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A Systematic Review of Evidence-Based Family Interventions for Trauma-Affected Refugees. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159361. [PMID: 35954717 PMCID: PMC9367780 DOI: 10.3390/ijerph19159361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022]
Abstract
Family connections are crucial for trauma-affected refugees from collectivistic cultures. Evidence-based family interventions are consistently promoted to support a host of mental and relational health needs of families exposed to traumatic stressors; however, there is still limited research focused on cultural adaptation and the testing of the effectiveness of these interventions on some of the most disenfranchised populations in the aftermath of forced displacement. This systematic review was conducted to examine the reach of existing evidence-based family interventions implemented with newly resettled refugees globally. Studies included in this review include those testing the effectiveness of a systemic treatment with pre and post intervention evaluation, studies with or without control groups, and studies that include at least one family member in addition to the target participants. Twelve studies met the inclusion criteria. Barriers to conducting randomized control trials with displaced refugee populations are discussed. Recommendations are made for future studies to include a focus on scientifically rigorous multi-method designs, specific cultural adaptation frameworks, and the integration of relational aspects rather than focusing only on individual adjustment. Global displacement continues to rise; therefore, it is imperative that the mental health and wellbeing of displaced populations be treated with a comprehensive, multi-level framework.
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Lane P, Smith D. Culture, Ageing and the Construction of Pain. Geriatrics (Basel) 2018; 3:E40. [PMID: 31011078 PMCID: PMC6319244 DOI: 10.3390/geriatrics3030040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 01/12/2023] Open
Abstract
In this paper, the authors seek to discuss some of the complexities involved in cross-cultural working in relation to the communication and management of pain in older people. Specifically, the paper addresses the culture construction of ageing and how pain is often constructed as a natural part of ageing. The authors also suggest that with the rise of the ideology of active-ageing, many older people who are disabled or living in chronic pain, may feel a moral imperative to hide pain and ill-health. The discussion extends into looking at the impact of culture and the communication of pain, including specific idioms of distress, somaticize and the lay-management of pain through stoicism. The literature utilised in this paper was based on a thematic review, exploring the cultural dimensions of health, illness and pain in old age. The review also drew on the authors' previous publications, as well as their extensive community research experience working with ethnic minority communities.
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Affiliation(s)
- Pauline Lane
- Faculty of Health Social Care and Education, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, Essex, CM1 1SQ, UK.
| | - David Smith
- Faculty of Health Social Care and Education, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, Essex, CM1 1SQ, UK.
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Migraine-Like Visual Auras Among Traumatized Cambodians with PTSD: Fear of Ghost Attack and Other Disasters. Cult Med Psychiatry 2018; 42:244-277. [PMID: 29019040 DOI: 10.1007/s11013-017-9554-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article profiles visual auras among traumatized Cambodian refugees attending a psychiatric clinic. Thirty-six percent (54/150) had experienced an aura in the previous 4 weeks, almost always phosphenes (48% [26/54]) or a scintillating scotoma (74% [40/54]). Aura and PTSD were highly associated: patients with visual aura in the last month had greater PTSD severity, 3.6 (SD = 1.8) versus 1.9 (SD = 1.6), t = 10.2 (df = 85), p < 0.001, and patients with PTSD had a higher rate of visual aura in the last month, 69% (22/32) versus 13% (7/55), odds ratio 15.1 (5.1-44.9), p < 0.001. Patients often had a visual aura triggered by rising up to the upright from a lying or sitting position, i.e., orthostasis, with the most common sequence being an aura triggered upon orthostasis during a migraine, experienced by 60% of those with aura. The visual aura was often catastrophically interpreted: as the dangerous assault of a supernatural being, most commonly the ghost of someone who died in the Pol Pot period. Aura often triggered flashback. Illustrative cases are provided. The article suggests the existence of local biocultural ontologies of trauma as evinced by the centrality of visual auras among Cambodian refugees.
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Comellas RM, Makhashvili N, Chikovani I, Patel V, McKee M, Bisson J, Roberts B. Patterns of somatic distress among conflict-affected persons in the Republic of Georgia. J Psychosom Res 2015; 78:466-471. [PMID: 25676335 PMCID: PMC4390160 DOI: 10.1016/j.jpsychores.2015.01.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/27/2015] [Accepted: 01/30/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are substantial risk factors for somatic distress (SD) among civilian populations affected by armed conflict in low and middle income countries. However, the evidence is very limited. Our aim was to examine patterns of SD among conflict-affected persons in the Republic of Georgia, which has over 200,000 internally displaced persons (IDPs) from the wars over separatists regions in the 1990s and with Russia in 2008. METHODS A cross-sectional household survey was conducted with 3600 randomly selected IDPs and former IDPs (returnees). SD was measured using the Patient Health Questionnaire (PHQ-15). Post-traumatic stress disorder (PTSD), depression, anxiety, and disability were measured using the Trauma Screening Questionnaire, Patient Health Questionnaire 9, Generalised Anxiety Disorder 7, and WHO Disability Assessment Schedule 2.0, respectively. Descriptive, tetrachoric and multivariate regression analyses were used. RESULTS Forty-two percent of respondents (29% men; 48% women) were recorded as at risk of SD (PHQ-15 score >5). In tetrachoric analysis, SD scores were highly correlated with depression (r = 0.60; p < 0.001), PTSD (r = 0.54; p < 0.001), and anxiety (r = 0.49; p < 0.001). Factors significantly associated with SD in the multivariate regression analysis were depression, PTSD, anxiety, individual trauma event exposure, cumulative trauma exposure, female gender, older age, bad household economic status, and being a returnee compared to an IDP. SD was also associated with increased levels of functional disability (b = 6.73; p < 0.001). CONCLUSIONS The high levels of SD among IDPs and returnees in Georgia indicate significant suffering. The findings have implications for both mental and physical health services in Georgia.
