PSYCHOLOGY, PSYCHIATRY, IMAGING & BRAIN NEUROSCIENCE SECTION
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Pain Medicine 2018; 19: 50–59
doi: 10.1093/pm/pnx005
PSYCHOLOGY, PSYCHIATRY, IMAGING & BRAIN
NEUROSCIENCE SECTION
Original Research Article
The Association of Post-traumatic and
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Postmigration Stress with Pain and Other
Somatic Symptoms: An Explorative Analysis in
Traumatized Refugees and Asylum Seekers
Naser Morina, PhD,* Alexa Kuenburg, MD,* Ulrich Methods. One hundred thirty-four treatment-seek-
Schnyder, MD,* Richard A. Bryant, PhD,† Angela ing traumatized refugees (78% male, mean age 5 42
Nickerson, PhD,† and Matthis Schick, MD* years) were assessed regarding lifetime traumatic
experiences, symptoms of post-traumatic stress,
overall pain and somatic symptoms, and postmigra-
*Department of Psychiatry and Psychotherapy, tion living difficulties.
University Hospital Zurich, University of Zurich, Zurich,
Switzerland; †School of Psychology, University of New Results. An exploratory factor analysis of the 12 so-
South Wales, Sydney, Australia matic symptoms revealed two distinct factors: so-
matic symptoms related to bodily dysfunction
Correspondence to: Naser Morina, PhD, Department (“weakness”) and somatic symptoms related to in-
of Psychiatry and Psychotherapy, University Hospital, creased sympathetic activity (“arousal”). DSM-5
University of Zurich, Culmannstrasse 8, 8091 Zurich, PTSD Criteria D “alterations in cognitions and mood”
Switzerland. Tel: þ41-44-255-52-80; Fax: þ41-44-255- and E “alterations in arousal and reactivity” were pri-
44-08; E-mail naser.morina@usz.ch. marily related to “weakness,” while PTSD Criterion E
“alterations in arousal and reactivity” and postmigra-
Funding sources: This study was partly supported by tion living difficulties were associated with “arousal.”
the Parrotia Foundation, the Swiss Federal Office for Overall pain was associated primarily with living diffi-
Migration (3a-12-0495), and the Swiss Federal Office culties and PTSD Criterion D and Criterion E.
for Health (12.005187). AN was supported by a
National Health and Medical Research Council Conclusions. Results indicate that somatic symptoms
Clinical Early Career Fellowship (1037091). are of considerable concern among traumatized refu-
gees and that different patterns of somatic symptoms
Conflicts of interest: The authors disclose no conflicts are associated with different clusters of PTSD symp-
of interest. toms. The findings contribute to the better understand-
ing of the symptom presentation of traumatized
people who are experiencing somatization and poten-
Abstract tially inform treatment directions and highlight the im-
portance of screening for PTSD in refugees presenting
Objective. Post-traumatic stress disorder (PTSD) with pain and somatic symptoms.
and somatic symptoms, such as pain, are fre-
Key Words. Post-traumatic Stress Disorder;
quently seen in refugees. Their relationship is
Trauma; Pain; Somatic Symptoms; Postmigration
poorly understood, and the treatment of these co-
Living Difficulties; Refugee
morbid conditions can be very challenging. The cur-
rent cross-sectional study examined pain and other
somatic symptoms and their relationship with Introduction
trauma history, PTSD symptom clusters, and cur-
rent living difficulties among treatment-seeking In the current international context, the number of refu-
refugees. gees and internally displaced people worldwide is
C 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V 50Trauma and Somatic Symptoms in Traumatized Refugees
increasing dramatically and recently exceeded 65 million family, which may increase the risk of developing psy-
[1]. By definition, refugees have experienced persecution chological symptoms [29,30]. Despite numerous studies
and are thus often subject to repeated and severe trau- attesting to the link between trauma exposure,
matic experiences, including life-threatening situations, postmigration stressors, and psychological disorders in
torture, and multiple bereavement [2]. Accordingly, high refugees, there is little evidence on how somatic symp-
rates of trauma-related psychological disorders, includ- toms in traumatized refugees can be explained and how
ing post-traumatic stress disorder (PTSD), depression, they interfere with other determinants of refugee mental
and anxiety, have been reported in refugees [3–5]. health. There is little research that has demonstrated
that postmigration stress is associated with somatization
PTSD is often associated with comorbid conditions, and and somatoform disorders in refugee and immigrant
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physical complaints have been found to be among the groups [31–33]. Literature has shown that patients with
most frequently reported symptoms in individuals with somatic symptoms have excessively higher rates of
PTSD [6]. Comorbid chronic pain—a prominent mani- health care utilization and in addition such patients may
festation of somatic symptoms—has been reported in contribute to increasing cost of health care services
34% to 80% of PTSD patients [7–9], and the frequent [34]. A better understanding is needed to provide effec-
co-occurrence of PTSD with unexplained somatic tive treatment for this highly vulnerable population.
