PSYCH  Vol.3 No.9 , September 2012
Cumulative Trauma Disorder Scale (CTD): Two Studies
Measures that screen for mental health in multiple traumatized populations (e.g., refugees, minorities, mental health patients, prison inmates) lack theoretical clarity that makes it difficult to develop a measure that has robust psychometrics. The paper proposes cumulative trauma disorders (CTD) model and develops a scale that measures the concept and can be used as a general mental health screening tool in such populations. The measure has been tested on two studies: on representative community sample of Iraqi refugees in Michigan and on a clinic sample of refugees. Further, the measure was used on samples of Iraqi refugee and African American adolescents, West Bank and Gaza in Palestinian territories, as well as a mental health screening tool in some centers that screen refugees and torture survivors in US. The measure has been found to have high alpha and test-retest reliability, good construct, concurrent, discriminative and predictive validity in the two main samples and on all the studies and centers that utilized it. The measure can be used as a general mental health screening tool for adult and adolescent in public health settings in different cultures, as well as for refugees, torture survivors, and highly traumatized populations.

Cite this paper
Kira, I. , Templin, T. , Lewandowski, L. , Ashby, J. , Oladele, A. & Odenat, L. (2012). Cumulative Trauma Disorder Scale (CTD): Two Studies. Psychology, 3, 643-656. doi: 10.4236/psych.2012.39099.
[1]   Arfken, C. L., Kubiak, S. P., & Farrag, M. (2009). Acculturation and polysubstance abuse in Arab-American treatment clients. Transcultural Psychiatry, 46, 608-622. doi:10.1177/1363461509351364

[2]   Betemps, E., Smith, R., Baker, D., & Rounds-Kugler, B. (2003). The measurement precision of the Clinician Administered PTSD sale: A RASCH model analysis. Journal of Applied Measurement, 4, 59-69.

[3]   Bowlby, J. (1988). A secure base: Parent child attachment and healthy human development. New York: Basic Books.

[4]   Breslau, N., Chilcoat, H., Kessler, R., & Davis, G. (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit area survey of trauma. American Journal of Psy- chiatry, 156, 902-907.

[5]   Byrne, B. M., Shavelson, R. J., & Muthén, B. (1989). Testing for the equivalence of factor covariance and mean structures: The issue of partial measurement invariance. Psychological Bulletin, 105, 456- 466. doi:10.1037/0033-2909.105.3.456

[6]   Cassidy, J., & Shaver, P. (1999). Handbook of attachment: Theory, research, and clinical applications. New York: Guilford Press.

[7]   Cassiman, S. A. (2005). Toward more inclusive poverty knowledge: Traumatological contributions to the poverty discourse. Cutting Edge of Social Policy Research, 4, 93-106.

[8]   Cattell, R. B. (1966). The scree test for the number of factors. Multivariate Behavioral Research, 1, 629-637. doi:10.1207/s15327906mbr0102_10

[9]   Cheung, G. W., & Rensvold, R. B. (2002). Evaluating goodness-of-fit indexes for testing measurement invariance. Structural Equation Modeling, 9, 233-255. doi:10.1207/S15328007SEM0902_5

[10]   Chochinov, H., Wilson, K., Ennus, M., & Lander, S. (1997). “Are you depressed” screening for depression in the terminally ill. American Journal of Psychiatry, 145, 674-676.

[11]   Cloitre, M., Stolbach, B., Herman. J., van der Kolk, B., Pynoos, R., Wang, J., & Petkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22, pp. 399-408.

[12]   Cook A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2003). Complex trauma in children and adolescents: White paper. Allston, MA: National Child Traumatic Stress Network, Complex Trauma (NCTSN) Task force.

[13]   Fao, E. B. (1996). Failure of emotional processing: Post-trauma psychopathology and its treatment. Invited Address Presented in the American Psychological Annual Convention, Toronto.

[14]   Ford, J. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of posttraumatic stress disorder or comorbid but distinct syndromes? Journal of Consulting & Clinical Psychology, 67, 3-12. doi:10.1037/0022-006X.67.1.3

[15]   Freyd, J. J., DePrince, A. P., & Gleaves, D. (2007). The State of Betrayal trauma theory: Reply to McNally (2007)—Conceptual issues and future directions. Memory, 15, 295-311. doi:10.1080/09658210701256514

[16]   Hamby, S., Finkelhor, D., Turner, H., & Ormrod, R. (2010). The overlap of witnessing partner violence and child maltreatment and other victimizations in a nationally representative survey of youth. Child Abuse & Neglect, 34, 734-741. doi:10.1016/j.chiabu.2010.03.001

[17]   Herman, J. L. (1992). Trauma and recovery, New York: Basic Books.

