Cumulative Trauma Disorder Scale (CTD): Two Studies


Measures that screen for mental health in multiple traumatized populations (e.g., refugees, minorities, mental health patients, prison inmates) lack theoretical clarity that makes it difficult to develop a measure that has robust psychometrics. The paper proposes cumulative trauma disorders (CTD) model and develops a scale that measures the concept and can be used as a general mental health screening tool in such populations. The measure has been tested on two studies: on representative community sample of Iraqi refugees in Michigan and on a clinic sample of refugees. Further, the measure was used on samples of Iraqi refugee and African American adolescents, West Bank and Gaza in Palestinian territories, as well as a mental health screening tool in some centers that screen refugees and torture survivors in US. The measure has been found to have high alpha and test-retest reliability, good construct, concurrent, discriminative and predictive validity in the two main samples and on all the studies and centers that utilized it. The measure can be used as a general mental health screening tool for adult and adolescent in public health settings in different cultures, as well as for refugees, torture survivors, and highly traumatized populations.

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Kira, I. , Templin, T. , Lewandowski, L. , Ashby, J. , Oladele, A. & Odenat, L. (2012). Cumulative Trauma Disorder Scale (CTD): Two Studies. Psychology, 3, 643-656. doi: 10.4236/psych.2012.39099.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Arfken, C. L., Kubiak, S. P., & Farrag, M. (2009). Acculturation and polysubstance abuse in Arab-American treatment clients. Transcultural Psychiatry, 46, 608-622. doi:10.1177/1363461509351364
[2] Betemps, E., Smith, R., Baker, D., & Rounds-Kugler, B. (2003). The measurement precision of the Clinician Administered PTSD sale: A RASCH model analysis. Journal of Applied Measurement, 4, 59-69.
[3] Bowlby, J. (1988). A secure base: Parent child attachment and healthy human development. New York: Basic Books.
[4] Breslau, N., Chilcoat, H., Kessler, R., & Davis, G. (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit area survey of trauma. American Journal of Psy- chiatry, 156, 902-907.
[5] Byrne, B. M., Shavelson, R. J., & Muthén, B. (1989). Testing for the equivalence of factor covariance and mean structures: The issue of partial measurement invariance. Psychological Bulletin, 105, 456- 466. doi:10.1037/0033-2909.105.3.456
[6] Cassidy, J., & Shaver, P. (1999). Handbook of attachment: Theory, research, and clinical applications. New York: Guilford Press.
[7] Cassiman, S. A. (2005). Toward more inclusive poverty knowledge: Traumatological contributions to the poverty discourse. Cutting Edge of Social Policy Research, 4, 93-106.
[8] Cattell, R. B. (1966). The scree test for the number of factors. Multivariate Behavioral Research, 1, 629-637. doi:10.1207/s15327906mbr0102_10
[9] Cheung, G. W., & Rensvold, R. B. (2002). Evaluating goodness-of-fit indexes for testing measurement invariance. Structural Equation Modeling, 9, 233-255. doi:10.1207/S15328007SEM0902_5
[10] Chochinov, H., Wilson, K., Ennus, M., & Lander, S. (1997). “Are you depressed” screening for depression in the terminally ill. American Journal of Psychiatry, 145, 674-676.
[11] Cloitre, M., Stolbach, B., Herman. J., van der Kolk, B., Pynoos, R., Wang, J., & Petkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22, pp. 399-408.
[12] Cook A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2003). Complex trauma in children and adolescents: White paper. Allston, MA: National Child Traumatic Stress Network, Complex Trauma (NCTSN) Task force.
[13] Fao, E. B. (1996). Failure of emotional processing: Post-trauma psychopathology and its treatment. Invited Address Presented in the American Psychological Annual Convention, Toronto.
[14] Ford, J. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of posttraumatic stress disorder or comorbid but distinct syndromes? Journal of Consulting & Clinical Psychology, 67, 3-12. doi:10.1037/0022-006X.67.1.3
[15] Freyd, J. J., DePrince, A. P., & Gleaves, D. (2007). The State of Betrayal trauma theory: Reply to McNally (2007)—Conceptual issues and future directions. Memory, 15, 295-311. doi:10.1080/09658210701256514
[16] Hamby, S., Finkelhor, D., Turner, H., & Ormrod, R. (2010). The overlap of witnessing partner violence and child maltreatment and other victimizations in a nationally representative survey of youth. Child Abuse & Neglect, 34, 734-741. doi:10.1016/j.chiabu.2010.03.001
[17] Herman, J. L. (1992). Trauma and recovery, New York: Basic Books.