symptoms and medical conditions is well documented
[10,11,12]. Particularly high comorbidity rates of PTSD This exploratory study examines the nature of pain and
and somatic symptoms have been demonstrated in somatic symptoms, as well as their interaction with
samples of refugees [13,14] and torture survivors [15]. PTSD and postmigration living difficulties (PMLDs), in a
Furthermore, somatization is considered a vital part of sample of treatment-seeking refugees. On the premise
post-traumatic symptomatology in relation to complex that pain is associated with elevated stress, we hypoth-
trauma [16]. esized 1) a positive association of PTSD symptoms,
pain, and somatic symptoms; and 2) due to the explor-
While there is solid evidence with regard to the frequent ative character of this study, no hypothesis was made
co-occurrence of trauma-related mental and somatic regarding the exact nature of the association between
health problems, the nature of this relationship is still PTSD symptoms and level of PMLDs.
poorly understood. Psychological, behavioral, and bio-
logical factors, as well as the complex interactions be- Methods
tween these factors, serve as possible mechanisms
through which PTSD may be associated with physical Participants
health [10,17]: Somatic presentations may occur in
PTSD patients as a result of a number of mechanisms, These data were collected between May 2012 and
including 1) trauma-independent somatic disorders; 2) August 2013. Participants were refugees or asylum
traumatic injuries and tissue damage sustained in the seekers who had survived war and/or torture and came
course of the initial traumatic event; 3) somatic condi- from a variety of refugee backgrounds. At the time of
tions related to the increased allostatic load or to unfa- the study, they were receiving psychological treatment
vorable health habits associated with PTSD; 4) for trauma-related health complaints at the outpatient
autonomic, neuroendocrine, and immunologic dysregu- units for victims of torture and war in either Zurich or
lation resulting from PTSD; 5) genetic and epigenetic Bern, Switzerland. Inclusion criteria were written in-
predispositions; 6) somatoform disorders, particularly formed consent, being 18 years or older, and speaking
dissociative or conversion disorders associated with ele- one of the study languages, that is, German, English,
vated stress levels; 7) somatic intrusions that function Turkish, Arabic, Farsi, or Tamil. Patients were excluded
as a form of re-experiencing of the trauma; or 8) alexi- if they were unable to fill in self-report questionnaires, if
thymia or culture-dependent expression of psychological they were pregnant, if they had a severely impaired dis-
distress [18–22]. So far, several theoretical models, tress tolerance (for example, severe dissociative symp-
such as the mutual maintenance model [23], the shared toms), or if they were currently suffering from psychosis
vulnerability model [24], and the fear avoidance model or were acutely suicidal or a threat to others.
