International Journal of Psychology, 2015 Vol. 50, No. 5, 402–406, DOI: 10.1002/ijop.12146
Relationship of posttraumatic growth to symptoms of posttraumatic stress disorder and depression: A pilot study of Iraqi students Kathryn M. Magruder1,2 , Cengiz Kılıç3 , and Mehmet M. Koryürek4 1 Department
of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA 2 Fulbright Senior Research Scholar, Hacettepe University, Ankara, Turkey 3 Department of Psychiatry, Hacettepe University, Ankara, Turkey 4 Psychiatry Clinic, Aksaray State Hospital, Aksaray, Turkey
P
osttraumatic growth (PTG) and psychopathology are common outcomes following exposure to adversity and trauma. We examined the relationship of PTG to posttraumatic stress disorder (PTSD) and depression in a group of young Iraqi students with war trauma exposure. These young Iraqis had experienced an average of 13 different war-related adversities. The prevalence of probable PTSD was 17.2% and probable depression 23.1%. PTSD was associated with higher and depression with lower PTG. In addition, the relationship between PTG and PTSD was stronger among males than females. Although PTSD and depression were relatively common, they were related to PTG in opposite directions. Keywords: Posttraumatic growth; PTSD; Depression; War trauma; Iraq war.
The notion of positive psychological gains as a result of struggles with adversity and trauma is not new, but it is only in the last two decades that systematic studies have been undertaken and scales developed, coining the term “posttraumatic growth” (or PTG) to capture this concept (Tedeschi & Calhoun, 1996). As posttraumatic stress disorder (PTSD) and depression are also frequently results of traumatic experiences, there have been several studies of the relationship between growth and psychopathology. Helgeson, Reynolds, and Tomich (2006), reported positive relationships between PTG and PTSD, and a weak negative relationship with depression; however, more recent studies either found no relationship between depression and PTG (Cobb, Tedeschi, Calhoun, & Cann, 2006; Hall et al., 2008; Hobfoll, Tracy, & Galea, 2006; Sattler et al., 2006) or a positive correlation (Dekel, Ein-Dor, & Solomon, 2012). Women have consistently higher prevalence than men of both PTSD and depression (Kessler, 2007). They also report higher levels of PTG than men, possibly because of differences in cognitive appraisal and coping styles (Vishnevsky, Cann, Calhoun, Tedeschi, & Demakis,
2010). Helgeson et al. (2006) reviewed 77 studies that included assessments of PTG and psychopathology and concluded that as the percentage of males in a sample increased, the correlation between growth and psychopathology also increased. Growth has been shown to occur in civilian war survivors. Studying war-exposed civilians in Israel, Hall et al. (2010) showed that PTG is associated positively with PTSD and that gender did not have a moderating effect on the PTG–PTSD relationship. Their measure, however, was the Conservation of Resources Scale, not one of the commonly used PTG measures. Likewise, Powell, Rosner, Butollo, Tedeschi, and Calhoun (2003) did not find a gender effect on the relationship between PTSD and growth in a group of Bosnian war survivors. Our own work has focused on young Iraqi civilians of Turkmen ethnicity who have lived most of their lives with war and civil unrest. At least 100,000 people were killed in Iraq as a direct result of the wars in 1980. Iraqi minority groups, such as Kurds and Turkmens, have experienced both the ravages of war as well as discrimination for being ethnic minorities. Turkmens are the third largest ethnic
Correspondence should be addressed to Cengiz Kılıç, Department of Psychiatry, Hacettepe University, Ankara 06100, Turkey. (E-mail: cengiz.kilic@ ymail.com). All authors have significantly contributed to conception or design (Kılıç and Koryürek), data collection (Koryürek and Kılıç), analysis (Kılıç and Magruder), interpretation of data (Kılıç, Magruder and Koryürek) and drafting the article (Magruder, Kılıç and Koryürek).
