PROLONGED GRIEF DISORDER, DEPRESSION, AND POSTTRAUMATIC STRESS DISORDER AMONG BEREAVED KOSOVAR CIVILIAN WAR SURVIVORS: A PRELIMINARY INVESTIGATION

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1 288 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 56(3) PROLONGED GRIEF DISORDER, DEPRESSION, AND POSTTRAUMATIC STRESS DISORDER AMONG BEREAVED KOSOVAR CIVILIAN WAR SURVIVORS: A PRELIMINARY INVESTIGATION NEXHMEDIN MORINA, VISAR RUDARI, GABY BLEICHHARDT & HOLLY G. PRIGERSON ABSTRACT Background: This study aimed at examining diagnostic concordance between Prolonged Grief Disorder (PGD), Major Depressive Disorder (MDD), and Posttraumatic Stress Disorder (PTSD) among bereaved war survivors who had lost relatives due to war-related violence. Method: We investigated the rates of PGD and its association with PTSD and MDD among 60 bereaved people who had lost fi rst-degree relatives due to war-related violence seven years ago and had also experienced other war-related events. Results: The results indicated that 38.3% of the sample fulfi lled the criteria for PGD, 55.0% for PTSD, and 38.3% for MDD. Thirty per cent of the participants without PTSD and 21.6% of those without MDD met criteria for PGD. Women were more likely to have PGD than men. The immediate threat to life was signifi cantly associated with an elevated risk for PTSD and MDD, but not PGD. Conclusion: The fi ndings suggest that many cases of PGD would be missed by an exclusive focus on PTSD among bereaved war survivors. Key words: bereavement, civilian war survivors, depression, post-traumatic stress disorder, prolonged grief disorder INTRODUCTION A growing body of literature indicates that a significant number of the bereaved people in the USA and Western European countries suffer prolonged complex grief reactions that are associated with significant distress and disability (Lichtenthal, Cruess, & Prigerson, 2004; Prigerson & Maciejewski, 2005; Zhang, El-Jawahri, & Prigerson, 2006; Prigerson, Vanderwerker, & Maciejewski, in press). Many studies indicate that symptoms of prolonged grief (also labelled as complicated or traumatic grief) differ from the symptomatology of major depression disorder (MDD) and anxiety such as posttraumatic stress disorder (PTSD) (Prigerson et al., 1996; Boelen & van den Bout, 2005). Recent research has also replicated earlier evidence (Prigerson et al., 1997; Prigerson et al., 1999; Latham & Prigerson, 2004) that has demonstrated the incremental validity of prolonged grief (Bonanno et al., 2007). Furthermore, treatments shown to work for established disorders such International Journal of Social Psychiatry. The Author(s), Reprints and permissions: Vol 56(3): DOI: /

2 MORINA ET AL.: PROLONGED GRIEF DISORDER, DEPRESSION, AND POSTTRAUMATIC STRESS 289 as MDD are not more effective than placebo for the reduction of PGD symptoms (Lichtenthal et al., 2004; Zhang et al., 2006). Due to these findings, many researchers point out the necessity of inclusion of Prolonged Grief Disorder (PGD) in the DSM-V (Lichtenthal et al., 2004; Prigerson & Maciejewski, 2005). Despite growing attention of PGD in the Western countries and despite estimates that nowadays due to new methods of warfare 90% of the human war casualties are civilians (IFRCRCS, 1993), research on the loss of family members due to war-related violence in civilian war survivors is very scarce. A search in Medline and PsycINFO (on 3 February 2008) yielded only one research article on this subject (Momartin, Silove, Manicavasagar, & Steel, 2004). In this study, Momartin et al. investigated prolonged grief among 126 Bosnian refugees in Australia and concluded that 31% of the subjects scored above the specified threshold for prolonged grief. The findings of this study suggested that symptoms of prolonged grief and PTSD can be distinguished from each other with the exception of a low order association with the intrusion dimension of PTSD. Furthermore, the results suggested that symptoms of prolonged grief were significantly associated with depression and that grief might lead to depression. Although Momartin et al. listed the loss experiences among the participants, it remains unclear from this list how many of the participants did not experience loss at all. Furthermore, the authors included also those participants who reported loss of secondary relatives as well as friends and colleagues and did not distinguish between these groups. Bereavement reactions following war-related death of relatives might vary from rates and risk factors associated with deaths from natural causes because war survivors have themselves been exposed to and are possibly direct casualties of war (Maciejewski, Zhang, Block & Prigerson, 2007). Research on the impact of war-related stress has grown recently, however, the majority of studies still focus almost exclusively on PTSD (Johnson & Thompson, 2008). The aim of our study was to investigate the association of PGD with MDD and PTSD and to examine correlates of each in order to advance understanding of how risk factors may differ for these separate psychiatric disorders that are common following exposure to traumatic losses. We conducted our study with civilian war