[25], have been suggested to explain the mechanisms
of the co-occurrence of pain and PTSD. Based on the inclusion criteria, 152 patients were invited
to participate in the study and 137 patients (90.1%)
Refugee mental health is becoming an increasingly im- agreed to participate. After three participants failed to
portant public health concern in hosting societies attend the assessment, 134 participants were included
[3,26,27]. While evidence-based therapies for PTSD in in the final sample.
refugees do exist [28], there are no empirically sup-
ported treatments for trauma-related somatic symp- Measures
toms. In addition, over and above the adverse
psychological and physical effects of trauma, refugees The measures used in this study have been used across
and asylum seekers are often subjected to a variety of multiple cultural groups. Accredited translators trans-
postmigration stressors, including unemployment, inse- lated them into Turkish, Arabic, Farsi, and Tamil. Blind
cure visa status, discrimination, and separation from back-translation procedures were also implemented
51Morina et al.
[35], with differences between the two translations with social worker”). The 17 items were rated on a five-
being rectified by independent bilingual individuals expe- point scale (0 ¼ “not a problem” to 4 ¼ “very serious
rienced in working with health-related questionnaires. problem”). Items scored at least 2 (“moderately serious
Sociodemographic sample characteristics were as- problem”) were considered positive responses, yielding
sessed at the beginning of the assessment. a total count of living difficulties.
Trauma exposure was measured by combining the
Procedures
trauma event lists of two standardized questionnaires,
the Harvard Trauma Questionnaire (HTQ) [36], and the
The ethics committees of the respective Cantons of
Post-traumatic Diagnostic Scale (PDS) [37,38]. This
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Zurich and Bern, Switzerland, approved the study (KEK-
combined scale indexes exposure to 23 types of trau-
ZH-Nr. 2011-0495). A therapist-assisted computer-
matic events associated with the refugee experience
based assessment tool (MultiCASI) was used to
(i.e., brainwashing, torture, being close to death) and
implement the self-report measures [48]. In MultiCASI,
traumatic experiences associated with other civilian
participants can read each item and the range of possi-
trauma (i.e., natural disaster, serious accident, fire, or
ble responses in their respective mother tongue on a
explosion). A count of the number of types of traumatic
tablet screen and—in case of illiteracy—can listen to the
events experienced by each participant was computed.
audio-recorded items/responses. Items are answered
by touching the screen. A study team member ex-
To measure PTSD symptom severity over the past
plained the purpose of the study to potential partici-
month, part three of the PDS [37,38] was used. The
pants, including that the study would be performed
PDS has been used with several refugee groups [39–
anonymously and would have no influence on their sta-
41]. As data collection for this study was conducted
tus of residence or asylum procedures. Written informed
prior to publication of the DSM-5 in 2013, the additional
consent was obtained from all participants. Participants
items included in DSM-5 for the proposed PTSD diag-
were informed that they were free to withdraw from the
nostic criteria were added to the PDS [42,43].
study at any time without jeopardizing their ongoing
According to the DSM-5, to meet criteria for PTSD one
treatment. Participants attended a research assessment
must initially be exposed to a traumatic event (Criterion
of 60 to 120 minutes’ duration. Assessments were su-
A). PTSD symptoms are then divided into four main cri-
pervised by a psychiatrist, clinical psychologist, or a
teria: Criterion B: intrusion symptoms; Criterion C: per-
Master’s-level student of clinical psychology.
sistent avoidance of stimuli associated with the trauma;
Participants were reimbursed CHF 40 (approximately
Criterion D: negative alterations in cognitions and mood;
USD 40) for participation.
Criterion E: alterations in arousal and reactivity.
Probable PTSD diagnosis was determined by applying
DSM-5 criteria to symptoms in the PDS [39]. Internal Data Analysis
consistency for this scale was high (a ¼ 0.94).
