Work For Expert Ahmed. Research I. Week 4

Global Posttrauma Symptoms: A Systematic Review of Qualitative Literature

Lynn Murphy Michalopoulos1, Melissa Meinhart2, Justina Yung2, Samuel Monroe Barton2, Xinyi Wang2, Urmi Chakrabarti2, Megan Ritchey3, Emily Haroz4, Nakita Joseph2, Judith Bass5, and Paul Bolton6

Abstract Exposure to potentially traumatic events is a global health problem, especially in low- and middle-income countries. Assessments for symptoms resulting from trauma exposure rely heavily on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for post-traumatic stress disorder (PTSD), which may not be relevant in all regions of the globe. We examined posttrauma symptoms that were not limited to Western constructs of mental health (i.e., PTSD). In a systematic review, we searched nine databases to identify posttrauma symptoms arising in qualitative literature published before July 17, 2017. A total of 17,938 records were identified and 392 met inclusion criteria. The 392 studies represented data on 400 study populations from 71 different nationalities/ethnicities. The presence and frequency of posttrauma symptoms were examined across all regions. Fisher’s exact tests were also conducted to compare frequencies in posttrauma symptoms across region and gender. Based on a weighted analysis across regions, a list of global posttrauma symptoms (N ¼ 85) was compiled into an item bank. We found that the majority of DSM-5 PTSD symptoms were mentioned across regions (with the exception of inability to recall specific aspects of the trauma and blame of self or others for the event). Across all regions, we also found a number of symptoms mentioned that were not part of PTSD and its associated features. Findings suggest that assessing posttrauma symptoms solely based on PTSD may be limiting to global populations. Research, policy, and practice implications are discussed.

Keywords cultural contexts, mental health and violence, ethnicity, PTSD

Exposure to traumatic events is a global health problem (Benjet

et al., 2016). Global estimates suggest that, by adulthood, one

in four individuals will experience a traumatic event (Norris &

Slone, 2013). Populations from low- and middle-income coun-

tries (LMIC) are at an increased risk of experiencing multiple

and ongoing traumatic events and daily stressors as a result of

extreme poverty, child labor, human trafficking, the migration

process, and political unrest (Fox, 2003; Hollifield et al., 2002;

Masinda & Muhesi, 2004; Porter & Haslam, 2005). Moreover,

populations from LMIC have experienced a disproportionate

share of the world’s armed conflicts, which not only places a

burden on how individuals function but can adversely impact

communities, economies, cultural traditions, and ways of life

(Summerfield, 2000).

Non-Western, LMIC populations bear a disproportionately

high burden of trauma, but global standards for assessing and

treating psychosocial problems that result from it (i.e., post-

trauma symptoms) have been set primarily by mental health

professionals from North America and Europe. These standards

are heavily rooted in the Diagnostic and Statistical Manual of

Mental Disorders’ (DSM) classification of post-traumatic

stress disorder (PTSD; Rasmussen, Keatley, & Joscelyne,

2014; Summerfield, 2004). Many of these assessment tools and

treatment modalities assume the universality of PTSD and are

validated through research that is etic in nature. That is, it

interprets findings from an outsider’s perspective rather than

from the perspective of the local study population (Hollifield

et al., 2002; Rasmussen et al., 2014). While there is some

1 Global Health and Mental Health Unit, Social Intervention Group, Columbia

University School of Social Work, New York, NY, USA 2 Columbia University School of Social Work, New York, NY, USA

3 Yale University School of Nursing, New Haven, CT, USA 4 Center for American Indian Health, Johns Hopkins Bloomberg School of

Public Health, Baltimore, MD, USA 5 Department of Mental Health, Johns Hopkins Bloomberg School of Public

Health, Baltimore, MD, USA 6 Department of International Health, Center for Refugee and Disaster

Response Baltimore, Johns Hopkins Bloomberg School of Public Health,

Baltimore, MD, USA

Corresponding Author:

Lynn Murphy Michalopoulos, Global Health and Mental Health Unit, Social

Intervention Group, Columbia University School of Social Work, 1255

Amsterdam Avenue, New York, NY 10027, USA.

Email: [email protected]

TRAUMA, VIOLENCE, & ABUSE 1-15 ª The Author(s) 2018 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838018772293 journals.sagepub.com/home/tva

evidence of PTSD’s cross-cultural validity (Hinton & Lewis-

Fernandez, 2011; LM Michalopoulos et al., 2015), multiple

studies have found cross-cultural variation in trauma sympto-

mology (Murray et al., 2006; Rasmussen et al., 2015; Rasmus-

sen et al., 2014; Smith & Patton, 2016). This variation creates a

need to account for potential symptoms not limited to PTSD

and its associated features. In a review of mental health liter-

ature related to cross-cultural expressions of PTSD, Hinton and

Lewis-Fernandez (2011) found differences in meaning and pre-

valence specifically related to avoidance and numbing symp-

toms. In addition, they found the presence of somatic

symptoms, providing some evidence that the cross-cultural use

of PTSD is limited. In a systematic literature review that exam-

ined cultural concepts of distress in non-Western, postconflict,

and disaster settings, Rasmussen and colleagues (2014) found

that some cross-cultural posttrauma symptoms differ from

DSM PTSD diagnostic criteria and that only a few of the stud-

ies they reviewed indicate avoidance symptoms.

These two reviews contribute significantly to our under-

standing of posttrauma symptoms across cultures, but infor-

mation on global posttrauma symptoms (i.e., posttrauma

symptoms present in both Western and non-Western con-

texts), which may include PTSD and are not limited to a

particular type of trauma, is still sparse. However, a robust

understanding of global posttrauma symptoms is critical.

Using Western-based assessment tools that focus solely on

PTSD symptom criteria to determine psychosocial outcomes

among trauma-affected populations in both LMIC and West-

ern contexts can lead to both inaccurate measurement and

subsequent contextually inappropriate treatments (see review

by Hollifield et al., 2002).

Because PTSD symptoms may be cross-culturally relevant

without accounting for all global posttrauma symptoms,

research is growing on the development and validation of emic

approaches to Western-based instruments that measure post-

trauma symptoms (Betancourt, Speelman, Onyango, & Bolton,

2009; Ertl et al., 2011; Haroz et al., 2014; Lima et al., 2016; LT

Michalopoulos et al., 2015; Rasmussen et al., 2015). However,

assessing posttrauma symptoms with instruments developed in

Western populations, or based exclusively on local perspec-

tives, may include bias or overlook symptoms that go unre-

ported but remain relevant. To close this gap, we sought to

build on current literature by identifying global posttrauma

symptoms that may not be identified in current assessment

tools. We aimed to identify posttrauma symptoms using an

approach not limited to a specific culture, study population,

or trauma type. To address potential bias in existing instru-

ments, we specifically reviewed studies that used open-ended

interviewing methods. We also took a neo-Kraepelinian

(Compton & Guze, 1995; Rasmussen et al., 2014) approach,

placing an emphasis on symptoms, to inform the development

of a posttrauma symptom assessment tool.

This review is the first we know of that has systematically

examined how posttrauma symptoms may be relevant to global

populations, rather than being limited to Western or non-

Western populations. We conducted a systematic review of

qualitative literature and aimed to (1) examine the presence

of global posttrauma symptoms, (2) examine differences in

posttrauma symptoms across region and gender, and (3)

develop an item bank of potentially global posttrauma

symptoms.