survivors in Kosovo who had lost first-degree relatives due to war-related violence. After about 10 years of apartheid in the Kosovar Albanian population imposed by the Milos evicled Serbian government, a full-scale war began in mid-1998 and was ended by NATO air strikes in June To our knowledge, this is the first study to measure correlates of PGD among civilian war survivors who still live in the area of former conflict. To achieve our goals we investigated a sample of civilian war survivors who had lost first-degree relatives due to war-related violence in addition to other war-related stressors. We hypothesized that PGD will have distinct clinical correlates relative to those associated with PTSD and MDD. Specifically, we expected the number of warrelated traumatic events would be associated with an elevated risk of PTSD and MDD but not PGD, given that grief is less a function of the traumatic exposure than it is of the quality of the attachment to the deceased (Prigerson et al., in press). METHOD Participants To recruit bereaved participants for this study, we contacted the communal services in the Kosovar county of Podujeva that provided us with a list of people who were killed during the war in Kosovo

3 290 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 56(3) in 1998/1999. We then contacted 78 families of the dead from that list. Some 18 potential participants did not agree to participate in the study with all of them indicating they did not want to talk about their relatives for emotional reasons. The remaining 60 participants (one participant per family; 76.9 % response rate) reported losing first-degree family members during the war due to violence 7 to 8 years prior to the time of assessment. After describing the study to the participants, informed consent was obtained. The average age of the participants was 40.6 (SD = 10.9) and ranged from years. 33.3% (N = 20) of the participants were women; 47 participants were married, 8 were widowed because of the war, and 5 were single. On average, the participants had 12.6 years of education and 18.3% of them were unemployed. The interviews were conducted by one of the authors (VR) whose native tongue is Albanian. Instruments Prolonged Grief Disorder (PGD) was assessed with the Inventory of Complicated Grief-revised (ICG-r; Prigerson & Jacobs, in press). The ICG-r is a clinical rating scale assessing the presence of 12 symptoms of PGD for the last month on a 5-point Likert scale in which 1 = less than once per month, 2 = monthly, 3 = weekly, 4 = daily, and 5 = several times per day. A symptom is coded as present if it has an intensity of 4 or 5. The ICG-r assesses criteria for PGD proposed for DSM-V that have proven reliable and which demonstrate incremental validity (Prigerson & Maciejewski, 2005; Prigerson et al., in press), and such criteria were used to make a diagnosis of PGD in the present sample. These criteria specify that the bereaved individual shows symptoms of separation distress (disruptive yearning, pining, and longing for the deceased one) as well as difficulty accepting the death; inability to trust others since the loss; excessive bitterness related to the death; feeling uneasy about moving on; detachment from formerly close others; feeling life is meaningless without the deceased; feeling that the future holds no prospect for fulfilment without the deceased; or feeling agitated since the death. Finally, it is required that the symptoms have been experienced for at least 6 months and are associated with significant impairment in social, occupational, or other important aspects of functioning. The ICG-r was translated into Albanian by the first author whose mother tongue is Albanian and backtranslated into English. In the current study, the ICG-r had an internal consistency of α =.80. If a participant reported the loss of more than one family member, the interviewer asked him or her about the most significant loss. Subsequently, the items of the ICG-r were asked in relation to the family member whose loss was reported as the most significant one (i.e. how often have you felt yourself longing and yearning for x? ). Major Depression Disorder (MDD) was assessed with the MINI International Neuropsychiatric Interview (MINI; Sheehan et al., 1998; Albanian version: Morina, 2006). The MINI is a structured diagnostic interview for 16 major psychiatric disorders. The MINI is the only structured psychiatric interview translated for use among Kosovar Albanians and was therefore used in the current study. The MINI has shown similar diagnostic sensitivity compared to the Structured Clinical Interview for DSM-III-R and Composite International Diagnostic Interview (Sheehan et al., 1998). The severity of depressive symptoms was assessed with the Beck Depression Inventory (Beck, Steer, & Brown, 1996) that is a 21-item self-report inventory with each item scored from 0 3. Scores of 0 13 mean minimal depression, mild, moderate, and severe depression. Adequate correlations with several clinical assessment ratings of depression have been reported (Beck et al., 1996). The Albanian version of the BDI-II translated by the first author reached an internal consistency of.89.