Analyses were conducted using SPSS version 22
Somatic symptoms were measured using the somatiza- (SPSS-IBM, INC). Exploratory factor analysis (principal
tion subscale of the Symptom Checklist (SCL) [44]. This components) was used to derive somatization patterns
subscale is a self-report inventory of 12 physical symp- based on the 12 SCL items. Two factors were retained,
toms with strong autonomic mediation that are often as- with the criteria for extraction being an eigenvalue equal
sociated with emotional distress. Symptom severity to or greater than 1. The factors were rotated by the di-
during the last seven days is rated on a five-point Likert rect oblimin (oblique) function in order to obtain a sim-
scale ranging from 0 ¼ “not at all” to 4 ¼ “extremely.” pler structure with greater interpretability. Items with a
Items scored as 2 ¼ “moderately” or above are consid- loading higher than 0.40 on a given factor were consid-
ered positive responses, yielding a total count of so- ered to contribute substantially to that factor. Only one
matic symptoms. The SCL has been used with item failed to load to one of the two factors; for this rea-
individuals from many cultural backgrounds [45]. In the son, we omitted this item. After deriving these two fac-
current study, internal consistency was set at an tors, multiple linear regression (using the method
a of 0.89. stepwise) was utilized to examine the relationship be-
tween the two somatic symptom factors and pain as
Overall pain over the past four weeks was assessed outcome variables and age, gender (Step 1), potentially
with a single item on a five-point scale ranging from traumatic events and current living difficulties (Step 2),
0 ¼ “not at all” to 4 ¼ “extremely.” and PTSD core symptom clusters (Step 3) as indepen-
dent variables. Assumptions for regression analyses
A version of the Postmigration Living Difficulties were checked in terms of linearity of the relationships
Checklist (PMLDC) [46,47] adapted to the Swiss context between somatic symptoms and independent variables,
was used to examine the extent to which postmigration autocorrelation of residuals (Durbin-Watson
challenges had been of concern to the individual over test ¼ 1.974), and homoscedasticity and normal distribu-
the past 12 months (i.e., “communication difficulties,” tion of residuals, and all were found to be satisfactory.
“discrimination,” “difficulties in interviews with immigra- Furthermore, we found no multicollinearity between in-
tion officials,” “difficulties with employment,” “conflict dependent variables (all VIF < 1.7).
52Trauma and Somatic Symptoms in Traumatized Refugees
Results Table 1 Sample characteristics
Participants in this study had a mean age of 42.4 years Variable
(SD ¼ 9.9), and the sample comprised 78.4% (N ¼ 105)
males. Participants reported having experienced a mean Male gender, N (%) 105 (78.4)
of 13.11 (SD ¼ 4.80) types of traumatic events, with Age, mean (SD), y 42 (9.9)
over 90% of the sample having experienced torture Nationality, N (%)
(N ¼ 114, 92.7%) and a mean of 9.77 (SD ¼ 4.2) types Turkey (with N ¼ 58 being Kurdish) 71 (53.0)
of living difficulties during the last 12 months. Iran 15 (11.2)
Approximately half of the sample (N ¼ 66, 49.3%) had a Sri Lanka 11 (8.2)
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probable diagnosis of PTSD according to the DSM-5 Bosnia 6 (4.5)
criteria. Further sociodemographic and sample charac- Iraq 6 (4.5)
teristics are presented in Table 1. Afghanistan 5 (3.7)
Others (i.e., Algeria, Bangladesh, 20 (14.9)
An exploratory factor analysis of the 12 SCL items re- Ethiopia, Congo, Kosovo, Lebanon,
vealed two distinct factors of somatic complaints. A fac- Liberia, Libya, Somalia, Syria, Tunesia)
tor-loading matrix is shown in Table 2. The first factor,
Years of education, N (%)
with five items, was labeled “weakness” as it presented
Less than 4 18 (10.4)
high loadings of items referring to weakness, soreness,
4–8 25 (18.7)
or heaviness symptoms and accounted for 45.7% of
8–12 39 (29.1)
the variance. For this factor, the internal consistency
was set at an a of 0.85. The second factor comprised 12þ 49 (36.6)
six items and was characterized by high loadings of so- Employment status, N (%)
matic symptoms predominantly associated with sympa- Full time 9 (6.79)
