a second language program. The mean number of trauma events reported at time 1 was 9.6 (out of a possible 17), SD 3.6 (Table 2a). We review briefly the following findings relating to concordance between time 1 and time 2 for trauma experiences reported elsewhere [8]. Intrasubject concordance, over a l-week period for the items relating to the 17 events or experiences using the full scale, had correlation coefficients ranging from 0.23 for injury to 0.90 for murder of family member or friend; the median for the 17 items was 0.62. Concordance based on the dichotomous scale (experienced/not experienced) was similar as was the Kappa statistic for agreement (Table 2b). The higher the percent reporting an event the lower the Kappa for that event; the correlation coefficient between percent reporting at time 1 and Kappa is -0.51, p = 0.04 The reporting of trauma events increased
of total sample by ethnic group
Variable
Total (N = 30)
Cambodian (N = 10)
Loatian (N = 10)
Vietnamese (N = 10)
Gender % male PTSD diagnosis % Major affect dis %
40 56.7 56.7
30 80 60
50 60 50
40 30 60
Age Year arrived U.S. Year clinic patient
292
Mean
SD
Mean
SD
Mean
SD
Mean
SD
44.267 82.567 85.767
10.683 1.906 1.305
41.000 83.600 86.700
9.763 1.577 0.483
51.700 80.900 85.100
8.769 1.100 1.449
40.100 83.200 85.500
10.148 1.813 1.269
Traumatic Events and Psychiatric Symptoms
Table 2a. Trauma
Trauma events
No food Ill health No shelter Prison Serious injury Torture Brainwashing Rape/Sex abuse Isolation Close to death Separation family Murder family Death family Murder strangers Lost/Kidnapped Combat situation Other
events reported
at time 1, total sample,
and by ethnic group
Total (N = 30)
Cambodian (N = 10)
Loatian (N = 10)
Vietnamese (N = 10)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
9.600
3.645
13.100
1.911
7.300
3.334
8.400
2.633
% 86.7 76.7 73.3 43.3 53.3 36.7 53.3 13.8 69.0 80.0 73.3 50.0 43.3 16.7 30.0 76.7 86.7
% 100 100 100 40 50 60 100 22.2” 100 100 100 90 90 10 60 90 100
% 70 50 60 40 60 40 20 10 50 70 60 30 10 20 00 60 80
% 90 80 60 50 50 10 40 10 55.5+ 70 60 30 30 20 30 80 80
“N=9
slightly but not significantly from time 1 to time 2, from 9.6 + 3.6 (mean 2 SD) to 10.2 ? 3.3. Differences in the reporting of events was bidirectional; the mean of the differences was -0.62 2 2.1 but the mean of the absolute value of differences was 1.4 + 1.6, significantly different from zero, p < 0.0001. (Data for both time 1 and time 2 were obtained from 29 subjects.) Table 3a and b show in full detail symptoms scores at time 1 for all subjects and for the three ethnic groups, and the differences in symptom scores between time 1 and time 2 for the entire group. The mean score at time 1 for all symptoms combined is 2.59, SD 0.65, at time 2, 2.73, SD 0.72. The mean difference for all symptoms is - 0.14, SD 0.29, indicating an increase in symptom scores from time 1 to time 2; this difference is statistically significant, p < 0.05. Three symptoms showed no change, four a small decrease, and 23 a small increase. The concordance for the 30 symptoms ranged from 0.32 for symptom “avoiding thoughts or feelings associated with the traumatic event,” to 0.85 for “feeling as if you don’t have a future.” The main findings on the relation between the reporting of trauma events and symptoms of psychiatric distress are as follows:
The number of traumatic events reported correlated significantly with severity of symptoms. For all symptoms combined, the correlation with trauma events reported at time 1 is r = 0.533, p = 0.002; at time 2, r = 0.584, p = 0.001. For PTSD-related symptoms, the correlation at time 1 is r = 0.526, p = 0.003; for non-PTSD related symptoms, r = 0.479, p = 0.007. The major new finding based on the subjects who responded to the questionnaire twice, 1 week apart, is that symptom scores are inversely correlated with differences in the reporting of events on the two occasions. Those who showed the most change (bidirectional) in the number of events or traumas reported (expressed as a percentage of total number of traumatic events reported at time 2) had a lower average on the symptom scale. (The percent change in reporting of trauma events expressed as the number of changes between time 1 and time 2 divided by the number of events reported at time 2 normalizes for the total number of events, which as noted above, varies considerably among subjects.) The results are presented as correlations between symptoms at time 1 and percent change in reporting of 293
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Table 2b. All subjects:
percent
reporting
% Reporting at time 1 N = 30 No food Ill health No shelter Prison Serious injury Torture Brainwashing Rape/Sex abuse Isolation Close to death Separation family Murder family Death family Murder strangers Lost/Kidnapped Combat situation Other
86.7 76.7 73.3 43.3 53.3 36.7 53.3 13.8 69.0 80.0 73.3 50.0 43.3 16.7 30.0 76.7 86.7
N = 29 (86.2) (75.9) (72.4) (44.8) (55.2) (37.9) (51.7) (14.3) (67.9) (79.3) (72.4) (48.3) (41.4) (17.2) (31.0) (75.9) (86.2)
trauma events
% Reporting at time 2 (N = 29)
Difference between times 1 and 2 (N = 29)
Kappa
SE
Obs (PO)
Exp (PE)
96.6 96.6 82.8 48.3 62.1 41.4 62.1 13.8 50.0 86.2 69.0 48.3 41.4 31.0 27.6 75.9 86.2
- 10.3 -20.7 - 10.3 -3.4 -6.9 -3.4 - 10.3 3.6 14.8 -6.9 3.4 0.0 0.0 - 13.8 3.4 0.0 0.0
