Moses Kareth

The structure of post-traumatic stress disorder and complex post-traumatic stress disorder amongst West Papuan refugees

BackgroundThe validity of applying the construct of post-traumatic stress disorder (PTSD) across cultures has been the subject of contention. Although PTSD symptoms have been identified across multiple cultures, questions remain whether the constellation represents a coherent construct with an interpretable factor structure across diverse populations, especially those naïve to western notions of mental disorder. An important additional question is whether a constellation of Complex-PTSD (C-PTSD) can be identified and if so, whether there are distinctions between that disorder and core PTSD in patterns of antecedent traumatic events. Our study amongst West Papuan refugees in Papua New Guinea (PNG) aimed to examine the factorial structure of PTSD based on the DSM-IV, DSM-5, ICD-10 and ICD-11 definitions, and C-PTSD according to proposed ICD-11 criteria. We also investigated domains of traumatic events (TEs) and broader psychosocial effects of conflict (sense of safety and injustice) associated with the factorial structures identified.MethodsCulturally adapted measures were applied to assess exposure to conflict-related traumatic events (TEs), refugees’ sense of safety and justice, and symptoms of PTSD and C-PTSD amongst 230 West Papuan refugees residing in Port Morseby, PNG.ResultsConfirmatory factor analysis (CFA) supported a unitary construct of both ICD-10 and ICD-11 PTSD, comprising the conventional symptom subdomains of intrusion, avoidance, and hyperarousal. In contrast, CFA did not identify a unitary construct underlying C-PTSD. The interaction of witnessing murders and sense of injustice was associated with both the intrusion and avoidance domains of PTSD, but not with the unique symptom clusters characterizing C-PTSD.ConclusionsOur findings support the ICD PTSD construct and its three-factor structure in this transcultural refugee population. Traumatic experiences of witnessing murder associated with a sense of injustice were specifically related to the intrusion and avoidance domains of PTSD. The unitary nature of C-PTSD across cultures remains in question.

Human rights trauma and the mental health of West Papuan refugees resettled in Australia.

Objectives: To document the extent and nature of human rights violations and other traumatic events reported by West Papuan refugees resettled in Australia and to assess trauma‐related psychological disorders, distress and disability.

Associations of Conflict-Related Trauma and Ongoing Stressors with the Mental Health and Functioning of West Papuan Refugees in Port Moresby, Papua New Guinea (PNG)

Documentation is limited in relation to the mental health of the people of West Papua, a territory that has been exposed to decades-long political persecution. We examined associations of traumatic events (TEs) and current stressors with mental disorder and functioning, amongst 230 West Papuan refugees residing in six settlements in Port Morseby, Papua New Guinea (PNG). We used culturally adapted modules to assess exposure to TEs and mental disorders. Current stressors and functioning were assessed using modifications of measures developed by the World Health Organization (WHO). 129 of 230 respondents (56%) reported exposure to at least one traumatic event (TE), including: political upheaval (36.5%), witnessing or hearing about family members tortured and murdered (33.9%), and not being able to access medical care for family members (33%). One fifth of respondents (47, 20.4%) experienced exposure to high levels of TEs (16 to 23). 211 (91.7%) endorsed at least one or more ongoing stressors, including: exposure to illicit substance use in the community (91.7%), problems with safety and the protection of women (89.6%), no access to legal rights and citizenship (88.3%), and lack of adequate shelter and facilities (85.2%). A quarter (26.9%) met criteria for one or more current mental disorder, and 69.1% reported functional impairment ranging from mild to extreme. Mental disorder was associated with being male (adjusted odds ratio=2.00; 95% CI=1.01-3.97), and exposure to the highest category of ongoing stressors (AOR=2.89; 95% CI=1.08-7.72). The TE count showed a dose-response pattern in its relationship with functional impairment, the greatest risk (AOR=11.47; 95% CI=2.11-62.37) being for those experiencing the highest level of TE exposure (16-23 events). West Papuans living in settlements in Port Moresby reported a range of TEs, ongoing stressors and associated mental disorders characteristic of populations exposed to mass conflict and persecution, prolonged displacement, and ongoing conditions of extreme hardship.

The coherence and correlates of intermittent explosive disorder amongst West Papuan refugees displaced to Papua New Guinea.