Method

Literature Review

We conducted a systematic review of qualitative studies that

examined posttrauma symptoms, psychosocial problems

related to trauma. Peer-reviewed academic journals, books/

book chapters, and dissertations were reviewed. We followed

the PRISMA guidelines (Moher, Liberati, Tetzlaff, & Altman,

2009), which were developed to assist in the reporting of

systematic reviews (see PRISMA checklist in the Online Sup-

plemental Material). The search was conducted on studies

published before July 21, 2017. We used nine databases for

our literature search: PubMed, Web of Science, PsycINFO,

Scopus, Embase, Anthrosource, Anthropology Plus, Global

Health, and Sociological Abstracts. The following terms were

included in our initial search: PTSD, posttraumatic stress dis-

order, posttraumatic stress, post-traumatic stress, anxiety,

trauma outcome, and posttraumatic neuroses. We conducted

a secondary search within the results of the first, using the

following terms: anthropology, ethnology, cross cultural dif-

ferences, cross-cultural comparison, ethnopsychology, cul-

tural characteristics, ethnography, cross culture, idiom of

distress, and qualitative. The literature search examined study

titles, abstracts, and study populations. Medical subject head-

ings terms were used when possible. While review articles

were excluded, reference lists were examined for additional

relevant studies.

All titles and abstracts were reviewed by LM to determine

whether they met inclusion criteria. Authors LM and JY split

and reviewed all full texts for eligibility. Approximately 15% of all studies were selected by a random number generator.

These were double screened to determine consistency in

eligibility. Interrater reliability, using a k statistic with the following ranges, was calculated for record eligibility during

the full-text reviews: k of 0 indicating less than chance agree- ment, 0.21–0.40 indicating fair agreement, 0.41–0.60 indicat-

ing moderate agreement, 0.61–0.80 indicating substantial

agreement, and 0.81–0.99 indicating high and almost perfect

agreement (Viera & Garrett, 2005).

Inclusion Criteria

We established the following inclusion criteria: (a) used qua-

litative methods; (b) included psychological and psychosocial

problems related to, or reported in the context of, a traumatic

event (i.e., thoughts, feelings, behaviors, interpersonal issues);

(c) written in English; and (d) reported on populations of adults

aged 18 and older. We excluded studies if the study population

did not directly experience the traumatic event (e.g., historical

trauma, vicarious trauma, secondary traumatic stress) or if the

2 TRAUMA, VIOLENCE, & ABUSE XX(X)

data were related specifically to symptoms experienced at the

time of rather than after the traumatic event. All populations

included our study experienced a traumatic event. All studies

included in our review aimed to describe the posttrauma expe-

rience, specifically psychosocial outcomes. These included

thoughts, feelings, behaviors, interpersonal problems, somatic

complaints, or negative shift in world view. We included stud-

ies that aimed specifically to examine posttrauma symptoms or

describe the lived experience (related to psychosocial out-

comes) of a trauma-affected study population. We included

studies in which the author(s) included data that reflected the

personal trauma experience of the study population as directly

observed (e.g., through ethnography) or obtained from the

study population (e.g., in-depth interviews). However, due to

potential bias, we did not include studies in which authors

reported data based solely on their perception of the study

population’s trauma symptoms.

Review and Data Extraction

Each article that met inclusion criteria was reviewed in full

with the following data extracted when available: (a) sex of

study population, (b) region of the world where the study was

conducted, (c) nationality and/or ethnicity, (d) religious affilia-

tion, (e) class status, (f) specific type of trauma, (g) interperso-

nal or noninterpersonal trauma, (h) research method used (to

differentiate between mixed methods and qualitative methods

only), (i) type of qualitative method used, (k) posttrauma symp-

toms mentioned in text, and (l) indication of whether the study

population was displaced. If displaced, migration pattern was

also noted (i.e., LMIC to LMIC; LMIC to high-income coun-

try). In addition, for displaced study populations, region was

indicated as region of origin rather than current place of

residence.

Coding

After all data were extracted from the included studies, we

coded posttrauma symptoms based on study content. We

started coding with the 20 symptoms of PTSD included in the

DSM, fifth edition (DSM-5; American Psychiatric Association,

2013). We then coded additional symptoms mentioned that

were not a part of the DSM-5. As much as possible, we initially

coded symptoms in their original terms. As such, some specific

terms were coded individually and under a PTSD symptom.

For example, symptoms such as sadness, guilt, and shame were

coded individually as well as under the PTSD symptom persis-

tent negative emotional state. Additional coded symptoms (i.e.,

other than DSM-5 PTSD symptoms) were grouped together

under one coded symptom in an iterative fashion if symptoms

had similar meanings. We compiled a data set that included all

DSM-5 PTSD symptoms and additional coded posttrauma

symptoms for each study population.

Studies that included and reported symptoms of multiple

study populations (by region or gender) were recorded as mul-

tiple, distinct study populations (i.e., separated by region or

gender). Conversely, symptoms that were experienced by one

study population but were described in multiple studies were

regarded as a single population. Thus, the number of study

populations differs from the number of studies included in the

review. In the data set, each study population was labeled by

row and each symptom code was labeled by column. For each

row (study population), symptoms were indicated as present or

not present (dichotomous). Author LM conducted all coding in

Microsoft Excel. Author NJ checked the reliability of data

extraction on 15% of all studies (selected through a random number generator) by assessing interrater reliability through

the k statistic for the 20 PTSD-coded symptoms.

Quality Assessment

To ascertain the overall quality of the articles included in this

review, we conducted a quality assessment for 25% of all stud- ies in the final review. There is no consensus in the field

regarding criteria or standards for assessing qualitative research

(Thomas & Magilvy, 2011; Tobin & Begley, 2004). As such,

we did not base our inclusion criteria on rigor alone. We built

on criteria established by Lincoln and Guba (1985) for evalu-

ating the quality of qualitative research, in addition to assessing

the use of a priori theory in the analysis. We assigned studies a

score of 1–5, with 5 representing the highest possible score in

the category. We determined confirmability by identifying evi-

dence that the findings were not shaped by researcher bias,

motivation, or interests. Confirmability criteria could be met

through confirmability audit, audit trail, triangulation, and/or

reflexivity. We determined credibility by identifying the use of

techniques to establish credibility such as prolonged engage-

ment, persistent observation, triangulation, peer debriefing,

negative case analysis, referential adequacy, and/or member-

checking. Three authors of the present study independently

rated the randomly selected articles.

Quantitative Analyses

Descriptive and exploratory analyses were conducted for each

of the 20 PTSD and additional symptoms/codes. Descriptive

analyses were conducted to assess all coded symptoms by fre-

quency. Analyses across gender only included studies which

were limited to single-gender populations. For region, we first

conducted an analysis comparing coded symptoms of all study

populations to non-Western populations. Then, we conducted

an analysis comparing symptoms across specific regions.

Regional analyses were categorized into the following: Latin

America; Middle East and North Africa; North America, Eur-

ope, Australia, and New Zealand; South Asia; Southeast Asia;

sub-Saharan Africa; Russia and Central Asia; and East Asia.

Studies that reported symptoms on multiple regions and did not

separate the symptoms by region were not included in the

region-specific analysis.

Had we only compared percentages to assess differences in

posttrauma symptoms across gender and region, we could have

made the false assumption that we had obtained all qualitative

Michalopoulos et al. 3

studies. However, we are aware that we may have only a sam-

ple of studies that examine posttrauma symptoms. To help

determine where true differences in posttrauma symptoms exist

across region and gender, we conducted Fisher’s exact tests on

the 20 most frequently coded symptoms (including PTSD

symptoms and additional symptoms) using StataSE Version

13.1 (StataCorp, 2013). We adjusted the significance level

(p < .003) to account for multiple tests with a Bonferroni cor-

rection (MacDonald & Gardner, 2000) but presented results for

p < .05.

A weighted analysis was also conducted by taking the prod-

uct of the frequencies of each symptom by region to determine

the presence and relative frequency of global symptoms across

all regions. In the weighted analysis, all coded symptoms were

included. Examining all symptoms mentioned across many

regions allowed us to compile a list of global symptoms men-

tioned (even if rarely) across all regions. Therefore, all symp-

toms mentioned at least once in each region were deemed

global. As a final step, we compiled a list of all coded post-

trauma symptoms into an item bank of global posttrauma

symptoms.

