Journal of Traumatic Stress, Vol. 10, No.

1, 1997

Brief RepoH

The Validity of Posttraumatic Stress Disorder

Among Vietnamese Refugees
Mary Catherine Smith Fawzi,lP2 Thang Pham,' Lien Lin,' Tho Viet
Nguyen,' Dung Ngo,' Elizabeth Murphy,' and Richard E Mollica'

The aim of this study was to examine the validity of posttraumatic stress
disorder (PTSD) among Vietnamese refugees. The study population included
74 Vietnamese refugees who had resettled in the metropolitan Boston area.
The previously validated Harvard Trauma Questionnaire was used to assess
traumatic events and trauma-related symptoms. The number of traumatic
events experienced was positively correlated with the severity of PTSD-related
symptoms in this population. Internal consistency estimates and principal
components analysis provided results that generally supported DSM-IV
symptom dimensions of arousa 1, avoidance, and reecperiencing. Howevel; the
emergence of two separate dimensions of avoidance reflected the important
contribution of depression to the traumatic response.
KEY WORDS: validiv, PTSD; refugees; immigrants.

There has been very little systematic investigation of the appropriate

use of the posttraumatic stress disorder (PTSD) diagnosis in different cul-
tural settings (Mollica & Caspi-Yavin, 1991) despite the fact that PTSD has
been frequently reported among refugees and torture survivors in non-west-
ern populations (Basoglu, Paker, Omen, Tasdemir, & Sahin, 1994; Kinzie
et a!., 1990). The prevalence of PTSD from community-based studies con-
ducted among refugee populations varies widely, from 7% among Vietnam-
ese refugees (Hinton, Chen, Du, Pan, Miranda, & Bust, 1993) to 86%
among Cambodian refugees (Carlson & Rosser-Hogan, 1991). This observed
'Harvard Program in Refugee Trauma, Department of Health Policy and Management,
Harvard School of Public Health, Boston, Massachusetts.
'To whom correspondence should be addressed at the Harvard School of Public Health,
Epidemiology Dept. 9th floor, 677 Huntington Ave., Boston, Massachusetts 02115.

lo!
0894-9867/97/0100~10lf12.5W10 1997 Inlernalional Society for Ttaurnalic Stress Studies
102 Fawzi et aL

variation in prevalence may possibly reflect difficulties in assessing this di-

agnosis or inherent problems with the construct validity of F'TSD among
refugee populations. Ethnographic data presented by Eisenbruch (1991) sug-
gest that the use of the PTSD diagnosis among Cambodian refugees would
result in the inappropriate imposition of diagnostic criteria largely developed
from clinical experience with American Vietnam veterans.
The purpose of this report is to contribute to the current knowledge
of the validity of PTSD by examining the traumatic experiences and post-
trauma symptoms among a community sample of Vietnamese refugees. Em-
pirical information on the symptom dimensions of PTSD is needed from
different cultural settings in order to provide evidence for the universal
applicability, and hence validity, of the diagnosis. The validity of PTSD in
this population will be assessed by (1) investigating the relationship between
traumatic events and symptoms of PTSD in this population, and (2) exam-
ining the empirical clustering of PTSD-related symptoms in comparison
with the PTSD symptom categories as defined by the DSM-IV (MA, 1994).

Method

Participants

The sample consisted of 74 Vietnamese refugees who had resettled in

the metropolitan Boston area. Among this group, 51 former political de-
tainees (POWs) who had migrated to the Boston metropolitan area be-
tween January 1990 and July 1992 under the auspices of the Special
Released Reeducation Center Detainees Resettlement Program partici-
pated in the study. This special program resettles Vietnamese former po-
litical detainees who were imprisoned in reeducation camps in Vietnam for
an average of 7-8 years. All of the POWs in this study experienced torture
in the reeducation camps. This group was recruited from those who were
accessing services at the Vietnamese-American Civic Association (VACA),
a mutual assistance association in Boston, MA. The age range of this group
was between 38 and 66 years. Among POWs who accessed services at
VACA and arrived in Boston between January 1990 and July 1992, 82%
of those who were invited agreed to participate in the study.
Twenty-three Vietnamese refugee men between the ages of 40 and 65
who did not come to the United States through the Special Released
Reeducation Center Detainees Resettlement Program also participated in
the study. This group entered the United States as political refugees, either
fleeing Vietnam by boat or coming through the Orderly Departure Pro-
gram. Prospective participants from this general refugee group were also
Validity of E’TSD among Vietnamese Refugees 103

