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European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2026 Apr 8;17(1):2646128. doi: 10.1080/20008066.2026.2646128

ICD-11 PTSD and CPTSD in Serbia: clinical validation of the International Trauma Questionnaire

TEPT y TEPTC según la CIE-11 en Serbia: validación clínica del Cuestionario Internacional de Trauma

Bojana Pejušković a,b, Marija Lero a,CONTACT, Viktor Pavlović a,c, Mila Arsenijević d, Mihailo Ilić a, Danilo Pešić a,b
PMCID: PMC13063324  PMID: 41949027

ABSTRACT

Background: ICD-11 distinguishes post-traumatic stress disorder (PTSD) from complex PTSD (CPTSD) by introducing disturbances in self-organization (DSO) as a defining feature of CPTSD. Accurate identification of these conditions requires instruments aligned with the ICD-11 framework. The International Trauma Questionnaire (ITQ) was specifically developed to assess PTSD and CPTSD from ICD-11, but the Serbian version has not yet been validated in a clinical population.

Objective: This study aimed to evaluate the psychometric properties of the Serbian version of the ITQ in a clinical sample, including its factor structure, reliability, and concurrent and discriminant validity in relation to trauma exposure, childhood adversity, emotional distress, emotional dysregulation, dissociation, suicidality, and quality of life.

Method: A total of 199 adult psychiatric patients at the Institute of Mental Health in Belgrade completed the ITQ, Life Events Checklist (LEC-5), Impact of Event Scale–Revised (IES-R), Adverse Childhood Experiences Questionnaire (ACE-Q), Depression Anxiety Stress Scales (DASS-21), Difficulties in Emotion Regulation Scale (DERS), Brief Dissociative Experiences Scale (DES-B), Suicidal Ideation Attributes Scale (SIDAS), and the Manchester Short Assessment of Quality of Life (MANSA). Confirmatory factor analysis was used to compare competing ICD-11 models of PTSD and CPTSD.

Results: Both the six-factor correlated model and the second-order PTSD-DSO model showed good fit, whereas the single-factor model of CPTSD was not supported. CPTSD was more common than PTSD (25.7% vs. 18.7%) and was associated with higher levels of emotional dysregulation, dissociation, suicidality, and poorer quality of life. PTSD symptoms were more strongly associated with trauma-related distress, while DSO showed stronger associations with depression, anxiety, and negative self-concept.

Conclusions: The Serbian version of the ITQ demonstrates good reliability, validity, and clinical utility for the assessment of PTSD and CPTSD according to ICD-11. Its use may improve diagnostic differentiation and support more targeted trauma-informed treatment in Serbian clinical settings.

KEYWORDS: Post-traumatic stress disorder (PTSD), complex post-traumatic stress disorder (CPTSD), the International Trauma Questionnaire (ITQ), ICD-11

HIGHLIGHTS

  • In this study, the International Trauma Questionnaire (ITQ) was adapted and psychometrically evaluated in a clinical population of trauma-exposed adults in Serbia.

  • As a result of this study, the first reliable and valid instrument for assessing Post-Traumatic Stress Disorder (PTSD) and Complex Post-Traumatic Stress Disorder (CPTSD) according to ICD-11 is now available for use in clinical and research settings in Serbia, allowing for accurate differentiation between PTSD and Disturbances in self-organization (DSO).

  • The results of confirmatory factor analyses indicate that the two-factor model provides the most appropriate representation of trauma-related symptoms in this population, supporting the clinical relevance of differentiating CPTSD from PTSD in mental health services in Serbia.

1. Introduction

The World Health Organization (WHO) released the 11th revision of the International Classification of Diseases (ICD-11) in 2018, guided by the principles that mental disorders should demonstrate clinical utility, focus on a limited set of core symptoms, and be applicable across diverse international settings (WHO, 2018). Within this revision, Post-traumatic stress disorder (PTSD) has undergone major changes, where it is defined as a primarily fear-based disorder and classified in the group of ‘Disorders Specifically Associated with Stress’. Furthermore, in the same group, ICD-11 included a new diagnosis, complex post-traumatic stress disorder (CPTSD) (Pejušković, 2023). CPTSD is more associated with prolonged, repeated, and interpersonal traumatic exposures, particularly those from which escape is difficult or impossible, compared with PTSD (Bisson et al., 2021).

PTSD includes six symptoms organised into three clusters: re-experiencing the trauma in the present, avoidance of trauma-related reminders, and a persistent sense of current threat. A diagnosis requires the presence of at least one symptom from each cluster, lasting for several weeks and significantly impairing daily functioning. CPTSD encompasses all PTSD criteria, along with additional symptoms of disturbances in self-organisation (DSO), which are grouped into three clusters: affective dysregulation, negative self-concept, and interpersonal difficulties. A diagnosis of CPTSD requires symptoms from both PTSD and DSO domains and their significant impact on daily functioning (WHO, 2018).

Although the ICD-11 distinguishes PTSD and CPTSD as two related but separable conditions, some authors argue that the empirical distinction is still debated, especially with regard to the uniqueness of DSO symptoms that some authors observe within the broader distress that can occur within other psychiatric disorders (Møller et al., 2020).

Studies grounded in ICD-11 diagnostic conceptualizations indicate that cumulative trauma exposure and adverse childhood experiences are associated with an increased risk of developing both PTSD and CPTSD, with higher trauma burden predicting greater symptom severity and diagnostic likelihood (Cloitre et al., 2019; Karatzias et al., 2019; Korte et al., 2020). Among the most common comorbid conditions are depression, anxiety, and suicidality, with these problems being more prevalent and severe in individuals diagnosed with CPTSD (Camden et al., 2023; Cloitre et al., 2019). CPTSD has also been associated with increased functional impairment (Brenner et al., 2019), longer duration of treatment (Billings & Nicholls, 2025), and higher health care utilisation (Li et al., 2023) compared to PTSD alone, emphasising the importance of its accurate assessment in clinical populations.

Despite compelling evidence supporting the distinction between PTSD and CPTSD, there was a recognised need for a valid and standardised instrument for diagnosis and research. The International Trauma Questionnaire (ITQ) was developed specifically to assess PTSD and CPTSD symptoms based on ICD-11 criteria and remains the only instrument explicitly designed to measure CPTSD (Cloitre et al., 2018). In contrast to widely used instruments such as the Impact of Event Scale – Revised (IES-R) or PTSD Checklist for DSM-5 (PCL-5), which assess PTSD based on DSM-4 and DSM-5 criteria and do not capture DSO symptoms, the ITQ offers a comprehensive assessment aligned with the ICD-11 conceptualisation of CPTSD.