Results

Literature Search

We identified a total of 17,938 studies through the database

searches. Initial screening based on title was conducted by

authors LM and MR. Based on the initial screening, 13,382

studies did not meet inclusion criteria, resulting in 4,556 stud-

ies that qualified for abstract review. Of these, 106 randomly

selected full studies were double screened for eligibility by

authors LM, MM, and JY. Interrater reliability for abstract

screening was good (k ¼ 0.76, agreement ¼ 88.3%) indicating substantial agreement. Discrepancies in determining article

eligibility were resolved through a discussion among the raters

until a consensus was reached. Of the studies qualifying for

abstract review, 3,897 were excluded after abstract review,

resulting in 659 studies for full-text review. Of studies qualify-

ing for full-text review, 267 were subsequently excluded for the

following reasons: (a) did not focus on trauma symptoms from

the survivor (e.g., reported from a health worker or family

member about the participant; n ¼ 54), (b) could not find the article (n ¼ 28), (c) did not provide qualitative data in the paper or specifically focus on trauma symptoms (n ¼ 65), (d) symp- toms presented were focused on the time of the traumatic event

rather than posttrauma symptoms (n ¼ 25), (e) did not clearly indicate that all participants experienced a traumatic event

(n ¼ 36), (f) solely used quantitative methods (n ¼ 18), (g) was a systematic review of the literature (n ¼ 20), (h) study population was youth or adolescents (n ¼ 8), (i) the study paper was not written in English (n ¼ 4), (j) focused on secondary or vicarious trauma, and (k) focused solely on post-traumatic

growth (n ¼ 1). Four studies provided data on the same popu- lation in more than one article. In addition, four studies

reported on multiple study populations by region and/or

gender. In total, 392 studies (with 400 study populations)

met inclusion criteria and were included in the full review

(Figure 1; see also Online Supplemental Table S1 for all

included studies).

Quality of Articles

Evidence from the quality assessment indicated the data from

the selected studies were adequate for synthesis. Credibility

and confirmability, with average scores of 3.7, were the high-

est performing criteria. Dependability, determined through

inclusion of an inquiry audit, scored above the median of

possible scores, but it was the lowest performing criterion

with average scores of 3.2. Transferability, determined

through the inclusion of thick descriptions of the field experi-

ment, scored an average of 3.6. A priori theory scored an

17,938 references identi�ied

through database searches

13,382 references excluded

because did not meet inclusion

criteria

4,556 references for abstract

review

3,897 references excluded after

abstract review: did not meet

inclusion criteria

659 references full text reviewed

N=392 Studies included in �inal review

N=400 study Populations

267 references excluded:

• n=54 did not focus on trauma

symptoms from the survivor

• n=28 could not �ind

• n= 65 did not provide qualitative

data or focus on trauma

symptoms

• n=25 symptoms focused at the

time of the trauma rather than

PTS

• n= 36 not clear that participants

all experienced traumatic event

• n= 18 quantitative

• n=20 review of the literature

• n=4 provided data on same

population in more than one

article

• n=8 youth or adolescent focus

• n=4 not in English

• n=4 secondary or vicarious

trauma

• n=1 post traumatic growth focus

• n=4 reported on multiple study

populations by region or gender

Figure 1. Literature review flowchart.

4 TRAUMA, VIOLENCE, & ABUSE XX(X)

average of 3.9. This score indicated low overall evidence of a

priori theory in the included studies.

Study Population Characteristics

Studies included in the review used many different methods.

As indicated by the authors of the articles reviewed, the most

common methods were semistructured interviews (n ¼ 150), open-ended interviews (n ¼ 65), multiple qualitative methods (e.g., focus groups and individual interviews; n ¼ 54), mixed methods (both qualitative and quantitative); n ¼ 37), ethnogra- phies (n ¼ 26), focus groups (n ¼ 22), and in-depth interviews (n ¼ 21). Less common methods included narrative interviews (n ¼ 8), case study analysis (n ¼ 6), life history interviews (n ¼ 4), analysis from written reflections of the trauma experience (n ¼ 2), free list interviews (n ¼ 3), cognitive interviews (n ¼ 1), and a rapid qualitative field study (n ¼ 1).

The 400 study populations reported data from 71 different

nationalities/ethnicities. Study populations were from the fol-

lowing regions: North America/Europe/Australia nonnative

populations (196 study populations), sub-Saharan Africa (71

study populations), Middle East/North Africa (35 study popu-

lations), Latin America (32 study populations), Southeast Asia

(19 study populations), South Asia (12 study populations), East

Asia (9 study populations), North America/Europe/Australia

native populations (2 study populations), Russia and Central

Asia (2 study populations), and multiregional (22 study popu-

lations). Of study populations, 135 were female-only (34%), 35 were male-only (9%), and 230 included both male and female study populations (58%). Of the 400 populations, 266 (67%)

reported data from populations who experienced interpersonal

trauma (e.g., childhood abuse, intimate partner violence, tor-

ture, political violence), 23% reported data from populations who experienced noninterpersonal trauma (natural disasters,

physical health–related trauma, accidents, etc.), and 47 (12%) reported data from populations who experienced multiple trau-

matic events, both interpersonal and noninterpersonal (e.g.,

diagnosis of HIV with a history of childhood sexual abuse).

Of the 400 study populations, 108 (27%) study populations reported in populations who were displaced. The majority of

displaced study populations (n ¼ 72) had a migration pattern from LMIC to high-income country, while fewer (n ¼ 22) indicated a migration pattern from LMIC to LMIC.

Symptom Codes

In addition to the 20 symptoms of PTSD based on the DSM-5,

220 additional symptoms were indicated during coding—a

total of 240 coded symptoms (see Online Supplemental Table

S2). Interrater reliability for the 20 PTSD-coded symptoms was

calculated for n ¼ 65 randomly chosen study populations. Results indicated a k statistic of 0.69 (with percent agreement of 85.7%), which is in the substantial range.

Table 1 shows the most commonly mentioned posttrauma

symptoms across all study populations (N ¼ 400). These symp- toms included the following: persistent negative emotional

state (n ¼ 340, 85%), detachment from others (n ¼ 235, 59%), fear (n ¼ 227, 57%), and alienation/isolation (n ¼ 198, 50%). Ten of the 20 most frequently mentioned symptoms are from the DSM-5. In non-Western populations only (n ¼

Table 1. Most Frequent Symptoms Across All Study Populations and in Non-Western Populations.

All Populations (N ¼ 400) All Non-Western Populations (N ¼ 208)

Symptoma Frequency (%) Symptoma Frequency (%)

Persistent negative emotional state 340 (85.0) Persistent negative emotional state 176 (84.6) Detachment from others 235 (58.8) Fear 120 (57.7) Fear 227 (56.8) Detachment from others 118 (56.7) Alienation/isolation 198 (49.5) Alienation/isolation 106 (51.0) Lack of social support/no one understands 190 (47.5) Lack of support/no one understands 89 (42.8) Inability to experience positive emotions 161 (40.3) Sleep disturbance 87 (41.8) Intrusive distressing memories 159 (39.8) Persistent negative expectations 81 (38.9) Anger 155 (38.8) Inability to experience positive emotions 79 (38.0) Sleep disturbance 150 (37.5) Sadness 76 (36.5) Anxiety 147 (36.8) Intrusive distressing memories 74 (35.6) Persistent negative expectations 142 (35.5) Anger 72 (34.6) Intimate relationship problems 142 (35.5) Thinking too much 71 (34.1) Depressed mood 135 (33.8) Crying 70 (33.7) Psychological reaction 131 (32.8) Excessive worry 68 (32.7) Sense of loss 128 (32.0) Family problems 68 (32.7) Inability to socialize 126 (31.5) Unable to function 67 (32.2) Unable to function/cope 124 (31.0) Anxiety 66 (31.7) Excessive worry 115 (28.8) Depressed 66 (31.7) Sadness 114 (28.5) Intimate relationship problems 66 (31.7) Crying 113 (28.3) Sense of loss 63 (30.3)

Note. PTSD ¼ post-traumatic stress disorder. a Boldfaced indicates DSM-5 PTSD symptom.

