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Impact of past events and comorbidity of Quis and PTSD in Bali

The impact of traffic accidents in Indonesia

The Qids Is a Tool Which Is Used To Design a Self-Report To Screening For Depression And To Measure The Changes In Individual’s Life. These Qids Involve Basic Questions Which Involves The Basic Daily Life Question Of An Individual Like Their Sleep Pattern And Hours, Concentration, Their Thoughts On Their Life To Examine Whether They Have One Disorder Or More. The Quis Is Responsible To Measure The Impact Of Past Events Of An Individual That How Much The Affected From Their Circumstances. It Also Used To Measure The Severity Of Ptsd. The Comorbidity Between These Two Is Occur Is To Analyze The Severity Of Ptsd By Questionnaire. By This, The Questions Are Interlinked With The Past Conditions Of Individuals. With The Help Of Co-Morbidity, The Analyses Of The Ptsd Can Be Achieved In More Effective Manner So The Patient Can Be Treated Well. The Comorbidity Of Quis And Ptsd Is Involved Both Mentally And Physically Disorders So That The Researcher Can Find Out The Cause Of Ptsd Effectively (Maccani Et Al., 2012).  

Post-Traumatic Stress Disorder (PTSD) is found in people who have experienced major negative events in their life such as a natural or man-made disaster. Researches show that people who have survived devastating car accidents have the symptoms of PTSD and it is said that the main cause of PTSD is car accidents in the general population.

Traffic in Indonesia is the reason for many accidents occurring, which is causing severe and fatal injury in the last 10 years. The most popular means of transport in Indonesia is motor vehicles because of its unmatched degree of mobility and agility. Even though it is not prone to accidents but injuries due to motor vehicle is the major cause of accidents in this area and traumatic events that comes after a serious road accident can affect both mentally and physically. PTSD is the most common disorders that affects patients who have survived major accidents.

In Bali, the general population has faced severe cases of PTSD due to which a range of observations is noted. The population of Bali believes that when people experience an accident or a trauma, their soul loss is a physical, social and spiritual condition. The shock that occurs due to the accident makes a person’s soul leave their body and travels to the site where the calamity occurred. They also believe that the accidents are caused by deities and spirits and some of them agree that it is caused by physical forces. This belief conflicts the spiritual and physical aspects of life and so the prevention of accidents is related to spirituality. The spiritual and social repercussions are remedied through soul retrieved rituals because of them being central to social, spiritual and psychological healing to the accident victims. Balinese people say that accident causes soul loss, which is a threatening condition that makes them consider all types of spiritual rituals so that they can prevent such accidents. Bali’s 90% population practices Hinduism and they are highly ritualized and intensely spiritual and this religion has principles that black magic, spirits and the Gods are always around the human world. People in Bali are acceptable of this belief and they make it a part of their life. They consider a motor accident to be a material representation of a major change occurring in their life and an approaching car accident in the context of Balinese Hinduism might be about a changing spiritualty that offers control to the people. An accident indicates that people in Bali should slow down their worldly activities and involve in more of traditional soul retrieval rituals (Wilson & Moran et al., 1998).

Beliefs on PTSD and soul loss in Bali

The western society reacts to PTSD in an informative manner, which suggests that they are more aware about the disorder of this disease and the consequences. They also realize the problems faced by a PTSD patient, who are seeking for help. On the contrary, people in Bali have a different take on PTSD because they consider it as a spiritual change in a person’s life and the way it can be prevented is with the help of spiritual guidance. The western society is more progressive about certain issues such as mental disorders as compared to Balinese people because they are adaptable to these diseases (Blevins et al., 2015).

Cronbach’s alpha will be used for this study as it is an internal consistency measurement and is closely related to set of items as a group. The scale reliability is included in cronbach’s alpha and the one dimensional aspect is not necessary during a high value.

PCL-5: The Posttraumatic Stress Disorder Checklist is one of the most commonly studied and used assessment instruments for PTSD (Weathers, Litz, Herman, Huska, & Keane, 1993; Weathers et al., 2013). The scale was recently updated to comport with changes to the PTSD symptom criteria adopted in the DSM-5 (American Psychiatric Association, 2013).

It is a reliable screening instrument for PTSD in community samples (Ashbaugh, Houle-Johnson, Herbert, El-Hage, & Brunet, 2016; Biehn et al., 2013). Although studies have examined the previous version of the PCL in different cultural contexts like China, Sri Lanka and Chile, only one published study (Ashbaugh et al., 2016) validated the newer PCL-5 in a language other than English (French).

At present, there are no known evidence that prove the validation of PCL-5 in Balinese population. The PCL-5 was used to assess the DSM-5 symptoms of PTSD. It is composed of 20 items which are for PTSD outlined in DSM-5 and contains four sub-scales corresponding to the four symptom clusters: The four factors structure are interpersonal, lifestyle, antisocial and effective. They are internally linked. It is rated by psychologist and is used to allow people to rate their psychopathic and antisocial habits (Fodor and et. al., 2015).