Questions remain about the nosological status of intermittent explosive disorder (IED) as a universal diagnosis. Cross-cultural studies are needed to establish whether IED symptoms form a coherent pattern and are distinguishable from other related symptom constellations. A study amongst a refugee population also allows further inquiry of the relationship between exposure to potentially traumatic events (PTEs) and other adversities with the IED constellation. In the present study amongst West Papuan refugees residing in Port Moresby, Papua New Guinea, we apply culturally adapted interview modules to assess symptoms of IED, post-traumatic stress disorder (PTSD), and depression, as well as the potentially traumatic events (PTEs) of conflict and ongoing adversity in the post-migration environment. Latent class analysis yielded a PTSD class (23%), a posttraumatic depressive class (14%), an IED class (12%), and a low/no symptom class (49%). Compared to the low/no-symptom class, the PTSD class had high levels of exposure to all PTE domains including childhood-related adversities, witnessing murder, human rights trauma, and traumatic losses, as well as ongoing adversity relating to displacement and separation from families, safety concerns, and lack of access to basic needs and health care. The posttraumatic depression class had greater exposure to traumatic losses and childhood-related adversities, higher levels of stress relating to material loss and deprivation, as well as to displacement and separation from families. In contrast, the IED class was distinguished only by the ongoing stress of displacement and separation from families in the homeland. Our findings provide support for the phenomenological distinctiveness of IED symptoms in this transcultural setting. Although not exclusive to IED, conditions of long-term displacement and separation appear to be a source of ongoing anger and explosive aggression amongst this population.

The Relationship of Complex Post-traumatic Stress Disorder and Post-traumatic Stress Disorder in a Culturally Distinct, Conflict-Affected Population: A Study among West Papuan Refugees Displaced to Papua New Guinea

Background Controversy continues about the validity of the construct of complex post-traumatic stress disorder (C-PTSD). In particular, questions remain whether C-PTSD can be differentiated from post-traumatic stress disorder (PTSD) and, secondarily, other common mental disorders. The examination of these issues needs to be expanded to populations of diverse cultural backgrounds exposed to prolonged persecution. We undertake such an inquiry among a community sample of West Papuan refugees exposed to extensive persecution and trauma. Methods We interviewed over 300 West Papuan refugees using the Refugee-Mental Health Assessment Package to record symptoms of PTSD, C-PTSD, major depressive disorder (MDD), and complex grief (CG). We used first- and second-order confirmatory factor analysis (CFA) to test aspects of the convergent and discriminant validity of C-PTSD. Results The CFA analysis supported both a one-factor and two-factor model of PTSD and C-PTSD. Nested model comparison tests provide support for the parsimonious one-factor model solution. A second-order CFA model of PTSD and C-PTSD produced a poor fit. The modified three-factor multi-disorder solution combining a traumatic stress (TS) factor (amalgamating PTSD and C-PTSD), MDD, and CG yielded a good fit only after removing three CG domains (estrangement, yearning, and behavioral change), a model that produced large standardized residuals (>0.20). Conclusion The most parsimonious model yielded a single TS factor combining symptom domains of C-PTSD and PTSD in this culturally distinct community exposed to extensive persecution and conflict-related trauma. There may be grounds for expanding the scope of psychological treatments for refugees to encompass this wider TS response. Our findings are consistent with theoretical frameworks focusing on the wider TS reaction of refugees exposed to human rights-related traumas of mass conflict, persecution, and displacement.

Dua sakit (double sick): trauma and the settlement experiences of West Papuan refugees living in North Queensland.

There is mounting evidence of systematic abuses, including torture, rape and extrajudicial killings directed against independence activists as well as the civilian population in Indonesian occupied West Papua. Refugees from West Papua have sought safety in neighbouring Australia, experiencing hazardous journeys during their flight. We report early observations from a mental health study among West Papuan refugees living in North Queensland, Australia. The project includes qualitative methods aimed at gathering histories of trauma and human rights violations as well as standard mental health assessments and indices of acculturation and resettlement stresses. We consider the emerging data from the vantage point of the Adaptation and Development After Persecution and Trauma model that identifies five psychosocial domains that require repair following exposure to gross human rights violations and refugee trauma. The model emphasizes the inter-relatedness of key challenges, the compounding of adversity, and the bivalent effects of complex experiences, with both positive and negative elements shaping the adaptive trajectory of displaced persons. Refugee groups have their own approaches to conceptualizing the complexity of their problems, with the term dua sakit representing the expression used by West Papuans to identify the multiple challenges they face. The study highlights the importance of assessing each refugee group within its unique social and cultural context, taking into account such diverse factors as geographical location, employment, and ongoing conflict in the homeland in designing appropriate interventions.