© 2015 International Union of Psychological Science
POSTTRAUMATIC GROWTH, PTSD AND DEPRESSION
group in Iraq (after Arabs and Kurds) and reside primarily in Kirkuk, Mosul, Erbil, Diyala and Baghdad. Turkmens have been part of Iraq since the seventh century, and throughout have maintained a Turkish affinity, including retaining Turkish linguistic abilities. All Turkmens are Muslim (about 60% Sunni and 40% Shia). The Turkmen population was 500,000 at the 1965 census. It is unclear how many Turkmens currently live in Iraq, as Turkmen ethnicity was not allowed on the most recent census. The Turkish government provides university scholarships for 100 Iraqi Turkmen students annually, allowing them to study in Turkey, but requiring them to return to Iraq upon degree completion. These scholarships are administered and controlled through the Turkmeneli Association, an NGO established in 1996 with the main aim of preserving Turkmen culture and identity. Scholarship candidates must be living in Iraq and are required to pass approved qualifying tests. More male than female Turkmen students come to Turkey, reflecting the conservative nature of Iraqi Turkmens. Scholarships cover accommodation and other living expenses, plus travel to Iraq twice a year. Our study examined the relationship of PTG to PTSD and depression in these young Iraqis currently living in Turkey, all of whom experienced the war that started in 2003. In our model, trauma and stress are presumed precursors to PTSD and depression, with a hypothesised relationship to PTG. If there is a relationship, then that may help to refine interventions that both address psychopathology and promote PTG. Our aim was to examine the prevalence of PTSD and depression among these Iraqi students and how that related to posttraumatic growth. Secondarily, we were interested in the effect of gender on those relationships.
403
information, war-related events they experienced in Iraq, PTG and symptoms of PTSD and depression. Although students were Iraqi, they all spoke Turkish (as is required in the universities). All subjects who volunteered to participate in the study gave written informed consent. The study was approved by the Ethics Committee of Hacettepe University in Ankara. Measures War Trauma Questionnaire (WTQ) It includes 31 war-related events ranging from severe traumas (i.e. being wounded, being tortured, being raped or sexually harassed) to non-traumatic, but still disruptive events (i.e. house raided, car stopped by soldiers). The internal consistency (alpha) of the 31 items was .88. The total score (number of types of events, all coded as 0 = absent, 1 = present) was used in the analyses. Posttraumatic Growth Inventory (PTGI) This is a widely used questionnaire designed to measure positive change after adverse events (Tedeschi & Calhoun, 1996). The original scale (21 items and a 6-point scale), was translated into and adapted for Turkish. Cronbach alpha of the Turkish version was .91. In the Turkish version, one item (“My priorities about life have changed”) was dropped and a 4-point (instead of a 6-point) scale was adopted for ease of administration. In this study, subjects were instructed to think about the changes they observed because of their war-related experiences after 2003. Total PTGI score was used in the analyses. Cronbach alpha for this study was .92.
METHODS
Traumatic Stress Symptom Checklist (TSSC)
All known Iraqi Turkmen students studying at various universities (N = 254) in Ankara were invited to take part in a survey of mental health in 2010. This was a complete roster of students recruited through the Turkmeneli Association in Ankara.
This is a 17-item, self-rated questionnaire that taps current traumatic stress on a 4-point scale (Ba¸so˘glu et al., 2001, in Turkish). Internal consistency of the scale was .92. When used with a cut-off score, it has been shown to predict validly DSM-IV PTSD in earthquake survivors in Turkey (Ba¸so˘glu et al., 2001). We used the total score of the TSSC as the first outcome variable in our analyses. We also used the cut-off score of 24/25 to report probable PTSD. Cronbach alpha for the current sample was .90.
Participants
Procedure All subjects were notified and invited to come to the Turkmeneli Association to complete study questionnaires. One of the investigators (MK) is an Iraqi Turkmen and had credibility within the Iraqi Turkmen student network. Volunteering students were administered paper and pencil interviews with questions about sociodemographic © 2015 International Union of Psychological Science
Beck Depression Inventory (BDI) This widely used, 21-item, self-report questionnaire measures depressive symptomatology for the last week (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Validity and reliability in Turkish were established by Hisli (1988). BDI score was used as the second outcome variable in analyses. Probable depression was also
404
MAGRUDER ET AL. TABLE 1 Participant characteristics by gender Male (N = 153)Mean (SD)
Female (N = 33)Mean (SD)
Total (N = 186)Mean (SD)
25.3 (3.9) 15.6 (9.2) 11.4 (9.1) 55.0 (11.1) 13.6 (6.2) 3.1 (2.6)
24.4 (3.2) 16.1 (11.2) 10.4 (8.2) 55.0 (12.0) 11.5 (5.5) 3.5 (3.7)
25.2 (3.8) 15.7 (9.6) 11.2 (8.9) 55.0 (11.2) 13.2 (6.1) 3.2 (2.9)
Age (18–36) PTSD score (0–51) Depression score (0–63) PTGI score (20–80) Number of events (0–31) Years since left Iraq (0–19)
Probable PTSD Probable depression Average monthly income < $500 Family member living in Ankara
N (%)
N (%)
N (%)
25 (16.3) 38 (24.8) 64 (41.9) 44 (28.0)
7 (21.2) 5 (15.2) 16 (48.5) 20 (51.3)
32 (17.2) 43 (23.1) 80 (43) 64 (32.7)**
*p < .05. **p < .01.