[18]   Holmes, D. & Tinnin, L. (1995). The problem of auditory hallucinations in combat PTSD. Traumatology: An International Journal, 1, 1-7.

[19]   Kaiser, H. F. (1960). The application of electronic computers to factor analysis. Educational and Psychological Measurement, 20, 141-151. doi:10.1177/001316446002000116

[20]   Kaysan, D., Rosen, G., Bowman, M., & Resick, P. (2010). Duration of exposure and dose-response model of PTSD. Journal of Interpersonal Violence, 25, 63-74. doi:10.1177/0886260508329131

[21]   Kira, I. (1999). Type III trauma and Iraqi refugees’ traumatic experiences. Paper presented in the American Psychological Association Annual Convention, Boston.

[22]   Kira, I. (2001). Taxonomy of trauma and trauma assessment. Trau- matology, 2, 1-14.

[23]   Kira, I. (2002). Torture assessment and treatment: The wraparound approach. Traumatology: An International Journal, 8, 23-51.

[24]   Kira, I. (2004). Secondary trauma in treating refugee survivors of torture, and their families. Torture, 14, 38-44.

[25]   Kira, I. (2010). Etiology and treatments of post-cumulative traumatic stress disorders in different cultures. Traumatology: An International Journal, 16, 128-141.

[26]   Kira, I., Lewandowsk, L., Templin, T., Ramaswamy, V., Ozkan, B., & Mohanesh, J. (2008). Measuring cumulative trauma dose, types and profiles using a development-based taxonomy of trauma, Trauma- tology, 14, 62-87. doi:10.1177/1534765608319324

[27]   Kira, I., Smith, I., Lewandowski, L., &Templin, T. (2010a).The effects of perceived gender discrimination on refugee torture survivors: A cross-cultural traumatology perspective. Journal of the American Psychiatric Nurses Association, 16, 299-306. doi:10.1177/1078390310384401

[28]   Kira, I., Lewandowsi, L., Templin, T., Ramaswamy, V., Ozkan, B., & Mohanesh, J. (2010b). The effects of perceived discrimination and backlash on Iraqi refugees’ physical and mental health. Journal of Muslim Mental Health, 5, 59-81. doi:10.1080/15564901003622110

[29]   Kira, I., Templin, T., Lewandowski, L., Ramaswamy, V., Bulent, O., Abu-Mediane, S., Mohanesh, J., & Alamia, H. (2011a). Cumulative tertiary appraisal of traumatic events across cultures: Two studies. Journal of Loss and Trauma: International Perspectives on Stress & Coping, 16, 43-66.

[30]   Kira, I., Alawneh, A. N., Aboumediane, S., Mohanesh, J., Ozkan, B., & Alamia, H. (2011b). Identity salience and its dynamics in palestinians adolescents. Psychology, 2, 781-791. doi:10.4236/psych.2011.28120

[31]   Kira, I., Ashby, J., Lewandowski, L.; Smith, I., & Odenat, L. (2012a). Gender inequality and its effects in females torture survivors. Psychology, 3, 352-363. doi:10.4236/psych.2012.34050

[32]   Kira, I., Lewandowski, L., Somers, C., Yoo, J., & Chiodo, L. (2012b). The linear and non-linear associations between multiple types of trauma and IQ discrepancy indexes in African American and Iraqi refugee adolescents. Journal of Child & Adolescent Trauma, 5, 47-62.

[33]   Kira, I., Abou-Mediene, S., Ashby, J., Odenat, L., Mohanesh, J., & Alamia, H. (in press). The dynamics of post-traumatic growth across different trauma types in a Palestinian sample. Journal of Loss and Trauma: International Perspectives on Stress & Coping.

[34]   Kira, I., Templin, T., Lewandowski, L., Ramaswamy, V., Hammad, A., Mohanesh, J., Abdul-Khalek, H. (2012c). Annihilation Anxiety, Trau- ma Dose and Trauma Negative Appraisal: A New Measure for Annihilation Anxiety. Psychology, 3, 90-99.

