Month: February 2022

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Assessment of Trauma in Children and Adolescents

The Child Trauma Screen is an assessment tool to identify children ages 6-17 who are experiencing symptoms of traumatic distress (Lang & Connell, 2018). It is short, free, and meant for use by a variety of professionals working with children. It is not meant to be comprehensive and screen for all possible symptoms or reactions, but rather a quick initial step to identify the most common reactions and exposures, for further follow up of clinical treatment or more comprehensive assessment. It is recommended to be conducted using an in-person interview, but it can also be used as a self-report measure, and also recommended to get both reports from the child and the caregiver or multiple caregivers. One concern I noted for the Child Trauma Screen is that all three of the studies listed on its hosted website which found it valid and reliable were all conducted by the creator of the screen (Child Health and Development Institute of Connecticut, Inc., 2021).

The context which I would use this assessment personally is within my practice as a Licensed Professional Counselor and Registered Play Therapist, specializing in treating trauma in children and adolescents. An ethical consideration is that if a child reports any abuse, I would need to report it to the Child Welfare office. Another consideration that I would prefer is to first have several sessions with the child to build rapport and safety before administering the screen, and I would also request that the parent leave the room. The child may not feel comfortable sharing in front of their parent for a variety of reasons, such as not wanting to upset them, fear over their reaction, or the parent instigating the abuse.

Reducing traumatic exposure for children and adolescents may ultimately not be possible, although developing better prevention and interventions to interrupt cycles of abusers could make a large difference. Still, trauma is present in nearly all of our lives (van der Kolk & McFarlane, 1996). In reducing the burden of trauma on children and adolescents, I believe we should instead focus on creating resilient support systems which help children process trauma in healthy ways and develop skills for self- and co-regulation of emotions.

See this image below depicting Bronfenbrenner’s Ecological Theory or socio-ecological model (Stanger, 2011). Using this theory, we could construct levels of systems, which all interact and influence each other, embedding resilience building factors into each level. Such a design might buffer negative mental health impacts for children after experiencing traumatic events.

Here is another image which shows the same concept but in a slightly different way which may be helpful (University of Minnesota, n.d.).

See here for a larger, clearer version from the source website.

This same resource listed multiple ideas on how to apply this model in practical applications. I believe these would apply to reducing the burden of trauma on children, adults, families, communities, society, and so on.

  • Promote individual and family solutions to support mental well-being (e.g., self-efficacy) 
  • Learn and teach others to manage stress and cope with adversity
  • Provide health education to support parent-child/caregiver-child relationships
  • Promote social connections – between family, neighbors, employees, etc.
  • Expand youth development in schools
  • Increase skill-based learning to promote adaptability, coping and resilience  
  • Coordinate mental health prevention efforts at the federal, state, and local levels 
  • Support local communities taking an active role in co-creating solutions
  • Increase collaboration between service organizations to strengthen service coverage, access and the referral process for a more integrative, comprehensive approach
  • Leverage the role of service providers to increase natural social support systems 
  • Fund mental health promotion research and community-based supports 
  • Promote equitable resource allocation

(University of Minnesota, n.d., par. 8).

References

Child Health and Development Institute of Connecticut, Inc. (2021). Child Trauma Screen. https://www.chdi.org/our-work/mental-health/trauma-informed-initiatives/ct-trauma-screen-cts/

Lang, J., & Connell, C. (2018). The Child Trauma Screen: A follow-up validation. Journal of Traumatic Stress, 31(4), 540-548.

Stanger, N. (2011). Moving “eco” back into socio-ecological models: A proposal to reorient ecological literacy into human developmental models and school systems. Human Ecology Review, 18, 167-173.

University of Minnesota. (n.d.). Mental health and well-being ecological model. Center for Leadership Education in Maternal & Child Public Health. https://mch.umn.edu/resources/mhecomodel/

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

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Assessment-Based Ethical Referral of Traumatized Individuals to Psychosocial Services

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When conducting assessments for trauma as a psychologist, it is important to have a plan in place on the provision of mental health services and resources for the client or participant. Those participants who screen as having posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), acute stress disorder (ASD), or who may not qualify for a disorder but still have significant symptoms in amount or severity should be referred for more in-depth assessments or treatment. The International Society for Traumatic Stress Studies (ISTSS) (Forbes et al., 2020) suggests treatments of varying evidence bases for recommendations. This also aligns, and in some cases conflicts, with ethical standards as proposed by the American Psychological Association (APA) (2017) and the International Union of Psychological Science (IUPS) (2008). However, a crucial consideration is the barriers to such treatments, such as cultural factors, socioeconomics, and available resources, which may be difficult to access in some areas of the world.

