臺灣版複雜性創傷評估工具的效度研究：複雜性創傷與童年逆境經驗、身心健康的關聯

Validity Study of the Taiwanese Version of the Complex Trauma Inventory: Associations Between Complex Trauma, Adverse Childhood Experiences, and Mental Health

世界衛生組織在2022年修訂的ICD - 11公布了複雜性創傷後壓力症（CPTSD）。然而，在心理衡鑑實務中，個案往往較難清處辨識與報告該症狀，需藉助自陳式量表以覺察與報告該症狀。本研究依據Litvin等人（2017）編製的工具，並採取符合受試者文化適應的最佳翻譯原則，翻譯出「臺灣版複雜性創傷評估工具」（T-CTI），並進行信、效度檢驗。研究方法採線上問卷調查，研究對象以自陳在18歲之前曾經驗較嚴重的創傷或重大壓力事件的成年人為主，有效樣本共計437位，平均年齡為28.77歲。施測工具包括：T-CTI、臺灣版童年逆境經驗問卷、臺灣憂鬱症量表，以及華人健康問卷。研究結果發現，除了T-CTI具有良好的翻譯效度，T-CTI總分及各子因素的計分上，Cronbach’s α 皆落在 .804∼.961之間，顯示具有良好的信度；在驗證性因素分析上亦獲得良好的適配度，標準化因素負荷量約為 .54∼.88之間，且T-CTI與童年逆境經驗、憂鬱傾向、一般身心健康程度，在迴歸分析結果皆達顯著，顯示具有同時效度。本研究亦發現，CPTSD與單純的創傷後壓力症症狀有所不同，且憂鬱傾向與不佳的身心健康狀態可能隱藏CPTSD的危機。T-CTI在諮商臨床的心理衡鑑實務工作上具有重要性，可協助個案與助人工作者更能辨識與覺察複雜性創傷反應的存在。

Research Motivation and Objective

The concept of Adverse Childhood Experiences (ACEs) was noticed by the field of health psychology. Felitti et al. (1998) found that ACEs are potentially long-lasting, repetitive, and contextual traumatic events experienced during childhood. These events have a long-term impact on an individual’s physical and mental health in adulthood. Frewen et al. (2019) perceived that the traumatic reactions resulting from ACEs manifest as symptoms of complex trauma (CT). The World Health Organization revised the ICD-11 in 2022, introducing Complex Posttraumatic Stress Disorder (CPTSD). In psychological assessments, individuals with complex trauma often struggle to recognize symptoms, requiring self-report measures to assist in awareness and reporting. Therefore, it is more suitable to use self-report assessment tools. By having clients fill out these questionnaires, helpers can then proactively inquire about the symptoms and psychological phenomena indicated by the results. This helps clients more clearly report what has happened to them. This study, based on the tool developed by Litvin et al. (2017), employed the “Translation and Cultural Adaptation of Patient Reported Outcomes Measures—Principles of Good Practice” to translate the “Taiwanese version of the Complex Trauma Inventory (T-CTI)” suitable for clinical application in Taiwan and examined its reliability and validity.

Literature Review

CPTSD refers to the long-term, continuous, and repetitive experiences of psychological and physical trauma related to interpersonal interactions (Barbieri et al., 2019). As defined by the ICD-11, the symptoms of CPTSD include both the core Post-Traumatic Stress Disorder (PTSD) symptoms and additional symptoms known as Disturbances in Self-Organization (DSO). The PTSD symptom clusters include re-experiencing (RE), avoidance (AV), and sense of threat (SOT). The DSO symptom clusters include affect dysregulation (AD), negative self-concept (NSC), and disrupted relationships (DR). (Litvin et al., 2017; Rocha et al., 2020; Sachser et. al., 2022).