Michalopoulos et al. 5

134; Table 1), the top four symptoms remain the same but in

different order, and only six symptoms are from the DSM-5.

Commonly mentioned posttrauma symptoms not accounted for

in PTSD among non-Western populations included the follow-

ing: fear (n ¼ 120, 58%), alienation/ isolation (n ¼ 106, 51%), lack of support/feeling that no one understands (n ¼ 89, 43%), sadness (n ¼ 76, 37%), anger (n ¼ 72, 35%), and thinking too much (n¼ 71, 34%).

Results by Region

Both DSM-5 PTSD symptoms and additional symptom codes

were represented in the 20 most frequently mentioned symp-

toms across all regions (Table 2). Each region included at least

6 of the 20 PTSD symptoms. The PTSD symptom persistent

negative emotional state was the most frequently mentioned

symptom across all regions: Latin America (n ¼ 26, 81%); Middle East/North Africa (n ¼ 30, 86%); North America, Europe, Australia, and New Zealand (n ¼ 167, 85%); South Asia (n ¼ 12, 100%); Southeast Asia (n ¼ 16, 84%); and sub- Saharan Africa (n ¼ 59, 83%). Among study populations from the Middle East and North Africa, North America, Europe,

Australia, and New Zealand, South Asia, Southeast Asia, and

sub-Saharan Africa, detachment from others was among the

five most frequently mentioned symptoms in the region (n ¼ 17, 49%; n ¼ 120, 61%; n ¼ 7, 58%; n ¼ 10, 52%; and n ¼ 47, 66%, respectively). Inability to experience positive emotions was among the five most frequently mentioned symptoms in

Latin America (n ¼ 16, 50%) and the Middle East and North Africa (n ¼ 15, 43%). Persistent negative expectations was among the five most frequently mentioned symptoms in South

Asia (n ¼ 7, 58%) and sub-Saharan Africa (n ¼ 30, 42%). Further, sleep disturbance was among the five most frequently

mentioned symptoms in Latin America (n ¼ 16, 50%) and Southeast Asia (n ¼ 13, 68%). Only three PTSD symptoms were not among the 20 most frequently mentioned in

any regions: hypervigilance, inability to recall aspects of

the trauma, and distorted blame of self or others related to

the trauma.

Among coded symptoms not part of the DSM-5 PTSD, fear

was among the most frequently mentioned symptom across all

regions: Latin America (n ¼ 22, 69%); Middle East and North Africa (n ¼ 21, 60%); North America, Europe, Australia, and New Zealand (n ¼ 109, 56%); South Asia (n ¼ 11, 92%); Southeast Asia (n ¼ 15, 79%); and sub-Saharan Africa (n ¼ 29, 41%). Alienation/isolation was also commonly mentioned in five of the six regions: Latin America (n ¼ 15, 47%); Middle East and North Africa (n ¼ 20, 57%); North America, Europe, Australia, and New Zealand (n ¼ 93, 47%); South Asia (n ¼ 5, 42%); and sub-Saharan Africa (n ¼ 40, 56%). Headaches/ migraines was also a coded symptom among the most fre-

quently mentioned symptoms in Latin America (n ¼ 14, 44%), South Asia (n ¼ 6, 50%), and Southeast Asia (n ¼ 10, 53%). Anger was also commonly mentioned in Latin America (n ¼ 11, 34%); North America, Europe, Australia, and New Zealand (n ¼ 84, 43%); South Asia (n ¼ 5, 42%); Southeast

Asia (n¼ 10, 53%); and sub-Saharan Africa (n ¼ 25, 35%). Finally, lack of social support/feeling that no one understands

was frequently mentioned in Middle East and North Africa

(n ¼ 14, 40%); North America, Europe, Australia, and New Zealand (n ¼ 102, 52%); and sub-Saharan Africa (n ¼ 39, 55%).

Fisher’s exact tests, used to examine statistically significant

differences in frequency across region, resulted in symptoms

which were not a part of the 20 DSM-5 PTSD or associated

features (see Table 2). We found that only three regions had

symptoms with significantly higher frequency compared to the

other regions together. Specifically, the following symptoms

had significantly higher frequency compared to posttrauma

symptom in all other regions together: headaches/migraines

in Latin America (n ¼ 14, 44%, p < .003) and Southeast Asia (n ¼ 10, 53%, p < .003); thinking too much in Southeast Asia (n ¼ 12, 63%, p < .003) and sub-Saharan Africa (n ¼ 30, 42%, p < .003); chest pain/pressure in the chest (n ¼ 9, 47%, p < .003), heart palpitations/cardiovascular problems (n ¼ 8, 42%, p < .003), lack of appetite (n ¼ 8, 42%, p < .003), and issues related to the heart (e.g., heartache, weak heart, sick heart;

n ¼ 7, 37%, p < .003) in Southeast Asia; and family prob- lems/discord in sub-Saharan Africa (n ¼ 29, 41%, p < .003). The following symptoms were significant at the p < .05 level

but were not significant after adjusting for multiple compari-

sons: confusion/disorientation fatigue/weakness/exhaustion,

feeling that no one understands, anxiety, avoidance of thoughts

and memories related to the trauma, loss of sense of self, head-

aches, migraines, exaggerated startle response, lack of control,

sadness, issues related to the heart, and problems with commu-

nity relationships.

Symptoms Across Gender

The 20 most frequently mentioned symptoms across single-

gender populations are presented in Table 3. For both

female-only and male-only populations, persistent negative

emotional state (female: n ¼ 117, 87%, male: n ¼ 32, 91%) and detachment from others (female: n ¼ 89, 66%, male: n ¼ 21, 60%) were the most frequently mentioned symptoms. Com- pared to male-only study populations, female-only populations

had more posttrauma symptoms that were not a part of the

DSM-5 PTSD. Of the 20 most frequently mentioned symptoms

for female-only study populations, only 7 were DSM-5 PTSD

symptoms compared to 9 for male-only study populations.

While there was considerable overlap across gender (n ¼ 12 commonly mentioned symptoms), a number of the top 20

symptoms were limited to either female-only or male-only

study populations. Specifically, two of the most frequently

mentioned DSM-5 PTSD symptoms were limited to female-

only populations: sleep disturbance and psychological reaction

to trauma reminders (n ¼ 47, 35%; and n ¼ 41, 30%, respec- tively). Reckless or self-destructive behavior (n ¼ 18, 51%), irritable behavior or angry outbursts (n ¼ 14, 40%), trauma- related dreams (n ¼ 12, 34%), and flashbacks (n ¼ 12, 34%) were among the 20 most frequently mentioned DSM-5 PTSD

symptoms limited to male-only populations. Among the top 20

6 TRAUMA, VIOLENCE, & ABUSE XX(X)

Table 2. Twenty Most Frequent Symptoms by Region.a

Latin America (n ¼ 32)

Middle East and North Africa (n ¼ 35)

North America/ Europe/Australia/ New Zealand (n ¼ 196) South Asia (n ¼ 12) Southeast Asia (n ¼ 19)

Sub-Saharan Africa (n ¼ 71)

Negative emotional state

Negative emotional state

Negative emotional state

Negative emotional state

Negative emotional state

Negative emotional state

Fear Fear Detached from others

Fear Fear Detachment from others

Inability to experience positive emotions

Alienation/ isolation

Fear Intrusive memories Sleep disturbance Alienation/ isolation

Sleep disturbance

Detachment from others

Lack of social support/no one understandsb

Negative expectations Thinking too much c

Lack of social support/no one understands

Alienation/ isolation

Inability to experience positive emotions

Alienation/ isolation

Detachment from others

Detachment from others

Persistent negative expectations

Detachment from others

Sense of loss Intrusive distressing memories

Sleep disturbance Anger Thinking too muchc

Headaches/ migraines

c Lack of social

support/no one understands

Inability to experience positive emotions

Sadnessb Headaches/migrainesc Fear

Crying Persistent negative expectations

Anger Trauma-related dreams Inability to experience positive emotions

Family problems/ discord

c

Intrusive distressing memories

Diminished interest in activities

Anxietyb Headaches/migrainesd Chest pain/pressure in the chestc

Sadnessb

Fatigue/weakness/ exhaustionb

Psychological reaction

Intimate relationship problems

Lack of social support/no one understands

Crying Intimate relationship problems

Persistent negative expectations

Sleep disturbance

Psychological reaction

Flashbacks Persistent negative expectations

Sleep disturbance

Depressed mood Anxiety Depressed mood Inability to experience positive emotions

Excessive worry Anger

Sadness Crying Inability to socialize

Exaggerated startle responseb

Sadness Problems with community relationshipsb

Anger Depressed mood Sense of loss Heartache/weak heart/ spoiled heart/dead heart/ sick heart/tired heartd