The ITQ has been translated into 33 languages, including Serbian. The ITQ has shown good psychometric properties in general adult populations (Ben-Ezra et al., 2018; Karatzias et al., 2019), as well as in clinical or highly traumatised adult samples (Hyland, Shevlin, Brewin et al., 2017; Vallières et al., 2018). Validation studies have been conducted across various cultural contexts and population types, generally supporting two structural models: a six-correlated first-order factor model and a two second-order factor model (PTSD and DSO) (Redican et al., 2021). The two-factor higher-order model is most strongly supported in clinical populations (Vallières et al., 2018), whereas the six-factor correlated model shows better fit in community samples (Ben-Ezra et al., 2018).

However, although the ITQ has been translated into Serbian as part of international research collaborations, psychometric validation in a Serbian-speaking clinical population has not yet been conducted. This is particularly relevant in post-conflict regions such as the Western Balkans, where cumulative trauma exposure, adverse childhood experiences, and interpersonal violence may influence trauma symptom expression and diagnostic profiles (Lecic-Tosevski et al., 2013; Priebe et al., 2010a, 2010b).

Considering the clinical importance of distinguishing between PTSD and CPTSD, the potential impact on treatment planning, and the need for culturally adapted diagnostic tools, a psychometric evaluation of the Serbian version of the ITQ is warranted. Establishing its reliability, factor structure, and validity and association with trauma exposure, adverse childhood experience, comorbid symptoms such as depression, anxiety, stress, emotional dysregulation, suicidality, dissociation, and quality of life will provide a valuable instrument for clinical practice and research in Serbia. Accordingly, the present study aimed to validate the Serbian version of the ITQ in a clinical population and to examine its relationships with relevant comorbid symptoms domains.

Grounded in ICD-11 theory and prior empirical work (Ben-Ezra et al., 2018; Cloitre et al., 2018; Hyland, Shevlin, Elklit et al., 2017; Karatzias et al., 2019; World Health Organization, 2018), we formulated the theoretically driven expectations regarding patterns of association. First, we expected that PTSD symptoms would show stronger associations with trauma-related distress, whereas DSO symptoms would be more strongly associated with indicators of emotional dysregulation, broader psychological distress, dissociation, suicidality, and reduced quality of life. Second, we hypothesised that individuals meeting criteria for CPTSD would report greater exposure to cumulative and interpersonal trauma, compared to those with PTSD or no diagnosis.

2. Method

2.1. Participants and procedure

The study was approved by the Ethics Committee of the Institute of Mental Health in Belgrade. Prior to participation, the purpose and procedures of the study were explained in detail, and all participants provided written informed consent. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Participants were informed that they could refuse participation or withdraw consent at any time without negative consequences for their ongoing treatment. No financial or material compensation was offered, and participation was entirely voluntary.

Inclusion criteria were: (a) age 18 years or older, (b) ability to understand the study procedures and provide informed consent, (c) lifetime exposure to at least one traumatic event, and (d) participants receiving mental health treatment at the time of recruitment.

The initial dataset consisted of 211 participants. After excluding two cases with missing data and ten individuals who did not report a potentially traumatic experience, the final sample included 199 participants (M = 41.68, SD = 14.62), of whom 66.3% were female and 33.7% male. Other sociodemographic characteristics are presented in Table 1.

Table 1.

Sociodemographic characteristics (n = 199).

Characteristics n (%)
Education  
 Elementary school (8 years) 9 (4.5)
 High school (4 years) 110 (55.3)
 Undergraduate studies (4–6 years) 80 (40.2)
Employment status  
 Unemployed 81 (40.7)
 Employed 96 (48.2)
 Retired 22 (11.1)
Marital status  
 In a relationship 111 (55.8)
 Married 46 (23.1)
 Divorced 42 (21.1)
Socio-economic status  
 Low income 21 (10.6)
 Middle income 98 (49.2)
 High income 80 (40.2)
Household size  
 Lives alone 52 (26.1)
 Two members 55 (27.6)
 Three members 40 (20.1)
 Four or more members 52 (26.1)
Living with biological parents 84 (42.2)
Living without biological parents 115 (57.8)
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All participants were recruited from the Institute of Mental Health in Belgrade, Serbia. The sample included inpatients from the Clinical Department for Crisis States, Stress, and Affective Disorders (N = 170), as well as partially hospitalised patients from the Adult Day Hospital (N = 29). All participants met identical inclusion criteria and underwent the same assessment procedures. Data collection was conducted between December 2024 and June 2025.

2.2. Measures

2.2.1. The International Trauma Questionnaire (ITQ)

The Serbian version of the ITQ was adapted using a forward–backward (double-blind) translation procedure, in line with international standards for cross-cultural adaptation.

Participants responded to the items in reference to their worst (most distressing) traumatic experience. The ITQ measures PTSD and DSO symptom clusters across six dimensions. An additional six items evaluate functional impairment linked to each symptom cluster (Cloitre et al., 2018).

All items are rated on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely), referring to symptom severity in the past month.

A probable ICD-11 PTSD diagnosis is indicated when at least one symptom from each PTSD cluster and the corresponding functional impairment item are rated ≥ 2 (moderately). A CPTSD diagnosis is assigned when the PTSD diagnostic criteria are met, alongside at least one symptom from each DSO cluster and associated functional impairment rated ≥ 2.

Internal consistency of the ITQ total and subscale scores was evaluated using Cronbach’s alpha, which demonstrated good reliability (α = .85 for the total scale; PTSD subscale α = .84; DSO subscale α = .85). A summary of the measures used and their internal consistency estimates is provided in Supplementary Table 1.

2.2.2. Life events checklist for DSM-5 (LEC-5)

Exposure to potentially traumatic events was assessed using the LEC-5, a self-report instrument that includes 16 categories of traumatic events (Weathers et al., 2013). In accordance with DSM-5 recommendations, items labelled ‘happened to me’ or ‘witnessed’ were coded as traumatic exposure in our sample (Weathers et al., 2013). This measure demonstrates good psychometric properties and has shown consistent associations with PTSD symptoms in previous studies (Stevenson et al., 2023).

2.2.3. The impact of event scale – revised (IES-R)

Concurrent validity was assessed by examining correlations between ITQ scores and IES-R scores. We used the revised version of the IES-R (Weiss & Marmar, 1997), a widely used and psychometrically robust 22-item measure that has demonstrated strong reliability and validity across populations (Krupelnytska et al., 2025). Its three symptom clusters conceptually overlap with the core features of PTSD assessed by the ITQ.

