Complex post-traumatic stress disorder (CPTSD) is a newly recognized trauma disorder in ICD-11. Little is known about the prevalence and correlates of CPTSD in primary care settings. Its cultural aspects also remained minimally explored. This study investigated the prevalence and sociocultural correlates of PTSD and complex PTSD among Chinese community health service users in Hong Kong.
Methods:
This study investigated ICD-11 PTSD and CPTSD in a sample of adults (N = 376) who had recently received services from Registered Chinese Medicine Practitioners in Hong Kong. Traditional Chinese medicine service is part of primary care services in Chinese societies. Participants completed self-report measures of CPTSD, trauma exposure, perceived family support, perceived caregiver’s Chinese traditionality/modernity, participation (social activities and occupational productivity), depression and pain.
Results:
The past-month prevalence of ICD-11 PTSD and CPTSD was 5.6% and 18.4%, respectively, in our sample. Chi-square tests and one-way ANOVAs revealed that participants with CPTSD were younger and reported more trauma, lower family support, lower levels of social participation and productivity, more depressive symptoms and pain, and more social welfare and mental health service usages than those without PTSD. We found that perceived caregiver’s Chinese modernity (e.g. egalitarianism) was negatively correlated with CPTSD symptoms. Apart from age, non-betrayal trauma had the strongest association with classical PTSD symptoms, while betrayal trauma and perceived family support had the strongest association with disturbances in self-organization symptoms.
Conclusion:
This study provides the first data regarding the prevalence and correlates of ICD-11 PTSD and CPTSD among community health service users in Hong Kong. PTSD and CPTSD are common but often unrecognized mental health problems which are associated with more impairments and more service needs.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Author.
2.
CamposB.KimH. S. (2017). Incorporating the cultural diversity of family and close relationships into the study of health. American Psychologist, 72(6), 543–554. https://doi.org/10.1037/amp0000122
3.
Canty-MitchellJ.ZimetG. D. (2000). Psychometric properties of the multidimensional scale of perceived social support in urban adolescents. American Journal of Community Psychology, 28(3), 391–400.
4.
ChangF.-H. (2017). Measuring participation of rehabilitation patients: Test-retest reliability and mode of administration concordance of the participation measure-3 domains, 4 dimensions (PM-3D4D). Archives of Physical Medicine and Rehabilitation, 98(8), 1622–1627. https://doi.org/10.1016/j.apmr.2017.02.022
5.
ChangF.-H.ChangK.-H.LiouT.-H.WhiteneckG. G. (2017). Validation of the participation measure-3 domains, 4 dimensions (PM-3D4D). Archives of Physical Medicine and Rehabilitation, 98(12), 2498–2506. https://doi.org/10.1016/j.apmr.2017.05.027
6.
ChangF.-H.LiouT.-H.NiP.ChangK.-H.LaiC.-H. (2017). Development of the participation measure-3 domains, 4 dimensions (PM-3D4D): A new outcome measure for rehabilitation. Archives of Physical Medicine and Rehabilitation, 98(2), 286–294. https://doi.org/10.1016/j.apmr.2016.08.462
7.
ChiarottoA.BoersM.DeyoR. A.BuchbinderR.CorbinT. P.CostaL. O. P.FosterN. E.GrotleM.KoesB. W.KovacsF. M.LinC. C.MaherC. G.PearsonA. M.PeulW. C.SchoeneM. L.TurkD. C.van TulderM. W.TerweeC. B.OsteloR. W. (2018). Core outcome measurement instruments for clinical trials in nonspecific low back pain. Pain, 159(3), 481–495. https://doi.org/10.1097/j.pain.0000000000001117
8.
ChiarottoA.MaxwellL. J.OsteloR. W.BoersM.TugwellP.TerweeC. B. (2019). Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: A systematic review. Journal of Pain, 20(3), 245–263. https://doi.org/10.1016/j.jpain.2018.07.009
9.
ChienW. T.FungH. W. (2022). Commentary: The assessment of dissociative pathology in culturally and clinically diverse contexts. Alpha Psychiatry, 23, 104–105. https://doi.org/10.5152/alphapsychiatry.2022.0006
10.
ChiuC.-D.YehY.-Y.HuangC.-L.WuY.-C.ChiuY.-C.LinC.-C. (2010). Unintentional memory inhibition is weakened in non-clinical dissociators. Journal of Behavior Therapy and Experimental Psychiatry, 41(2), 117–124. https://doi.org/10.1016/j.jbtep.2009.11.003
11.