Karatzias et al. (2017) suggests that the biggest difference between PTSD and CPTSD is that CPTSD is more strongly linked to childhood traumatic experiences. Using a metaphor, while PTSD is a sudden and unexpected traumatic event, CPTSD is more like boiling frog syndrome. Individuals with CPTSD have often lived in dysfunctional family environments for extended periods. This continuous exposure to trauma significantly damages their attachment relationships with important caregivers (Murphy et al., 2014). When an individual grows up in a poor attachment ecosystem due to ACEs, the family fails to provide healthy responses and reflective functioning to the growing child, and the individual has a higher chance of developing the DSO symptoms of CPTSD. Another theory that helps explain the link between ACEs and CT is polyvagal theory (Porges, 2022). CPTSD can especially trigger a dorsal vagal response, leading the individual to “freeze” or “shut down”, cutting off selfawareness and feelings. This makes it even more difficult for the individual to clearly describe and report their CPTSD symptoms and overall mental and physical health.

International studies on the validity of CPTSD have identified depression, anxiety, and general physical and mental health as excellent concurrent validity criteria for assessing CPTSD (Gilbar, 2020; Løkkegaard et al., 2023). This also suggests that CPTSD may have a comorbidity with other psychological disorders. While there are currently no studies in Taiwan specifically exploring the link between complex trauma (CT) and physical and mental health, numerous studies have shown a high correlation between trauma responses and depressive tendencies. Based on the research mentioned, measures of depression, anxiety, or general physical and mental health are likely very suitable criteria for verifying the concurrent validity of the T-CTI.

Research Methodology

The research utilized an online questionnaire survey, focusing on adults who self-reported experiencing significant trauma or major stress events before the age of 18, with a total sample of 437 participants and an average age of 28.77 years. The research instruments included the T-CTI, the Taiwanese version of Adverse Childhood Experiences Questionnaire 10 items (T-ACE-Q-10), the Taiwan Depression Scale (TDS), and the Chinese Health Questionnaire (CHQ- 12).

Research Results

The results revealed that the T-CTI demonstrated good reliability and validity. Both the total score and the scores of individual subscales of the T-CTI fell within the range of .804 to .961 for Cronbach’s α , indicating high reliability. In addition to its good translation validity, it conducted a Confirmatory Factor Analysis using Structural Equation Modeling on the T-CTI. The model fit results for the T-CTI, regardless of whether scoring was based on frequency, intensity, or severity, showed good fit and mediocre fit, indicating that the T-CTI has appropriate validity. Furthermore, the T-CTI demonstrated concurrent validity with adverse childhood experiences, depressive tendencies, and general mental health, as indicated by significant results in regression analysis. This study also found distinctions between CPTSD and simple PTSD symptoms, with depressive tendencies and poor mental and physical health potentially masking the presence of CPTSD. The T-CTI holds importance in psychological assessment practices, aiding both clients and practitioners in identifying and recognizing the presence of complex trauma responses.

Discussion and Recommendations

The reliability of the T-CTI is better for the total scores of PTSD and DSO, while the reliability for the sub-factors (RE, AV, SOT, AD, NSC, DR) is slightly lower but still acceptable. The fewer questions for each sub-factor may contribute to lower reliability scores. However, considering the need for the tool to be easy to use and accepted by clients, the number of questions represents the most ideal balance between practical usability and research-based reliability and validity.

This study also indirectly validates that CPTSD presents differently than PTSD. The concurrent validity results with the CTI, CHQ-12, and TDS show that, regardless of whether the assessment measures the frequency, intensity, or severity of CT, the DSO component is more highly correlated with depression and overall mental and physical health than simple PTSD.

The research also found that the measurements of frequency, intensity, and severity of CPTSD have high explanatory power in regression analyses with both CHQ-12 and depressive tendencies. If a client presents with symptoms of depression or poor physical and mental health, and also has multiple ACEs, there may be a hidden risk of CPTSD. This is an important reminder for clinical practitioners.

In the practical application of the T-CTI, the score may not be the most important. Workers can review the client’s responses to each question, and proactively inquire about the client’s life experiences. This could help clients report and identify their own traumatic experiences and reactions.