2.2.4. Adverse childhood experiences questionnaire (ACE-Q)

The ACE-Q (Felitti et al., 1998) is a 10-item self-report instrument designed to assess exposure to various forms of childhood adversity. Items are scored dichotomously (yes/no), indicating the presence or absence of each adverse experience. Total scores are calculated by summing the items that are validated, with higher scores reflecting greater cumulative exposure to childhood adversity.

2.2.5. Manchester short assessment of quality of life (MANSA)

For the assessment of quality of life, we used MANSA, a 16-item measure assessing overall life satisfaction and satisfaction across specific life domains (Priebe et al., 1999). MANSA demonstrates solid psychometric properties (Björkman & Svensson, 2005) and is sensitive to change over time (Priebe et al., 2011). Standard scoring procedures are applied by averaging the Likert-type items, with higher scores indicating better quality of life (Priebe et al., 1999).

2.2.6. Comorbidities and related psychological constructs

To assess symptoms of depression, anxiety, and stress, we used the Depression Anxiety Stress Scales (DASS) (Lovibond & Lovibond, 1995), a 21-item self-reported instrument comprising three subscales with seven items each. Participants rated their symptoms over the past week on a 4-point Likert scale. This DASS-21 demonstrated good internal consistency (Moya et al., 2022).

Assessment of depressive symptom severity was conducted using the Montgomery–Åsberg Depression Rating Scale (MADRS) (Montgomery & Åsberg, 1979). It is a clinician-rated instrument consisting of 10 items that evaluate core features of depression. The MADRS is sensitive to changes in symptom severity (Carmody et al., 2006).

Given the need to assess emotion dysregulation, we used the Difficulties in Emotion Regulation Scale (DERS), a 36-item self-report measure that assesses six domains of emotion regulation difficulties (Gratz & Roemer, 2004). Emotion dysregulation is known to be strongly associated with trauma exposure (Conti et al., 2023) and complex post-traumatic presentations (Jannini et al., 2025).

Dissociative experiences were measured using the Brief Dissociative Experiences Scale (DES-B), an 8-item self-report instrument assessing the frequency of symptoms such as depersonalisation, derealization, and memory disturbances (Dalenberg & Carlson, 2010). Dissociation is a clinically relevant feature in individuals with PTSD (Stein et al., 2013) and CPTSD (Fung et al., 2024).

The Suicidal Ideation Attributes Scale (SIDAS) was used to assess the severity of suicidal ideation across several dimensions (Van Spijker et al., 2014). The SIDAS provides a concise yet clinically meaningful assessment of suicide risk (Van Spijker et al., 2014).

2.3. Data analysis

Descriptive statistics were computed for all relevant study variables. Differences between male and female participants were examined using chi-square tests for categorical variables and analysis of variance (ANOVA) for continuous variables with Bonferroni correction for multiple comparisons and effect sizes (Cohen’s d). Sociodemographic information was obtained using a structured, study-specific questionnaire developed for the purposes of this research.

The factorial structure of the ITQ was examined through confirmatory factor analysis (CFA) focusing on items representing PTSD and DSO symptom domains. Three competing models previously reported in the literature were evaluated (Redican et al., 2021): (1) a unidimensional model capturing CPTSD as a single factor, (2) a correlated six-factor model reflecting ICD-11 symptom clusters, (3) a two second-order factor model with PTSD and DSO as separate but correlated higher-order factors. Models were estimated using robust maximum likelihood (MLR) to account for potential non-normality (Maydeu-Olivares, 2017).

Model fit was assessed using multiple indices, including the chi-square statistic (χ²), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Root-Mean-Square Error of Approximation with 90% confidence intervals (RMSEA 90% CI), and Standardized Root Mean Square Residual (SRMR). Conventional thresholds for acceptable fit were applied: CFI and TLI values ≥ .90, and RMSEA and SRMR values ≤ .08 (Hu & Bentler, 1999).

Internal consistency of PTSD and DSO items was estimated using Omega (ω) based on the factor loadings obtained in the CFA (Viladrich et al., 2017). Concurrent and discriminant validity were evaluated by examining correlations between theoretically related constructs (e.g. depression, anxiety, suicidal ideation, emotional dysregulation) to determine whether the measures were appropriately associated with similar constructs and distinct from unrelated variables. Convergent validity was also evaluated via AVE index (Cheung et al., 2024). The analyses were conducted by using SPSS v26 and AMOS.

3. Results

3.1. Trauma exposure and psychometric characteristics of the measures

Based on the recommended diagnostic algorithm for PTSD and CPTSD implemented in the ITQ, 30 participants (18.7%) met criteria for PTSD, 41 participants (25.7%) met criteria for CPTSD, and 128 participants (55.7%) did not meet criteria for either diagnosis. Descriptive statistics for symptom severity are presented in Table 2.

Table 2.

Descriptive symptom severity by diagnostic group.

Symptom domain PTSD/PTSD (n = 30) PTSD/CPTSD (n = 41)
  Mean (SD) Mean (SD)
PTSD domains    
Re-experiencing 6.36 (1.64) 6.20 (1.69)
Avoidance 6.65 (1.38) 6.73 (1.40)
Sense of threat 6.39 (1.49) 6.46 (1.42)
DSO domains    
Affect dysregulation 3.87 (2.39) 6.22 (1.33)
Negative self-concept 3.47 (2.43) 7.07 (1.06)
Disturbed relationships 4.20 (1.90) 6.78 (1.15)
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Note: PTSD = Post-Traumatic Stress Disorder; CPTSD = Complex Post-Traumatic Stress Disorder; DSO = Disturbances in Self-Organization.

According to LEC-5, participants reported an average of 4.7 (SD = 3.32) traumatic events with either direct or indirect exposure. The most reported traumatic events by both genders were physical assault (60.8%), severe human suffering (56.1%). A series of chi-square tests examined gender differences in exposure to various traumatic events. Significant associations were found for exposure to sexual assault (χ²(1) = 11.93, p < .001), combat or exposure to war-zone (χ²(1) = 9.46, p < .05) and severe human suffering (χ²(1) = 4.52, p < .05), with females reporting higher exposure than males across all three categories. For all other LEC-5 items, gender differences were nonsignificant. Trauma exposure by type and gender is presented in Supplementary Table 2. When cumulative trauma exposure was examined, nearly half of the sample (46.2%) reported exposure to five or more different trauma types. Increasing cumulative trauma exposure was associated with higher PTSD and DSO symptom severity, with the highest levels observed among participants reporting five or more trauma types. Cumulative trauma and its relation with PTSD and DSO are reported in Table 3.