Heart palpitations/ cardiovascular problems/ heart conditionsc

Intrusive distressing memories

Unable to function/cope

Fatigue/weakness/ exhaustion

Sleep disturbance

Thinking too much Cannot eat/lack of appetite c

Silence

Physiological reaction

Loss of sense of self

Avoid thoughts and memoriesb

Depressed mood Diminished interest in activities

Crying

Avoid external reminders

Problems with concentration

Persistent negative expectations

Anger Irritable behavior or angry outbursts

Thoughts of suicide

Excessive worry Unable to function/cope

Loss of sense of self

b Agitation/frustration/

irritation Heartache/weak heart/

spoiled heart/dead heart/ sick heart/tired heartc

Unable to function/cope

Anxiety Inability to socialize

Unable to function/cope

Alienation/isolation Lack of controlb Inability to socialize

Confusion/ disorientationd

Family problems/ discord

Flashbacks Unable to function/cope General somatic complaints Problems with concentration

Note. N ¼ 365. PTSD ¼ post-traumatic stress disorder. aSymptoms which were tied in frequency for the 20th symptom are only indicated if significantly different than other regions; Boldfaced indicates DSM-5 PTSD symptom; Russia and Central Asia, East Asia, and North America/Europe/Australia/New Zealand native populations are not included due to low frequency of study populations. bFisher’s exact significant at p < .05 (region compared to all other regions). cFisher’s exact significant at p < .003 (region compared to all other regions). dFisher’s exact significant at p < .01 (region compared to all other regions).

Michalopoulos et al. 7

coded symptoms that were not a part of the DSM-5 PTSD,

inability to socialize (n ¼ 48, 36%), sense of loss (n ¼ 44, 33%), loss of sense of self (n ¼ 42, 31%), thoughts of suicide (n ¼ 40, 30%), and shame (n ¼ 38, 28%) were limited to female-only study populations. Substance/alcohol abuse (n ¼ 14, 40%), agitation/frustration/irritation (n ¼ 13, 37%), and family problems/discord (n ¼ 12, 34%) were the top, non- PTSD-coded symptoms that were limited to male-only

populations. Fisher’s exact analyses indicated a statistically

significant difference in two of the top 20 coded posttrauma

symptoms across gender: reckless or self-destructive behavior

(n ¼ 18, 51%, p < .003) and substance/alcohol abuse (n ¼ 14, 40%, p < .003), with significantly higher frequencies among male-only populations. Irritable behavior or angry outbursts

trended on significance, with higher frequencies mentioned

among male-only populations (p < .05).

Weighted Analysis of Top Symptoms

Table 4 presents results of the weighted analysis across all

regions (excluding Russia and Central Asia, East Asia, and

North America/Europe/Australia/New Zealand native popula-

tions due to low frequency of study populations). Taking the

product of all posttrauma symptoms (including both DSM-5

PTSD symptoms and additional coded symptoms), 85 symp-

toms were mentioned at least once across each region. Of the

20 DSM-5 PTSD-coded symptoms, 18 were mentioned across

each region at least once. Inability to recall specific aspects of

the trauma was infrequently mentioned across studies of Mid-

dle East and North Africa (n ¼ 1) and South Asia (n ¼ 1) and

not mentioned at all in Southeast Asia (n ¼ 0). Blame of self or others for the event was also infrequently mentioned in Latin

America (n ¼ 2), Middle East and North Africa (n ¼ 2), and South Asia (n ¼ 1) and not mentioned in Southeast Asia (n ¼ 0). The 85 items were compiled to form an item bank for

universal posttrauma symptoms (Table 4).

Discussion

Assessment of mental health outcomes among trauma-affected

populations from both Western and non-Western contexts typi-

cally emphasizes PTSD symptoms. This is the first systematic

literature review of qualitative studies that aimed to determine

the potential of global posttrauma symptoms not limited to

PTSD symptoms. Our aim was not to determine diagnostic

criteria but to understand the potential for posttrauma symp-

toms that are experienced globally. The number of symptoms

frequently mentioned across both Western and non-Western

regions supported the perspective that a common set of post-

trauma signs and symptoms is experienced globally. While we

found that the majority of DSM-5 PTSD symptoms were men-

tioned globally, our results suggest that additional posttrauma

symptoms are also consistently mentioned and relevant across

cultures. Therefore, focusing solely on PTSD to assess trauma-

related mental health problems limits our understanding of the

experience of posttrauma symptoms among trauma-affected

populations worldwide.

We found that many posttrauma symptoms overlap with

symptoms of depression (e.g., depressed mood, crying,

thoughts of suicide) and anxiety (e.g., excessive worry, ongoing

Table 3. Twenty Most Frequent Symptoms Among Studies of Single-Gender Populations.

Female Only (n ¼ 135) Male Only (n ¼ 35)

Symptom Frequency (%) Symptom Frequency (%)

Persistent negative emotional state 117 (86.67) Persistent negative emotional state 32 (91.43) Detachment from others 89 (65.93) Detachment from others 21 (60.00) General sense of fear 79 (58.52) Alienation/isolation 19 (54.29) Lack of social support/no one understands 71 (52.59) Reckless or self-destructive behaviora 18 (51.43) Alienation/isolation 70 (51.85) General sense of fear 18 (51.43) Intimate relationship problems 59 (43.70) Anger 18 (51.43) Inability to experience positive emotions 58 (42.96) Lack of social support/no one understands 17 (48.57) Anger 53 (39.26) Intrusive distressing memories 15 (42.85) Persistent negative expectations 51 (37.78) Irritable behavior or angry outburstsb 14 (40.00) Inability to socialize 48 (35.56) Anxiety 14 (40.00) Sleep disturbance 47 (34.84) Intimate relationship problems 14 (40.00) Anxiety 46 (34.07) Substance use/alcohola 14 (40.00) Sense of loss 44 (32.93) Persistent negative expectations 13 (37.14) Loss of sense of self 42 (31.11) Inability to experience positive emotions 13 (37.14) Psychological reaction 41 (30.37) Agitation/frustration/irritation 13 (37.14) Depressed mood 40 (29.63) Trauma-related dreams 12 (34.29) Thoughts of suicide 40 (29.63) Flashbacks 12 (34.29) Unable to function/cope 39 (28.89) Depressed mood 12 (34.29) Intrusive distressing memories 38 (28.15) Unable to function/cope 12 (34.29) Shame 38 (28.15) Family problems/discord 12 (34.29)

Note. Boldfaced indicates DSM-5 PTSD symptom. PTSD ¼ post-traumatic stress disorder. a Fisher’s exact significant at p < .003.

b Fisher’s exact significant at p < .05.