0.36496 0.20183 0.51178 0.79236 0.57561 0.78412 0.65228 0.51163 0.55000 0.52066 0.58453 0.72381 0.85784 0.44937 0.58453 0.43506 0.13000
0.14345 0.11187 0.17755 0.18525 0.18383 0.18521 0.18161 0.18646 0.18359 0.18028 0.18505 0.18570 0.18570 0.17273 0.18505 0.18570 0.18570
0.89655 0.79310 0.82759 0.89655 0.79310 0.89655 0.82759 0.89286 0.77778 0.86207 0.82759 0.86207 0.93103 0.79310 0.82759 0.79310 0.79310
0.83710 0.74078 0.64685 0.50178 0.51249 0.52081 0.50416 0.78061 0.50617 0.71225 0.58502 0.50059 0.51486 0.62426 0.58502 0.63377 0.76219
Agreement (%)
Kappa
a Parentheses indicate percent reporting among those who reported at both Time 1 and Time 2
trauma events, because there is a question as to which is the outcome variable and which the predictor variable. That is, do symptoms influence memory or recall of traumatic events; or conversely, do traumatic events lead to symptoms? In this retrospective study, the answer cannot be determined. The correlation between the total symptom score (average of 30 items at first testing session) and the percent change in events reported is r = -0.478, p = 0.0088. The individual symptoms that showed the highest inverse relation with percent change in the reporting of traumatic events were blaming self for things that happened, r = -0.499, p = 0.0059; feeling guilty for having survived, r = -0.509, p = 0.005; and feeling ashamed of the traumatic events that happened to you, r = -0.630, p = 0.0002.For symptoms not related to the DSM-III-R criteria for PTSD, the correlation with percent change in trauma reporting is -0.463, p = 0.0115; for all PTSD-related r= symptoms, the correlation coefficient is - 0.444, p = 0.0158. Criterion B, persistence in reexperiencing the trauma had a correlation of - 0.280; criterion C, an attempt to avoid stimuli that trigger memories of the trauma, a correlation of -0.441; and criterion D, persistent anxiety, a correlation of - 0.416. 294
Discussion The concept of interrater reliability as a method for determining reliability and/or agreement among observers or raters is well established and accepted. Current approaches to interviewing include the concept of test-retest reliability, i.e., consistency by a given subject asked to report symptoms on two or more testing occasions. To our knowledge this is the first time patient reports of traumatic events and the change in these reports, sometimes within a relatively short period of time, have been examined in relation to patient symptoms. The results reported here suggest that a “test-retest,” that is, inquiry into the occurrence of traumatic events on two or more occasions (i.e., trauma stories) may have a use in therapeutic settings. The important observation in this study is that those whose reporting of traumatic events varied on the two testing occasions had less severe symptoms than those who showed less variation in the reporting of traumatic events. The questions arise: Is selective memory an adaptive mechanism? To what extent is change in recall of events due to impairment? Alternatively, to what extent are the processes of adjustment and coping at work? (It should be noted that the duration of symptoms of distress is included as criterion E of PTSD [6] and is
Traumatic Events and Psychiatric Symptoms
Table 3a. Symptom
scores at time 1 for total sample and by ethnic group Total (N = 30)
Cambodian (N = 10)
Loatian (N = 10)
Vietnamese (N = 10)
at time 1
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean all symptoms Mean PTSD Sx Mean not PTSD Mean PTSD criteria B Mean PTSD criteria C Mean F’TSD criteria D 1 Thoughts recur 2 Feel events recur 3 Nightmares recur 4 Feel detached 5 Can’t feel emotion 6 Feel jumpy 7 Can’t concentrate 8 Trouble sleeping 9 Feel on guard 10 Irritable, anger 11 Avoid activities 12 Can’t remember 13 Blame self for happenings 14 Guilt for survival 15 Ashamed of traumas 16 Think about events 17 Not understood 18 Can’t work 19 Avoid thoughts 20 Less interest 21 Hopelessness 22 Feel no future 23 React to memories 24 Feel going crazy 25 Feel only sufferer 26 Feel hostility 27 No one to rely on 28 Told did, but don’t remember 29 Feel split into 2 30 Feel betrayed
2.592 2.675 2.498 2.767 2.524 2.806 2.767 2.467 3.067 2.233 2.033 2.933 2.733 3.033 2.433 2.833 2.900 2.367 2.467 2.167 2.433 2.867 2.600 2.867 2.767 2.400 2.833 2.967 2.867 2.800 2.833 2.033 2.733 2.300 1.667 2.367
0.647 0.654 0.724 0.947 0.676 0.694 1.135 1.137 1.143 1.040 1.098 1.048 1.143 1.033 1.040 1.020 1.094 1.098 0.937 1.147 1.135 1.106 1.003 1.042 0.858 0.894 1.117 1.129 0.937 1.064 1.117 0.890 1.015 1.149 0.959 1.066
3.203 3.256 3.142 3.366 3.142 3.333 3.200 3.000 3.900 2.900 2.500 3.300 3.500 3.200 3.200 3.500 3.400 3.200 3.400 2.900 3.500 3.100 3.200 3.600 3.300 2.800 3.700 3.900 3.300 3.300 3.600 2.200 3.200 3.100 2.600 2.600
0.566 0.617 0.597 0.808 0.649 0.582 1.229 1.054 0.316 0.994 1.178 1.059 0.971 1.032 0.788 0.527 0.966 0.788 0.699 1.100 0.849 1.100 0.788 0.516 0.823 0.632 0.483 0.316 0.823 1.059 0.699 1.032 0.632 0.994 1.074 1.173
2.363 2.362 2.364 2.266 2.242 2.550 2.200 2.100 2.500 1.800 2.000 2.500 2.400 2.600 2.200 2.600 2.400 2.200 2.200 2.100 2.100 3.100 2.500 2.500 2.700 1.900 2.800 2.700 3.000 2.600 2.800 2.100 2.600 2.300 1.200 2.200