Table 3.

Cumulative trauma exposure and symptom severity.

Number of trauma types n (%) PTSD
M (SD)		 DSO
M (SD)
1 41 (20.6%) 10.34 (6.98) 12.25 (6.45)
2 18 (9.0%) 11.61 (6.13) 14.33 (5.55)
3 22 (11.1%) 13.86 (7.06) 15.45 (6.77)
4 26 (13.1%) 9.85 (6.78) 13.54 (6.11)
≥5 92 (46.2%) 14.92 (6.43) 14.32 (6.36)
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Note: PTSD – Post-Traumatic Stress Disorder; DSO – Disturbances in Self-Organization.

Open-ended responses on the ITQ referring to the item ‘Please recall the experience that bothers you the most and answer the following questions with respect to that experience’ were independently coded by a clinical psychologist and a psychiatrist. The qualitative content analysis of these responses resulted in seven thematic categories: Unexpected death (23.1%), Marital and family crises (19.1%), Health-related problems (12.6%), Physical aggression (10.1%), Financial crisis (9.5%), Sexual aggression (7.0%), and Other (18.6%). The ‘Other’ category encompassed responses such as cyberbullying, academic failure, and experiences of stigma associated with psychiatric disorders, which were either insufficiently elaborated or lacked the specificity required to be classified into one of the predefined categories. No significant associations were found between gender and identified categories (χ²(6) = 12.05, p = .061).

3.2. Construct validity and reliability

Fit indices for the three competing CFA models are presented in Table 4. Clear differences emerged in their ability to represent the CPTSD symptom structure. The single-factor CPTSD model demonstrated poor fit across all indices (CFI = .567, TLI = .471, RMSEA = .206), indicating that a unidimensional representation of CPTSD symptoms was not supported. In contrast, both multidimensional models showed good fit to the data. The six correlated first-order factors model demonstrated substantially improved fit (CFI = .964, TLI = .938, RMSEA = .070), suggesting that the six ICD-11 symptom clusters were reliably measured and strongly interrelated. The second-order two-factor PTSD–DSO model achieved comparably strong fit (CFI = .960, TLI = .944, RMSEA = .067), while offering a more parsimonious and theoretically coherent representation of the symptom structure.

Table 4.

Fit indices and model comparison for CFA models of CPTSD.

Model χ² (df) p CFI TLI RMSEA (90% CI) SRMR BIC
Second-order PTSD–DSO 88.80 (47) <.001 .960 .944 .067 [.045, .088] .066 5956.73
Six correlated first-order factors 77.40 (39) <.001 .964 .938 .070 [.047, .093] .053 7780.92
Single-factor CPTSD 511.00 (54) <.001 .567 .471 .206 [.190, .223] .152 8133.59
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Note: CFI – Comparative Fit Index; TLI – Tucker – Lewis Index; RMSEA – Root Mean Square Error of Approximation; SRMR – Standardized Root Mean Square Residual; AIC – Akaike Information Criterion; BIC – Bayesian Information Criterion.

Model comparisons based on the Bayesian Information Criterion (BIC) indicated substantial differences between the three models. Both the six-factor correlated model (BIC = 7780.92) and the second-order PTSD–DSO model (BIC = 5956.73) provided a markedly better fit than the single-factor CPTSD model (BIC = 8133.59). Comparison of the two multidimensional models further favoured the second-order PTSD–DSO model, which showed a substantially lower BIC despite comparable global fit indices, indicating superior parsimony. Taken together, these results indicate that while both multidimensional models outperform the single-factor solution, the hierarchical PTSD–DSO model provides the most parsimonious and theoretically coherent representation of CPTSD symptom structure in this clinical sample.

Standardised factor loadings for the CPTSD model are presented in Supplementary Table 3. The structural equation model demonstrated an overall good fit to the data, with CFI (.960), TLI (.944), and SRMR (.066) all indicating adequate to excellent model performance, and RMSEA (.067, 90% CI [.045, .088]) falling within an acceptable range. The measurement model showed that most latent constructs were robustly defined by their respective indicators, with high standardised loadings and substantial proportions of explained variance, particularly for the higher-order dimensions PTSD and DSO.

Most first-order factors demonstrated acceptable to excellent internal reliability (α = .69–.89; ω₁ = .49–.89), with average variance extracted (AVE) values supporting construct validity across most symptom clusters (AVE = .33–.81). However, the Affective Dysregulation factor represented a clear exception, showing low internal consistency (α = .47) and low convergent validity (AVE = .33). This likely reflects greater heterogeneity among its items compared with other symptom clusters, but does not compromise the validity of the hierarchical model given the robust standardised loadings and strong saturation of the higher-order DSO factor (Cheung et al., 2024). The standardised regression coefficient from PTSD to DSO was moderate and statistically significant (β = .417, p < .001), indicating a meaningful but not redundant association between the two higher-order symptom domains. Collectively, these findings support the adequacy of the proposed model and the distinct yet related nature of the higher-order constructs within this symptom framework.

3.3. Concurent and discriminant validity

In line with our hypotheses, PTSD and DSO showed distinct patterns of association with trauma exposure and criterion variables. PTSD symptom severity was significantly associated with cumulative trauma exposure (r = .310, p < .001), whereas DSO symptoms were not significantly related to the number of traumatic events (r = .047, p = .511). Consistent with ICD-11 conceptualizations of PTSD as a disorder primarily characterised by fear-based responses to traumatic events, subjective trauma-related distress, as measured by the IES-R, showed a moderate association with PTSD symptoms (r = .451, p < .001), but only a small association with DSO symptoms (r = .205, p < .001). At the symptom-cluster level, re-experiencing (r = .362, p < .001) and sense of threat (r = .298, p < .001) were significantly associated with trauma exposure, whereas avoidance, affective dysregulation, negative self-concept, and disturbances in relationships were not, further supporting the specificity of trauma exposure effects for core PTSD symptoms.

In contrast, DSO symptoms demonstrated stronger associations with indicators of emotional and psychological dysfunction. Childhood adversity was positively associated with both PTSD (r = .297, p < .001) and DSO (r = .232, p < .001), suggesting that early adverse experiences represent a general vulnerability factor rather than a disorder-specific predictor. However, emotional dysregulation showed its strongest association with DSO symptoms (r = .599, p < .001), compared to a more moderate association with PTSD symptoms (r = .395, p < .001), consistent with the central role of affective dysregulation within the DSO domain. Both PTSD and DSO symptoms were positively associated with depression, anxiety, stress, and suicidal ideation (r = .279–.631, p < .05), although these associations were generally stronger for DSO-related symptom clusters. Notably, negative self-concept showed particularly strong associations with depression (r = .464, p < .001), anxiety (r = .543, p < .001), and emotional dysregulation (r = .527, p < .001), underscoring its relevance for broader emotional distress. Quality of life was negatively associated with both PTSD and DSO symptom severity, indicating that higher symptom burden was linked to poorer perceived quality of life. The full correlation matrix is presented in Supplementary Table 4.