Trauma assessments could occur in at least two different scenarios, either within the context of a research assessment, or in a clinical environment. In a research context, the APA’s Ethical Principles of Psychologists and Code of Conduct (2017) states in section 8.08 that in order to reduce the risk of harm to participants, debriefing should occur quickly following the conclusion of the research. However, this is conflictual with debriefing as an early intervention in a clinical setting following assessment. The ISTSS (Forbes et al., 2020) reviewed evidence and found that debriefing interventions were largely ineffectual, including psychoeducation, in both individual and group interventions. It must be noted, though, that this was specific to those who had been exposed to trauma within the prior three months, and there appeared to be little research included for its use with survivors and refugees of civil war and genocide. This is relevant because the author of this paper, Emily Lutringer, is working to adapt the International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) into cultural idioms of distress for Syrians, who have significant rates of multiple trauma exposures occurring for potentially over a decade (Hassan et al., 2015). In doing an assessment for research purposes, individuals may have been exposed to trauma longer than three months ago. ISTSS (Forbes et al., 2020) guidelines found strong evidence to recommend the following psychological treatments for adults with PTSD: cognitive processing therapy, cognitive therapy, EMDR, trauma-focused CBT, and prolonged exposure.

In conducting clinical assessments, there may be clients who are recently exposed to trauma, and therefore could partake in prevention and early interventions if they show symptoms of trauma on the assessment. ISTSS (Forbes et al., 2020) found that single sessions of EMDR and Group 512 PM had emerging evidence to prevent or treat symptoms of PTSD. Brief dyadic therapy and self-guided internet-based interventions also showed emerging evidence for multiple-session prevention. Stronger evidence was found in early treatment multi-session interventions of trauma-focused CBT, cognitive therapy, and EMDR. Of pharmacological interventions, only hydrocortisone showed emerging evidence.

In any situation in which an individual screens positively for trauma symptoms or PTSD, there may be barriers to accessing the most effective treatments – or even any interventions at all. Firstly, the interventions proposed by ISTSS (Forbes et al., 2020) are primarily Western models, and may not be culturally appropriate in other contexts (Narvaez, 2019). While ISTSS (Forbes et al., 2020) offers a few treatments which may have limited efficacy which could be culturally accessible, such as acupuncture, it is notably lacking in covering the evidence for interventions from indigenous psychologies which would be highly culturally relevant.

Another serious concern is the lack of access, such as low rates of mental health providers, remote areas, high demand with limited availability, and socioeconomic factors (Patel, 2007). Rojas et al. (2019) found that mental health care could be utilized in such situations through the use of internet-based interventions in a variety of formats, such as virtual counseling, phone apps, and specialized video games. As more people worldwide have access to the use of internet and cellphones, these interventions could reach larger populations and at lower costs. There are two caveats to this, though. Firstly, there are still many areas of the world without such internet or cell phone access. Secondly, internet and phone-based interventions appear to have mixed results in their effectiveness, although ISTSS was able to give a standard recommendation for the use of guided internet-based trauma-focused CBT in adults diagnosed with PTSD (Forbes et al., 2020).

Other barriers include stigma and poor mental health literacy (Wong et al., 2019). For example, Syrians typically hold strong stigmas around mental health and may be afraid to seek help for how others may judge them or their families (Hassan et al., 2015). Wong et al. (2019) had positive results in their pilot study evaluating the reduction of stigma through a mental health course in Hong Kong. Similar strategies for psychoeducation and normalization may be valuable when working with people in high-stigma cultures, as they may otherwise resist any PTSD intervention.