recruited from clientele at the VACA, and from the respective neighbor-
hood@) of individuals in the POW group. Flfty two percent of individuals
selected for this group participated in the study. AU study participants were
interviewed by a social worker fluent in Vietnamese in a structured inter-
view format.

Measures

The traumatic events and trauma-related symptoms were derived from

the Harvard Trauma Questionnaire (HTQ) developed by Mollica, Caspi-
Yavin, Bollini, Thong, Tor, and Lavelle, (1992) at the Indochinese Psychia-
try Clinic (IPC) in Boston. The HTQ includes 17 traumatic events reflective
of the refugee experience, ranging from lack of food or water to torture.
The trauma symptoms section of the HTQ is a structured interview in which
the respondent is read a list of symptoms and is asked to report the extent
that each symptom bothered him/her within the past week based on a 4-
point scale (1-4), ranging from “not at all” to “extremely.”
The development of the HTQ scale was based upon the response for-
mat used in the Hopkins Symptom Checklist-25 (HSCL-25; Derogatis, Lip-
man, Rickels, Uhlenhuth, & Covi, 1974), which was previously translated
by Mollica and colleagues at IPC for use with Southeast Asian refugees
and demonstrated validity in a clinic-based population (Mollica et al.,
1986). For the HTQ, a validation study conducted among 91 Southeast
Asian refugee outpatients at IPC reported a sensitivity of 78% and a speci-
ficity of 65% (cut-off score = 2.5); in terms of reliability, one-week test-
retest reliability was reported as .92 and inter-rater reliability was estimated
as .98 (Mollica et al., 1992). In a more recent validation assessment con-
ducted among the POW group in this study (Smith Fawzi et al., in press),
the first 16 symptoms of the HTQ, derived from the DSM-111-R criteria
for PTSD ( M A , 1987), perfectly discriminated between individuals with
and without PTSD as established by a psychiatrist and a bilingual (viet-
namese and English) counsellor using the Structured Clinical Interview for
the DSM-111-R (Spitzer, Williams, Gibbon, & First, 1992). The first 16
symptoms of the HTQ, reflecting DSM criteria for PTSD, were included
in this analysis.

Statistical Analyses

Statistical analyses were conducted using the Statistical Analysis Sys-

tem (SAS) software package (SAS Institute, 1990). Principal components
analysis (PCA), calculation of internal consistency (Cronbach’s alpha), and
104 Fami d aL

correlational analyses were performed. PCA was conducted using orthogo-

nal varimax rotation; items with a factor loading of S O or greater were
reported for each factor.

Results

In order to examine the association between F’TSD-related symptoms

and traumatic experiences in this population, correlations between the
number of traumatic events experienced and the severity of PTSD-related
symptomatology were calculated. Overall, the number of traumatic events
was significantly associated with the severity of PTSD symptomatology,
Pearson’s r = .40; p = .0004.Interestingly, the reexperiencing (r = .41;
p = .0003) and arousal (r = .39; p = .0007) symptoms of PTSD demon-
strated higher correlations with the number of traumatic events compared
with the avoidance dimension (r = .30;p = .0094), although these differ-
ences in correlation coefficients were of borderline significance (reexperi-
encing vs. avoidance, p = .1075; arousal vs. avoidance, p = .1251).
In order to investigate the validity of DSM-IV symptom dimensions
of PTSD, internal consistency estimates were examined and principal com-
ponents analysis of PTSD-related symptoms was conducted. Internal con-
sistency was high for the DSM-IV derived PTSD symptoms (alpha = .92).
For specific symptom dimensions of PTSD, the arousal dimension had the
highest level of internal consistency (alpha = 35) in comparison with the
other symptom dimensions of reexperiencing (alpha = .79)and avoidance
(alpha = .78). In a PCA including DSM-IV derived PTSD symptoms from
the HTQ, four factors with eigenvalues greater than 1 emerged. In corre-
spondence with the DSM-IV, the first three factors represented dimensions
of arousal, avoidance, and reexperiencing, respectively (see Table 1). How-
ever, in contrast to the DSM-IV defined sub-categories where avoidance
represents one dimension of symptomatology, avoidance appeared to be
separated into two factors in this sample. The second factor reflected avoid-
ance associated with general withdrawal or numbing of responsiveness, with
high factor loadings for “unable to feel emotions” and “less interest in
daily activities.” The fourth factor reflected avoidance of stimuli related to
the traumatic event(s).

