Complex PTSD and phased treatment in refugees: a debate piece

Asylum seekers and refugees have been claimed to be at increased risk of developing complex posttraumatic stress disorder (complex PTSD). Consequently, it has been recommended that refugees be treated with present-centred or phased treatment rather than stand-alone trauma-focused treatment. This recommendation has contributed to a clinical practice of delaying or waiving trauma-focused treatment in refugees with PTSD. The aim of this debate piece is to defend two theses: (1) that complex trauma leads to complex PTSD in a minority of refugees only and (2) that trauma-focused treatment should be offered to all refugees who seek treatment for PTSD. The first thesis is defended by comparing data on the prevalence of complex PTSD in refugees to those in other trauma-exposed populations, using studies derived from a systematic review. The second thesis is defended using conclusions of systematic reviews and a meta-analysis of the efficacy of psychotherapeutic treatment in refugees. Research shows that refugees are more likely to meet a regular PTSD diagnosis or no diagnosis than a complex PTSD diagnosis and that prevalence of complex PTSD in refugees is relatively low compared to that in survivors of childhood trauma. Effect sizes for trauma-focused treatment in refugees, especially narrative exposure therapy (NET) and culturally adapted cognitive-behaviour therapy (CA-CBT), have consistently been found to be high. Complex PTSD in refugees should not be assumed to be present on the basis of complex traumatic experiences but should be carefully diagnosed using a validated interview. In line with treatment guidelines for PTSD, a course of trauma-focused treatment should be offered to all refugees seeking treatment for PTSD, including asylum seekers.

现有研究指出，寻求庇护者与难民罹患复杂性创伤后应激障碍（complex PTSD）的风险显著升高。据此，学界建议为难民采用当下聚焦疗法或分阶段疗法，而非单一聚焦创伤的治疗手段。该建议催生了一类临床实践：对确诊创伤后应激障碍（posttraumatic stress disorder, PTSD）的难民延迟实施甚至放弃聚焦创伤的治疗。本篇辩论专栏文章旨在论证两个核心论点：其一，复杂创伤仅会在少数难民群体中引发复杂PTSD；其二，应为所有因PTSD寻求治疗的难民提供聚焦创伤的治疗方案。第一个论点依托一项系统综述纳入的研究数据完成论证：对比难民群体与其他创伤暴露人群的复杂PTSD患病率差异。第二个论点则借助多项系统综述的结论，以及针对难民群体心理治疗有效性的元分析结果得到佐证。研究显示，相较于复杂PTSD诊断，难民更易被确诊为普通创伤后应激障碍或未达到创伤相关精神障碍诊断标准；且与童年创伤幸存者相比，难民群体的复杂PTSD患病率相对较低。研究一致证实，针对难民的聚焦创伤治疗（尤其是叙事暴露疗法（narrative exposure therapy, NET）与文化适配认知行为疗法（culturally adapted cognitive-behaviour therapy, CA-CBT））的效应量始终处于较高水平。不应仅凭难民存在复杂创伤经历就认定其罹患复杂PTSD，而应通过经过验证的诊断性访谈进行严谨诊断。参照创伤后应激障碍的治疗指南，应为所有因PTSD寻求治疗的难民（包括寻求庇护者）提供完整疗程的聚焦创伤治疗方案。