thetic hyperactivation, such as chest pain or shortness Part time 17 (12.6)
of breath, and was labeled “arousal.” This factor ex- Unemployed 82 (61.2)
plained 10.3% of the variance, and the internal consis- Retired/homemaker 23 (17.1)
tency was set at an a of 0.81. The item “hot or cold Duration of stay in Switzerland (SD), y 9.01 (6.67)
spells” did not load on either factor. No. of experienced trauma types, mean 13.23 (4.54)
(SD)
The results of the correlation analyses are shown in Probable PTSD diagnosis, N (%) 66 (49.3%)
Table 3. Multiple regression analyses revealed that only Number of somatic symptoms, mean (SD) 7.3 (3.5)
symptoms of the PTSD Criterion D “alterations in cogni- Symptom scores, mean (SD)
tions and mood” and Criterion E “alterations in arousal PTSD symptoms (range ¼ 0–60) 33.2 (13.8)
and reactivity” symptoms were independently associ- PTSD Criterion B (range ¼ 0–15) 9.2 (4.0)
ated with the “weakness” factor, accounting for 36% of PTSD Criterion C (range ¼ 0–6) 3.4 (1.9)
the variance, while the “arousal” factor was associated PTSD Criterion D (range ¼ 0–21) 10.9 (5.3)
with female gender, the PTSD Criterion E “alterations in PTSD Criterion E (range ¼ 0–18) 9.9 (4.5)
arousal reactivity,” and the postmigration living difficul-
Somatic symptoms
ties, accounting for 32% of the variance (see Table 4).
“Weakness” (range ¼ 0–4) 2.1 (0.9)
Overall pain was associated with age, female gender,
“Arousal” (range ¼ 0–4) 1.7 (0.8)
living difficulties, and both PTSD Criteria D and E.
Overall pain (range ¼ 0–4) 2.3 (1.2)
Discussion
This exploratory cross-sectional study examined the fac- PTSD symptom clusters as well as PMLD, with the
tor structure of somatic symptoms (as assessed with highest correlations emerging with Criterion D (“negative
the SCL) and the relationship of somatic symptoms and alterations in cognitions and mood”) and Criterion E (“al-
pain with PTSD symptom clusters and postmigration liv- terations in arousal and reactivity”). However, while the
ing difficulties in a clinical sample of severely trauma- “weakness” factor showed slightly higher correlations
tized refugees. with PTSD symptoms, “arousal” was more strongly re-
lated to PMLD. Regression analysis revealed that, when
An exploratory factor analysis revealed two distinct fac- controlling for all variables simultaneously, while both
tors of somatic complaints: Factor one included physical factors related to Criterion E, the “weakness” factor was
perceptions in terms of bodily dysfunction and was re- additionally related to PTSD Criterion D and the
ferred to as “weakness,” whereas factor two included “arousal” factor related to PMLD. Overall pain was re-
somatic symptoms predominantly associated with sym- lated to PMLD and both PTSD CRITERIA D and E.
pathetic hyperactivation and was referred to as
“arousal.” Correlation analyses revealed that both fac- While the relationship between traumatic experiences,
tors and overall pain were significantly related to all PTSD, and somatic complaints is well documented, this
53Morina et al.
Table 2 Summary of the factor loadings for the function that has been observed in PTSD [49].
somatization items of SCL (N ¼ 134) Conversely, potentially life-threatening somatic symp-
toms such as shortness of breath or chest pain may re-
Factor loadings sult in increased sympathetic activation, often
accompanied by secondary symptoms such as hyper-
Factor 1 Factor 2 ventilation, dizziness, muscular hypertension, and ten-
Item “weakness” “arousal” sion headache [50,51]. Dizziness has been noted in
prior traumatized populations, especially those from
Soreness of 0.925 0.118 non-Western backgrounds; for example, dizziness has
muscles been found to be a prominent complaint in a study on
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Numbness or tin- 0.813 0.251 traumatized Cambodians [51]. We also note that the
gling in part of items in the “arousal” factor overlap with those of panic
the body attacks; panic disorder is frequently comorbid with
Pains in lower 0.726 0.356 PTSD [52], and it is possible that many of the refugees
back in this sample had comorbid panic disorder. This possi-
Heavy feeling in 0.719 0.263 bility cannot be clarified because comorbid disorders
your arms or were not assessed.