ChiuS. W. K.SzeT.-O. (2018). Changes in the utilizationof Chinese medicine in Hong Kong (1993-2015) (in Chinese: 誰在看中醫?香港中醫就診趨勢回顧). Hong Kong Journal of Social Sciences, 51, 3–39.
12.
ChouK.-L. (2000). Assessing Chinese adolescents’ social support: The multidimensional scale of perceived social support. Personality and Individual Differences, 28(2), 299–307. https://doi.org/10.1016/s0191-8869(99)00098-7
13.
CloitreM.HylandP.BissonJ. I.BrewinC. R.RobertsN. P.KaratziasT.ShevlinM. (2019). ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population-based study. Journal of Traumatic Stress, 32(6), 833–842.
14.
CloitreM.HylandP.PrinsA.ShevlinM. (2021). The international trauma questionnaire (ITQ) measures reliable and clinically significant treatment-related change in PTSD and complex PTSD. European Journal of Psychotraumatology, 12(1), 1930961.
15.
CloitreM.ShevlinM.BrewinC. R.BissonJ. I.RobertsN. P.MaerckerA.KaratziasT.HylandP. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536–546. https://doi.org/10.1111/acps.12956
16.
de SilvaU.GloverN.KatonaC. (2021). Prevalence of complex post-traumatic stress disorder in refugees and asylum seekers: systematic review. BJPsych open, 7(6), e194. https://doi.org/10.1192/bjo.2021.1013 Article e194.
17.
EllisB. H.MacDonaldH. Z.Klunk-GillisJ.LincolnA.StruninL.CabralH. J. (2010). Discrimination and mental health among Somali refugee adolescents: The role of acculturation and gender. American Journal of Orthopsychiatry, 80(4), 564–575. https://doi.org/10.1111/j.1939-0025.2010.01061.x
18.
FungH. W.ChienW. T.ChanC.RossC. A. (2022). A cross-cultural investigation of the association between betrayal trauma and dissociative features. Journal of Interpersonal Violence. Advance online publication. https://doi.org/10.1177/08862605221090568
19.
FungH. W.ChienW. T.LingH. W. H.RossC. A.LamS. K. K. (2022). The mediating role of post-traumatic stress disorder symptoms in the relationship between childhood adversities and depressive symptoms in two samples. Child Abuse & Neglect, 131, 105707. https://doi.org/10.1016/j.chiabu.2022.105707
20.
GelezelyteO.RobertsN. P.KvedaraiteM.BissonJ. I.BrewinC. R.CloitreM.KairyteA.KaratziasT.ShevlinM.KazlauskasE. (2022). Validation of the International Trauma Interview (ITI) for the clinical assessment of ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in a Lithuanian sample. European Journal of Psychotraumatology, 13(1), 2037905. https://doi.org/10.1080/20008198.2022.2037905
21.
GlassD. C.KelsallH. L.SlegersC.ForbesA. B.LoffB.ZionD.FritschiL. (2015). A telephone survey of factors affecting willingness to participate in health research surveys. BMC Public Health, 15, 1017. https://doi.org/10.1186/s12889-015-2350-9
22.
GoldbergL. R.FreydJ. J. (2006). Self-reports of potentially traumatic experiences in an adult community sample: Gender differences and test-retest stabilities of the items in a brief betrayal-trauma survey. Journal of Trauma & Dissociation, 7(3), 39–63. https://doi.org/10.1300/j229v07n03_04
23.
GreeneT.NeriaY.GrossR. (2016). Prevalence, detection and correlates of PTSD in the primary care setting: A systematic review. Journal of Clinical Psychology in Medical Settings, 23(2), 160–180. https://doi.org/10.1007/s10880-016-9449-8
24.
HeimE.KaratziasT.MaerckerA. (2022). Cultural concepts of distress and complex PTSD: Future directions for research and treatment. Clinical Psychology Review, 93, 102143. https://doi.org/10.1016/j.cpr.2022.102143
25.
HermanJ. L. (1992). Trauma and recovery. Basic Books.
26.
HoG. W. K.HylandP.ShevlinM.ChienW. T.InoueS.YangP. J.ChenF. H.ChanA. C. Y.KaratziasT. (2020). The validity of ICD-11 PTSD and Complex PTSD in East Asian cultures: Findings with young adults from China, Hong Kong, Japan, and Taiwan. European Journal of Psychotraumatology, 11(1), 1717826.