0.462 0.451 0.517 0.604 0.485 0.643 0.788 0.567 1.080 0.788 1.054 1.178 0.966 0.966 0.918 1.074 1.173 0.918 0.632 0.994 0.737 0.994 0.707 0.971 0.674 0.567 1.032 1.059 0.666 0.966 0.788 0.737 0.966 0.948 0.421 0.918
2.210 2.406 1.985 2.666 2.185 2.533 2.900 2.300 2.800 2.000 1.600 3.000 2.300 3.300 1.900 2.400 2.900 1.700 1.800 1.500 1.700 2.400 2.100 2.500 2.300 2.500 2.000 2.300 2.300 2.500 2.100 1.800 2.400 1.500 1.200 2.300
0.425 0.479 0.538 1.088 0.415 0.576 1.197 1.494 1.316 1.054 0.966 0.816 1.159 1.059 0.994 1.074 0.994 1.059 0.632 0.971 0.948 1.173 1.197 1.178 0.823 1.178 1.054 1.159 1.059 1.080 1.286 0.918 1.264 0.971 0.421 1.159
Symptoms
important in other diagnoses. Change in symptoms points to the effectiveness of therapy; symptoms sometimes worsen in the course of therapy before they improve.) The findings suggest that clinicians and researchers should give attention to variability in the recall of traumatic events and reexamine the emphasis placed on the memory of traumatic events in the treatment of PTSD. Among the patients in this study who responded on two occasions, 1 week apart, there was noteworthy discordance in
the reporting or recall of traumatic events. The events reported may have occurred as much as 10 or 12 years prior to reporting; one might expect faulty memory with regard to some of the circumstances surrounding major traumatic events. It is more problematic to account for changes in the fact of whether or not the traumatic events took place. The study reported here has obvious limitations. The sample, Southeast Asian refugees, is small and the patients are heterogeneous in terms or their traumatic experiences. The severity of the
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Table 3b. All subjects
(N = 30) Difference between
Time 1
Time 2
1 and 2
Mean all symptoms
Mean
SD
Mean
SD
Mean
SD
Thoughts recur Feel events recur Nightmares recur Feel detached Can’t feel emotion Feel jumpy Can’t concentrate Trouble sleeping Feel on guard Irritable, anger Avoid activities Can’t remember Blame self for happenings Guilt for survival Ashamed of traumas Think about events Not understood Can’t work Avoid thoughts Less interest Hopelessness Feel no future React to memories Feel going crazy Feel only sufferer Feel hostility No one to rely on Told did, but don’t remember Feel split into 2 Feel betrayed
2.59 2.77 2.47 3.07 2.23 2.03 2.93 2.73 3.03 2.43 2.83 2.90 2.37 2.47 2.17 2.43 2.87 2.60 2.87 2.77 2.40 2.83 2.97 2.87 2.80 2.83 2.03 2.73 2.30 1.67 2.37
0.65 1.14 1.14 1.14 1.04 1.10 1.05 1.14 1.03 1.04 1.02 1.09 1.10 0.94 1.15 1.14 1.11 1.00 1.04 0.86 0.89 1.12 1.13 0.94 1.06 1.12 0.89 1.01 1.15 0.96 1.07
2.73 2.80 2.47 2.87 2.43 2.27 3.00 2.93 3.03 2.43 3.00 2.63 2.57 2.77 2.37 2.93 3.03 2.77 2.83 2.87 2.67 3.00 3.07 3.10 2.93 3.07 2.20 2.67 2.77 2.00 2.43
0.72 1.06 1.01 1.07 1.10 1.08 0.98 0.98 1.00 1.14 0.95 1.03 1.17 1.04 1.22 1.08 0.96 1.07 1.02 1.01 0.96 1.08 1.08 0.96 1.08 1.01 0.92 1.12 1.14 1.11 1.17
-0.14 -0.03 0.00 0.20 -0.20 -0.23 -0.07 -0.20 0.00 0.00 -0.17 0.27 -0.20 -0.30 -0.20 -0.50 -0.17 -0.17 0.03 -0.10 -0.27 -0.17 -0.10 -0.23 -0.13 -0.23 -0.17 0.07 -0.47 -0.33 -0.07
0.29 0.85 0.74 0.76 0.96 1.25 0.98 1.03 0.32 0.91 0.99 1.17 1.21 0.92 0.76 1.20 1.09 1.02 1.07 1.09 0.94 0.75 0.61 0.94 0.63 0.97 0.65 0.94 0.86 0.92 0.69
traumatic events was not determined, simply, whether they occurred. The participants are patients of a psychiatric clinic and severely impaired. However, the significant positive correlation (r = 0.53, p = 0.002) between symptoms and the number of traumatic events reported points to face validity of the questionnaire, in accord with findings of other investigators [9]. The reporting of traumatic events was recorded on only two occasions, one week apart; the patients come from non-western cultures and were highly traumatized before coming to the United States. To what extent the observations are generalizable to other refugee groups [lo] and/or to highly traumatized groups such as veterans is not known. Despite these limitations, the associations observed are statistically significant.
296
The data are presented as correlations; outcome and predictor relationships among the two major variablewhange in reports of traumatic events and severity of symptoms-are not obvious. The questions are: Do symptoms influence memory or recall of traumatic events? Or conversely, Do traumatic events lead to more severe symptoms? In this retrospective study, the answer cannot be determined. The issues of memory and the fallacy of memory, in the context of the Diagnostic Interview Schedule, have recently been addressed by Rogler et al. [ll]. The findings reported here relate to the recall of traumatic events not per se, but rather in the context of their association with present symptoms of the psychiatric distress. This analysis of the differences in the reporting of trauma and/or
Traumatic Events and Psychiatric Symptoms torture experiences on two occasions, 1 week apart, provides new insights into the relationship between perception of events and psychiatric symptoms as measured by the trauma/symptom questionnaire reported on here. Further research is needed to interpret and understand better changes in the reporting of ‘events’ in contrast to symptoms over time, and to gain insight into the psychological distress of trauma victims.
Conclusion
2.
3.
4.