4 MORINA ET AL.: PROLONGED GRIEF DISORDER, DEPRESSION, AND POSTTRAUMATIC STRESS 291 Posttraumatic Stress Disorder (PTSD) was assessed with the Posttraumatic Stress Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997; Albanian version: Morina, Böhme, Morina, & Asmundson, submitted). The PDS assesses the 17 PTSD symptoms specified in the DSM-IV. The items are scored on a 4-point Likert-type scale ranging from 0 (never) to 3 (5 times per week or more/nearly always). In addition to the presence-absence of PTSD, the PDS also measures the overall severity of PTSD symptoms. The PDS has shown good psychometric properties (Foa et al., 1997). In the current study, the internal consistence of the PDS was.90. The Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983; Albanian version Morina, 2007) is a 53-item scale of psychological symptoms and psychopathology experienced during the prior week. A general severity index (GSI) is calculated by summing all scores. All scales range from 0 ( not at all ) to 4 ( extremely ). In the current study, the mean GSI score as well as the mean score of the anxiety subscale (six items) are reported. Based on non-patient normal subjects, the anxiety mean norm is 0.35, whereas the mean score on psychiatric in- and outpatients is 1.7 (Derogatis & Melisaratos, 1983). Thus, the score of 1.7 can be used as the cut-off score. The internal consistency of the BSI in the current sample was.96. Further assessment variables included sleeping problems and the feeling of embitterment. Sleeping problems were assessed with an item asking about trouble falling or staying asleep during the past 7 days. The feeling of embitterment was assessed with an item asking about this feeling during the last two months. Embitterment is understood as the general feeling of being insulted and let down. Furthermore, embitterment can contain feelings of revenge and helplessness which have been shown to be salient in the context of psychological reactions to trauma (Baures, 1996). Traumatic events were measured using an adjusted checklist for war-related events that is based on the first part of the Harvard Trauma Questionnaire (Mollica et al., 1992). This checklist assesses 16 potential types of war-related traumatic events (Table 1). Table 1 Reported war-related traumatic experiences and their association with meeting criteria for PGD (N = 60) Traumatic experiences N (%) With PGD (N = 23) (%) Without PGD (N = 37) (%) χ 2 df = 1 Murder of family 60 (100.0) Forced evacuation under dangerous conditions 52 (86.7) Combat situation 49 (81.7) Lack of shelter 47 (78.3) Being close to one s own death 40 (66.7) * Lack of food or water 40 (66.7) * Repetitive house search by armed forces 39 (65.0) Forced separation from family members 35 (58.3) Ill health without access to medical care 34 (56.7) Torture/Abuse 22 (35.0) Serious injury 13 (21.7) Imprisonment 12 (20.0) Murder of stranger or strangers 5 (8.3) Kidnapped 4 (6.7) Sexual abuse 3 (5.3) Note: * p <.05

5 292 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 56(3) Data analysis Our statistical approach was to first provide background characteristics of the sample. Multivariate logistic regression analyses modelled the likelihood of meeting diagnosis of PGD as a function of each background characteristic. Finally, the associations between one of the three diagnoses- PGD vs. PTSD vs. MDD-and other mental health conditions were examined. Data analysis was conducted using SPSS software, version 13, and all tests were two-sided. RESULTS All participants reported the killing of at least one first-degree relative that had taken place during the war in 1998/1999. In addition to that, all reported multiple war-related traumatic experiences. The most common reported events were forced evacuation under dangerous conditions (86.7%), followed by combat exposure (81.7%) and lack of shelter (78.3%) (see Table 1). An analysis of the association between the war-related events and meeting diagnostic criteria for PGD revealed that out of 16 war events, only two were significantly