 Any mental health resources should include facilities or providers who have experience working with the specific population, to meet the ethical standard of competency (APA, 2017; IUPS, 2008). A researcher would ideally, finding an option that participants could engage in immediately after the study if they chose would allow them to process any trauma that came up without a waitlist. As the assessments are specifically measuring for trauma, a participant may suddenly become aware for the first time that they are suffering from a mental illness and may need immediate support. Furthermore, providing exceptional mental health and other resources is critical to preventing the re-enactment of trauma or intergenerational trauma which could lead to a continued cycle of violence (van der Kolk & McFarlane, 1996). It constitutes the ethical responsibilities of beneficence and nonmaleficence, fidelity and responsibility, justice, and respect for people’s rights and dignity (APA, 2017) not only to individual participants, but in taking a responsibility in the reduction of harm in communities as well.

References

American Psychological Association [APA]. (2017). Ethical Principles of Psychologists and Code of Conduct. https://www.apa.org/ethics/code

Cloitre, M., Shevlin M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta Psychiatrica Scandinavica. DOI: 10.1111/acps.12956

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. Geneva: UNHCR.

International Union of Psychological Science [IUPS]. (2008). Universal Declaration of Ethical Principles for Psychologists. https://www.iupsys.net/about/governance/universal-declaration-of-ethical-principles-for-psychologists.html

Narvaez, D.F. (October 20, 2019). Indigenous Psychologies Contrast With Western Psychology. Psychology Today. https://www.psychologytoday.com/us/blog/moral-landscapes/201910/indigenous-psychologies-contrast-western-psychology

Patel, V. (2007). Mental health in low-and middle-income countries. British medical bulletin, 81(1), 81-96.

Rojas, G., Martínez, V., Martínez, P., Franco, P., & Jiménez-Molina, Á. (2019). Improving Mental Health Care in Developing Countries Through Digital Technologies: A Mini Narrative Review of the Chilean Case. Frontiers in public health, 7, 391. https://doi.org/10.3389/fpubh.2019.00391

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

Wong, P. W. C., Arat, G., Ambrose, M. R., Qiuyuan, K. X., & Borschel, M. (2019). Evaluation of a mental health course for stigma reduction: A pilot study. Cogent Psychology, 6(1), Article 1595877. https://doi.org/10.1080/23311908.2019.1595877

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Cross-Cultural Adaptation of Trauma Instruments

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The seven steps provided by Sousa and Rojjanasrirat (2011) for the cultural adaptation of health care assessment instruments primarily focuses on translation. This does include some cultural considerations as well, and they suggest it best to use translators who are not only fluent in both languages, but also from the culture in question, in order to capture meanings accurately rather than a direct word-for-word translation.

The seven steps are:

  1. Initial translation from the original language of the instrument into the language sought for adaptation by two translators. One of translators should also possess fluency in the scientific terminology of the discipline being used, while the other should not be, but still familiar with common expressions related to the discipline.
  2. Initial synthesis – comparing both the original and translated instruments by a separate translator for accuracy of meanings. Any discrepancies would be handled by a meeting between all translators to decide on the best meaning to use.
  3. The newly updated translated instrument from the previous step is then back-translated to the original language by two other translators who have never seen the original instrument. These translators should possess similar qualities to the initial two translators.
  4. Secondary synthesis – The two back-translated instruments are compared, and any discrepancies are similarly resolved as the initial synthesis by consensus, and all versions of both the translated versions and back-translated versions are compared.
  5. Pilot test the first draft of the instrument with individuals who speak the target language only and are not bi-lingual. The participants rate the questions, instructions, and items on the assessment itself for being clear or unclear. The use of an expert panel who are within the discipline or have knowledge of it is also recommended for this step to evaluate the clarity.
  6. Preliminary stage testing with participants who are bilingual. This often is skipped over in testing instruments, but it can be a valuable step if it is incorporated.
  7. Complete full testing with the final draft of the translated instrument using a sample from the target population. This test can help to iron out any final inconsistencies or issues, and can be used to determine the general validity and reliability of the instrument.

Raghavan (2018) shares recommendations when conducting assessments for survivors of torture, but, these suggestions are also highly useful to consider for any cross-cultural adaptation of assessments and instruments. These recommendations are based in the premise that cultural contextual factors are critically important to understanding, assessing, and treating how individuals from differing backgrounds express, conceptualize, and experience mental illness. Some researchers believe that inconsistencies in assessments and instruments cross-culturally are not due to actual differences in the rates and underlying symptomology of a mental illness, but rather that the measurement tool does not accurately portray definitions or options which reflect the cultural viewpoint of those being assessed.