A series of one-way ANOVA with Bonferroni-corrected post hoc tests examined differences among No Diagnosis, PTSD, and CPTSD groups across trauma exposure, symptom severity, and psychosocial outcomes (Supplementary Table 5). As hypothesised, Significant omnibus group effects were observed for all outcomes: traumatic life events (F(2, 197) = 6.68, p < .05, ηp² = .08), impact of life events (F(2, 197) = 14.99, p < .001, ηp² = .16), adverse childhood experiences (F(2, 197) = 10.55, p < .001, ηp² = .12), PTSD symptoms (F(2, 197) = 99.35, p < .001, ηp² = .56), DSO symptoms (F(2, 197) = 85.32, p < .001, ηp² = .52), suicidal ideation (F(2, 197) = 23.85, p < .001, ηp² = .23), emotional dysregulation (F(2, 197) = 21.79, p < .001, ηp² = .22), dissociation (F(2, 197) = 15.34, p < .001, ηp² = .16), quality of life (F(2, 197) = 16.54, p < .001, ηp² = .21), anxiety (F(2, 197) = 19.99, p < .001, ηp² = .20), depression (F(2, 197) = 25.31, p < .001, ηp² = .24), stress (F(2, 197) = 23.21, p < .001, ηp² = .23), clinican rated depression scale (F(2, 197) = 13.84, p < .001, ηp² = .15).

Bonferroni-corrected post hoc comparisons showed that the no-diagnosis group reported the lowest trauma-related burden, whereas both PTSD and CPTSD groups exhibited higher trauma-related distress, posttraumatic stress severity, adverse childhood experiences, and perceived impact of traumatic events, with no differences between PTSD and CPTSD in trauma exposure measures. Clinician-rated depressive severity was higher in CPTSD than in the no-diagnosis group, while PTSD did not differ from either group. As hypothesised, CPTSD was characterised by greater impairment than PTSD in domains central to complex trauma, including suicidal ideation, emotion dysregulation, dissociative symptoms, and disturbances in self-organisation, with PTSD generally showing intermediate levels. Affective symptoms further differentiated the groups, with CPTSD associated with higher anxiety, depressive symptoms, and stress compared with PTSD; depressive symptoms also distinguished PTSD from the no-diagnosis group. Quality of life was substantially lower in CPTSD than in both PTSD and no-diagnosis groups, whereas the latter two did not differ.

4. Discussion

This study represents the first psychometric evaluation of the Serbian version of the ITQ in a clinical population. The findings support the construct validity and reliability, as well as concurrent and discriminant validity of the ITQ in identifying PTSD and CPTSD in treatment-seeking adults. The results demonstrate a clear differentiation between PTSD and CPTSD symptom profiles, along with significant associations with trauma exposure, adverse childhood experiences, relevant comorbidities and psychological constructs, as well as quality of life outcomes.

Confirmatory factor analyses indicated that two of the three tested models demonstrated good fit, namely the six correlated first-order factor model and the second-order two-factor model, with the latter showing the best fit to the data. The alternative model of the single-factor CPTSD model showed poor fit and was not supported empirically. This pattern is consistent with previous studies, in which the two-factor second-order model has demonstrated superior fit in clinical samples and among highly traumatised individuals, both in research using the ITQ (Cloitre et al., 2018; Kazlauskas et al., 2018; Redican et al., 2021; Vallières et al., 2018) and in studies employing other instruments to assess PTSD and DSO symptoms (Hyland, Shevlin, Elklit et al., 2017). These findings reinforce the conceptualisation of PTSD and DSO as distinguishable domains within a treatment-seeking Serbian clinical population.

Although most ITQ subscales demonstrated adequate reliability, the affective dysregulation domain showed lower internal consistency. This finding is consistent with previous studies indicating that the AD scale may exhibit substantial heterogeneity (Draczyńska et al., 2025), suggesting that hypoactivation and hyperactivation might need to be considered as separate first-order factors rather than combined under a single second-order factor (Redican et al., 2021).

In our sample, the prevalence of CPTSD was higher than the prevalence of PTSD (25.7% vs. 18.7%), which is consistent with findings reported by Rácz and colleagues in a Hungarian clinical sample (Rácz et al., 2023), as well as with other studies conducted among a help-seeking clinical population (Cloitre et al., 2018; Møller et al., 2020). This finding suggests that CPTSD may constitute a substantial proportion of trauma-related presentations encountered in routine clinical practice, underscoring the importance of assessing disturbances in self-organisation alongside core PTSD symptoms (Cloitre et al., 2018; Karatzias et al., 2019).

The domains of re-experiencing and sense of threat were associated with trauma exposure, which may be explained by their role as proximal responses to traumatic events (Cloitre et al., 2018), whereas DSO symptoms are typically understood as being shaped by developmental context and prolonged or interpersonal trauma (Cloitre et al., 2018). However, in our study, adverse childhood experiences were associated with both PTSD and CPTSD, with no significant differences between the two, suggesting that early adversity functioned as a general rather than disorder-specific risk factor in our sample. From a measurement perspective, it is noteworthy that a proportion of participants identified index experiences such as marital and family crises or financial hardship as the most distressing events when completing the ITQ, despite these experiences not aligning directly with the traumatic event categories assessed by the LEC-5. This observation does not challenge the ICD-11 definition of trauma exposure, but rather highlights an important aspect of ITQ administration in clinical settings. Specifically, the open-ended index event prompt appears to capture subjectively salient experiences that organise current symptom reporting, even when these experiences differ from checklist-based trauma classifications. This finding underscores the complementary roles of structured trauma exposure measures and symptom-focused instruments such as the ITQ, and supports the clinical utility of the ITQ in assessing PTSD and CPTSD symptoms as they are experienced and contextualised by patients.