reported with greater frequency by participants with PGD compared to those without PGD: Being close to one s own death (χ 2 = 4.27, df = 1, p <.05) and Lack of food or water (χ 2 = 4.27, df = 1, p <.05). As to the murder of family members, 26 participants reported the killing of their parents, 28 the killing of their siblings, 8 the killing of their children, and 8 the killing of their spouses; 31.7% participants reported two or more murders of family members (Table 2). No participant reported traumatic events after the war and 12 (20%) reported traumatic events before the war. However, all of these events were reported to have taken place in connection with the years of apartheid prior to the war. Four participants (6.7%) reported beating by police forces, three participants (5.0%) reported house search by armed police forces, and the following events were experienced by one participant each: imprisonment, threat by firing arms at the participant, witnessing the killing of a stranger, and being exposed to a corpse. Some 73.3% of the participants (N = 44) met the criteria for at least one of the three disorders: PGD, PTSD, or MDD. 38.3% of the participants met criteria for PGD and 55.0% for PTSD. According to the MINI, 38.3% of the participants met criteria for MDD and 15% of the subjects had a BDI score of 29 (i.e. severe depression). Only 12 participants (20%) fulfilled the criteria for all three disorders: PGD, PTSD, and MDD. Some 21.7% of the participants met criteria only for PGD, 21.7% only for PTSD, and 5% only for MDD. The mean score for the symptoms of PGD as measured with the ICG-r was 28.7 (SD = 7.2). The mean scores of the symptoms of PTSD as measured with the PDS and the symptoms of depression as measured with the BDI were 18.1 (SD = 11.6) and 17.6 (SD = 10.3) respectively. The distribution of the general severity index of the BSI ranged from 3 to 143, with a mean of 47.1 (SD = 33.0). The anxiety subscale of the BSI had a mean of 6.0 (SD = 5.2). The demographic characteristics are presented in Table 2. PGD was significantly associated with gender, such that women were more likely to suffer under PGD (χ 2 = 9.03, df = 1, p <.01). However, neither age nor education nor employment status were significantly associated with meeting criteria for PGD. A logistic regression analysis was performed to examine the associations between PGD and the predictor variables. In the first step, demographic variables were entered: Age, gender, and years of education. Here, only gender was significantly related to PGD with females being nearly six

6 MORINA ET AL.: PROLONGED GRIEF DISORDER, DEPRESSION, AND POSTTRAUMATIC STRESS 293 Table 2 Background and loss characteristics and their association with meeting criteria for PGD (N = 60) N (%) With PGD (N = 23) (%) Without PGD (N = 37) (%) χ 2 df = 1 Sex 9.03** Women 20 (33.3) Men 40 (66.7) Age > Education > Employment 1.50 Employed Unemployed Number of family members killed (68.3) (15.0) or more 10 (16.7) Child killed 1 8 (13.3) Son 8 (13.3) Daughter 0 (0.0) Parent killed 1 26 (43.3) Father 21 (35.0) Mother 5 (8.3) Sibling killed 1 28 (46.7) Brother 19 (31.7) Sister 9 (15.0) Spouse killed 1 8 (13.3) Husband 6 (10.0) Wife 2 (3.3) Note: ** p <.01, n.a.: not applicable; 1 due to the multiple losses characteristic of the sample no χ 2 tests were performed. times more likely, OR = 5.83 (95% CI ). In the second step, the number of murdered family members was entered and still only gender was significantly related to PGD, OR = 6.26 (95% CI ). When the number of traumatic events was entered in the final step, gender still remained the only significant relationship to PGD, OR = 5.80 (95% CI ). A similar logistic regression analysis to examine the relationship between PTSD and the predictor variables revealed that only the number of war-related traumatic events was significantly related to PTSD, OR = 1.26 (95% CI ). When the logistic regression analysis was performed with MDD as the dependent variable, both gender and the number of war-related traumatic experiences were significantly correlated to MDD, OR = 4.03 (95% CI ) and 1.32 (95% CI ) respectively, both p <.05. To assess the impact of war-related traumatic events on the three disorders we subdivided the events into the following two categories: category 1: immediate threat to one s own life, including