reported using a cut-off score of 16/17 (moderate to severe depression). Cronbach alpha for the current sample was .88. Statistics We used chi-square tests, t-tests and correlation analyses to examine the relationships among PTG, gender, PTSD, depression and other study variables. To test our hypothesis, we examined factors (gender, age, number of event types and PTGI score) associated with the outcome variables (PTSD and depression) using linear regression. Because of our interest in gender, we also examined a gender by growth interaction for each outcome. RESULTS Of the 254 students invited to participate, 203 (80%) consented and completed the questionnaires. Because 17 subjects did not report any traumatic event that created horror or helplessness, they did not respond to the PTSD assessment. The final sample, therefore, consisted of 186 subjects. Table 1 shows the sociodemographics and outcomes for the total sample and by gender. Average age was 25.2 and average number of event types 13.2. Probable PTSD was reported by 17.2% and probable depression by 23.1%. More young women than men reported living with a family member in Ankara—the only significant gender difference. As expected, number of events was positively correlated with both PTSD and depression scores (Table 2). Also as expected, PTSD and depression were significantly correlated. PTGI was related to PTSD, but not depression. Neither gender nor age was significantly correlated with any of the variables. In our first set of models (Table 3), gender (1 = male, 2 = female), age, number of events, PTGI score, PTSD
score and depression score were regressed on PTSD and depression variables in turn. PTSD was positively related to number of events, PTGI score and depression; depression was negatively related to age and PTGI score, but positively related to PTSD. Model 2 included the PTG by gender interaction term. For PTSD, all prior relationships remained significant, and the interaction term was also significant (β = −.64, p = .04), indicating that PTSD relates positively to growth for males, but not for females. PTG by gender was not significant for the depression model. DISCUSSION We examined the relationship of PTG to self-reported PTSD and depression in a group of young Iraqi Turkmens who experienced the 2003 war as teenagers and were temporarily living in Turkey as university students. We found high levels of exposure to trauma and adversity, and relatively high rates of both probable PTSD (16.3% males, 21.2% females) and depression (24.8% males, 15.2% females) compared with general population studies in the Middle East. For example, PTSD prevalence was reported to be
Relationship of posttraumatic growth to symptoms of posttraumatic stress disorder and depression: A pilot study of Iraqi students Kathryn M. Magruder1,2 , Cengiz Kılıç3 , and Mehmet M. Koryürek4 1 Department
of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA 2 Fulbright Senior Research Scholar, Hacettepe University, Ankara, Turkey 3 Department of Psychiatry, Hacettepe University, Ankara, Turkey 4 Psychiatry Clinic, Aksaray State Hospital, Aksaray, Turkey
P
osttraumatic growth (PTG) and psychopathology are common outcomes following exposure to adversity and trauma. We examined the relationship of PTG to posttraumatic stress disorder (PTSD) and depression in a group of young Iraqi students with war trauma exposure. These young Iraqis had experienced an average of 13 different war-related adversities. The prevalence of probable PTSD was 17.2% and probable depression 23.1%. PTSD was associated with higher and depression with lower PTG. In addition, the relationship between PTG and PTSD was stronger among males than females. Although PTSD and depression were relatively common, they were related to PTG in opposite directions. Keywords: Posttraumatic growth; PTSD; Depression; War trauma; Iraq war.