These strategies include:

  1. Cultural idioms of distress. How mental illness manifests within a culture, how it is commonly understood and described, and experienced. Many collectivistic cultures use somatic symptoms to express mental distress, for example.
  2. Impact of Interpreters. When clients or participants must use an interpreter to communicate with a provider or researcher, the true meaning of what they try to convey may be misconstrued or lost. Furthermore, the skills and bias of the interpreter may alter both the meaning of the client/participant and the clinician/researcher, and the interpreter may suffer from secondary trauma. It would be best to use a researcher/clinician who is already fluent in the client’s language, but, if this is not possible, using an interpreter is still a better option than not using one.
  3. Cross-cultural equivalence of measures. Five criteria are proposed to determine if measures are equivalent in differing cultures, such as being contextually relevant, differences in the cultural understanding of constructs, or if the method of data collection itself creates a response bias, or is inaccessible to some.
  4. Adaptation and Translation of Measures. Here Raghavan (2018) seems to agree with the steps of translation proposed by Sousa and Rojjanasrirat (2011).
  5. Use of culture-specific normative data. This consists of the baseline sample to which the assessment would be comparing. For example, the normative data would be the general rate of PTSD among community members in Guatemala, but the assessment would be measuring rates of PTSD of Guatemalan refugees. Rather than comparing to PTSD rates among worldwide populations, this ensures that there is accuracy within a cultural framework.

In reviewing a study by Oe et al. (2020), the researchers did make use of the above steps by Sousa and Rojjanasrirat (2011) and recommendations by Raghavan (2018). They used a Japanese-developed trauma screen, the TEC-J, and compared this with the Global Psychotrauma Screen (GPS) which was developed elsewhere and then modified/translated for use in Japan using the guidelines by Sousa and Rojjanasrirat (2011). The use of the TEC-J is important because it was developed internal to the culture in question, and therefore included culturally relevant considerations in its design (Oe et al., 2020). However, this may be outdated, as the TEC-J was developed in the 1990s and therefore avoided asking about highly taboo topics in Japan such as childhood sexual abuse. It is unclear whether this would still be such a taboo today to the point that it would be avoided on an instrument all together. In their analysis, Oe et al. (2020) consider cultural factors which may have impacted the scores particularly on the GPS, including response bias as mentioned by Raghavan (2018). One limitation, which is mentioned by the authors (Oe et al., 2020), is that the sample was skewed to those with severe trauma and who were seeking help; in other words, no normative data for comparison (Raghavan, 2018).

References

Raghavan, S. S. (2019). Cultural Considerations in the Assessment of Survivors of Torture. Journal of Immigrant and Minority Health, 21(3), 586-595. http://dx.doi.org/10.1007/s10903-018-0787-5

Sousa, V.D. & Rojjanasrirat, W. (2011). Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. Journal of Evaluation in Clinical Practice, 17, 268–274. 

Oe, M., Kobayashi, Y., Ishida, T., Chiba, H., Matsuoka, M., Kakuma, T., Frewen, P. & Olff, M. (2020). Screening for psychotrauma related symptoms: Japanese translation and pilot testing of the Global Psychotrauma Screen. European Journal of Psychotraumatology, 11(1). 

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Trauma, Physical Health, & Psychological Wellbeing in the Context of Adverse Life Events

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Exposure to adverse or traumatic events in life is a common experience (van der Kolk & McFarlane, 1996). These events can vary from minor to severe, can affect individuals or communities, and people react to them in different ways. Many people are resilient, but some develop symptoms of posttraumatic stress disorder (PTSD), have lower physical health, higher rates of mental disorders, and lower psychological well-being. Furthermore, these reactions can vary in how they are expressed between cultural contexts, can be vastly different for everyone, and can both improve or worsen over time. PTSD relates to numerous biological processes, including brain chemistry and hormonal changes. McFarlane (2010) writes, “…PTSD is not simply a psychosocial disorder, but one underpinned by a major neurobiological disruption” (p. 8). In assessing the whole-person impact of PTSD, it is important to consider and treat a variety of factors.