7 294 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 56(3) being close to one s own death, forced evacuation under dangerous conditions, combat exposure, torture, abuse, serious injury or sexual abuse; and category 2: ongoing strains, including lack of shelter, lack of food or water, ill health without access to medical care, or imprisonment. As all participants had experienced murder of a family member we did not put this into any of the categories. Logistic regression analyses indicated that immediate threat to one s life was a significant predictor of PTSD, OR = 4.18 (95% CI ), p <.05, and MDD, OR = 5.08 (95% CI ), p <.05, however, not of PGD. Ongoing strains was a significant predictor of MDD, OR = 3.32 (95% CI ), p <.05, however, not of PTSD or PGD. An examination of the pre-war traumatic experiences revealed no significant prediction of the three diagnoses. An examination of the bivariate associations between PGD and other variables revealed a number of significant relationships. A diagnosis of PGD was significantly related to the diagnosis of MDD, OR = 6.80 (95% CI ), p <.01; symptoms of anxiety, OR = 8.71 (95% CI ), p <.001, sleeping difficulties, OR = 4.96 (95% CI ), p <.05, and embitterment, OR = (95% CI ), p <.001. About two-thirds of the participants with PGD (65.2%) also met criteria for PTSD, however, about one-half of the participants with PTSD (48.6%) did not meet criteria for PGD and thus there was no significant relationship between PTSD and PGD. The relationship between PGD and the diagnosis of PTSD or MDD was also not significant as 56.8% of the participants with PTSD or MDD screened negative for PGD (Table 3). A similar examination of the bivariate relationships between PTSD and other variables suggested two significant relationships, one with MDD, OR = 3.72 (95% CI I, p <.05, and one with symptoms of anxiety, OR = (95% CI ), p <.001. The other relationships were not significantly associated with PTSD. The examination of the associations between MDD and PGD, PTSD, anxiety, sleeping difficulties, and embitterment revealed only significant relationships (Table 3). DISCUSSION The aim of this study was the investigation of PGD among Kosovar civilian war survivors. In addition to the killing of first-degree relatives, the participants reported multiple traumatic warrelated experiences. Eight different categories of war experiences, such as forced evacuation, combat situation, or being close to one s own death, were experienced across more than half of the sample. The high vulnerability to mental illness within this sample was demonstrated by the result that even seven years after the war, 73.3% of the participants fulfilled the criteria for at least PGD, PTSD, or MDD. A comparison with a parallel but unrelated study conducted with Kosovar civilian war survivors reveals some more insights into the mental health of the bereaved current sample (Morina & the CONNECT Group, 2007). The sample of this comparison study included 423 traumatized civilian war survivors who did not report loss of family members during the war and it could be matched on important characteristics with the current sample; that is, matched on age (M = 38.3, SD = 11.6) and education (M = 10.4, SD = 3.5), but not for gender (54.8% female). Compared to the sample of the other study, the participants of the current study had higher rates of psychiatric morbidity as measured with the BSI (M = 47.1, SD = 33.0 vs. M = 32.5, SD = 29.4) and higher prevalence rates of depression (38.2 vs. 32.9%) and PTSD (55.0 vs.14.2%) as measured with the MINI. Furthermore, the refusal rate of 23.1% of potential participants in the current study because of emotional reasons might mean that the estimates of PGD and other disorders might even be underestimated.

