Adaptação transcultural e evidências de validade do international trauma questionnaire

Abstract

Posttraumatic Stress Disorder (PTSD) is a recent diagnosis in the literature; and controversies about it are frequent, especially in relation to its factorial structure. The 5th of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) and the 11th edition of the International Classification of Diseases (ICD-11), in order to reflect important scientific discussions, performed a review of the diagnostic criteria for PTSD. These reviews eventually generated distinct models of the disorder, which now need to be evaluated through empirical studies in different cultures, in order that a more accurate understanding of the phenomenon could be achieved. To this end, specific instruments for these models are needed. While the DSM-5 model already has an instrument adapted for Brazilian Portuguese; the ICD-11 model, although presenting more promising preliminary empirical evidence, still does not have an instrument properly adapted to be used in the Brazilian context. The International Trauma Questionnaire (ITQ) is the gold standard instrument for assessing the ICD-11 trauma-related disorder model. The ITQ is composed of two questionnaires of six items that evaluate post-traumatic symptoms and three other items that assess functional impairment on a 5-point Likert scale. The first questionnaire assesses PTSD symptoms in three factors: reexperience, avoidance and elevated sense of threat. The second questionnaire evaluates symptoms of disturbances in self-organization (DSO) also in three factors: affective dysregulation, negative self-concept and disturbances in relationships. Following recommendations of the instrument authors, to be diagnosed with PTSD, the individual must score at least 2 in each of the factors of the first questionnaire; and at least 2 in one of the functional impairment items. In order to be diagnosed with Complex PTSD, the subject must score at least 2 in each factor of the DSO questionnaire and also 2 in at least one of the items of functional impairment. The ICD-11 model indicates that individuals can be diagnosed with one of the disorders but never with both. The main goal of this dissertation was to translate, cross-culturally adapt and investigate evidences of validity of ITQ in its Brazilian Portuguese version (ITQ-Br). The structure of this dissertation is composed of a theoretical foundation and two empirical articles. The theoretical basis presents the most recent scientific discussions about the factorial structure of PTSD and the models proposed by the diagnostic manuals. In addition, a review of studies already carried out internationally with ITQ was presented. Both studies were approved by Ethics Committee of Pontificia Universidade Católica do Rio Grande do Sul. The first empirical study aimed to translate and transcultural adapt the scale for the Brazilian context, through five steps: (1) translation of the instrument into the target language by two bilingual psychologists with experience in trauma-related disorders; (2) synthesis of translated versions, in which a committee of specialists compared the two translations with the aim of constructing a single version, attentive to possible linguistic, cultural and comprehension biases. At this stage, changes were suggested in six items because of idiomatic expressions or aiming a better technical translation. (3) Evaluation of the synthesis by three expert judges regarding the comprehensiveness and appropriateness of the expressions for generalization in different contexts and populations through the Content Validity Coefficient (CVC), which was satisfactory (CVC > 0.7) already in the first round of evaluations; (4) a pilot study, in which 35 research participants in the cities of Porto Alegre, Belo Horizonte and Rio de Janeiro assessed the comprehension level of the questionnaire. Again, items were considered adequate (average item comprehension > 3) already in the first round of evaluations; and (5) reverse translation, which consisted of translating the draft version of the instrument into the source language by a translator without mental health experience and blind to the original instrument; which was then sent and approved by the authors of the original scale. This study demonstrated evidences of good content validity of the Brazilian Portuguese version of ITQ (ITQ-Br). The second empirical study aimed to evaluate the psychometric properties of ITQ-Br. 245 participants answered to an online survey with ITQ-Br and other psychological instruments assessing exposure to traumatic events (Life Event Checklist; LEC-5), posttraumatic symptomatology (Posttraumatic Symptom Checklist; PCL-5), depression (Patient Health Questionnaire 9; PHQ-9), emotional dysregulation (Difficulties in Emotion Regulation Scale; DERS), dissociation (Dissociative Experiences Scale; DES) and childhood maltreatment (Childhood Trauma Questionnaire; CTQ). The construct validity was investigated through (1) confirmatory factorial analysis; (2) internal consistency analysis (Cronbach's alpha); (3) comparisons between the diagnostic groups’ PTSD, Complex PTSD and non-significant symptoms; and (4) analysis of related constructs. The analyzes were performed in the Statistical Package for the Social Sciences (SPSS) version 21 and in Analysis of Moment Structures (AMOS) version 21. Results of the confirmatory factorial analysis indicated good adjustment of the ICD-11 models to the data in the Brazilian sample. The internal consistency analysis was satisfactory (α > .70) in both questionnaires and in all factors, with the exception of the Affective Dysregulation factor (α = .59). The analysis of related constructs indicated evidence of convergent and discriminant validity of the PTSD and Complex PTSD questionnaires; with the first being more strongly associated with intrusive, avoidant and hyperarousal symptoms (PCL-5); while the second to symptoms of negative alterations in cognition and mood (PCL-5), depression (PHQ-9), dissociation (DES), emotional dysregulation (DERS), and increased exposure to childhood maltreatment (CTQ). Complex PTSD (29%) was more prevalent than PTSD (7.8%); and exposure to traumatic events was significantly higher in the path of diagnosis complexity. Comparisons were made with results from international studies using the ITQ. This study demonstrated good evidences of construct validity of ITQ-Br. Taken together, both studies in this dissertation indicate good psychometric properties of ITQ-Br through evidence of content validity, internal consistency, and different types of construct validity. The instrument, a self-reporting measure of simple and quick application, can now be used in national clinical and research contexts. Future studies with Brazilian samples should investigate predictors, course and nature of PTSD and CPTSD according to the ICD-11 model, in order to contribute to the international scientific discussions that investigate the models of trauma related disorders.