Discussion

Evidence from this study provides preliminary support for the appli-
cability of the PTSD diagnosis among Vietnamese refugees. The number
Validity of FTSD among Vietnamese Refugees 105

Table 1. Factor Loadings for Principal Components Analysis of F E D DSM-IV Symptoms

for 74 Vietnamese Refugees
Factor
Symptom Dimension Loading

Arousal
Recurrent nightmares .79
Difficulty concentrating .78
Feeling irritable/outburst of anger .77
Inability to remember parts of the most traumatic events .74
Trouble sleeping .n
Avoiding activities that remind you of traumatic events .70
Feeling jumpy, easily startled .67
% Variance explained 44%

Avoidancehithdrawal
Unable to feel emotions .79
Less interest in daily activities .70
Feeling detached or withdrawn .65
Feeling jumpy, easily startled .51
Feeling as if you don’t have a future .51
% Variance explained 24%

Reexperiencing
Recurrent thoughts/memories of most terrifying events .83
Feeling as though the event is happening again .83
Sudden emotional or physical reaction when reminded of most traumatic events 57
% Variance explained 22 %

Avoidance of stimuli related to trauma event(s)

Avoiding thoughts or feelings associated with traumatic events .71
% Variance explained 11%

of traumatic events experienced was positively correlated with the severity

of PTSD-related symptomatology in this population. Exposure to traumatic
events was also observed to be positively associated with PTSD symptoms
among other Southeast Asian refugee populations (Carlson & Rosser-
Hogan, 1994; Clarke, Sack, & Goff, 1993) as well as among American
Vietnam veterans (Cordray, Polk, & Britton, 1992; Fontana, Rosenheck, &
Brett, 1992).
Principal components analysis including DSM-IV criteria for PTSD
empirically demonstrated symptom dimensions of arousal, avoidance, and
reexperiencing in this population. Empirical support also exists for the di-
mensions of reexperiencing, avoidance, and arousal among war veterans
(Davidson, Smith, & Kudler, 1989; Watson, Kucala, Juba, Manifold, & An-
derson, 1991); these studies reported avoidance and numbing symptoms as
106 Fawli et aL