legs
Feeling weak in 0.691 0.200 With regard to the “weakness” factor, a recent meta-
parts of your analysis found traumatic experiences to be associated
body with an increased prevalence of functional somatic syn-
dromes (FSS), including fibromyalgia, chronic widespread
Trouble getting 0.156 0.829
pain, and chronic fatigue syndrome [53]. Individuals re-
your breath
porting exposure to trauma had 2.7 times higher odds of
Pains in heart or 0.082 0.747
having FSS. Combat exposure and PTSD had the stron-
chest
gest association with FSS. FSS typically accompanies
Faintness or 0.060 0.698 complaints included in the “weakness” factor. Apart from
dizziness sympathetic activation, the association of the “weakness”
Headaches 0.135 0.602 factor and overall pain with the PTSD CRITERION of
Nausea or upset 0.213 0.588 “negative alterations in cognitions and mood” is notable
stomach and points to other potential mechanisms; for example, it
Lump in your 0.350 0.490 is possible that the “weakness” symptoms may be asso-
throat ciated with fatigue overreported in dysphoric states that
Hot or cold spells 0.397 0.339 is incorporated in Criterion D.
Variance, % 45.7 10.3
Internal a ¼ 0.85 a ¼ 0.81 Somatic Symptoms and PMLD
consistency
The association of somatic complaints (i.e., somatization
Factor loadings higher than 0.40 are presented in bold. symptoms and pain) with postmigration living difficulties
has attracted little research attention to date. While
PMLDs have repeatedly been identified to be related to
mental health problems in refugees over and above
is one of the very first studies to examine distinct clus- trauma exposure [32,46,54–56], this is one of the first
ters of somatic symptoms and pain, their association studies to our knowledge to show an association with
with different PTSD clusters, and their association with regard to physical health complaints. The association of
PMLD. Our findings suggest a model of triangular rela- PMLD with the PTSD Criterion E and the “arousal” fac-
tion between the three elements: post-traumatic stress, tor and pain suggests a shared basis in terms of an ele-
postmigration living difficulties, and somatic symptoms. vated stress level, in analogy to the above-cited
Though by virtue of the cross-sectional study design the neurobiological and cognitive models. Again, it remains
causal direction of the respective associations remains unclear whether PMLDs result in stress and stress-
unclear, some subpatterns can be distinguished. associated somatic complaints, or if PTSD and somatic
complaints would rather map into PMLD due to func-
Somatic Symptoms and PTSD tional impairment, or a combination of both.
The relationship between the “arousal” factor of somatic Apart from nonspecific elevated stress levels resulting
symptoms and PTSD Criterion E is not surprising. PTSD from PMLD, another hypothesis for the relationship be-
models have suggested that the relationship between tween somatic symptoms and PMLD is social rejection,
pain and PTSD, particularly the arousal symptoms (i.e., in terms of social pain. Social rejection might be particu-
hypervigilance, exaggerated startle response), is a func- larly perceived by refugees, who, after their displace-
tion of sympathetic hyperactivation (or diminished para- ment, are confronted with often adverse social
sympathetic activation) and the altered HPA-axis environments in hosting societies. In an experimental
54Trauma and Somatic Symptoms in Traumatized Refugees
Table 3 Pearson’s correlation of somatization symptoms and overall pain with potentially traumatic
events, PTSD symptom criteria and living difficulties (N ¼ 134)
1 2 3 4 5 6 7 8
1 “Weakness”
2 “Arousal” 0.634**
3 Overall pain 0.658** 0.630**
4 PTE 0.208* 0.193* 0.120
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5 PTSD Criterion B 0.349** 0.329** 0.278* 0.159
6 PTSD Criterion C 0.241** 0.233** 0.227* 0.179* 0.428**
7 PTSD Criterion D 0.439** 0.392** 0.385* 0.161 0.450** 0.501**
8 PTSD Criterion E 0.572** 0.511** 0.434* 0.300** 0.480** 0.441** 0.532**
9 PMLD 0.296** 0.340** 0.261* 0.201* 0.233** 0.221* 0.260** 0.267**
Criterion B ¼ intrusion symptoms; Criterion C ¼ persistent avoidance of stimuli associated with the trauma; Criterion D ¼ negative
alterations in cognitions and mood; Criterion E ¼ alterations in arousal and reactivity; PMLD ¼ postmigration living difficulties;
PTE ¼ potentially traumatic events; PTSD ¼ post-traumatic stress disorder.