8 TRAUMA, VIOLENCE, & ABUSE XX(X)

sense of panic). This finding provides evidence for the co-

occurrence of depression and anxiety and is consistent with

research conducted among trauma-affected populations in both

Western (Caramanica, Brackbill, Liao, & Stellman, 2014;

Greene, Neria, & Gross, 2016; Hruska, Irish, Pacella, Sledjeski,

& Delahanty, 2014; Kessler, Chiu, Demler, Merikangas, &

Walters, 2005) and non-Western settings (Meyer, Robinson,

Chhim, & Bass, 2014; Murray et al., 2006). In addition, many

frequently mentioned posttrauma symptoms that emerged dur-

ing our review overlap with symptoms of complex PTSD (or

disorder of extreme stress not otherwise specified [DESNOS];

Herman, 1992; Pelcovitz et al., 1997). Specifically, difficulties

related to emotion regulation (e.g., anger), interpersonal rela-

tionships (e.g., problems with relationships with intimate part-

ner/family, isolation, inability to socialize), dissociation

(e.g., derealization), negative shift in belief systems/worldview

(e.g., loss of faith and trust), and somatic distress (e.g., head-

aches, heart palpitations, fatigue) were frequently mentioned

across all regions. This frequent mention supports DESNOS

symptomatology as a potentially common posttrauma out-

come. De Jong, Komproe, Spinazzola, van der Kolk, and Van

Ommeren (2005) examined the cross-cultural equivalence of

DESNOS using the Structured Interview for Disorders of

Extreme Stress (SIDES) among three trauma-affected, non-

Western populations. Findings from the study did not indicate

construct equivalence across the populations. Based on the

findings, de Jong and colleagues suggest that some specific

SIDES items are limited in cross-cultural equivalence. As a

potential remedy, de Jong and colleagues argue for the use of

qualitative methods for future cross-cultural research to assess

posttrauma symptoms (specifically DESNOS symptoms). Our

findings, which include symptoms that fall under the DESNOS

domain, suggest the benefits of using qualitative methods in

this regard. Our findings also overlap with the posttrauma

symptoms from the Harvard Trauma Questionnaire (i.e., non

DSM-5 PTSD symptoms), which suggests the utility of both an

Table 4. Weighted Frequency Results (Mentioned in at Least Each Region Once).

1. Persistent negative emotional state

30. General somatic complaints 59. Substance/alcohol use

2. Fear 31. Thoughts of suicide 60. Depersonalization 3. Detachment from others 32. Flashbacks 61. Heart palpitations/cardiovascular problems/

heart conditions 4. Alienation/isolation 33. Reckless or self-destructive behavior 62. Fear of trauma recurring 5. Sleep disturbance 34. Inability to socialize 63. Trembling/shaking 6 Inability to experience positive

emotions 35. Irritable behavior or angry outbursts 64. Issues related to the heart

b

7. Persistent negative expectations 36. Sense of uncertainty 65. Chest pain/pressure in the chest 8. Lack of social support/no one

understands a

37. Physical pain 66. Madness/psychosis/feel as if gone crazya

9. Anger 38. Avoid external reminders 67. Suppress feelings 10. Intrusive distressing memories 39. Problems with community relationships 68. Apathy 11. Sadness 40. Cannot eat/lack of appetite 69. Inability to act/initiate new activities 12. Unable to function/cope 41. Guilta 70. Ongoing sense of panic 13. Ruminating about a problem/thinking

too much 42. Withdrawn 71. Feel like suffocating/can’t breathe/shortness of

breath 14. Crying 43. Shamea 72. Shock 15. Anxiety 44. Lack of control 73. Terror 16. Sense of loss 45. Avoid thoughts and memories 74. Sorrow 17. Excessive worry 46. Loss of sense of self 75. Nausea/vomiting 18. Intimate relationship problems 47. Memory loss/forgetful 76. Not feeling normal or ordinary 19. Psychological reaction 48. Despair/distress 77. Dizziness 20. Diminished interest in activities 49. Confusion/disorientation 78. Chronic diseasec

21. Trauma-related dreams 50. Loneliness 79.Disbelief 22. Depressed mood 51. De-realization 80. Damaged 23. Family problems/discord 52. Exaggerated startle response 81. Vision problems/eye problems/weak or

tired eyes 24. Agitation/irritation/frustration 53. Helplessnessa 82. Visual hallucinations 25. Problems with concentration 54. Hypervigilance 83.Screaming 26. Fatigue/weakness/exhaustion 55. Life has become meaningless 84. Sweating 27. Silence 56. Pain (emotional) 85. Muscle aches/body aches/soreness 28. Physiological reaction 57. Loss of faith and trust 29. Headaches/migraines 58. Upset stomach/digestive problems

Note. Boldfaced indicates symptom of DSM-5 PTSD. PTSD ¼ post-traumatic stress disorder. a Overlap with Harvard Trauma Questionnaire but not part of PTSD symptoms.

b Heartache/weak heart/spoiled heart/dead heart/sick heart/tired heart/wounded

heart/broken heart/heart in trouble/unclear heart/disturbed heart/falling heart/hot heart. c Examples of chronic diseases included, but was not limited to, diabetes

and immune disorders.

Michalopoulos et al. 9

emic approach specific to one target culture (Mollica et al.,

1992) and the approach we took, which aimed to find global

symptoms of post-traumatic stress not limited to a specific

culture (see Table 4).

Regional Comparisons

In comparing Western and non-Western populations, we found

more non-PTSD symptoms for non-Western populations, sug-

gesting the limitation of relying solely on assessing symptoms

of PTSD among trauma-affected populations in these settings.

Posttrauma symptoms such as thinking too much and somatic

complaints (e.g., headaches, heart palpitations, and pressure in

the chest) were commonly mentioned, building on previous

research conducted in non-Western settings (Hinton &

Lewis-Fernández, 2011; Kaiser et al., 2015; Meyer et al.,

2014; Mollica et al., 1992; Rasmussen et al., 2015). Further,

even among Western populations, we found that roughly half

of the 20 most frequently mentioned symptoms comprised

DSM-5 PTSD symptoms, offering insight into the limitation

of PTSD worldwide as a globally applicable construct.

In regional comparisons, we found considerable overlap in

the top posttrauma symptoms (both PTSD and non-PTSD

symptoms) across region. For example, fear, persistent nega-

tive emotional state, detachment from others, and headaches

were commonly mentioned across regions, indicating the

importance in including these items in the assessment of global

posttrauma symptoms. Also noteworthy was thinking too

much, which—consistent with earlier studies of the region—

was mentioned with significantly higher frequency in South-

east Asia (Hinton, Hinton, Eng, & Choung, 2012; Kaiser et al.,

2015), which has been found to be associated with PTSD

(Hinton, Reis, & de Jong, 2015). Although not in the top

20 across all regions, thinking too much was mentioned in all

regions. This prevalence is consistent with previous literature

suggesting the universality of this symptom following a trau-

matic event (Kaiser et al., 2015). In addition to thinking too

much, three additional symptoms were mentioned with signif-

icantly higher frequency in specific regions compared to other

regions. These included headaches in Latin America and

Southeast Asia; chest pain/pressure in the chest, heart palpita-

tions, lack of appetite, and issues related to the heart in South-

east Asia; and family problems/discord in sub-Saharan Africa.

These symptoms are important to consider when assessing

posttrauma symptoms in these specific regions.

Gender

The results of research comparing posttrauma symptoms (spe-

cifically PTSD) between males and females have been incon-

sistent. Some research has found invariance in the factor

structure of PTSD (Hall, Elhai, Grubaugh, Tuerk, & Magruder,

2012; King, Orcutt, & King, 2002; Rivollier et al., 2015), while

other research has found differences in item endorsement after

controlling for PTSD severity (He, Glas, & Veldkamp, 2014;

Palm, Strong, & MacPherson, 2009). Our study found

significant differences in posttrauma symptom frequency

across gender, with higher frequencies of reckless or self-

destructive behavior and substance/alcohol use among

male-only study populations. Our analyses also indicated more

non-PTSD symptoms for women than men. This difference

may be traced to the origins of PTSD symptoms, which were

developed based on the experience of male veterans of the U.S.

armed forces. In addition, our results found more internalizing

behavior reported among women than men. These behaviors

included psychological reaction to reminders of the trauma,

shame, loss of sense of self, and suicidal thoughts. Conversely,

results from male-only study populations indicated more exter-

nalizing behavior such as irritable behavior, agitation/frustra-

tion, and family problems. These findings are in line with

previous research, which found that women who have experi-

enced trauma report higher levels of internalizing behavior,

such as negative beliefs and restricted affect, than men (Carra-

gher et al., 2016; He et al., 2014; Palm et al., 2009). Despite

these differences, we found considerable overlap in symptoms

across gender, with 13 of the 20 common symptoms reported

by both men and women. This is consistent with a study by

Rivollier and colleagues (2015), which found no substantial

difference in endorsement of PTSD symptoms across gender

after accounting for PTSD Scale score in a nationally represen-

tative U.S. sample. Future research should use quantitative

methods to examine potential gender differences in item endor-

sement and experience of posttrauma symptoms, specifically

among non-PTSD symptoms.