occurring within the same dimension. However, in this study avoidance a p

peared to reflect two dimensions of general social withdrawal or numbing
of responsiveness and avoidance of activities and thoughts reminiscent of
the most traumatic event(s). Some evidence of a separate factor reflecting
isolation/social withdrawal is also apparent among war veterans (Pearce,
Schauer, Garfield, Ohlde, & Patterson, 1985; Silver & Iacono, 1984). Simi-
larly, in a principal components analysis of the PTSD items from the Struc-
tured Clinical Interview for the DSM (SCID), Keane (1993) reported a
fourth factor that included symptoms of “marked diminished interest in
significant activities” and “feelings of detachment or estrangement.” A fac-
tor representing symptoms of “numbing,” such as “loss of interest” and
“detachment” also separated from symptoms of avoidance specific to the
traumatic event in a factor analysis conducted by Foa and colleagues (1995)
among women who experienced rape or assault. These results indicate that
further research on the relative homogeneity of the PTSD symptom di-
mension of avoidance as defined in DSM-IV is needed.
The emergence of the avoidance factor corresponding with “social
withdrawal” may provide support for the importance of depressive symp-
tomatology in the post-trauma context among refugees. These results cor-
respond with the inclusion of depressive as well as arousal symptoms in
Eitinger’s (1961) concentration camp syndrome, Eisenbruch’s (1991) ern-
phasis on cultural loss in Cambodian refugees, and Mollica and colleagues’
(1993) demonstration of high levels of depressive symptoms in Cambodian
refugees living in camps on the Thai-Cambodian border. Given the exten-
sive exposure to war trauma, forced dislocation, and stressors related to
resettlement, refugees may be more likely to feel isolated in their traumatic
experiences and may potentially present with social withdrawal more fre-
quently than other traumatized populations.
Limitations of the study include the cross-sectional design, the small
sample size, and the low participation rate of the general refugee group.
Due to the small sample size, the subject-to-item ratio for the principal
components analysis is low. Therefore, replication of this analytic strategy
in a larger study is warranted. Due to a lack of diagnostic information, it
is unclear to what extent comorbidity with other disorders (e.g. major de-
pression) affected the observed symptom profdes.
In conclusion, the PTSD stressor criterion has been demonstrated to
be relevant within this group of Vietnamese refugees, i.e., reported trau-
matic events were associated with PTSD in this population. Internal con-
sistency estimates and principal components analysis of PTSD symptoms
provided support for the clinical utility of dimensions of arousal, avoidance,
and reexperiencing in this population. However, avoidance separated into
two factors, with one factor representing social withdrawal, possibly reflec-
Validity of PTSD among Vietnamese Refugees 107

tive of depression. Symptoms of depression and loss are important to un-

derstanding the trauma response in this population. Given the extensive
trauma history frequently experienced by refugees, further research is
needed in order to examine the validity of PTSD and associated posttrauma
diagnoses to develop appropriate and effective treatment and rehabilitation
strategies for refugee populations at risk.

Acknowledgments

Supported by the Bank of Boston and Mackintosh Foundations. The

first author was supported by the Harvard Training Program in Psychiatric
Epidemiology and Biostatistics, funded by the NIMH Epidemiology and
Psychopathology Branch (732-MH17119). The authors acknowledge the as-
sistance and support of Yael Caspi-Yavin, Martha Dunn-Strohecker, and
La-Tia Mitchell as well as the helpful comments and advice from Charles
Poole, Jane Murphy, Chung-cheng Hsieh, Constantine Gatsonis, and
Jonathan Mann. We would also like to extend our gratitude €or assistance
from Hiep Chu and Doi Dung at the Vietnamese-American Civic Associa-
tion in Boston, MA.

References

American Psychiatric Association (1994). Diagnostic and statisfical manual of mental disorders
(4th ed.). Washington, D.C.: Author.
American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders
(3rd ed., rev.). Washington, D.C.: Author.
Basoglu, M., Paker, M.,O m e n , E.. Tasdemir. O., & Sahin, D. (1994). Factors related to
long-term traumatic stress responses in survivors of torture in Tbrkey. Journal of the
American Medical Association, 272, 357-363.
Carlson, E., & Rosser-Hogan, E. (1994). Cross-cultural response to trauma: A study of
traumatic experiences and posttraumatic symptoms in Cambodian refugees. Journal of
Traumatic Stress, 7, 43-58.
Carlson, E., & Rosser-Hogan, E. (1991). Traumatic experiences, posttraumatic stress,
dissociation, and depression in Cambodian refugees. Americon Journal of Psychiatry, 148,
1548-1551.
Clarke, G., Sack, W. H., & Goff, B. (1993). Three forms of stress in Cambodian adolescent
refugees. Joumal of Abnormal Child Psychology, 21, 65-77.
Cordray, S. M., Polk, K R., & Britton, B. M. (1992). Premilitary antecedents of posttraumatic
stress disorder in an Oregon cohort. Journal of Clinical Pqchofogv, 48, 271-280.
Davidson, J., Smith, R., & Kudler, H. (1989). Validity and reliability of the DSM-111 criteria
for posttraumatic stress disorder. Joumul of Nervous and Mental Direuse, 177, 336-341.
Derogatis, L. R., Lipman, R. S., Rickels, K, Uhlenhuth, E.,& Covi, L. (1974). The Hopkins
Symptom Checklist (HSCL): A self-report symptom inventoly. Behavioral Sciences, 19,
1-15.
Eisenbruch, M. (1991). From posttraumatic stress disorder to cultural bereavement: Diagnosis
of Southeast Asian refugees. Social Science in Medicine, 33, 673-680.
108 Fawzi d aL