The notion of positive psychological gains as a result of struggles with adversity and trauma is not new, but it is only in the last two decades that systematic studies have been undertaken and scales developed, coining the term “posttraumatic growth” (or PTG) to capture this concept (Tedeschi & Calhoun, 1996). As posttraumatic stress disorder (PTSD) and depression are also frequently results of traumatic experiences, there have been several studies of the relationship between growth and psychopathology. Helgeson, Reynolds, and Tomich (2006), reported positive relationships between PTG and PTSD, and a weak negative relationship with depression; however, more recent studies either found no relationship between depression and PTG (Cobb, Tedeschi, Calhoun, & Cann, 2006; Hall et al., 2008; Hobfoll, Tracy, & Galea, 2006; Sattler et al., 2006) or a positive correlation (Dekel, Ein-Dor, & Solomon, 2012). Women have consistently higher prevalence than men of both PTSD and depression (Kessler, 2007). They also report higher levels of PTG than men, possibly because of differences in cognitive appraisal and coping styles (Vishnevsky, Cann, Calhoun, Tedeschi, & Demakis,
2010). Helgeson et al. (2006) reviewed 77 studies that included assessments of PTG and psychopathology and concluded that as the percentage of males in a sample increased, the correlation between growth and psychopathology also increased. Growth has been shown to occur in civilian war survivors. Studying war-exposed civilians in Israel, Hall et al. (2010) showed that PTG is associated positively with PTSD and that gender did not have a moderating effect on the PTG–PTSD relationship. Their measure, however, was the Conservation of Resources Scale, not one of the commonly used PTG measures. Likewise, Powell, Rosner, Butollo, Tedeschi, and Calhoun (2003) did not find a gender effect on the relationship between PTSD and growth in a group of Bosnian war survivors. Our own work has focused on young Iraqi civilians of Turkmen ethnicity who have lived most of their lives with war and civil unrest. At least 100,000 people were killed in Iraq as a direct result of the wars in 1980. Iraqi minority groups, such as Kurds and Turkmens, have experienced both the ravages of war as well as discrimination for being ethnic minorities. Turkmens are the third largest ethnic
Correspondence should be addressed to Cengiz Kılıç, Department of Psychiatry, Hacettepe University, Ankara 06100, Turkey. (E-mail: cengiz.kilic@ ymail.com). All authors have significantly contributed to conception or design (Kılıç and Koryürek), data collection (Koryürek and Kılıç), analysis (Kılıç and Magruder), interpretation of data (Kılıç, Magruder and Koryürek) and drafting the article (Magruder, Kılıç and Koryürek).
© 2015 International Union of Psychological Science
POSTTRAUMATIC GROWTH, PTSD AND DEPRESSION
group in Iraq (after Arabs and Kurds) and reside primarily in Kirkuk, Mosul, Erbil, Diyala and Baghdad. Turkmens have been part of Iraq since the seventh century, and throughout have maintained a Turkish affinity, including retaining Turkish linguistic abilities. All Turkmens are Muslim (about 60% Sunni and 40% Shia). The Turkmen population was 500,000 at the 1965 census. It is unclear how many Turkmens currently live in Iraq, as Turkmen ethnicity was not allowed on the most recent census. The Turkish government provides university scholarships for 100 Iraqi Turkmen students annually, allowing them to study in Turkey, but requiring them to return to Iraq upon degree completion. These scholarships are administered and controlled through the Turkmeneli Association, an NGO established in 1996 with the main aim of preserving Turkmen culture and identity. Scholarship candidates must be living in Iraq and are required to pass approved qualifying tests. More male than female Turkmen students come to Turkey, reflecting the conservative nature of Iraqi Turkmens. Scholarships cover accommodation and other living expenses, plus travel to Iraq twice a year. Our study examined the relationship of PTG to PTSD and depression in these young Iraqis currently living in Turkey, all of whom experienced the war that started in 2003. In our model, trauma and stress are presumed precursors to PTSD and depression, with a hypothesised relationship to PTG. If there is a relationship, then that may help to refine interventions that both address psychopathology and promote PTG. Our aim was to examine the prevalence of PTSD and depression among these Iraqi students and how that related to posttraumatic growth. Secondarily, we were interested in the effect of gender on those relationships.
403
information, war-related events they experienced in Iraq, PTG and symptoms of PTSD and depression. Although students were Iraqi, they all spoke Turkish (as is required in the universities). All subjects who volunteered to participate in the study gave written informed consent. The study was approved by the Ethics Committee of Hacettepe University in Ankara. Measures War Trauma Questionnaire (WTQ) It includes 31 war-related events ranging from severe traumas (i.e. being wounded, being tortured, being raped or sexually harassed) to non-traumatic, but still disruptive events (i.e. house raided, car stopped by soldiers). The internal consistency (alpha) of the 31 items was .88. The total score (number of types of events, all coded as 0 = absent, 1 = present) was used in the analyses. Posttraumatic Growth Inventory (PTGI) This is a widely used questionnaire designed to measure positive change after adverse events (Tedeschi & Calhoun, 1996). The original scale (21 items and a 6-point scale), was translated into and adapted for Turkish. Cronbach alpha of the Turkish version was .91. In the Turkish version, one item (“My priorities about life have changed”) was dropped and a 4-point (instead of a 6-point) scale was adopted for ease of administration. In this study, subjects were instructed to think about the changes they observed because of their war-related experiences after 2003. Total PTGI score was used in the analyses. Cronbach alpha for this study was .92.