The discordance in the reporting of traumatic experiences and its relationship to the reporting of symptoms of psychological distress (using the Trauma Questionnaire) have important implications for the treatment of highly traumatized patients. Examination of test-retest concordance/ discordance yielded results that may be important for the evaluation and treatment of psychiatric patients. Further research is needed to better understand changes in the reporting of ‘events’ in contrast to symptoms over time, and to gain insight into the psychological distress of trauma victims.
5.
6.
7.
8. The staff of the Indochinese Psychiatry Clinic, Dr. R. Mollica, Director, Dr. P. Bollini, Ms. Svang Tor, and many others participated in the development of the Trauma Questionnaire and the interviewing of patients. Without their input these data would not have been available for analysis. Dr. Kathleen Adams not only made helpful comments, but provided valuable editorial suggestions. 1 also thank Drs. Arthur Kleinman, Alexander Leighton, and Ladson Hinton for useful comments on the manuscript.
10.
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11.
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Ph.D.
Abstract: This study examines change in the reporting of trauma events in relation to the reporting of severity of symptoms of psychiatric distress among refugees from Southeast Asia. Patients (N = 30) from a specialized clinic were interviewed on two occasions using a questionnaire which includes inquiry about traumatic events and about psychiatric symptoms. The changes in responses to the questionnaire, administered twice, 1 week apart, were assessed. In accord with other studies, results indicated that the number of trauma events reported correlates positively with severity of symptoms (r = 0.533, p = 0.002). Severity of symptoms of psychiatric distress increased slightly from time 1 to time 2 for 23 of the 30 symptoms. The reporting of trauma events varied between time 1 and time 2; the correlation coefficient ranged from 0.23 to 0.90, with a median 0.62 for the 17 trauma events. The important new finding is that of an inverse relation between total symptom score and the percent change in the reporting of trauma events on two occasions (r = -0.478, p = 0.009). Findings suggest that clinicians and researchers should give attention to variability in recall of traumatic events and reexamine the emphasis placed on the memory of traumatic events in the treatment of Posttraumatic Stress Disorder.
Introduction Southeast Asian refugees report a multitude of traumatic experiences, including rape and torture; these trauma stories influence psychiatric treatment approaches to these patients. In the present paper we report findings, based on a trauma ques-
Departments of Population and International Health and Biostatistics, Harvard School of Public Health and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts Address reprint requests to: Dr. G. Wyshak, Department of Population and International Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115.
tionnaire relating to symptoms of depression, anxiety, and posttraumatic stress disorder among Southeast Asian refugees; viz., an inverse association has been observed between symptom scores and change in the reporting of traumatic events. Variability in reporting traumatic events may have important implications for the understanding and treatment of patients suffering from severe trauma. Previous work in a specialized psychiatric clinic (the Indochinese Psychiatric Clinic; IPC) serving Indochinese refugees [l-5] revealed that the Cambodian patients were more highly traumatized than the other two groups. Cambodian widows reported a mean of 17.1 traumatic experiences, including 3.5 torture experiences. The Laotians reported a mean of 10.7 traumatic experiences, including 1.2 torture experiences; the Vietnamese 2.1 and 0.3, respectively. In previous work, we found that major affective disorder was the most prominent diagnosis for each ethnic group: 57% (12/21) of the Cambodians, 92% (12/13) of the Laotians, and 11% (2/18) of the Vietnamese were diagnosed as having posttraumatic stress disorder, with or without other diagnoses. In this paper we examine the relation between trauma experiences and the severity of symptoms of psychological distress.
Methods The study instrument which has been denoted as the Trauma Questionnaire was developed by the staff of the IPC which is part of St. Elizabeth’s Hospital, a general hospital in Boston, and has been described in detail elsewhere [6]. Briefly, the quesGeneral Hospital
290 ISSN 0163-8343/94/$7.00
Psychiatry 16, 290-297, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Traumatic Events and Psychiatric Symptoms tionnaire consists of three sections: basic sociodemographic data, questions about traumatic experiences, and questions about current symptoms. Linguistic equivalence for each item of the questionnaire was established for the three Southeast Asian languages-Cambodian, Vietnamese, and Laotian. The questionnaire was administered by IPC bicultural clinicians of the same ethnic group as the subject and in the subject’s native language. The 30 symptoms in the questionnaire relate to the Posttraumatic Stress Disorder (PTSD) diagnostic criteria of DSM-III-R [7] as follows: Questions 1, 2, and 3 relate to criterion B, a persistent reexperiencing of the traumatic event. Questions 4, 5, 11, 12, 19, 20, and 22 relate to criterion C, a persistent avoidance of circumstances and responses similar to those of the trauma event. Questions 6, 7, 8, 9, 10, and 23 relate to criterion D, persistent anxiety or heightened arousal. Question 13 about selfblame and question 21 about hopelessness are similar to items in the Hopkins Symptom Checklist [2]. The remaining 12 items (14-18 and 24-30) are unique to the trauma questionnaire. The trauma questionnaire in its present form consists of the following: 1. Sociodemographic data 2. 17 questions on whether the patient experienced, witnessed, or heard about the following trauma/torture events: Lack of food or water :: Ill health without access to medical care Lack of shelter Imprisonment Serious injury Torture Brainwashing Rape or sexual abuse i. Enforced isolation from others Being close to death j. k. Forced separation from family members 1. Murder of family or friend m. Unnatural death of family or friend n. Murder of stranger or strangers Lost or kidnapped 0. Combat situation P* Any other situation that was very frighten9. ing or you felt your life was in danger.
L-. ;. E:
Responses were coded according to yes/no for experienced, witnessed, or heard about the events of experienced, witnessed, or and combinations heard about.