27.
HoG. W. K.KaratziasT.CloitreM.ChanA. C. Y.BressingtonD.ChienW. T.HylandP.ShevlinM. (2019). Translation and validation of the Chinese ICD-11 International Trauma Questionnaire (ITQ) for the assessment of Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). European Journal of Psychotraumatology, 10(1), 1608718.
28.
KaratziasT.HylandP.BradleyA.CloitreM.RobertsN. P.BissonJ. I.ShevlinM. (2019). Risk factors and comorbidity of ICD-11 PTSD and complex PTSD: Findings from a trauma-exposed population based sample of adults in the United Kingdom. Depression and Anxiety, 36(9), 887–894. https://doi.org/10.1002/da.22934
29.
KazarianS. S.McCabeS. B. (1991). Dimensions of social support in the MSPSS: Factorial structure, reliability, and theoretical implications. Journal of Community Psychology, 19(2), 150–160.
30.
KoiralaR.Iyer SøegaardE. G.KanZ.OjhaS. P.HauffE.ThapaS. B. (2021). Exploring complex PTSD in patients visiting a psychiatric outpatient clinic in Kathmandu, Nepal. Journal of Psychiatric Research, 143, 23–29. https://doi.org/10.1016/j.jpsychires.2021.08.030
31.
KroenkeK.SpitzerR. L.WilliamsJ. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.
32.
KungS.AlarconR. D.WilliamsM. D.PoppeK. A.Jo MooreM.FryeM. A. (2013). Comparing the Beck Depression Inventory-ii (BDI-II) and Patient Health Questionnaire (PHQ-9) depression measures in an integrated mood disorders practice. Journal of Affective Disorders, 145(3), 341–343. https://doi.org/10.1016/j.jad.2012.08.017
33.
LamL. C.-W.WongC. S.-M.WangM.-J.ChanW.-C.ChenE. Y.-H.NgR. M.-K.HungS. F.CheungE. F. C.ShamP. C.ChiuH. F. K.LamM.ChangW. C.LeeE. H. M.ChiangT. P.LauJ. T. F.van OsJ.LewisG.BebbingtonP. (2015). Prevalence, psychosocial correlates and service utilization of depressive and anxiety disorders in Hong Kong: The Hong Kong Mental Morbidity Survey (HKMMS). Social Psychiatry and Psychiatric Epidemiology, 50(9), 1379–1388. https://doi.org/10.1007/s00127-015-1014-5
34.
LeungA. S.LamT. H.HedleyA. J.TwomeyL. T. (2003). Psychometric properties of a generic health measure in Chinese patients with low back pain in Hong Kong. Manual Therapy, 8(3), 151–160. https://doi.org/10.1016/s1356-689x(03)00006-7
35.
LuL.UngK.-C. (2006). Psychological traditionality, modernity and academic advisor-student fit and their influence on the quality of the relationship and students’ well-being (in Chinese: 師生的心理傳統性與現代性、關係契合性對師生互動品質及學生心理福祉的影響). Indigenous Psychological Research in Chinese Societies, 27, 81–118.
36.
LuxenbergT.SpinazzolaJ.Van der KolkB. A. (2001). Complex trauma and disorders of extreme stress (DESNOS) diagnosis, part one: Assessment. Directions in Psychiatry, 21(25), 373–392.
MurphyD.KaratziasT.BusuttilW.GreenbergN.ShevlinM. (2021). ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in treatment seeking veterans: Risk factors and comorbidity. Social Psychiatry and Psychiatric Epidemiology, 56, 1289–1298. https://doi.org/10.1007/s00127-021-02028-6
39.
NiM. Y.YaoX. I.LeungK. S. M.YauC.LeungC. M. C.LunP.FloresF. P.ChangW. C.CowlingB. J.LeungG. M. (2020). Depression and post-traumatic stress during major social unrest in Hong Kong: A 10-year prospective cohort study. Lancet, 395(10220), 273–284. https://doi.org/10.1016/s0140-6736(19)33160-5
40.
SchnyderU.BryantR. A.EhlersA.FoaE. B.HasanA.MwitiG.KristensenC. H.NeunerF.OeM.YuleW. (2016). Culture-sensitive psychotraumatology. European Journal of Psychotraumatology, 7(1), 31179. https://doi.org/10.3402/ejpt.v7.31179
41.