As expected, both PTSD and DSO scores were associated with higher levels of depression, anxiety, emotional dysregulation, dissociation, and suicidality. PTSD scores showed a stronger association with the IES-R, which is not surprising given that both instruments assess core symptoms of posttraumatic stress (Weiss & Marmar, 1997). In contrast, DSO scores showed a stronger association with depression, anxiety and suicidal ideation, with negative self-concept emerging as a key explanatory factor, as self-identity disturbances and pervasive feelings of worthlessness are central features of the DSO profile (Melia et al., 2025). Suicidality was almost twice as common among individuals with DSO symptoms, highlighting the intensity of self-directed suffering in this group, as well as the role of hopelessness as a direct contributing factor (Jannini et al., 2023). Previous research showed that comorbid PTSD and depression are prevalent and are characterised by more psychological distress, with high level of suicidality and poorer quality of life (Pejušković et al., 2020). In the light of the new diagnosis, it can be considered that it may have been unrecognised CPTSD.

Moreover, CPTSD showed stronger associations with emotional dysregulation, dissociation, and poorer quality of life, confirming its broader impact on functional impairment (Brenner et al., 2019). Dissociation was also evident among individuals with CPTSD in our sample, consistent with meta-analytic findings indicating that dissociative symptoms are common in CPTSD (Fung et al., 2022) and are associated with higher levels of impairment (Hyland et al., 2023). Taken together, these results may further suggest increased suicidality within this group (Jannini et al., 2023).

This study has several limitations. First, most of the measures were based on self-report, and the absence of clinician-administered diagnostic interviews may have limited the depth of assessment, particularly with regard to developmental history and clinical symptoms. Second, the sample was drawn from a single clinical setting, which limits the generalizability of findings beyond this specific setting. Also, in our study participants were recruited from both in-patient and partial hospitalisation settings; however, the small number of partially hospitalised participants precluded formal subgroup comparisons, and subtle effects related to recruitment setting cannot be entirely excluded. A larger and more diverse sample would have allowed for more stable estimates and more detailed analyses. Finally, the cross-sectional design precludes conclusions about causality or temporal relationships between trauma exposure, symptom profiles, and comorbidities.

5. Conclusion

The present study provides support for the reliability, validity, and clinical utility of the Serbian version of the ITQ. The clear distinction between PTSD and DSO in this clinical sample suggests that incorporating the ITQ into routine assessment may significantly improve the detection of DSO-related difficulties that are not captured by instruments that measure PTSD alone. Integrating the ITQ into standard clinical procedures may therefore support more accurate diagnostic differentiation and, in turn, inform more targeted treatment planning and intervention selection. Future research should build on these findings by further refining the assessment of PTSD and CPTSD in Serbia, particularly through the development and validation of clinician-administered diagnostic interviews, such as the International Trauma Interview (ITI), to complement self-report measures and strengthen diagnostic accuracy in clinical practice.

Supplementary Material

SUPPLEMENTARY MATERIAL.docx
ZEPT_A_2646128_SM4011.docx (34.2KB, docx)

Acknowledgements

We would like to express our sincere gratitude to Milica Lazić, MD, for her assistance with data collection at the Clinical Department for Crisis States, Stress, and Affective Disorders. We also thank Jelena Buzejić, MD, Teodora Ljubičić, MD, Emilija Jankov, MD, Stefan Perović, MD, and Assistant Professor Milutin Kostić, MD, for their valuable support in data collection within the Adult Day Hospital.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets generated and/or analysed during the current study are not publicly available due to the sensitive nature of the data but are available from the corresponding author on reasonable request.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2026.2646128.