3. 30 symptoms that the patient was bothered by in the past week based on a 4-point scale: l-not at all, 2-a little, 3-quite a bit, 4xtremely. 1. Recurrent thought or memories of the most hurtful or terrifying events 2. Feeling as though the event is happening again 3. Recurrent nightmares 4. Feeling detached or withdrawn from peo5. 6. 7. 8. 9. 10.
ple Unable to feel emotions Feeling jumpy, easily startled Difficulty concentrating Trouble sleeping Feeling on guard Feeling irritable or having outbursts
of an-
ger 11. Avoiding activities that remind you of the most traumatic or hurtful event parts of the most 12. Inability to remember traumatic or hurtful events 13. Blaming yourself for things that have happened 14. Feeling guilty for having survived 15. Feeling ashamed of the hurtful or traumatic events that have happened to you 16. Spending time thinking about why these events happened to you 17. Feeling that people do not understand what happened to you 18. Difficulty performing work or daily tasks 19. Avoiding thoughts or feelings associated with the traumatic or hurtful events 20. Less interest in daily activities 21. Hopelessness 22. Feeling as if you don’t have a future 23. Sudden emotional or physical reaction when reminded of the most hurtful or traumatic events 24. Feeling as if you are going crazy 25. Feeling that you are the only one who has suffered these events 26. Feeling others are hostile towards you 27. Feeling that you have no one to rely on 28. Finding out or being told by other people that you have done something you cannot remember 29. Feeling as if you are split into two people, and one of you is watching what the other is doing 30. Feeling that someone has betrayed you.
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Subjects The questionnaire was administered to 30 patients-10 each of Cambodians, Vietnamese, and Laotians-by bicultural clinicians on two occasions 1 week apart. All were patients at the IPC and are members of larger patient groups served at this clinic. DSM-III-R diagnoses were made by IPC staff western psychiatrists and bicultural teams on the basis of semistructured interviews after the subject had received a minimum of 3 months of treatment. Participation consisted of responding to the three parts of the Trauma Questionnaire, and a psychiatric interview.
Statistical Methods Pearson correlations were computed for determining the associations between traumatic events and symptoms of psychiatric distress. The “test-retest” reliability, concordance of response on the two occasions, was assessed using the Kappa statistic. Trauma events were analyzed based on experienced, witnessed, heard-about (full scale), and a dichotomous scale-experienced/not experienced. Percent change in trauma events was defined as the total number of changes in the reporting of trauma events (experienced/not experienced) from time 1 to time 2 divided by the sum of the trauma events at time 2. This method controls (normalizes) for the number of trauma events reported.
Results The characteristics of the study sample and symptoms of psychological distress are presented in Table 1. For the entire sample of 30,40% were males,
Table 1. Characteristics
with mean age of 44.3 2 SD 10.7; 56.7% had a diagnosis of PTSD with or without other psychiatric diagnoses; and 56.7% had diagnoses of major affective disorder with or without other psychiatric diagnoses; other diagnoses included schizophrenia, personality disorder, organic brain syndrome, and others. On average, subjects arrived in the U.S. in 1982 and became clinic patients in 1985-86 (the means and SDS are in Table 1). Eighty percent were married or widowed. Seventy-three percent had less than 6 years of schooling. Only 10% were employed and in unskilled occupations; the remainder were on Supplemental Security Income (SSI), refugee assistance, or Aid to Families with Dependent Children (AFDC). English skills were good among 13%, fair for 47%, and poor for 40%; 30% reported current attendance in English as a second language program. The mean number of trauma events reported at time 1 was 9.6 (out of a possible 17), SD 3.6 (Table 2a). We review briefly the following findings relating to concordance between time 1 and time 2 for trauma experiences reported elsewhere [8]. Intrasubject concordance, over a l-week period for the items relating to the 17 events or experiences using the full scale, had correlation coefficients ranging from 0.23 for injury to 0.90 for murder of family member or friend; the median for the 17 items was 0.62. Concordance based on the dichotomous scale (experienced/not experienced) was similar as was the Kappa statistic for agreement (Table 2b). The higher the percent reporting an event the lower the Kappa for that event; the correlation coefficient between percent reporting at time 1 and Kappa is -0.51, p = 0.04 The reporting of trauma events increased
of total sample by ethnic group
Variable
Total (N = 30)
Cambodian (N = 10)
Loatian (N = 10)
Vietnamese (N = 10)
Gender % male PTSD diagnosis % Major affect dis %
40 56.7 56.7
30 80 60
50 60 50
40 30 60
Age Year arrived U.S. Year clinic patient
292
Mean
SD
Mean
SD
Mean
SD
Mean
SD
44.267 82.567 85.767
10.683 1.906 1.305
41.000 83.600 86.700
9.763 1.577 0.483
51.700 80.900 85.100
8.769 1.100 1.449
40.100 83.200 85.500
10.148 1.813 1.269
Traumatic Events and Psychiatric Symptoms
Table 2a. Trauma
Trauma events
No food Ill health No shelter Prison Serious injury Torture Brainwashing Rape/Sex abuse Isolation Close to death Separation family Murder family Death family Murder strangers Lost/Kidnapped Combat situation Other
events reported
at time 1, total sample,
and by ethnic group
Total (N = 30)
Cambodian (N = 10)