*Morina et al.
Table 4 Summary of the multiple regression analyses of somatization factors and overall pain, age,
gender, trauma, PTSD symptom criteria, and living difficulties (N ¼ 134)
Outcome Independent Adjusted
variable variable B SEB b T P F P R2 R2
“Weakness” 10.313 0.000 0.398 0.359
Age 0.014 0.007 0.139 1.960 0.052
Gender 0.067 0.166 0.028 0.400 0.690
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Trauma 0.007 0.016 0.032 0.427 0.670
Living difficulties 0.033 0.017 0.144 1.937 0.055
PTSD Criterion B 0.150 0.245 0.052 0.613 0.541
PTSD Criterion C 0.203 0.178 0.097 1.141 0.256
PTSD Criterion D 0.438 0.187 0.213 2.344 0.021
PTSD Criterion E 0.881 0.184 0.434 4.783 0.000
“Arousal” 8.843 0.000 0.361 0.321
Age 0.011 0.006 0.124 1.694 0.093
Gender 0.313 0.150 0.153 2.087 0.039
Trauma 0.008 0.014 0.045 0.591 0.556
Living difficulties 0.044 0.016 0.215 2.819 0.006
PTSD Criterion B 0.186 0.221 0.073 0.844 0.401
PTSD Criterion C 0.131 0.160 0.071 0.816 0.416
PTSD Criterion D 0.272 0.168 0.151 1.618 0.108
PTSD Criterion E 0.640 0.166 0.360 3.861 0.000
Overall pain 7.285 0.000 0.322 0.277
Age 0.023 0.009 0.206 2.771 0.008
Gender 0.553 0.204 0.206 2.708 0.008
Trauma 0.002 0.020 0.007 0.088 0.930
Living difficulties 0.043 0.021 0.159 2.010 0.047
PTSD Criterion B 0.142 0.300 0.043 0.472 0.638
PTSD Criterion C 0.086 0.222 0.036 0.387 0.699
PTSD Criterion D 0.512 0.230 0.217 2.231 0.028
PTSD Criterion E 0.646 0.226 0.277 2.857 0.005
Criterion B ¼ intrusion symptoms; Criterion C ¼ persistent avoidance of stimuli associated with the trauma; Criterion D ¼ negative
alterations in cognitions and mood; Criterion E ¼ alterations in arousal and reactivity; Gender ¼ 1: male, 2: female; Living difficul-
ties ¼ count of postmigration living difficulties; PTSD ¼ post-traumatic stress disorder; Trauma ¼ count of experienced potentially
traumatic events.
Future research should include longitudinal studies con- involved in the conception of the study, in the analysis
ducting multivariate analyses with larger sample sizes in and interpretation of the data, and in the drafting of the
order to investigate indicators and causal factors, in manuscript. RB was involved in the conception of the
which the two factors “weakness” and “arousal” are study, in the analysis and interpretation of the data, and
related to aspects of trauma experience and in the drafting of the manuscript. AN was involved in the
postmigration living difficulties. conception and design of the study, the analysis and in-
terpretation of the data, and the drafting of the manu-
script. MS was involved in the design of the study, the
Authors’ Contributions acquisition, analysis and interpretation of the data, and
the drafting of the manuscript. NM and AK contributed
Naser Morina and Alexa Kuenburg contributed equally equally to this manuscript. All authors read and ap-
to this article. proved the final manuscript.
NM was involved in the conception and design of the
study, the acquisition, analysis, and interpretation of the
data, and the drafting of the manuscript. He is account- References
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