METHODS
Traumatic Stress Symptom Checklist (TSSC)
All known Iraqi Turkmen students studying at various universities (N = 254) in Ankara were invited to take part in a survey of mental health in 2010. This was a complete roster of students recruited through the Turkmeneli Association in Ankara.
This is a 17-item, self-rated questionnaire that taps current traumatic stress on a 4-point scale (Ba¸so˘glu et al., 2001, in Turkish). Internal consistency of the scale was .92. When used with a cut-off score, it has been shown to predict validly DSM-IV PTSD in earthquake survivors in Turkey (Ba¸so˘glu et al., 2001). We used the total score of the TSSC as the first outcome variable in our analyses. We also used the cut-off score of 24/25 to report probable PTSD. Cronbach alpha for the current sample was .90.
Participants
Procedure All subjects were notified and invited to come to the Turkmeneli Association to complete study questionnaires. One of the investigators (MK) is an Iraqi Turkmen and had credibility within the Iraqi Turkmen student network. Volunteering students were administered paper and pencil interviews with questions about sociodemographic © 2015 International Union of Psychological Science
Beck Depression Inventory (BDI) This widely used, 21-item, self-report questionnaire measures depressive symptomatology for the last week (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Validity and reliability in Turkish were established by Hisli (1988). BDI score was used as the second outcome variable in analyses. Probable depression was also
404
MAGRUDER ET AL. TABLE 1 Participant characteristics by gender Male (N = 153)Mean (SD)
Female (N = 33)Mean (SD)
Total (N = 186)Mean (SD)
25.3 (3.9) 15.6 (9.2) 11.4 (9.1) 55.0 (11.1) 13.6 (6.2) 3.1 (2.6)
24.4 (3.2) 16.1 (11.2) 10.4 (8.2) 55.0 (12.0) 11.5 (5.5) 3.5 (3.7)
25.2 (3.8) 15.7 (9.6) 11.2 (8.9) 55.0 (11.2) 13.2 (6.1) 3.2 (2.9)
Age (18–36) PTSD score (0–51) Depression score (0–63) PTGI score (20–80) Number of events (0–31) Years since left Iraq (0–19)
Probable PTSD Probable depression Average monthly income < $500 Family member living in Ankara
N (%)
N (%)
N (%)
25 (16.3) 38 (24.8) 64 (41.9) 44 (28.0)
7 (21.2) 5 (15.2) 16 (48.5) 20 (51.3)
32 (17.2) 43 (23.1) 80 (43) 64 (32.7)**
*p < .05. **p < .01.
reported using a cut-off score of 16/17 (moderate to severe depression). Cronbach alpha for the current sample was .88. Statistics We used chi-square tests, t-tests and correlation analyses to examine the relationships among PTG, gender, PTSD, depression and other study variables. To test our hypothesis, we examined factors (gender, age, number of event types and PTGI score) associated with the outcome variables (PTSD and depression) using linear regression. Because of our interest in gender, we also examined a gender by growth interaction for each outcome. RESULTS Of the 254 students invited to participate, 203 (80%) consented and completed the questionnaires. Because 17 subjects did not report any traumatic event that created horror or helplessness, they did not respond to the PTSD assessment. The final sample, therefore, consisted of 186 subjects. Table 1 shows the sociodemographics and outcomes for the total sample and by gender. Average age was 25.2 and average number of event types 13.2. Probable PTSD was reported by 17.2% and probable depression by 23.1%. More young women than men reported living with a family member in Ankara—the only significant gender difference. As expected, number of events was positively correlated with both PTSD and depression scores (Table 2). Also as expected, PTSD and depression were significantly correlated. PTGI was related to PTSD, but not depression. Neither gender nor age was significantly correlated with any of the variables. In our first set of models (Table 3), gender (1 = male, 2 = female), age, number of events, PTGI score, PTSD
score and depression score were regressed on PTSD and depression variables in turn. PTSD was positively related to number of events, PTGI score and depression; depression was negatively related to age and PTGI score, but positively related to PTSD. Model 2 included the PTG by gender interaction term. For PTSD, all prior relationships remained significant, and the interaction term was also significant (β = −.64, p = .04), indicating that PTSD relates positively to growth for males, but not for females. PTG by gender was not significant for the depression model. DISCUSSION We examined the relationship of PTG to self-reported PTSD and depression in a group of young Iraqi Turkmens who experienced the 2003 war as teenagers and were temporarily living in Turkey as university students. We found high levels of exposure to trauma and adversity, and relatively high rates of both probable PTSD (16.3% males, 21.2% females) and depression (24.8% males, 15.2% females) compared with general population studies in the Middle East. For example, PTSD prevalence was reported to be