Loatian (N = 10)
Vietnamese (N = 10)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
9.600
3.645
13.100
1.911
7.300
3.334
8.400
2.633
% 86.7 76.7 73.3 43.3 53.3 36.7 53.3 13.8 69.0 80.0 73.3 50.0 43.3 16.7 30.0 76.7 86.7
% 100 100 100 40 50 60 100 22.2” 100 100 100 90 90 10 60 90 100
% 70 50 60 40 60 40 20 10 50 70 60 30 10 20 00 60 80
% 90 80 60 50 50 10 40 10 55.5+ 70 60 30 30 20 30 80 80
“N=9
slightly but not significantly from time 1 to time 2, from 9.6 + 3.6 (mean 2 SD) to 10.2 ? 3.3. Differences in the reporting of events was bidirectional; the mean of the differences was -0.62 2 2.1 but the mean of the absolute value of differences was 1.4 + 1.6, significantly different from zero, p < 0.0001. (Data for both time 1 and time 2 were obtained from 29 subjects.) Table 3a and b show in full detail symptoms scores at time 1 for all subjects and for the three ethnic groups, and the differences in symptom scores between time 1 and time 2 for the entire group. The mean score at time 1 for all symptoms combined is 2.59, SD 0.65, at time 2, 2.73, SD 0.72. The mean difference for all symptoms is - 0.14, SD 0.29, indicating an increase in symptom scores from time 1 to time 2; this difference is statistically significant, p < 0.05. Three symptoms showed no change, four a small decrease, and 23 a small increase. The concordance for the 30 symptoms ranged from 0.32 for symptom “avoiding thoughts or feelings associated with the traumatic event,” to 0.85 for “feeling as if you don’t have a future.” The main findings on the relation between the reporting of trauma events and symptoms of psychiatric distress are as follows:
The number of traumatic events reported correlated significantly with severity of symptoms. For all symptoms combined, the correlation with trauma events reported at time 1 is r = 0.533, p = 0.002; at time 2, r = 0.584, p = 0.001. For PTSD-related symptoms, the correlation at time 1 is r = 0.526, p = 0.003; for non-PTSD related symptoms, r = 0.479, p = 0.007. The major new finding based on the subjects who responded to the questionnaire twice, 1 week apart, is that symptom scores are inversely correlated with differences in the reporting of events on the two occasions. Those who showed the most change (bidirectional) in the number of events or traumas reported (expressed as a percentage of total number of traumatic events reported at time 2) had a lower average on the symptom scale. (The percent change in reporting of trauma events expressed as the number of changes between time 1 and time 2 divided by the number of events reported at time 2 normalizes for the total number of events, which as noted above, varies considerably among subjects.) The results are presented as correlations between symptoms at time 1 and percent change in reporting of 293
G. Wyshak
Table 2b. All subjects:
percent
reporting
% Reporting at time 1 N = 30 No food Ill health No shelter Prison Serious injury Torture Brainwashing Rape/Sex abuse Isolation Close to death Separation family Murder family Death family Murder strangers Lost/Kidnapped Combat situation Other
86.7 76.7 73.3 43.3 53.3 36.7 53.3 13.8 69.0 80.0 73.3 50.0 43.3 16.7 30.0 76.7 86.7
N = 29 (86.2) (75.9) (72.4) (44.8) (55.2) (37.9) (51.7) (14.3) (67.9) (79.3) (72.4) (48.3) (41.4) (17.2) (31.0) (75.9) (86.2)
trauma events
% Reporting at time 2 (N = 29)
Difference between times 1 and 2 (N = 29)
Kappa
SE
Obs (PO)
Exp (PE)
96.6 96.6 82.8 48.3 62.1 41.4 62.1 13.8 50.0 86.2 69.0 48.3 41.4 31.0 27.6 75.9 86.2
- 10.3 -20.7 - 10.3 -3.4 -6.9 -3.4 - 10.3 3.6 14.8 -6.9 3.4 0.0 0.0 - 13.8 3.4 0.0 0.0
0.36496 0.20183 0.51178 0.79236 0.57561 0.78412 0.65228 0.51163 0.55000 0.52066 0.58453 0.72381 0.85784 0.44937 0.58453 0.43506 0.13000
0.14345 0.11187 0.17755 0.18525 0.18383 0.18521 0.18161 0.18646 0.18359 0.18028 0.18505 0.18570 0.18570 0.17273 0.18505 0.18570 0.18570
0.89655 0.79310 0.82759 0.89655 0.79310 0.89655 0.82759 0.89286 0.77778 0.86207 0.82759 0.86207 0.93103 0.79310 0.82759 0.79310 0.79310
0.83710 0.74078 0.64685 0.50178 0.51249 0.52081 0.50416 0.78061 0.50617 0.71225 0.58502 0.50059 0.51486 0.62426 0.58502 0.63377 0.76219
Agreement (%)
Kappa
a Parentheses indicate percent reporting among those who reported at both Time 1 and Time 2
trauma events, because there is a question as to which is the outcome variable and which the predictor variable. That is, do symptoms influence memory or recall of traumatic events; or conversely, do traumatic events lead to symptoms? In this retrospective study, the answer cannot be determined. The correlation between the total symptom score (average of 30 items at first testing session) and the percent change in events reported is r = -0.478, p = 0.0088. The individual symptoms that showed the highest inverse relation with percent change in the reporting of traumatic events were blaming self for things that happened, r = -0.499, p = 0.0059; feeling guilty for having survived, r = -0.509, p = 0.005; and feeling ashamed of the traumatic events that happened to you, r = -0.630, p = 0.0002.For symptoms not related to the DSM-III-R criteria for PTSD, the correlation with percent change in trauma reporting is -0.463, p = 0.0115; for all PTSD-related r= symptoms, the correlation coefficient is - 0.444, p = 0.0158. Criterion B, persistence in reexperiencing the trauma had a correlation of - 0.280; criterion C, an attempt to avoid stimuli that trigger memories of the trauma, a correlation of -0.441; and criterion D, persistent anxiety, a correlation of - 0.416. 294