Eitinger, L (1961). Pathology of the concentration camp syndrome. Archives of General

Psychiahy, 5, 79-87.
Foa, E. B., Riggs, D. S.,& Gershuny, B. A. (1995). Arousal, numbing, and intrusion: Symptom
structure of PTSD following assault. American Journal of Psychiaoy, 152, 116-120.
Fontana, A., Rosenheck, R., & Brett, E. (1992). War zone traumas and posttraumatic stress
disorder symptomatology. Journal of Nervous and Mental Disease, 180, 148-755.
Hinton, W. L,Chen, Y., N., Du,%an, E G., Miranda, J., & Faust, S. (1993). DSM-111-R
disorders in Vietnamese refugees. Journal of Nervous and Menfal Direase, 181, 113-12.
Keane, T (1993). Symptomatology of Vietnam veterans with posttraumatic stress disorder. In
J. Davidson & E. Foa (Eds.) Posffraumatic sfress disorder: DSM-lV and beyond (pp.
99-111). Washington, D.C.: American Psychiatric Press.
Kinzie, J. D., Boehnlein, J. K., Leung, I? K, Moore, L. J., Riley, C., & Smith, D. (1990). The
prevalence of posttraumatic stress disorder and its clinical significance among Southeast
Asian refugees. American Journal of Psychiahy, 147, 913-917.
Mollica, R. E, Donelan, K., Tor, S.,Lavelle, J., Elias, C., Frankel, M., & Blendon, R. J. (1993).
The effect of trauma and confinement on functional health and mental health status of
Cambodians living in Thailand-Cambodia border camps. Journal of the American Medical
Association, 270, 581-586.
Mollica, R. E, Caspi-Yavin, Y.. Bollini, l?, Thong, T,B r , S., Lavelle, J. (1992). Validating a
cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder
in Indochinese refugees. Joumal of Nervous and Menfal Disease, I80, 110-115.
Mollica, R. E, & Caspi-Yavin, Y. (1991). Measuring torture and torture-related symptoms.
Psychological Assessment: Journal of Consulting and Clinical Psychology, 3, 581-587.
Mollica,R. E, Wyshak, G., de Marneffe, D;, "h, B., Yang, T,Khuon, E, Coelho, R.. Lavelle,
J. (1986). Hopkins Symptom Checklist-25 Manual: Cambodian, Laofian, and Vietnamese
versions. Washington, D.C.: US. Office of Refugee Resettlement.
Pearce, K. A., Schauer, A. H., Garfield, N. J., Ohlde, C. O., & Patterson, 'I: W. (1985). A
study of posttraumatic stress disorder in Vietnam veterans. Journal of Cfinical Psychology,
41, 9-14.
SAS Institute. (1990). Sfatisficafanalysis sysfem-PC, Cary, N.C.: SAS Institute.
Silver, S. M., & Iacono, C. U. (1984). Factor-analytic support for DSM-Ill's posttraumatic
stress disorder for Vietnam veterans. Journnl of Clinicof Psychologx 40, 5-14.
Smith Fawi, M. C., Murphy, E., Pham, T,Lin, L,Poole, C., & Mollica, R. E (in press). The
validity of screening for posttraumatic stress disorder and major depression among
Vietnamese former political prisoners. Acta Psychiam'ca Scandinavica.
Spitzer, R. L., Williams, J. B. W., Gibbon, M., & First, M. (1992). The Structured Clinical
Interview for DSM-111-R (SCID) I: History, rationale, description. Archives of General
Psychiatry, 49, 624-629.
Watson, C. G., Kucala, T,Juba, M., Manifold, V, & Anderson, P. E. (1991). A factor analysis
of the DSM-111 posttraumatic stress disorder criteria. Journal of Clinical Psycholw, 47,
205-214.