The Government of The Hong Kong Special Administrative Region. (2020). Thematic Household Survey Report No. 69" published. Hong Kong: The Government of The Hong Kong Special Administrative Regionhttps://www.info.gov.hk/gia/general/202003/26/P2020032600444.htm
42.
ThirthalliJ.ZhouL.KumarK.GaoJ.VaidH.LiuH.HankeyA.WangG.GangadharB. N.NieJ. B.NichterM. (2016). Traditional, complementary, and alternative medicine approaches to mental health care and psychological wellbeing in India and China. The Lancet Psychiatry, 3(7), 660–672. https://doi.org/10.1016/s2215-0366(16)30025-6
43.
TianY.LiW.WuX.ChengX. (2022). Complex PTSD in Chinese adolescents exposed to childhood trauma: A latent profile analysis. Journal of Interpersonal Violence, 37, n20190–n20211. https://doi.org/10.1177/08862605211050111
44.
van der KolkB. A.RothS.PelcovitzD.SundayS.SpinazzolaJ. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18(5), 389–399. https://doi.org/10.1002/jts.20047
WongW.LamC. L. K.BianX. Z.ZhangZ. J.NgS. T.TungS. (2017). Morbidity pattern of traditional Chinese medicine primary care in the Hong Kong population. Scientific Reports, 7(1), 1–10. https://doi.org/10.1038/s41598-017-07538-5
47.
World Health Organization. (2018). The ICD-11 classification of mental and behavioral disorders. Clinical description and diagnostic guidelines. Author.
48.
WuK. K.LeungP. W. L.WongC. S. M.YuP. M. W.LukB. T. C.ChengJ. P. K.WongR. M. F.WongP. P. S.LuiJ. C. C.NganJ. C. F.LeungF. L. T.LamL. C. W. (2019). The Hong Kong survey on the epidemiology of trauma exposure and posttraumatic stress disorder. Journal of Traumatic Stress, 32(5), 664–676. https://doi.org/10.1002/jts.22430
49.
YangK. (2006). Indigenized conceptual and empirical analyses of selected Chinese psychological characteristics. International Journal of Psychology, 41(4), 298–303.
50.
YangK. S. (1991). Chinese individual traditionality and modernity: Conceptualization and measurement (in Chinese: 中國人的個人傳統性與現代性 : 概念與測量). In YangK. S.HwangK. K. (Eds.), Chinese psychology and behavior (pp. 241–306). Gui Guan Tu Shu Gong Si.
51.
YangK. S. (2003). Methodological and theoretical issues on psychological traditionality and modernity research in an Asian society: In response to Kwang-Kuo Hwang and beyond. Asian Journal Of Social Psychology, 6(3), 263–285. https://doi.org/10.1046/j.1467-839x.2003.00126.x
52.
YangL. H.PhelanJ. C.LinkB. G. (2008). Stigma and beliefs of efficacy towards traditional Chinese medicine and western psychiatric treatment among Chinese-Americans. Cultural Diversity & Ethnic Minority Psychology, 14(1), 10–18. https://doi.org/10.1037/1099-9809.14.1.10
53.
YehK.-H.BedfordO.WuC.-W.WangS.-Y.YenN.-S. (2017). Suppression benefits boys in Taiwan: The relation between gender, emotional regulation strategy, and mental health. Frontiers in Psychology, 8, 135. https://doi.org/10.3389/fpsyg.2017.00135
54.
YeungA.FungF.YuS.-C.VoronoS.LyM.WuS.FavaM. (2008). Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans. Comprehensive Psychiatry, 49(2), 211–217. https://doi.org/10.1016/j.comppsych.2006.06.002
55.
YuM.HuangL.MaoJ.DnaG.LuoS. (2022). Childhood maltreatment, automatic negative thoughts, and resilience: The protective roles of culture and genes. Journal of Interpersonal Violence, 37(1–2), 349–370. https://doi.org/10.1177/0886260520912582
56.
ZimetG. D.PowellS. S.FarleyG. K.WerkmanS.BerkoffK. A. (1990). Psychometric characteristics of the multidimensional scale of perceived social support. Journal of Personality Assessment, 55(3–4), 610–617. https://doi.org/10.1207/s15327752jpa5201_2