[35]   Larik, N., Hauf, E., Skeondal, A., & Solberg, O. (1996). Mental disorder among refugees and the impact of persecution and exile: Some findings from an out-patient population. British Journal of Psychiatry, 196, 726-732.

[36]   Lifton, B. (1992). The adopted self: Toward theory of cumulative trau- ma. Dissertation Abstracts International, 53, 2548.

[37]   Lomranz, J. (1990). Long term adaptation to traumatic stress in light of adult development and aging perspectives. In M. P. Stephens, J. Crowther, S. E. Hobfoll, & D. Tenebaum (Eds.), Stress and coping in later life families (pp. 99-121). New York: Hemisphere.

[38]   Laurie, J. (1996). Cumulative trauma: The non-problem problem. Transactional Analysis Journal, 26, 276-283.

[39]   Meredith, W. (1993). Measurement invariance, factor analysis and factorial invariance. Psychometrika, 58, 525-543. doi:10.1007/BF02294825

[40]   Mollica , R. F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., Lavelle, J. (1992). The harvard trauma questionnaire: Validating a cross- cultural instrument for measuring torture, trauma, and posttraumatic stress disorder. Journal of Nervous and Mental Diseases, 180, 111- 116.

[41]   Mollica, R., McInnes, K., Poole, C., & Tor, S. (1998). Dose-effect relationship of trauma to symptoms of depression and PTSD among Cambodian survivors of mass violence. British Journal of Psychiatry, 173, 482-488. doi:10.1192/bjp.173.6.482

[42]   Muthén, B. (1989). Multiple group structural modeling with nonnormal continuous variables. British Journal of Mathematical and Statistical Psychology, 42, 55-62.doi:10.1111/j.2044-8317.1989.tb01114.x

[43]   Nagy, L. M., Blake, D. D., Dan, E., Riney, S., Mangine, W., Southwick, S. M., Gusman, F. & Charney, D. S. (1991). Clinician Administered PTSD Scale—Weekly Version (CAPS-2) Reliability, validity, and sensitivity to change. In D. D. Blake (Chair), An update on the Clinician Administered PTSD Scales (CAPS-1 and CAPS-2). Symposium paper presented at the 7th annual conference of the International Society for Traumatic Stress Studies, Washington DC.

[44]   Nishith, P., Mechanic, M., & Resick. P. (2000). Prior interpersonal trauma: The contribution to current PTSD symptoms in female rape victims. Journal of Abnormal Psychology, 109, 20-25.doi:10.1037/0021-843X.109.1.20

[45]   Patrick, M. (1995). The clinical boundaries of post-traumatic stress disorder. Australian and New Zealand Journal of Psychiatry, 29, 385-393. doi:10.3109/00048679509064945

[46]   Peretz, T., Baider, L., Ever-Hadani, P., & De-Nour, A. (1994). Psychological distress in Female cancer patients with Holocaust experience. General Hospital Psychiatry, 16, 413-418.doi:10.1016/0163-8343(94)90117-1

[47]   Perez, D. J., Fortuna, L., & Alegría, M. (2008). Prevalence and correlates of everyday discrimination among US Latinos. Journal of Community Psychology, 36, 421-433. doi:10.1002/jcop.20221

[48]   Pieterse, A., Todd, N., Neville, H., & Carter, R. (2011). Perceived racism and mental health among black American adults a meta-ana- lytic review. Journal of Counseling Psychology, 59, 1-9.

[49]   Pinel, E. C. (1999). Stigma consciousness: The psychological legacy of social stereotypes. Journal of Personality and Social Psychology, 76, 114-128. doi:10.1037/0022-3514.76.1.114

[50]   Pinto, P. & Gregory, R. (1995). PTSD with psychotic features. American Journal of Psychiatry, 152, 471.

[51]   Oser, E. (1999). Urban adolescents’ exposure to violence: The role of cumulative stress, support, and selected moderators in predicting psychological functioning in a school-based sample. Dissertation Abstracts International: Section B: The Sciences & Engineering, 60, 2357.