Allostatic load refers to the cumulative stress on the hypothalamic pituitary adrenal axis (HPA) as well as the autonomic nervous system (McFarlane, 2010). Exposure to trauma may not elicit symptoms of PTSD, nor acute stress disorder (ASD), for a significant time (more than 6 months) after the event; this is called delayed-onset PTSD. Furthermore, those who have experienced depression or been diagnosed with ASD may be able to initially manage symptoms to the point of remission – only later to have a resurgence of symptoms. In the case of ASD, this would change the diagnosis to PTSD. Research speculates that this is related to another traumatic event, or even the cumulation of smaller stressors, until the system becomes overloaded. This commonly results in somatic manifestations.

Chronic pain without a medical cause has a strong relationship to PTSD (Andreski et al., 1998), largely thought of to be related to the allostatic load (McFarlane, 2010). In those with chronic pain and PTSD, there are also noticeable changes in the hippocampus, cortisol, amygdala, and gene expressions. These biologic reactions also correspond with fibromyalgia, chronic fatigue, and irritable bowel syndrome. Furthermore, individuals with PTSD are at an increased risk for hypertension and cardiovascular disease, connected with repeated traumatic triggering leading to hyperactivity of the sympathetic nervous system. Significantly higher levels of cholesterol and triglycerides have been found in people with PTSD, even when compared to individuals with depression (Karlovic et al., 2004). Individuals with PTSD are also more likely to be overweight or obese or have coronary heart disease (McFarlane, 2010).

In a study of pregnant Peruvian women, there was shown to be a high correlation between those that had both migraines and PTSD (Friedman et al., 2017). Interestingly, the authors explain that there are numerous overlaps in brain chemistry and hormones between both migraines and PTSD, including lower levels of cortisol, plasma, norepinephrine, higher levels of pro-inflammatory cytokines, and reduced or unstable levels of serotonin. A study of Syrian and Iraqi refugees similarly found increased pro-inflammatory cytokines among those who had PTSD, depression, or anxiety (Grasser et al. 2020).

All of these medical issues are frequently comorbid with individuals with PTSD. Interestingly, many of them also correspond with common cultural idioms of distress in collectivistic cultures, such as in Syria, who often describe trauma and mental distress symptoms as having headaches, racing or pressure on the heart, insomnia, unexplained pain, and stomach pain (Hassan et al., 2015). Systemic, social, cultural, and community factors should also be addressed – especially if one is from a collectivistic society, or the traumatic event impacted a group – a family, a community, or a whole culture or country, such as in the case of war and genocide.

Furthermore, general psychological well-being is also often dramatically reduced in conjunction with traumatic stress. Roberts et al. (2020) write that more than “80% of individuals with PTSD will experience at least one additional lifetime mental health disorder, and around 50% will experience three or more comorbidities” (p.417) in the general population. Common psychological comorbidities are depression, anxiety and panic disorder, substance use disorders, severe mental illnesses, and personality disorders, especially borderline personality disorder. ADHD is also a common comorbidity (van der Kolk & McFarlane, 1996). Furthermore, people impacted by PTSD tend to organize their whole lives around the trauma, such as recreating the pattern in their relationships, and avoiding any hint of a traumatic trigger, causing profound changes in their thoughts, feelings, and behaviors (van der Kolk & McFarlane, 1996). Adults with a large number of adverse childhood experiences have significantly increased risk of a poor mental well-being (Hughes et al., 2016). Such individuals also have shown to have significantly lower social well-being (Mosley-Johnson et al., 2019).

Clinical implications are that treatment and assessment needs to expand to consider all of these factors. Traditionally, the use of anti-depressants and cognitive behavioral therapy have been the norm in treating PTSD (McFarlane, 2010), and medical doctors treat physical problems as separate issues. The ideal treatment would occur shortly after the traumatic event, even if an individual has not yet expressed symptoms, to train one’s psychophysiology to regulate itself early on. A study of Tutsi genocide survivors showed high rates of PTSD and CPTSD, and their children also suffered secondary symptoms of trauma (Shrira et al., 2019). Both parents and offspring had lower rates of resilience when parents suffered from CPTSD. Had trauma focused interventions occurred shortly after the genocide, it is possible that intergenerational trauma may have been avoided. Additionally, co-morbid symptoms both psychological and physical should be addressed in holistic approaches. One promising recent therapeutic modality that seeks to do this is Somatic Experiencing, which has been found to reduce symptom severity of PTSD and depression (Brom et al., 2017) and in PTSD-related chronic pain and disability (Andersen et al., 2017).

