Several clinicians highlight the importance of considering the different populations on which an assessment instrument for PTSD was validated when selecting a measure. The need to develop instruments that are culturally sensitive has been of great interest for many years as a result of documentation of ethnocu1tural-specific responses to traumatic events. For example, several researchers have provided evidence of differences between people from ethnic minorities and European Americans in the severity of PTSD symptoms experienced following a traumatic event (e.g., Frueh, Brady, & Arellano, 1998; Green, Grace, Lindy, & Leonard, 1990; Kulka et al., 1990). The need for culturally sensitive instruments is further emphasized by the growing awareness among scholars that developing countries have a higher prevalence of PTSD than industrialized nations (De Girolamo & McFarlane, 1996).
To date, the psychological assessment of PTSD has developed primarily within the context of Western, developed, and industrialized countries. Thus PTSD assessment may be limited by a lack of culturally sensitive measures and by the tremendous diversity among the cultural groups of interest (Marsella, Friedman, Gerrity, & Scurfield, 1996). However, progress in developing culturally sensitive measures has been made.
A good example of a measure that possesses culturally relevant features is the Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992), which has been widely used in refugee samples. The HTQ assesses a range of potentially traumatic events and trauma-related symptoms. The assessment of trauma includes many types of events to which refugees from war-torn countries may have been exposed, including torture, brainwashing, and deprivation of food or water. Originally developed in English, the HTQ has been translated and validated in Vietnamese, Laotian, and Khmer versions. In addition, the HTQ possesses linguistic equivalence across the many cultures and lan guages with which it has been used. Thus far, Mollica et al. have reported good reliability (test-retest = .89; interrater = .93; coefficient alpha = .96) for the HTQ (Cusack et al., 2002). Future research will need to document the reliability and validity of new instruments on a wider range of populations and develop additional instruments that have the culturally sensitive characteristics exemplified in the HTQ.
High rates of comorbidity are common in PTSD across diverse samples (e.g., males, females, veterans, sexual assault victims, crime victims, the general population), traumatic events (e.g., military, combat, rape, physical assault, childhood sexual abuse, violence), and patient and nonpatient status (help-seeking patients vs. community-based groups; Keane & Kaloupek, 1997; Kessler et al., 1994; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). The most commonly diagnosed comorbid disorders are substance use disorders, mood disorders (e.g., major depressive disorder and dysthymia), and anxiety disorders (e.g., panic and phobias). Unlike other forms of depression seen in the absence of PTSD, when combined with PTSD depression often seems unremitting and in many cases appears as a "double depression" (i.e., major depressive episodes combined with longstanding dysthymia). In many cases, substance abuse may be secondary to PTSD and represent an effort to self-medicate symptoms. The co-occurrence of other disorders with PTSD is likely to complicate an individual's clinical presentation, compromise functioning across multiple domains, and negatively affect treatment outcomes (e.g., Brown, Stout, & Mueller, 1996; Ouimette, Finney, & Moos, 1999). Thus careful consideration of the onset of each disorder may be important to assess in order to arrive at the most appropriate treatment plan for an individual.
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