[18] Holmes, D. & Tinnin, L. (1995). The problem of auditory hallucinations in combat PTSD. Traumatology: An International Journal, 1, 1-7.
[19] Kaiser, H. F. (1960). The application of electronic computers to factor analysis. Educational and Psychological Measurement, 20, 141-151. doi:10.1177/001316446002000116
[20] Kaysan, D., Rosen, G., Bowman, M., & Resick, P. (2010). Duration of exposure and dose-response model of PTSD. Journal of Interpersonal Violence, 25, 63-74. doi:10.1177/0886260508329131
[21] Kira, I. (1999). Type III trauma and Iraqi refugees’ traumatic experiences. Paper presented in the American Psychological Association Annual Convention, Boston.
[22] Kira, I. (2001). Taxonomy of trauma and trauma assessment. Trau- matology, 2, 1-14.
[23] Kira, I. (2002). Torture assessment and treatment: The wraparound approach. Traumatology: An International Journal, 8, 23-51.
[24] Kira, I. (2004). Secondary trauma in treating refugee survivors of torture, and their families. Torture, 14, 38-44.
[25] Kira, I. (2010). Etiology and treatments of post-cumulative traumatic stress disorders in different cultures. Traumatology: An International Journal, 16, 128-141.
[26] Kira, I., Lewandowsk, L., Templin, T., Ramaswamy, V., Ozkan, B., & Mohanesh, J. (2008). Measuring cumulative trauma dose, types and profiles using a development-based taxonomy of trauma, Trauma- tology, 14, 62-87. doi:10.1177/1534765608319324
[27] Kira, I., Smith, I., Lewandowski, L., &Templin, T. (2010a).The effects of perceived gender discrimination on refugee torture survivors: A cross-cultural traumatology perspective. Journal of the American Psychiatric Nurses Association, 16, 299-306. doi:10.1177/1078390310384401
[28] Kira, I., Lewandowsi, L., Templin, T., Ramaswamy, V., Ozkan, B., & Mohanesh, J. (2010b). The effects of perceived discrimination and backlash on Iraqi refugees’ physical and mental health. Journal of Muslim Mental Health, 5, 59-81. doi:10.1080/15564901003622110
[29] Kira, I., Templin, T., Lewandowski, L., Ramaswamy, V., Bulent, O., Abu-Mediane, S., Mohanesh, J., & Alamia, H. (2011a). Cumulative tertiary appraisal of traumatic events across cultures: Two studies. Journal of Loss and Trauma: International Perspectives on Stress & Coping, 16, 43-66.
[30] Kira, I., Alawneh, A. N., Aboumediane, S., Mohanesh, J., Ozkan, B., & Alamia, H. (2011b). Identity salience and its dynamics in palestinians adolescents. Psychology, 2, 781-791. doi:10.4236/psych.2011.28120
[31] Kira, I., Ashby, J., Lewandowski, L.; Smith, I., & Odenat, L. (2012a). Gender inequality and its effects in females torture survivors. Psychology, 3, 352-363. doi:10.4236/psych.2012.34050
[32] Kira, I., Lewandowski, L., Somers, C., Yoo, J., & Chiodo, L. (2012b). The linear and non-linear associations between multiple types of trauma and IQ discrepancy indexes in African American and Iraqi refugee adolescents. Journal of Child & Adolescent Trauma, 5, 47-62.
[33] Kira, I., Abou-Mediene, S., Ashby, J., Odenat, L., Mohanesh, J., & Alamia, H. (in press). The dynamics of post-traumatic growth across different trauma types in a Palestinian sample. Journal of Loss and Trauma: International Perspectives on Stress & Coping.
[34] Kira, I., Templin, T., Lewandowski, L., Ramaswamy, V., Hammad, A., Mohanesh, J., Abdul-Khalek, H. (2012c). Annihilation Anxiety, Trau- ma Dose and Trauma Negative Appraisal: A New Measure for Annihilation Anxiety. Psychology, 3, 90-99.