Research and Practice Implications

The current review used novel methods to examine the poten-

tial for posttrauma symptoms experienced by trauma-affected

populations worldwide. The use of open-ended qualitative

studies allowed us to obtain unbiased experiences of post-

trauma symptoms from an emic perspective. The global signs

and symptoms found in our systematic review show that a

majority of PTSD symptoms are considerably universal and

relevant across regions globally. However, we observed a num-

ber of posttrauma symptoms that are not currently included in

measures. Our study findings begin to close that gap by inform-

ing the development of an item bank that can be used for

screening, assessment of treatment outcomes, prevalence stud-

ies, and program evaluation. This item bank can then be piloted

and revised in multiple contexts.

This free item bank addresses the lack of posttrauma symp-

tom assessment tools that can be used cross-culturally. Items

emerging from our review can be used to assess posttrauma

symptoms where local scales have not been developed. This

bank has direct practice implications for promoting a new and

standardized way to assess posttrauma symptoms. This item

bank can be accessed and used globally in settings where non-

governmental organizations (NGOs) and health workers may

not otherwise have access to culturally relevant measures.

While a number of posttrauma scales—both self-report and

clinician administered—exist (Elhai, Gray, Kashdan, &

10 TRAUMA, VIOLENCE, & ABUSE XX(X)

Franklin, 2005), none are based on globally expressed post-

trauma symptoms.

Our overarching goal is to improve understanding and

assessment of posttrauma symptoms, so that those who are

suffering are not overlooked. Our study is the first step in

identifying global posttrauma symptoms; future studies will

test, refine, and validate, in multiple contexts, a scale partially

based on this review.

Results from our weighted analysis found a total of 85 signs

and symptoms indicated across all regions. Future research

should consider ways to reduce the number of symptoms in

the item bank, thus reducing the burden on those being

assessed. Specifically, we suggest removing or reducing broad

symptoms (e.g., persistent negative emotional state, general

physical, or somatic complaints), while retaining the specific

terms under these broad categories. For example, shame, as a

potential symptom currently classified under persistent nega-

tive emotional state, has been associated with higher levels of

dissociation (Talbot, Talbot, & Tu, 2004) and avoidant beha-

vior with intimate relationships (Dorahy et al., 2013). Thus, it

should be measured separately from symptoms such as sadness

and guilt. Also, equivalence in meaning of broader terms can-

not be assumed in cross-cultural comparisons of post-traumatic

stress symptoms. Results from our weighted analysis also indi-

cated that two DSM-5 PTSD symptoms (inability to recall

aspects of the trauma and blame of self or others) were not

present across all regions. We reviewed only studies that used

open-ended methods. This approach allowed symptoms that

may not be accounted for in Western conceptualizations of

post-traumatic stress to emerge. However, our approach cannot

confirm whether symptoms not indicated in each region exist in

that region or not. In this case, we recommend including the

two DSM-5 PTSD symptoms not indicated across all regions

until quantitative testing of the presence or absence of these

symptoms is conducted across multiple regions.

Our main interest is examining and expanding our under-

standing of global posttrauma symptoms. At the same time, our

objective is to use the findings emerging from this review as a

starting point for developing measures that may not exist in

specific contexts. This objective contains a tension between

adequate coverage of contextually relevant posttrauma symp-

toms (i.e., the use of the item bank) and the burden responding

to a lengthy questionnaire places on participants. To address

this tension in contexts where there are no measures to assess

posttrauma symptoms, we suggest using cognitive interviews

and item response theory, which can potentially aid in devel-

oping a culturally and contextually relevant measure that is

based on global posttrauma symptoms. More specifically, with

a small sample of respondents (e.g., N ¼ 15–20), researchers can use cognitive interviews to understand how participants

comprehend and answer items from questionnaires (Collins,

2003; Vreeman, Nyandiko, Ayaya, Walumbe, & Inui, 2014).

Using the think-aloud cognitive interviewing method, in which

participants describe each questionnaire item in their own

words with examples (Collins, 2003), items from the item bank

can be revised for relevance and context. We suggest that

researchers then use revised items from the cognitive inter-

views to conduct a validation study with (N ¼ 150–200) study participants from the specific context. Researchers can then use

item response theory methods to significantly reduce the num-

ber of items in the assessment based on discrimination and

difficulty parameters across the underlying latent trait of

post-traumatic stress (Nguyen, Han, Kim, & Chan, 2014).

We believe that these steps will not only reduce participant

burden but will afford the development of culturally relevant

measures in global contexts.

Limitations

We limited our search to peer-reviewed literature reported

in English. As such, we may have missed studies reported in

other languages, as well as reports that may have been

published through NGOs and/or governmental agencies.

Because our search is limited to studies reported in English,

the potential exists that our study may be biased toward

Western research. With a heavy influence of Western

researchers, the included studies may reflect an implicit bias

of recognizing and/or emphasizing posttrauma symptoms as

PTSD. Also, we did not examine differences in posttrauma

symptoms according to trauma type. We determined the

trauma type of included studies by relying on what the

authors report. It is unknown, however, if participants in

the study populations experienced trauma types that were

not studied (e.g., an included study assessed outcomes

related to an earthquake, but some participants may have

also been abused as children). As such, we were unable to

determine differences in posttrauma symptoms according to

trauma type. Future research should examine potential

differences in posttrauma symptoms according to trauma

type, much like previous studies have examined differences

in posttrauma symptoms and outcomes comparing interper-

sonal versus noninterpersonal trauma (Delker & Freyd,

2014; Freyd, DePrince, & Gleaves, 2007; Santiago et al.,

2013). In addition, posttrauma symptoms may have been

indicated in a study but not reported in its manuscript. Due

to the number of studies that met our inclusion criteria, we

were not able to contact authors of all studies to obtain

potentially unreported symptoms. This may lead to bias in

our results. Further, as our study was limited to research

conducted among trauma-affected populations, our review

may have overlooked some studies in which the study pop-

ulation deemed its experience traumatic, but where this was

not indicated by the study’s author. However, we believe

that our extensive inclusion criteria reduced this possibility.

Finally, our weighted analysis and item bank did not

include study populations from Russia and Central Asia,

East Asia, or native populations from North America,

Europe, Australia, and New Zealand. Future qualitative

studies assessing posttrauma symptoms are needed to deter-

mine additional signs and symptoms across trauma type and

gender in these regions.

Michalopoulos et al. 11

Conclusions

The aim of our systematic review was to examine whether

global posttrauma symptoms exist and can be identified. Our

findings indicate the presence of global posttrauma symptoms

related to thoughts, feelings, cognitions, interpersonal relation-

ships, somatic complaints, and shift in worldview not limited to

Western conceptualizations of mental health (specifically,

PTSD). Although additional research is needed, our findings

also suggest a lack of substantial difference in posttrauma

symptoms across region and gender, providing further support

for the existence of global posttrauma symptoms.

Critical Findings

� In addition to PTSD symptoms, findings suggest that additional symptoms should be included to accurately

assess posttrauma symptoms in global contexts.

� Findings suggest considerable overlap of global post- trauma symptoms with anxiety, depression, and com-

plex PTSD.

� Findings suggest considerable overlap across both region and gender in top posttrauma symptoms.

Research and Practice Implications

� The current review used novel methods which allowed for unbiased experiences of posttrauma symptoms from

an emic perspective.