A person suffering from PTSD due to accidents have almost similar effects compared to a person who is suffering from PTSD due to other reasons. Other reason for PTSD might be natural disasters, violent crime, sexual assault, riots, war, torture, terrorism or life threatening illness. The basic difference is that the person has recurring incidences of the accident in certain intervals. They have feelings of guilt, shock, helplessness and fear because accident is caused due to their fault most of times. On the contrary the PTSD caused due to other reasons are not as traumatic because of the above reason as natural death or disasters is not caused due to any man.

Western society's view of PTSD compared to Bali

The PTSD diagnosis has recently undergone substantial revision in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association, 2013). The most notable change for PCL-5 included that three new PTSD symptoms are added (blame, negative emotions, and reckless or self‐destructive behavior. The diagnosis now comprises 20 symptoms instead of the previous 17, grouped into four symptom clusters: Intrusion, Avoidance, Negative alterations of cognitions and mood, and Alterations in arousal and reactivity. An implication of these revisions is that instruments assessing symptoms of PTSD need to be revised according to the DSM-5. The PTSD Checklist (PCL), which is one of the most widely used self-report instruments for the assessment of PTSD symptoms, now exists in a modified fifth version with 20 items, each one corresponding to a single symptom of PTSD (PTSD Checklist for DSM-5, or PCL-5) (Weathers et al., 2013). It is one of the most widely used measures for PTSD in both research and clinical settings with satisfactory psychometric properties (McDonald & Calhoun, 2010).

Finally, according to risk factors the gender Differences have to be tested. Various studies have proved gender differences in PTSD. Females are approximately twice as likely as males to develop PTSD following exposure to a traumatic event (Breslau et al., 1998; Kessler et al., 1995). A meta-analysis by Tolin and Foa (2006)found that females were at greater risk for developing PTSD despite reporting exposure to fewer traumatic events than males. We are expecting that women will have more PTSD than men.

The LEC used for the exposure of PTSD traumatic event. The LEC are accessible from three information and it includes extended self-report, standard self-effort and interview. The LEC-5 is linked with the PCL-5 with 17 item self-report. A self-report is used to standard the health problem events in responsive life. It is in use to set up of revealing to a PTSD a traumatic event. The LEC is the most widely-used self-report instrument for assessment of potentially traumatic events in adults (Elhai et al., 2005). It is also one of the few scales of its type whose psychometric properties have already been critically evaluated (Gray et al., 2004).

A Quick Inventory of Depressive Symptomatology (QIDS) questionnaire is used for detecting the level of depression before or after a treatment. It finds the depressive symptoms in a person as it is a 16 item process. It is also used for diagnosing the stages of PTSD because the score suggests the condition of person’s mental health. The comorbid psychological symptoms are detected through this questionnaire in a person who is suffering from PTSD.

PCL-5 as a reliable screening instrument

The greatest trauma for a parent is the loss of a child and it is higher than losing a parent or a spouse. A child’s death is extremely traumatic because it is unexpected. It also violates the usual custom of a child burying a parent because a parent has to bury a child in this situation. The loss of a child can cause severe physiological and psychological traumas such as depression, cognitive and physical symptoms, anxiety and even PTSD. It can persist longer even after the death of the child and can lead to psychiatric conditions and grief disorders. The symptoms found in a person who has just lost their kid is similar to the case of PTSD, as it is also listed in DSM-5(Christiansen, Elklit & Olff, 2013).

To date, there is a lack of studies assessing the psychometric properties of PCL-5 in non-western societies, like Bali. The present study has multiple objectives.  The recent changes in the definition and diagnostic criteria of PTSD created an urgent need to revise the instruments available to measure the construct. The first is to assess the validity and reliability of PCL-5 in the Balinese population. Reliability will be assessed by internal consistency and inter rater reliability. Convergent validity will be assessed by combining PCL-5 with LEC and QUIDS questionnaires. Furthermore, construct validity will be assessed by examining gender differences, the type of the relationship with the deceased and the differences according to the presence of the accident. It is expected that, according to previous literature. Finally, factor analysis will be used to examine the factor structure of the PCL-5. It is expected to find the four factors that PCL-5 is based. The above analyses are run in a sample of Balinese at risk for PTSD.

By this cross-sectional survey of this project, the addresses and names of grieving persons (n=301), were given through the administration from the University of Udayana, insurance companies and the largest public hospital in Bali, the Sanglah Hospital. Moreover, applicants were newcomer through with the snowball selection method. The contestants were enquired to fill out many questionnaires including the TGI-SR, the QIDS and LEC. Furthermore, all participants were asked questions about multiple demographic information, details about the nature of their relationship to the deceased, their engagement in the accident, and information about mental unwellness the applicants or their family might suffer from. Male and female participants who are 18 years old and over are included and had lost a relative, spouse or relative-in-law due to a traffic accident. Excluded of the contestant who lost somebody more than three years earlier the study was passageway and participants who were not adept in Bahasa Indonesia. The language of Balinese dwell of aggregate sub-languages. To get clear written record, this study was translated to only Bahasa Indonesia.