Discussion The concept of interrater reliability as a method for determining reliability and/or agreement among observers or raters is well established and accepted. Current approaches to interviewing include the concept of test-retest reliability, i.e., consistency by a given subject asked to report symptoms on two or more testing occasions. To our knowledge this is the first time patient reports of traumatic events and the change in these reports, sometimes within a relatively short period of time, have been examined in relation to patient symptoms. The results reported here suggest that a “test-retest,” that is, inquiry into the occurrence of traumatic events on two or more occasions (i.e., trauma stories) may have a use in therapeutic settings. The important observation in this study is that those whose reporting of traumatic events varied on the two testing occasions had less severe symptoms than those who showed less variation in the reporting of traumatic events. The questions arise: Is selective memory an adaptive mechanism? To what extent is change in recall of events due to impairment? Alternatively, to what extent are the processes of adjustment and coping at work? (It should be noted that the duration of symptoms of distress is included as criterion E of PTSD [6] and is
Traumatic Events and Psychiatric Symptoms
Table 3a. Symptom
scores at time 1 for total sample and by ethnic group Total (N = 30)
Cambodian (N = 10)
Loatian (N = 10)
Vietnamese (N = 10)
at time 1
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean all symptoms Mean PTSD Sx Mean not PTSD Mean PTSD criteria B Mean PTSD criteria C Mean F’TSD criteria D 1 Thoughts recur 2 Feel events recur 3 Nightmares recur 4 Feel detached 5 Can’t feel emotion 6 Feel jumpy 7 Can’t concentrate 8 Trouble sleeping 9 Feel on guard 10 Irritable, anger 11 Avoid activities 12 Can’t remember 13 Blame self for happenings 14 Guilt for survival 15 Ashamed of traumas 16 Think about events 17 Not understood 18 Can’t work 19 Avoid thoughts 20 Less interest 21 Hopelessness 22 Feel no future 23 React to memories 24 Feel going crazy 25 Feel only sufferer 26 Feel hostility 27 No one to rely on 28 Told did, but don’t remember 29 Feel split into 2 30 Feel betrayed
2.592 2.675 2.498 2.767 2.524 2.806 2.767 2.467 3.067 2.233 2.033 2.933 2.733 3.033 2.433 2.833 2.900 2.367 2.467 2.167 2.433 2.867 2.600 2.867 2.767 2.400 2.833 2.967 2.867 2.800 2.833 2.033 2.733 2.300 1.667 2.367
0.647 0.654 0.724 0.947 0.676 0.694 1.135 1.137 1.143 1.040 1.098 1.048 1.143 1.033 1.040 1.020 1.094 1.098 0.937 1.147 1.135 1.106 1.003 1.042 0.858 0.894 1.117 1.129 0.937 1.064 1.117 0.890 1.015 1.149 0.959 1.066
3.203 3.256 3.142 3.366 3.142 3.333 3.200 3.000 3.900 2.900 2.500 3.300 3.500 3.200 3.200 3.500 3.400 3.200 3.400 2.900 3.500 3.100 3.200 3.600 3.300 2.800 3.700 3.900 3.300 3.300 3.600 2.200 3.200 3.100 2.600 2.600
0.566 0.617 0.597 0.808 0.649 0.582 1.229 1.054 0.316 0.994 1.178 1.059 0.971 1.032 0.788 0.527 0.966 0.788 0.699 1.100 0.849 1.100 0.788 0.516 0.823 0.632 0.483 0.316 0.823 1.059 0.699 1.032 0.632 0.994 1.074 1.173
2.363 2.362 2.364 2.266 2.242 2.550 2.200 2.100 2.500 1.800 2.000 2.500 2.400 2.600 2.200 2.600 2.400 2.200 2.200 2.100 2.100 3.100 2.500 2.500 2.700 1.900 2.800 2.700 3.000 2.600 2.800 2.100 2.600 2.300 1.200 2.200
0.462 0.451 0.517 0.604 0.485 0.643 0.788 0.567 1.080 0.788 1.054 1.178 0.966 0.966 0.918 1.074 1.173 0.918 0.632 0.994 0.737 0.994 0.707 0.971 0.674 0.567 1.032 1.059 0.666 0.966 0.788 0.737 0.966 0.948 0.421 0.918
2.210 2.406 1.985 2.666 2.185 2.533 2.900 2.300 2.800 2.000 1.600 3.000 2.300 3.300 1.900 2.400 2.900 1.700 1.800 1.500 1.700 2.400 2.100 2.500 2.300 2.500 2.000 2.300 2.300 2.500 2.100 1.800 2.400 1.500 1.200 2.300
0.425 0.479 0.538 1.088 0.415 0.576 1.197 1.494 1.316 1.054 0.966 0.816 1.159 1.059 0.994 1.074 0.994 1.059 0.632 0.971 0.948 1.173 1.197 1.178 0.823 1.178 1.054 1.159 1.059 1.080 1.286 0.918 1.264 0.971 0.421 1.159
Symptoms
important in other diagnoses. Change in symptoms points to the effectiveness of therapy; symptoms sometimes worsen in the course of therapy before they improve.) The findings suggest that clinicians and researchers should give attention to variability in the recall of traumatic events and reexamine the emphasis placed on the memory of traumatic events in the treatment of PTSD. Among the patients in this study who responded on two occasions, 1 week apart, there was noteworthy discordance in
the reporting or recall of traumatic events. The events reported may have occurred as much as 10 or 12 years prior to reporting; one might expect faulty memory with regard to some of the circumstances surrounding major traumatic events. It is more problematic to account for changes in the fact of whether or not the traumatic events took place. The study reported here has obvious limitations. The sample, Southeast Asian refugees, is small and the patients are heterogeneous in terms or their traumatic experiences. The severity of the
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G. Wyshak
Table 3b. All subjects
(N = 30) Difference between
Time 1
Time 2
1 and 2
Mean all symptoms
Mean
SD
Mean
SD
Mean
SD
Thoughts recur Feel events recur Nightmares recur Feel detached Can’t feel emotion Feel jumpy Can’t concentrate Trouble sleeping Feel on guard Irritable, anger Avoid activities Can’t remember Blame self for happenings Guilt for survival Ashamed of traumas Think about events Not understood Can’t work Avoid thoughts Less interest Hopelessness Feel no future React to memories Feel going crazy Feel only sufferer Feel hostility No one to rely on Told did, but don’t remember Feel split into 2 Feel betrayed
2.59 2.77 2.47 3.07 2.23 2.03 2.93 2.73 3.03 2.43 2.83 2.90 2.37 2.47 2.17 2.43 2.87 2.60 2.87 2.77 2.40 2.83 2.97 2.87 2.80 2.83 2.03 2.73 2.30 1.67 2.37
0.65 1.14 1.14 1.14 1.04 1.10 1.05 1.14 1.03 1.04 1.02 1.09 1.10 0.94 1.15 1.14 1.11 1.00 1.04 0.86 0.89 1.12 1.13 0.94 1.06 1.12 0.89 1.01 1.15 0.96 1.07