� Findings inform the development of an 85 symptom item bank that can be used for screening, assessment

of treatment outcomes, prevalence studies, and evalua-

tion of programs.

� Posttrauma symptoms, outside of the DSM-5, which occurred across all regions suggest the limitation of our

current conceptualization of mental health outcomes

among trauma-affected populations globally.

� Future studies can use this review to test, refine, and validate a scale in multiple contexts, especially where

local posttrauma scales do not exist.

� Future research may consider reducing symptoms from the item bank, through cognitive interviews and item

response theory, to reduce the burden on those being

assessed.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for

the research, authorship, and/or publication of this article: Funding for

this study was provided by the U.S. Agency for International Devel-

opment/Victims of Torture Fund (AID-DFD-A-00-08-00308).

Supplemental Material

Supplementary material for this article is available online.

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Author Biographies

Lynn Murphy Michalopoulos, PhD, is an associate professor at

Columbia School of Social Work. She has an extensive background

in conducting individual, couples, and group therapy with trauma

survivors. She specialized in direct clinical practice with women of

color who experienced both childhood and adult sexual violence. Her

current research focuses on how trauma outcomes vary across cultural

and contextual contexts, especially among non-Western low- and

middle-income countries. She has worked with the Victims of Torture

Fund through USAID and Johns Hopkins University’s Applied Mental

Health Research group on a project developing global and regionally

specific trauma scales across cultures and populations. Her research

interest also centers on the relationship between trauma, substance

use, mental health, and HIV among migrant populations from low-

and middle-income countries. She has conducted extensive research in

Zambia where she is currently examining the co-occurring issues of

trauma, substance use, and HIV among truck drivers and female fish

traders. She is also currently working in South Africa and Uganda

examining the relationship between trauma, mental health, and HIV

risk among vulnerable populations as well as adapting and validating

psychosocial assessment tools in the region.

Melissa Meinhart is a doctoral student at Columbia School of Social

Work and the project director for ASPIRE, a Columbia University

multidisciplinary approach to responding to the Syrian refugee crisis.

Her research interests include intervention modalities in the context of

forced migration, with a substantive focus how social norms, social

support, and social networks influence gendered violence and post-

traumatic stress disorder. She completed her MSW from Columbia,

focusing on international social welfare policy. Her career in social

work began while working with street children in Ghana. After return-

ing to the United States, she was a caseworker and direct-practice

researcher for refugee resettlement before spending time at UNICEF

focusing on gender-based violence in emergencies—whereby the

countries of focus included Chad, Pakistan, Philippines, Somalia, and

South Sudan. She has since worked in Kenya, Somalia, South Africa,

Zambia, and Iraq. She is currently working to integrate Geographic

Information Systems (GIS) and data mining methods within her

ongoing research in the Middle East and Horn of Africa.

Justina Yung is a graduate of Columbia School of Social Work where

she had a concentration of advanced clinical practice, health, mental

health, and disabilities. Upon graduation she worked as a Preventable

Admissions Care Team social worker, specifically working with high-

risk and chronically ill patients whom frequent emergency depart-

ments and hospital services. She currently works at NYC Health and

Hospitals/Bellevue as an adult inpatient psychiatric social worker. Her

areas of interest include trauma- and anxiety-related disorders.

Samuel Monroe Barton is a graduate of Columbia University School

of Social Work, where he earned his master of science in social work.

He is a licensed social worker with experience working in community

mental health and has served populations affected by trauma and

severe mental illness in New York City. He currently works as a

counselor for crime victims at the New York County District Attor-

ney’s Office.

14 TRAUMA, VIOLENCE, & ABUSE XX(X)

Xinyi Wang is a second-year clinical student at Columbia School of

Social Work. She has been devoted to establishing a career where she

can help individuals with mental health struggles to restore well-being

with a cross-cultural lens. Her first-year social work placement is with

Restore NYC, a non-profit organization where she works with foreign

national survivors of sex trafficking, providing court advocacy, case

management, and co-facilitating counseling groups. She is currently

placed at the New York State Psychiatric Institute. Apart from field

experiences, she is intrigued by the reciprocal relationship between

clinical practice and research. Her research interests focus on assess-

ment and treatment of trauma-related disorders and post-traumatic

spiritual growth with a cross-cultural perspective.

Urmi Chakrabarti has spent over a decade working with underserved

populations, including persons with substance abuse issues, undocu-

mented workers, and asylum seekers. She also has a MA in cognition

and learning and a MA in clinical psychology. She puts her experience

to use by advocating for improved access to existing health and well-

ness resources for both her individual clients and the broader groups

they are a part of. She is also working to move the field of behavioral

health forward by expanding the existing frameworks to incorporate a

more nuanced understanding of behavioral health that is sensitive to,

and responsive toward, issues arising from intersectionality and the

potential cross-cultural gaps between service providers and served

populations. She is now looking to take her approach, direct practice,

and perspective in behavioral health to a global setting by completing

her MSW at Columbia with a minor in International Social Welfare in

May 2018.

Megan Ritchey is an RN and MSN student in the Psychiatric-Mental

Health Nurse Practitioner clinical specialty program at the Yale

School of Nursing. She has previously worked as a research coordi-

nator for both the Johns Hopkins Mood Disorders Center and the Johns

Hopkins Applied Mental Health Research Group. She has completed a

Fulbright Fellowship to Ukraine in the field of child psychology.

Emily Haroz, PhD, joined the Center for American Indian Health at

Johns Hopkins Bloomberg School of Public Health as an assistant

scientist in July 2016. She has extensive experience in the implemen-

tation and evaluation of programs addressing mental and behavioral

health. Her background is in quantitative methods, advanced statistical

approaches, and epidemiology. She has conducted numerous studies

to understand mental and behavioral health problems and programs

across a wide range of diverse populations. She works with the beha-

vioral health team on implementation of programs to address mental

and behavioral health problems and promote well-being among Amer-

ican Indian/American Native populations.

Nakita Joseph graduated from the Columbia School of Social Work

(CUSSW) in the Accelerated Policy Track in May 2017. Prior to

CUSSW, she worked as a preventive caseworker for Harlem

Children’s Zone. It was there that her passion for addressing systemic

oppression deepened. She also proudly collaborates with Jews for

Racial and Economic Justice. Previously, she worked as an intern with

the Columbia School of Social Work–Social Intervention Group.

There she was as a cost-effectiveness intern on two HIV intervention

programs. Her research interests include the following: Black migrant

motivations, structural racism and health disparities, inequality, pov-

erty, social policy, global health, and historic trauma.

Judith Bass, PhD, is an associate professor at the Johns Hopkins

Bloomberg School of Public Health, Department of Mental Health.

Her areas of expertise include designing and evaluating methods for

assessing mental health in non-Western cultures and investigating the

effectiveness of innovative prevention and intervention strategies in

collaboration with in-country service providers. She is interested in

the interconnectedness of mental health and economic development

with the goal of understanding how interventions and programs

addressing each of these domains can be integrated to better improve

health and well-being.

Paul Bolton, MBBS, is a senior scientist in the Center for Refugee and

Disaster Studies. His main area of expertise is the application of field

research methods to low resource countries, specifically the use of

mixed methods to conduct needs assessments, design interventions

most likely to be locally feasible and effective, monitor and improve

interventions in the course of implementation, and evaluate their

appropriateness and impact. He is the primary author of the Design,

Implementation, Monitoring, and Evaluation manual describing these

methods for researchers and program implementers. He and col-

leagues have developed his approach over the last decade and a half

and have used it to conduct program-relevant research with service

providers in sub-Saharan Africa, Latin America, Central and South-

east Asia, Eastern Europe, the Caribbean, and the Middle East. He also

conducts Implementation and Dissemination Research to plan and

monitor scale up of programs in low- and middle-income countries.

His main health area of interest is mental health, particularly the

common mental disorders of depression, anxiety, post-traumatic

stress, and substance abuse.

Michalopoulos et al. 15