References

  1. Ben-Ezra, M., Karatzias, T., Hyland, P., Brewin, C. R., Cloitre, M., Bisson, J. I., Roberts, N. P., Lueger-Schuster, B., & Shevlin, M. (2018). Posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as per ICD-11 proposals: A population study in Israel. Depression and Anxiety, 35(3), 264–274. 10.1002/da.22723 [DOI] [PubMed] [Google Scholar]
  2. Billings, J., & Nicholls, H. (2025). PTSD and complex PTSD, current treatments and debates: A review of reviews. British Medical Bulletin, 156(1), ldaf015. 10.1093/bmb/ldaf015 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Bisson, J. I., Wright, L. A., Jones, K. A., Lewis, C., Phelps, A. J., Sijbrandij, M., Varker, T., & Roberts, N. P. (2021). Preventing the onset of post-traumatic stress disorder. Clinical Psychology Review, 86, 102004. 10.1016/j.cpr.2021.102004 [DOI] [PubMed] [Google Scholar]
  4. Björkman, T., & Svensson, B. (2005). Quality of life in people with severe mental illness: Reliability and validity of the Manchester Short Assessment of Quality of Life (MANSA). Nordic Journal of Psychiatry, 59(4), 302–306. 10.1080/08039480500213733 [DOI] [PubMed] [Google Scholar]
  5. Brenner, L., Köllner, V., & Bachem, R. (2019). Symptom burden and work-related impairment among patients with PTSD and complex PTSD. European Journal of Psychotraumatology, 10(1), 1694766. 10.1080/20008198.2019.1694766 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Camden, A. A., Petri, J. M., Jackson, B. N., Jeffirs, S. M., & Weathers, F. W. (2023). A psychometric evaluation of the International Trauma Questionnaire (ITQ) in a trauma-exposed college sample. European Journal of Trauma & Dissociation, 7(1), 100305. 10.1016/j.ejtd.2022.100305 [DOI] [Google Scholar]
  7. Carmody, T. J., Rush, A. J., Bernstein, I., Warden, D., Brannan, S., Burnham, D., Woo, A., & Trivedi, M. H. (2006). The Montgomery–Åsberg and the Hamilton ratings of depression: A comparison of measures. European Neuropsychopharmacology, 16(8), 601–611. 10.1016/j.euroneuro.2006.04.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cheung, G. W., Cooper-Thomas, H. D., Lau, R. S., & Wang, L. C. (2024). Correction to: Reporting reliability, convergent and discriminant validity with structural equation modeling: A review and best-practice recommendations. Asia Pacific Journal of Management, 41(2), 785–787. 10.1007/s10490-023-09880-x [DOI] [Google Scholar]
  9. Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M. (2019). ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population-based study. Journal of Traumatic Stress, 32(6), 833–842. 10.1002/jts.22454 [DOI] [PubMed] [Google Scholar]
  10. Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536–546. 10.1111/acps.12956 [DOI] [PubMed] [Google Scholar]
  11. Conti, L., Fantasia, S., Violi, M., Dell’Oste, V., Pedrinelli, V., & Carmassi, C. (2023). Emotional dysregulation and post-traumatic stress symptoms: Which interaction in adolescents and young adults? A systematic review. Brain Sciences, 13(12), 1730. 10.3390/brainsci13121730 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Dalenberg, C., & Carlson, E. (2010). DES-B. Modified for DSM-5 by C. Dalenberg and E. Carlson. DSM-5. 10.1176/appi.books.9780890425596 [DOI]
  13. Draczyńska, D., Mokros, Ł, Nowakowska, A., & Anczewska, M. (2025). Polish adaptation and validation of the International Trauma Questionnaire (ITQ) for PTSD and cPTSD according to ICD-11 in non-clinical and clinical samples. European Journal of Psychotraumatology, 16(1), 2468116. 10.1080/20008066.2025.2468116 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. 10.1016/S0749-3797(98)00017-8 [DOI] [PubMed] [Google Scholar]
  15. Fung, H. W., Chien, W. T., Lam, S. K. K., & Ross, C. A. (2022). The relationship between dissociation and complex post-traumatic stress disorder: A scoping review. Trauma, Violence, & Abuse. 10.1177/15248380221125434 [DOI] [PubMed] [Google Scholar]
  16. Fung, H. W., Yuan, G. F., Liu, C., Lin, E. S. S., Lam, S. K. K., & Wong, J. Y.-H. (2024). Prevalence and clinical correlates of dissociative symptoms in people with complex PTSD: Is complex PTSD a dissociative disorder? Psychiatry Research, 339, 116076. 10.1016/j.psychres.2024.116076 [DOI] [PubMed] [Google Scholar]
  17. Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. 10.1023/B:JOBA.0000007455.08539.94 [DOI] [Google Scholar]
  18. Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. 10.1080/10705519909540118 [DOI] [Google Scholar]
  19. Hyland, P., Hamer, R., Fox, R., Vallières, F., Karatzias, T., Shevlin, M., & Cloitre, M. (2023). Is dissociation a fundamental component of ICD-11 complex posttraumatic stress disorder? Journal of Trauma & Dissociation, 25, 1–17. 10.1080/15299732.2023.2231928 [DOI] [PubMed] [Google Scholar]
  20. Hyland, P., Shevlin, M., Brewin, C. R., Cloitre, M., Downes, A. J., Jumbe, S., Karatzias, T., Bisson, J. I., & Roberts, N. P. (2017a). Validation of post-traumatic stress disorder (PTSD) and complex PTSD using the International Trauma Questionnaire. Acta Psychiatrica Scandinavica, 136(3), 313–322. 10.1111/acps.12771 [DOI] [PubMed] [Google Scholar]
  21. Hyland, P., Shevlin, M., Elklit, A., Murphy, J., Vallières, F., Garvert, D. W., & Cloitre, M. (2017). An assessment of the construct validity of the ICD-11 proposal for complex post-traumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 9(1), 1–9. 10.1037/tra0000114 [DOI] [PubMed] [Google Scholar]
  22. Jannini, T. B., Daniele, G., Rossi, R., Niolu, C., & Di Lorenzo, G. (2025). Emotional dysregulation in complex post-traumatic stress disorder: A narrative review. Journal of Psychopathology, 31(1). 10.36148/2284-0249-N810 [DOI] [Google Scholar]
  23. Jannini, T. B., Longo, L., Rossi, R., Niolu, C., Siracusano, A., & Di Lorenzo, G. (2023). Complex post-traumatic stress disorder and suicide risk: A multigroup mediation analysis exploring the role of post-traumatic symptomatology on hopelessness. Journal of Psychiatric Research, 165, 165–169. 10.1016/j.jpsychires.2023.07.032 [DOI] [PubMed] [Google Scholar]
  24. Karatzias, T., Hyland, P., Bradley, A., Cloitre, M., Roberts, N. P., Bisson, J. I., & Shevlin, M. (2019). Risk factors and comorbidity of ICD-11 PTSD and complex PTSD: Findings from a trauma-exposed population-based sample of adults in the United Kingdom. Depression and Anxiety, 36(9), 887–894. 10.1002/da.22934 [DOI] [PubMed] [Google Scholar]
  25. Kazlauskas, E., Gegieckaite, G., Hyland, P., Zelviene, P., & Cloitre, M. (2018). The structure of ICD-11 PTSD and complex PTSD in Lithuanian mental health services. European Journal of Psychotraumatology, 9(1), 1414559. 10.1080/20008198.2017.1414559 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Korte, K. J., Jiang, T., Koenen, K. C., & Gradus, J. (2020). Trauma and PTSD: Epidemiology, comorbidity, and clinical presentation in adults. In Forbes J., Bisson J. I., Monson C. M., & Berliner L. (Eds.), Trauma and PTSD: Epidemiology, comorbidity, and clinical presentation in adults (3rd ed., pp. 13–29). The Guilford Press. [Google Scholar]
  27. Krupelnytska, L., Yatsenko, N., Keller, V., & Morozova-Larina, O. (2025). The Impact of Events Scale–Revised (IES-R): Validation of the Ukrainian version. Comprehensive Psychiatry, 139, 152593. 10.1016/j.comppsych.2025.152593 [DOI] [PubMed] [Google Scholar]