Associations of adult separation anxiety disorder with conflict-related trauma, ongoing adversity, and the psychosocial disruptions of mass conflict among West Papuan refugees

Refugees commonly experience traumatic events that threaten the self and close others, suggesting the possibility that they may experience overlapping symptoms of posttraumatic stress disorder (PTSD) and separation anxiety disorder (SAD). We examine this possibility among West Papua refugees (n = 230) displaced to Port Moresby, Papua New Guinea. We also examine associations between the combined PTSD-SAD construct and indices of past trauma exposure, ongoing adversity, and the psychosocial disruptions caused by mass conflict and displacement. We applied culturally adapted interview modules to assess symptoms of PTSD, SAD, traumatic events (TEs), ongoing adversity, and 5 psychosocial dimensions. Latent class analysis identified a PTSD class (23%), a posttraumatic (PT) SAD class (22%), and a low-symptom class (55%). Compared with the low-symptom class, both the PTSD and PT-SAD classes endorsed higher levels of exposure to all domains of TEs (conflict-related trauma, witnessing murder, childhood related adversities, traumatic losses, and health stress) and ongoing adversity (access to health care, displacement/separation, safety in the community, and access to basic needs), but the 2 comorbid groups did not differ on these indices. The PT-SAD class alone scored higher than the low-symptom reference class in relation to disruptions to the psychosocial domains (safety/security, bonds/network, access to justice, roles/identities, existential meaning) and higher than the PTSD class on safety/security, justice and roles/identities. Our findings suggest that the PT-SAD pattern may represent a response to the most severe forms of psychosocial disruptions of mass conflict among refugees. A focus on separation anxiety may enhance psychotherapies designed to treat PTSD in refugees. (PsycINFO Database Record

Pathways involving traumatic losses, worry about family, adult separation anxiety and posttraumatic stress symptoms amongst refugees from West Papua ☆

There is some evidence that adult separation anxiety disorder (ASAD) symptoms are closely associated with posttraumatic stress disorder (PTSD) amongst refugees exposed to traumatic events (TEs), but the pathways involved remain to be elucidated. A recent study suggests that separation anxiety disorder precedes and predicts onset of PTSD. We examined a path model testing whether ASAD symptoms and worry about family mediated the path from traumatic losses to PTSD symptoms amongst 230 refugees from West Papua. Culturally adapted measures were applied to assess TE exposure and symptoms of ASAD and PTSD. A structural equation model indicated that ASAD symptoms played an important role in mediating the effects of traumatic losses and worry about family in the pathway to PTSD symptoms. Although based on cross-sectional data, our findings suggest that ASAD symptoms may play a role in the path from traumatic losses to PTSD amongst refugees. We propose an evolutionary model in which the ASAD and PTSD reactions represent complementary survival responses designed to protect the individual and close attachments from external threats.

Pathways from conflict-related trauma and ongoing adversity to posttraumatic stress disorder symptoms amongst West Papuan refugees: The mediating role of anxiety and panic-like symptoms

BACKGROUND Although the relationship involving exposure to traumatic events (TEs), conditions of adversity, and posttraumatic stress disorder (PTSD) is well established in the refugee field, the psychological factors mediating the relevant pathways are not as clearly delineated. In the present path analysis, we examined a model in which anxiety and panic-like symptoms mediated the path between conflict-related TEs, ongoing adversity, and PTS symptoms amongst 230 refugees from West Papua. METHODS Culturally adapted measures were applied to assess TE exposure, ongoing adversity, anxiety, panic-like, PTS, and depressive symptoms. RESULTS Our model identified two pathways leading from conflict-related exposure to PTS symptoms, one a direct path, the other mediated by a sequence of ongoing adversity, anxiety and panic-like symptoms. Older refugees from West Papua had higher levels of anxiety and panic-like symptoms than the younger adult generation born in PNG. CONCLUSIONS Our findings suggest that a focus on reducing anxiety and panic together with addressing social deprivations and threats may improve anxiety and panic amongst refugees, ultimately improving outcomes for PTS symptoms.

Factor structures of Complex Posttraumatic Stress Disorder and PTSD in a community sample of refugees from West Papua

OBJECTIVES The intention to include a category of Complex Posttraumatic Stress Disorder (CPTSD) in ICD-11 has renewed interest in this construct. Although growing evidence from high income countries supports the construct validity of CPTSD, little parallel research has been undertaken across cultures. We tested theoretically supported CPTSD structures (a one-factor, six-factor, one-factor higher-order, and two-factor higher order structure) in a community sample of West Papuan refugees living in a remote town, Kiunga, in Papua New Guinea (PNG). PROCEDURES A community-wide survey was conducted (2016-2017; response rate 85.5%) amongst 486 West Papuans. Culturally adapted measures were applied to assess cumulative traumatic exposure, postmigration living difficulties (PMLDs), CPTSD symptoms, and functional impairment. FINDINGS A six factor structure for CPTSD provided the best fit to the data, consistent with our past study amongst West Papuans. CONCLUSIONS The cross-cultural validity of our findings is supported by the isolation of West Papuan participants from services treating traumatic stress. To further support the universal applicability of CPTSD, our findings need to be confirmed amongst other refugee groups from diverse cultural backgrounds.