Clearly, the implications of the havoc of PTSD are severe. “There is the potential for a pervasive disruption of an individual’s neurobiology and psychophysiology following exposure [of traumatic stress], and PTSD is only one end point…exposure to traumatic stress leads to a general disruption of an individual’s underlying homeostasis” (McFarlane, 2010, p.7). Trauma-exposed individuals should be treated immediately even without symptoms and should be educated to self-assess over their lifespan. Holistic models which treat both physical and mental disruptions and comorbidities are paramount. Culture and environmental factors also should be carefully considered in assessment and treatment. Trauma changes us to our very core and in our entire well-being; increasing awareness and treating it as such is critical for both sufferers, and medical and mental health providers.

References

Andersen, T. E., Lahav, Y., Ellegaard, H., & Manniche, C. (2017). A randomized controlled trial of brief Somatic Experiencing for chronic low back pain and comorbid post-traumatic stress disorder symptoms. European Journal of Psychotraumatology, 8(1). https://doi-org.tcsedsystem.idm.oclc.org/10.1080/20008198.2017.1331108

Andreski P, Chilcoat H, & Breslau N. (1998). Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res, 79, 131-8.

Brom, D., Stokar, Y., Lawi, C., Nuriel, P. V., Ziv, Y., Lerner, K., Ross, G., & Nuriel-Porat, V. (2017). Somatic Experiencing for Posttraumatic Stress Disorder: A Randomized Controlled Outcome Study. Journal of Traumatic Stress, 30(3), 304–312. https://doi-org.tcsedsystem.idm.oclc.org/10.1002/jts.22189

Friedman, L. E., Aponte, C., Perez Hernandez, R., Velez, J. C., Gelaye, B., Sánchez, S. E., Williams, M. A., & Peterlin, B. L. (2017). Migraine and the risk of post-traumatic stress disorder among a cohort of pregnant women. The journal of headache and pain, 18(1), 67. https://doi.org/10.1186/s10194-017-0775-5

Grasser, L. R., Burghardt, P., Daugherty, A. M., Amirsadri, A., & Javanbakht, A. (2020). Inflammation and Trauma-Related Psychopathology in Syrian and Iraqi Refugees. Behavioral Sciences, 10(4), 75. doi:10.3390/bs10040075

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. Geneva: UNHCR.

Hughes, K., Lowey, H., Quigg, Z. et al. (2016). Relationships between adverse childhood experiences and adult mental well-being: results from an English national household survey. BMC Public Health, 16,222. https://doi.org/10.1186/s12889-016-2906-3

Karlovic D, Buljan D, Martinac M et al. (2004). Serum lipid concentrations in Croatian veterans with post-traumatic stress disorder, post-traumatic stress disorder comorbid with major depressive disorder, or major depressive disorder. J Korean Med Sci, 19, 431-6.

McFarlane A. C. (2010). The long-term costs of traumatic stress: intertwined physical and psychological consequences. World psychiatry : official journal of the World Psychiatric Association (WPA), 9(1), 3–10. https://doi.org/10.1002/j.2051-5545.2010.tb00254.x

Mosley-Johnson, E., Garacci, E., Wagner, N., Mendez, C., Williams, J. S., & Egede, L. E. (2019). Assessing the relationship between adverse childhood experiences and life satisfaction, psychological well-being, and social well-being: United States Longitudinal Cohort 1995-2014. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, 28(4), 907–914. https://doi.org/10.1007/s11136-018-2054-6

Roberts, S.E., Mueser, K.T., & Murray, L.K. (2020). Treatment considerations for PTSD comorbidities. In Effective Treatments for PTSD, 3rd ed. Forbes, D., Bisson, J.I., Monson, C.M., & Berliner, L., eds. The Guilford Press.

Shrira, A., Mollov, B., & Mudahogora, C. (2019). Complex PTSD and intergenerational transmission of distress and resilience among Tutsi genocide survivors and their offspring: A preliminary report. Psychiatry research, 271, 121–123.   Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press.