2.73 2.80 2.47 2.87 2.43 2.27 3.00 2.93 3.03 2.43 3.00 2.63 2.57 2.77 2.37 2.93 3.03 2.77 2.83 2.87 2.67 3.00 3.07 3.10 2.93 3.07 2.20 2.67 2.77 2.00 2.43
0.72 1.06 1.01 1.07 1.10 1.08 0.98 0.98 1.00 1.14 0.95 1.03 1.17 1.04 1.22 1.08 0.96 1.07 1.02 1.01 0.96 1.08 1.08 0.96 1.08 1.01 0.92 1.12 1.14 1.11 1.17
-0.14 -0.03 0.00 0.20 -0.20 -0.23 -0.07 -0.20 0.00 0.00 -0.17 0.27 -0.20 -0.30 -0.20 -0.50 -0.17 -0.17 0.03 -0.10 -0.27 -0.17 -0.10 -0.23 -0.13 -0.23 -0.17 0.07 -0.47 -0.33 -0.07
0.29 0.85 0.74 0.76 0.96 1.25 0.98 1.03 0.32 0.91 0.99 1.17 1.21 0.92 0.76 1.20 1.09 1.02 1.07 1.09 0.94 0.75 0.61 0.94 0.63 0.97 0.65 0.94 0.86 0.92 0.69
traumatic events was not determined, simply, whether they occurred. The participants are patients of a psychiatric clinic and severely impaired. However, the significant positive correlation (r = 0.53, p = 0.002) between symptoms and the number of traumatic events reported points to face validity of the questionnaire, in accord with findings of other investigators [9]. The reporting of traumatic events was recorded on only two occasions, one week apart; the patients come from non-western cultures and were highly traumatized before coming to the United States. To what extent the observations are generalizable to other refugee groups [lo] and/or to highly traumatized groups such as veterans is not known. Despite these limitations, the associations observed are statistically significant.
296
The data are presented as correlations; outcome and predictor relationships among the two major variablewhange in reports of traumatic events and severity of symptoms-are not obvious. The questions are: Do symptoms influence memory or recall of traumatic events? Or conversely, Do traumatic events lead to more severe symptoms? In this retrospective study, the answer cannot be determined. The issues of memory and the fallacy of memory, in the context of the Diagnostic Interview Schedule, have recently been addressed by Rogler et al. [ll]. The findings reported here relate to the recall of traumatic events not per se, but rather in the context of their association with present symptoms of the psychiatric distress. This analysis of the differences in the reporting of trauma and/or
Traumatic Events and Psychiatric Symptoms torture experiences on two occasions, 1 week apart, provides new insights into the relationship between perception of events and psychiatric symptoms as measured by the trauma/symptom questionnaire reported on here. Further research is needed to interpret and understand better changes in the reporting of ‘events’ in contrast to symptoms over time, and to gain insight into the psychological distress of trauma victims.
Conclusion
2.
3.
4.
The discordance in the reporting of traumatic experiences and its relationship to the reporting of symptoms of psychological distress (using the Trauma Questionnaire) have important implications for the treatment of highly traumatized patients. Examination of test-retest concordance/ discordance yielded results that may be important for the evaluation and treatment of psychiatric patients. Further research is needed to better understand changes in the reporting of ‘events’ in contrast to symptoms over time, and to gain insight into the psychological distress of trauma victims.
5.
6.
7.
8. The staff of the Indochinese Psychiatry Clinic, Dr. R. Mollica, Director, Dr. P. Bollini, Ms. Svang Tor, and many others participated in the development of the Trauma Questionnaire and the interviewing of patients. Without their input these data would not have been available for analysis. Dr. Kathleen Adams not only made helpful comments, but provided valuable editorial suggestions. 1 also thank Drs. Arthur Kleinman, Alexander Leighton, and Ladson Hinton for useful comments on the manuscript.
10.
References
11.
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outcome study. Report for U.S. Federal Office of Refugee Resettlement, National Demonstration Project, 1985 Mollica RF, Wyshak G, deMarneffe D, Tu B, Yang T, Khuon F, Coehlo R, Lavelle J: Hopkins Symptom Checklist-25, Indochinese versions (HSCL-25). Manual for use in Cambodian, Lao, and Vietnamese versions, 1985 Mollica RF, Wyshak G, deMarneffe D, Khuon F, Lavelle J: The Hopkins Symptom Checklist-25, Cambodian version. A screening instrument for the psychiatric care of the refugee patient. Am J Psychiatry 144:497-500, 1987a Mollica RF, Wyshak G, Lavelle J, et al: The psychosocial impact of war trauma and torture on the Southeast Asian refugees. Am J Psychiatry 144: 1567-1572, 19871, Mollica RF, Wyshak G, Lavelle J, et al: The psychiatric treatment of refugee survivors of war trauma and torture: an outcome study. Am J Psychiatry 147: 83-88, 1990 Mollica RF, Caspi-yavin Y, et al: The Harvard Trauma Questionnaire: validating a cross-cultural stress disorder in Indochinese refugees. J Nerv Ment Dis 180(2):111-116, 1992 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders 3rd ed, revised. Washington, DC, American Psychiatric Press, 1987 Wyshak G: Assessing the Psychosocial Impact of War Trauma and Torture on Southeast Asian Refugees. 2nd Intl Congr on Medicine and Migration, Rome, Italy, July 11-13, 1990 Langner TS, Michael ST: The Midtown Manhattan Study: Volume II Life Stress and Mental Health. The Free Press of Glencoe, Toronto, 1963, pp 147 ff, 372 ff Gong-Guy E, Cravens RB, Patterson TE: Clinical issues in mental health delivery to refugees. Am Psychol46(6):642-648, 1991 Rogler LH, Malgady RG, Tryon WW: Evaluation of mental health: issues of memory in the Diagnostic Interview Schedule. J Nerv Ment Dis 180:215-222, 1992
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