[35] Larik, N., Hauf, E., Skeondal, A., & Solberg, O. (1996). Mental disorder among refugees and the impact of persecution and exile: Some findings from an out-patient population. British Journal of Psychiatry, 196, 726-732.
[36] Lifton, B. (1992). The adopted self: Toward theory of cumulative trau- ma. Dissertation Abstracts International, 53, 2548.
[37] Lomranz, J. (1990). Long term adaptation to traumatic stress in light of adult development and aging perspectives. In M. P. Stephens, J. Crowther, S. E. Hobfoll, & D. Tenebaum (Eds.), Stress and coping in later life families (pp. 99-121). New York: Hemisphere.
[38] Laurie, J. (1996). Cumulative trauma: The non-problem problem. Transactional Analysis Journal, 26, 276-283.
[39] Meredith, W. (1993). Measurement invariance, factor analysis and factorial invariance. Psychometrika, 58, 525-543. doi:10.1007/BF02294825
[40] Mollica , R. F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., Lavelle, J. (1992). The harvard trauma questionnaire: Validating a cross- cultural instrument for measuring torture, trauma, and posttraumatic stress disorder. Journal of Nervous and Mental Diseases, 180, 111- 116.
[41] Mollica, R., McInnes, K., Poole, C., & Tor, S. (1998). Dose-effect relationship of trauma to symptoms of depression and PTSD among Cambodian survivors of mass violence. British Journal of Psychiatry, 173, 482-488. doi:10.1192/bjp.173.6.482
[42] Muthén, B. (1989). Multiple group structural modeling with nonnormal continuous variables. British Journal of Mathematical and Statistical Psychology, 42, 55-62.doi:10.1111/j.2044-8317.1989.tb01114.x
[43] Nagy, L. M., Blake, D. D., Dan, E., Riney, S., Mangine, W., Southwick, S. M., Gusman, F. & Charney, D. S. (1991). Clinician Administered PTSD Scale—Weekly Version (CAPS-2) Reliability, validity, and sensitivity to change. In D. D. Blake (Chair), An update on the Clinician Administered PTSD Scales (CAPS-1 and CAPS-2). Symposium paper presented at the 7th annual conference of the International Society for Traumatic Stress Studies, Washington DC.
[44] Nishith, P., Mechanic, M., & Resick. P. (2000). Prior interpersonal trauma: The contribution to current PTSD symptoms in female rape victims. Journal of Abnormal Psychology, 109, 20-25.doi:10.1037/0021-843X.109.1.20
[45] Patrick, M. (1995). The clinical boundaries of post-traumatic stress disorder. Australian and New Zealand Journal of Psychiatry, 29, 385-393. doi:10.3109/00048679509064945
[46] Peretz, T., Baider, L., Ever-Hadani, P., & De-Nour, A. (1994). Psychological distress in Female cancer patients with Holocaust experience. General Hospital Psychiatry, 16, 413-418.doi:10.1016/0163-8343(94)90117-1
[47] Perez, D. J., Fortuna, L., & Alegría, M. (2008). Prevalence and correlates of everyday discrimination among US Latinos. Journal of Community Psychology, 36, 421-433. doi:10.1002/jcop.20221
[48] Pieterse, A., Todd, N., Neville, H., & Carter, R. (2011). Perceived racism and mental health among black American adults a meta-ana- lytic review. Journal of Counseling Psychology, 59, 1-9.
[49] Pinel, E. C. (1999). Stigma consciousness: The psychological legacy of social stereotypes. Journal of Personality and Social Psychology, 76, 114-128. doi:10.1037/0022-3514.76.1.114
[50] Pinto, P. & Gregory, R. (1995). PTSD with psychotic features. American Journal of Psychiatry, 152, 471.
[51] Oser, E. (1999). Urban adolescents’ exposure to violence: The role of cumulative stress, support, and selected moderators in predicting psychological functioning in a school-based sample. Dissertation Abstracts International: Section B: The Sciences & Engineering, 60, 2357.