[52]   Rachman, S. (1980). Emotional processing. Behavior Research and Therapy, 18, 51-60. doi:10.1016/0005-7967(80)90069-8

[53]   Richmond, J. M., Elliott, A. N., Pierce, T. W., Aspelmeier, J. E., & Alexander, A. A. (2009). Polyvictimization, childhood victimization, and psychological distress in college women. Child Maltreatment, 14, 127-47. doi:10.1177/1077559508326357

[54]   Silove, D. (1999). The psychosocial effects of torture, mass human rights violations, and refugee trauma: Toward an integrated conceptual framework. Journal of Nervous & Mental Disease, 187, 200-207. doi:10.1097/00005053-199904000-00002

[55]   Silove, D., Sinnerbrink, I., Field, A., Manicavasager, V. et al. (1997). Anxiety, depression and PTSD in asylum-seekers: Associations with pre-migration trauma and post migration stressors. British Journal of Psychiatry, 170, 351-357. doi:10.1192/bjp.170.4.351

[56]   Stampfer, H. (1990). “Negative symptoms”: A cumulative trauma stress disorder. Australian & New Zealand Journal of Psychiatry, 24, 516- 528. doi:10.3109/00048679009062908

[57]   Steenkamp, J., & Baumgartner, H. (1998). Assessing measurement invariance in cross-national consumer research. Journal of Consumer Research, 25, 78-90. doi:10.1086/209528

[58]   Sutker, P., Vasterling, J., Brailey, K., & Allain, A, (1995). Memory, attention, and executive deficits in POW survivors: Contributing biological and psychological factors. Neuropsychology, 9, 118-125.doi:10.1037/0894-4105.9.1.118

[59]   Scazufca, M., Menezes, P., Vallada, H., & Araya, R. (2009). Validity of the self reporting questionnaire-20 in epidemiological studies with older adults Results from the Sao Paulo ageing & health study. Social Psychiatry and Psychiatric Epidemiology, 44, 247-254.doi:10.1007/s00127-008-0425-y

[60]   Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148, 10-20.

[61]   Turner, S., & Gorst-Unworth, C. (1990). Psychological sequelae of torture: A descriptive model. British Journal of Psychiatry, 157, 475- 480. doi:10.1192/bjp.157.4.475

[62]   Turner, R., & Lloyd, D. (1995). Life time traumas and mental health: The significance of cumulative adversity. Journal of Health and Social Behavior, 36, 360-376. doi:10.2307/2137325

[63]   Van Der Kolk, B., McFarlane, A., & Weisaeth, L. (1996). Traumatic stress. New York: Guilford.

[64]   Wanous, J., & Hudy, M. J. (2001). Single-item reliability: A replication and extension. Organizational Research Methods, 4, 361-375.doi:10.1177/109442810144003

[65]   Weathers, F., Keane, T., & Davidson, J. (2001). The Clinician-Admin- istered PTSD scale: A review of the first ten years of research. Depression and Anxiety, 13, 132-156. doi:10.1002/da.1029

[66]   Weinstien, J., & del Pozo, E. (2001). Estimates of Michigan’s Iraqi refugee population. Unpublished manuscript, Dearborn, MI: Research Design and Consultation.

[67]   Wenzel, T., Sibitz, I., Kieffer, W., & Strobl, R. (1999). Capgras syndrome and functional psychosis in two survivors of torture. Psychopathology, 32, 203-306. doi:10.1159/000029091

[68]   Werbert, A,. & Lindbom-Jakobson, M. (1993). The “living dead”: Survivors of torture and psychosis. Psychoanalytic Psychotherapy, 7, 163-180. doi:10.1080/02668739300700121

[69]   Williams, D., & Mohammed, S. (2009). Discrimination and racial disparities in health: Evidence and needed research. Journal of Behavioral Medicine, 32, 20-47. doi:10.1007/s10865-008-9185-0

[70]   Youngmann, R., Zilber, N., Workneh, F., & Giel, R. (2008). Adapting the SRQ for ethiopian populations: A culturally-sensitive psychiatric screening instrument. Trans-cultural Psychiatry, 45, 566-589.doi:10.1177/1363461508100783

[71]   Zimmerman, M., Young, D., Chelminski, I., Dalrymple, K., & Galione, J. (2012). Overcoming the problem of diagnostic heterogeneity in applying measurement-based care in clinical practice: the concept of psychiatric vital signs. Comprehensive Psychiatry, 53, 117-124.doi:10.1016/j.comppsych.2011.03.004