8 MORINA ET AL.: PROLONGED GRIEF DISORDER, DEPRESSION, AND POSTTRAUMATIC STRESS 295 Table 3 Psychopathology among participants with or without PGD, PTSD or MDD PGD positive PGD negative OR 95% CI Psychopathology among participants with or without PGD PTSD MDD ** Either PTSD or MDD Anxiety *** Sleeping diffic * Embitterment *** Psychopathology among participants with or without PTSD PGD MDD * Either PGD or MDD Anxiety ** Sleeping diffic Embitterment Psychopathology among participants with or without MDD PGD ** PTSD * Either PGD or PTSD * Anxiety *** Sleeping diffic * Embitterment ** Notes: 1 either meeting criteria for PTSD or for MDD; * p <.05; ** p <.01; *** p <.001. Gender was a risk factor for PGD with female participants seven times more likely to suffer from this disorder. The issue of the association between gender and PGD, however, is still not clear as some studies indicated no gender differences (Chen et al., 1999). Yet, there exists some evidence that women are more likely to be depressed after interpersonal stressful events than men (Maciejewski et al., 2001). One explanation why the gender difference in the current study was so high might be related to the nature of the current sample and the post-war hardships. Of all female participants, 30% (6 out of 20) reported the killing of their husbands and of these all but one met criteria for PGD. In post-war Kosovo, it has been very hard for the absolute majority of the parents to provide their children and themselves with the necessities of life as the average wages (if employed) or state aid have been very low. If however, a widow in post-war Kosovo where usually men provide for the family has to provide for her children and herself, the hardships of the current situation might lead to thoughts on how life would be if her husband were still alive and lead to the maintenance of symptoms of PGD. Further research with a larger sample of war survivors is needed to further examine this issue. A diagnosis of PGD was furthermore significantly related to symptoms of anxiety, sleeping difficulties, and embitterment. These findings are consistent with several studies indicating that PGD is associated with substantial psychological distress and impairment (Lichtenthal et al., 2004; Prigerson & Maciejewski, 2005; Zhang et al., 2006; Prigerson et al., in press).

9 296 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 56(3) The number of war-related traumatic events was significantly related to PTSD and MDD, however, not to PGD. Furthermore, neither the war-related immediate threat to one s own life nor war-related ongoing stress was shown to have an impact on PGD, whereas the immediate threat to one s life was significantly related to both PTSD and MDD, and ongoing stress was significantly associated with MDD. PGD and PTSD were not significantly related to each other. An exclusive focus on PTSD in our sample would have missed about half of the participants with PGD. The findings most clearly highlight the distinction between PGD and PTSD which further suggests the need to distinguish these psychiatric sequelae following loss of family members during wartime. The fact that the participants in our study experienced a large number of war-related events makes this sample unique as previous studies on the association of PGD with MDD and PTSD have predominantly been conducted with bereaved samples that did not report additional traumatic experiences particularly as they relate to war. The fact that PGD was distinct from PTSD, despite the confounding effect of the loss of relatives with the experiencing of many other war-related stressors, makes the call for the use of the diagnosis of PGD stronger. A limitation of this study is the relatively small sample. This circumstance along with the fact that 31.7% of them reported the killing of two or more family members made a classification of distinct large enough groups in this respect difficult. Thus, it remains for future studies to examine the role of the relationship of family members on PGD among civilian war survivors. Furthermore, the cross-sectional nature of the study does not allow the establishment of causal effects between MDD, PTSD, and PGD. Finally, a non-culturally validated measurement of PGD was used. Nevertheless, the current study provides pioneering evidence on the distinction between PGD and PTSD among probably the most vulnerable subgroup of civilian war victims who have suffered multiple war-related events as well as the murder of family members. Replication of the current results with larger sample sizes is needed to attest to the mental health impairment of bereaved civilian war survivors. REFERENCES Baures, M.M. (1996) Letting go of bitterness and hate. Journal of Humanistic Psychology, 36, Beck, A.T., Steer, R.A. & Brown, G.K. (1996) Beck Depression Inventory-II: Manual. San Antonio, TX: Psychological Corporation. Boelen, P.A. & van den Bout, J. (2005) Complicated grief, depression, and anxiety as distinct post-loss syndromes: a confirmatory factor analysis study. American Journal of Psychiatry, 162, Bonanno, G.A., Neria, Y., Mancini, A., Coifman, K.G., Litz, B. & Insel, B. (2007) Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity. Journal of Abnormal Psychology, 116, Chen, J.H., Bierhals, A.J., Prigerson, H.G., Kasl, S.V., Mazure, C. & Jacobs, S. (1999) Gender differences in health bereavement outcomes resulting from bereavement-related emotional distress. Psychological Medicine, 29, Derogatis, L.R. & Melisaratos, N. (1983) The Brief Symptom Inventory: an introductory report. Psychological Medicine, 13, Foa, E.B., Cashman, L., Jaycox, L.H. & Perry, K. (1997) The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychological Assessment, 9, International Federation of Red Cross and Red Crescent Societies (IFRCRCS) (1993) World Disasters Report Dordrecht: Martinus Nijhoff. Johnson, H. & Thompson, A. (2008) The development and maintenance of post traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: a review. Clinical Psychology Review, 28,

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