[52] Rachman, S. (1980). Emotional processing. Behavior Research and Therapy, 18, 51-60. doi:10.1016/0005-7967(80)90069-8
[53] Richmond, J. M., Elliott, A. N., Pierce, T. W., Aspelmeier, J. E., & Alexander, A. A. (2009). Polyvictimization, childhood victimization, and psychological distress in college women. Child Maltreatment, 14, 127-47. doi:10.1177/1077559508326357
[54] Silove, D. (1999). The psychosocial effects of torture, mass human rights violations, and refugee trauma: Toward an integrated conceptual framework. Journal of Nervous & Mental Disease, 187, 200-207. doi:10.1097/00005053-199904000-00002
[55] Silove, D., Sinnerbrink, I., Field, A., Manicavasager, V. et al. (1997). Anxiety, depression and PTSD in asylum-seekers: Associations with pre-migration trauma and post migration stressors. British Journal of Psychiatry, 170, 351-357. doi:10.1192/bjp.170.4.351
[56] Stampfer, H. (1990). “Negative symptoms”: A cumulative trauma stress disorder. Australian & New Zealand Journal of Psychiatry, 24, 516- 528. doi:10.3109/00048679009062908
[57] Steenkamp, J., & Baumgartner, H. (1998). Assessing measurement invariance in cross-national consumer research. Journal of Consumer Research, 25, 78-90. doi:10.1086/209528
[58] Sutker, P., Vasterling, J., Brailey, K., & Allain, A, (1995). Memory, attention, and executive deficits in POW survivors: Contributing biological and psychological factors. Neuropsychology, 9, 118-125.doi:10.1037/0894-4105.9.1.118
[59] Scazufca, M., Menezes, P., Vallada, H., & Araya, R. (2009). Validity of the self reporting questionnaire-20 in epidemiological studies with older adults Results from the Sao Paulo ageing & health study. Social Psychiatry and Psychiatric Epidemiology, 44, 247-254.doi:10.1007/s00127-008-0425-y
[60] Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148, 10-20.
[61] Turner, S., & Gorst-Unworth, C. (1990). Psychological sequelae of torture: A descriptive model. British Journal of Psychiatry, 157, 475- 480. doi:10.1192/bjp.157.4.475
[62] Turner, R., & Lloyd, D. (1995). Life time traumas and mental health: The significance of cumulative adversity. Journal of Health and Social Behavior, 36, 360-376. doi:10.2307/2137325
[63] Van Der Kolk, B., McFarlane, A., & Weisaeth, L. (1996). Traumatic stress. New York: Guilford.
[64] Wanous, J., & Hudy, M. J. (2001). Single-item reliability: A replication and extension. Organizational Research Methods, 4, 361-375.doi:10.1177/109442810144003
[65] Weathers, F., Keane, T., & Davidson, J. (2001). The Clinician-Admin- istered PTSD scale: A review of the first ten years of research. Depression and Anxiety, 13, 132-156. doi:10.1002/da.1029
[66] Weinstien, J., & del Pozo, E. (2001). Estimates of Michigan’s Iraqi refugee population. Unpublished manuscript, Dearborn, MI: Research Design and Consultation.
[67] Wenzel, T., Sibitz, I., Kieffer, W., & Strobl, R. (1999). Capgras syndrome and functional psychosis in two survivors of torture. Psychopathology, 32, 203-306. doi:10.1159/000029091
[68] Werbert, A,. & Lindbom-Jakobson, M. (1993). The “living dead”: Survivors of torture and psychosis. Psychoanalytic Psychotherapy, 7, 163-180. doi:10.1080/02668739300700121
[69] Williams, D., & Mohammed, S. (2009). Discrimination and racial disparities in health: Evidence and needed research. Journal of Behavioral Medicine, 32, 20-47. doi:10.1007/s10865-008-9185-0
[70] Youngmann, R., Zilber, N., Workneh, F., & Giel, R. (2008). Adapting the SRQ for ethiopian populations: A culturally-sensitive psychiatric screening instrument. Trans-cultural Psychiatry, 45, 566-589.doi:10.1177/1363461508100783
[71] Zimmerman, M., Young, D., Chelminski, I., Dalrymple, K., & Galione, J. (2012). Overcoming the problem of diagnostic heterogeneity in applying measurement-based care in clinical practice: the concept of psychiatric vital signs. Comprehensive Psychiatry, 53, 117-124.doi:10.1016/j.comppsych.2011.03.004

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