Proposed risk factors for PTSD symptoms

Two bilingual Public Health Medical doctors interpreted two questionnaires (TGI-SR and WSAS) from English into Bahasa Indonesia, They get the translation of the QIDS from last study manage in Jakarta (Arjadi, Nauta, Utoya & Bckting, 2017). Following, the translated questionnaires were critically reviewed, focusing on the comprehensibility, relevance and cultural appropriateness.

The data were collected by interviewing the participants at home. The interviewers were recruited based on competence, commitment to the research and their study major as well as progress. Medical, psychology and public health students, who were in their last years of study, could join the project as research assistants. After being selected, they received a three-day training, including workshops on research skills and the administration of questionnaires.

The PCL-5 is used to measure of DSM-5 PTSD (Weathers et al., 2013).  It is used in quantifying severity of PTSD symptoms to change over time in members. These items are referred to a repeated, disturbing and unwanted memories of a stressful event that happened at least a last month ago. PCL-5 is rated on a 5- point Likert-type scale (0 = ‘‘not at all’’ to 4 = ‘‘extremely’’). Total scores range from 0 to 80 and a preliminary cutoff score of 38 is recommended as indicating PTSD case. The PCL-5 has 4 subscales, corresponding to each of the symptom clusters in the DSM-5: Intrusion (five items), Avoidance (two items), Negative alterations in cognitions and mood (seven items), and Alterations in arousal and reactivity (six items).  Respondents rated how much a problem described in the item statement bothered them over the past month.

The LEC is a self-report questionnaire asking for the prevalence of 16 potentially traumatic life-time events plus an added open category (“any other very stressful event or experience”) with five answer categories. The LEC was translated into Balinese language. The respondents are asked to indicate whether they have experienced, witnessed, or learned about 17 different traumatic events, or any other particularly distressing experiences not encompassed by the other 17 items. (Gray, 2004). These items include life events such as natural disasters, physical or sexual aggression, severe injuries, violent death (homicide or suicide), and others. For each situation, the respondent is asked to indicate the type of exposure (i.e., whether he/she experienced the event directly or witnessed an event or situation involving a close relative or friend and if it was related to occupational activities).

Date of death (of the victim), relationship between respondents and/ with the victim they were registered. Gender of participant were also assessed. Finally, the time of accident and if the participant was directly involved in an accident was examined.

Gender differences in PTSD

All analyses were performed with the statistical package SPSS Statistical package version 21. The internal consistency of the PCL-5 was evaluated with Cronbach’s alpha coefficients. Cronbach’s alpha of 0.70 and above is regarded as satisfactory (Nunnally, 1978). Inter-rater reliability construct and convergent validity were assessed with Pearson r correlations).


Ashbaugh, A. R., Houle-Johnson, S., Herbert, C., El-Hage, W., & Brunet, A. (2016). Psychometric validation of the English and French versions of the posttraumatic stress disorder checklist for DSM-5 (PCL-5). PloS one, 11(10), e0161645.

Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The posttraumatic stress disorder checklist for DSM‐5 (PCL‐5): Development and initial psychometric evaluation. Journal of traumatic stress, 28(6), 489-498.

Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. C., & Andreski, P. (1998). Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Archives of general psychiatry, 55(7), 626-632.

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Fodor, K. E., Pozen, J., Ntaganira, J., Sezibera, V., & Neugebauer, R. (2015). The factor structure of posttraumatic stress disorder symptoms among Rwandans exposed to the 1994 genocide: A confirmatory factor analytic study using the PCL-C. Journal of Anxiety Disorders, 32, 8-16.

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Maccani, M. A., Delahanty, D. L., Nugent, N. R., & Berkowitz, S. J. (2012). Pharmacological secondary prevention of PTSD in youth: challenges and opportunities for advancement. Journal of traumatic stress, 25(5), 543-550.

McDonald, S. D., & Calhoun, P. S. (2010). The diagnostic accuracy of the PTSD checklist: a critical review. Clinical psychology review, 30(8), 976-987.

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Nunnally, J. C. (1978). An overview of psychological measurement. In Clinical diagnosis of mental disorders (pp. 97-146). Springer, Boston, MA.

Tolin, D. F., Worhunsky, P., & Maltby, N. (2006). Are “obsessive” beliefs specific to OCD?: A comparison across anxiety disorders. Behaviour Research and Therapy, 44(4), 469-480.

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Wilson, J. P., & Moran, T. A. (1998). Psychological trauma: Posttraumatic stress disorder and spirituality. Journal of Psychology and Theology, 26(2), 168-178.

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