  28. Lecic-Tosevski, D., Pejuskovic, B., Miladinovic, T., Toskovic, O., & Priebe, S. (2013). Posttraumatic stress disorder in a Serbian community: Seven years after trauma exposure. Journal of Nervous and Mental Disease, 201(12), 1040–1044. 10.1097/NMD.0000000000000051 [DOI] [PubMed] [Google Scholar]
  29. Li, D., Luo, J., Yan, X., & Liang, Y. (2023). Complex posttraumatic stress disorder (CPTSD) as an independent diagnosis: Differences in hedonic and eudaimonic well-being between CPTSD and PTSD. Healthcare, 11(8), 1188. 10.3390/healthcare11081188 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the depression anxiety & stress scales (2nd ed.). Psychology Foundation. [Google Scholar]
  31. Maydeu-Olivares, A. (2017). Maximum likelihood estimation of structural equation models for continuous data: Standard errors and goodness of fit. Structural Equation Modeling: A Multidisciplinary Journal, 24(3), 383–394. 10.1080/10705511.2016.1269606 [DOI] [Google Scholar]
  32. Melia, A., Morant, N., Afrah, H., Menon, S., & Katona, C. (2025). How do clinicians conceptualise negative self-concept in complex post-traumatic stress disorder (CPTSD)? medRxiv. [Google Scholar]
  33. Montgomery, S. A., & Åsberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134(4), 382–389. 10.1192/bjp.134.4.382 [DOI] [PubMed] [Google Scholar]
  34. Møller, L., Augsburger, M., Elklit, A., Søgaard, U., & Simonsen, E. (2020). Traumatic experiences, ICD-11 PTSD, ICD-11 complex PTSD, and the overlap with ICD-10 diagnoses. Acta Psychiatrica Scandinavica, 141(5), 421–431. 10.1111/acps.13161 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Moya, E., Larson, L. M., Stewart, R. C., Fisher, J., Mwangi, M. N., & Phiri, K. S. (2022). Reliability and validity of Depression Anxiety Stress Scale (DASS)-21 in screening for common mental disorders among postpartum women in Malawi. BMC Psychiatry, 22(1), 352. 10.1186/s12888-022-03994-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Pejušković, B. (2023). Posttraumatic stress disorder: An overview in new diagnosis and treatment approaches. Medicinska Istraživanja, 57(1), 75–81. 10.5937/medi57-44935 [DOI] [Google Scholar]
  37. Pejušković, B., Lečić Toševski, D., & Toskovic, O. (2020). Longitudinal study of PTSD and depression in a war-exposed sample: Comorbidity increases distress and suicide risk. Global Psychiatry, 3(1), 64–71. 10.52095/gpa.2020.1317 [DOI] [Google Scholar]
  38. Priebe, S., Barnicot, K., McCabe, R., Kiejna, A., Nawka, P., Raboch, J., Schützwohl, M., & Kallert, T. (2011). Patients’ subjective initial response and the outcome of inpatient and day hospital treatment. European Psychiatry, 26(7), 408–413. 10.1016/j.eurpsy.2010.03.009 [DOI] [PubMed] [Google Scholar]
  39. Priebe, S., Bogic, M., Ajdukovic, D., Frančišković, T., Galeazzi, G. M., Kucukalic, A., Lecic-Tosevski, D., Morina, N., Popovski, M., Wang, D., & Schützwohl, M. (2010a). Mental disorders following war in the Balkans: A study in five countries. Archives of General Psychiatry, 67(5), 518–528. 10.1001/archgenpsychiatry.2010.37 [DOI] [PubMed] [Google Scholar]
  40. Priebe, S., Bogic, M., Ashcroft, R., Franciskovic, T., Galeazzi, G. M., Kucukalic, A., Lecic-Tosevski, D., Morina, N., Popovski, M., Roughton, M., Schützwohl, M., & Ajdukovic, D. (2010b). Experience of human rights violations and subsequent mental disorders: A study following the war in the Balkans. Social Science & Medicine, 71(12), 2170–2177. 10.1016/j.socscimed.2010.09.029 [DOI] [PubMed] [Google Scholar]
  41. Priebe, S., Huxley, P., Knight, S., & Evans, S. (1999). Application and results of the Manchester short assessment of quality of life (MANSA). International Journal of Social Psychiatry, 45(1), 7–12. 10.1177/002076409904500102 [DOI] [PubMed] [Google Scholar]
  42. Rácz, A., Horváth, Z., Vizin, G., Berán, E., & Unoka, Z. S. (2023). Measuring post-traumatic stress disorder and complex post-traumatic stress disorder using the International Trauma Questionnaire: Results from a Hungarian clinical and non-clinical sample. European Journal of Psychotraumatology, 14(1), 2152929. 10.1080/20008066.2022.2152929 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Redican, E., Nolan, E., Hyland, P., Cloitre, M., McBride, O., Karatzias, T., Murphy, J., & Shevlin, M. (2021). A systematic literature review of factor analytic and mixture models of ICD-11 PTSD and CPTSD using the International Trauma Questionnaire. Journal of Anxiety Disorders, 79, 102381. 10.1016/j.janxdis.2021.102381 [DOI] [PubMed] [Google Scholar]
  44. Stein, D. J., Koenen, K. C., Friedman, M. J., Hill, E., McLaughlin, K. A., Petukhova, M., Ruscio, A. M., Shahly, V., Spiegel, D., Borges, G., Bunting, B., Caldas-de-Almeida, J. M., de Girolamo, G., Demyttenaere, K., Florescu, S., Haro, J. M., Karam, E. G., Kovess-Masfety, V., Lee, S., … Kessler, R. C. (2013). Dissociation in posttraumatic stress disorder: Evidence from the world mental health surveys. Biological Psychiatry, 73(4), 302–312. 10.1016/j.biopsych.2012.08.022 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Stevenson, A., Beltran, M., Misra, S., Ametaj, A. A., Bronkhorst, A., Gelaye, B., Koenen, K. C., Pretorius, A., Stein, D. J., & Zingela, Z. (2023). Trauma exposure and psychometric properties of the life events checklist among adults in South Africa. European Journal of Psychotraumatology, 14(1), 2172257. 10.1080/20008066.2023.2172257 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., Byrne, S., Shevlin, M., Murphy, J., & Hyland, P. (2018). ICD-11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: The factor structure and the clinical utility of the International Trauma Questionnaire. Acta Psychiatrica Scandinavica, 138(6), 547–557. 10.1111/acps.12973 [DOI] [PubMed] [Google Scholar]
  47. Van Spijker, B. A. J., Batterham, P. J., Calear, A. L., Farrer, L., Christensen, H., Reynolds, J., & Kerkhof, A. J. F. M. (2014). The Suicidal Ideation Attributes Scale (SIDAS): Community-based validation study of a new scale for the measurement of suicidal ideation. Suicide and Life-Threatening Behavior, 44(4), 408–419. 10.1111/sltb.12084 [DOI] [PubMed] [Google Scholar]
  48. Viladrich, C., Angulo-Brunet, A., & Doval, E. (2017). A journey around alpha and omega to estimate internal consistency reliability. Anales de Psicología, 33(3), 755–782. 10.6018/analesps.33.3.268401 [DOI] [Google Scholar]
  49. Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013). The life events checklist for DSM-5 (LEC-5). National Center for PTSD. https://www.ptsd.va.gov [Google Scholar]
  50. Weiss, D. S., & Marmar, C. R. (1997). The impact of event scale–revised. In Wilson J. P. & Keane T. M. (Eds.), Assessing psychological trauma and PTSD: A practitioner’s handbook (pp. 399–411). Guilford Press. [Google Scholar]
  51. World Health Organization . (2018). International classification of diseases for mortality and morbidity statistics (11th Revision). https://icd.who.int/

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

SUPPLEMENTARY MATERIAL.docx
ZEPT_A_2646128_SM4011.docx (34.2KB, docx)

Data Availability Statement

The datasets generated and/or analysed during the current study are not publicly available due to the sensitive nature of the data but are available from the corresponding author on reasonable request.

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