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Affiliation(s)
- Ruben Moreno Comellas
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nino Makhashvili
- Global Initiative on Psychiatry–Tbilisi, Tbilisi, Georgia,Ilia State University, Tbilisi, Georgia
| | | | - Vikram Patel
- Cardiff University School of Medicine and Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Martin McKee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jonathan Bisson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bayard Roberts
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Wagner J, Burke G, Kuoch T, Scully M, Armeli S, Rajan TV. Trauma, healthcare access, and health outcomes among Southeast Asian refugees in Connecticut. J Immigr Minor Health 2014; 15:1065-72. [PMID: 22976796 DOI: 10.1007/s10903-012-9715-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Mental health problems among Southeast Asian refugees have been documented. However, longer term health consequences of mass violence as re-settled refugees age are less well described. This study investigated relationships among trauma symptoms, self-reported health outcomes, and barriers to healthcare among Cambodian and Vietnamese persons in Connecticut. An internet phone directory was used to generate a list of names that was compared to 2000 census data to estimate the proportion of the population in each group. From these lists, 190 telephone listings were selected at random. Interviewers telephoned selected listings to screen for eligible participants and obtain an appointment for interview. Surveys were administered through face-to-face interviews during home visits conducted in Khmer or Vietnamese. The Harvard Trauma Questionnaire assessed trauma symptoms. Questions regarding the presence of physician diagnosed heart disease, hypertension, diabetes, and chronic pain were adapted as written from the Health Interview Survey. Healthcare access and occurrence were measured with questions regarding cost and access, patient-provider understanding, and interpretive services. Hierarchical modeling was used to account for respondent nesting within family. Analyses controlled for age, sex, and country of origin. Individuals who reported greater trauma symptoms were more likely to report heart disease by a factor of 1.82, hypertension by a factor of 1.41, and total count of diseases by a factor of 1.22, as well as lower levels of subjective health. Greater trauma symptoms were also associated with greater lack of understanding, cost and access problems, and the need for an interpreter. Although the majority of Southeast Asian immigrants came to the United States as refugees approximately 20-30 years ago, there continues to be high levels of trauma symptoms among this population which are associated with increased risk for disease and decreased access to healthcare services.
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Affiliation(s)
- Julie Wagner
- University of Connecticut Health Center, MC3910, 263 Farmington Ave., Farmington, CT, 06030, USA,
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Ayazi T, Lien L, Eide A, Swartz L, Hauff E. Association between exposure to traumatic events and anxiety disorders in a post-conflict setting: a cross-sectional community study in South Sudan. BMC Psychiatry 2014; 14:6. [PMID: 24410951 PMCID: PMC3893536 DOI: 10.1186/1471-244x-14-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 01/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The negative effect of exposure to traumatic events on mental health is well known. Most studies of the effects of trauma on mental health in war-affected populations have focused on post-traumatic stress disorder (PTSD) and depression. Although some studies confirm the existence of anxiety symptoms in war-affected populations, the extent to which exposure to traumatic events is independently associated with anxiety diagnoses (other than PTSD) has received less attention. The study aimed to determine whether having an anxiety diagnosis, other than PTSD, was associated with experiencing traumatic events in a post-conflict setting, across genders and after controlling for demographic and socio-economic variables. METHODS In this cross-sectional community study (n = 1200), we applied the Harvard Trauma Questionnaire (HTQ) to investigate the extent of trauma exposure and PTSD. The Mini-International Neuropsychiatric Interview (MINI) was used to investigate the prevalence of anxiety disorders: generalized anxiety disorder (GAD), panic disorder (PD), social phobia, obsessive-compulsive disorder (OCD), and agoraphobia. Multinomial logistic regression analyses were conducted to examine the association between these disorders, previous trauma exposure, and socio-economic factors. RESULTS The participants were 56.4% male and 43.6% female. The age ranged between 18 and 73 years old (Mean 34.63, SD = 12.03). The estimated rates of GAD-only and PD-only (without comorbidity with PTSD) were 5.5% and 3.1%, respectively. Exposure to traumatic events and socio-economic disadvantage were significantly associated with having one or more anxiety diagnoses. After controlling for age, sex, rural/urban setting, and socio-economic disadvantage, exposure to trauma was independently associated with anxiety diagnosis. There were gender differences in the pattern of risk factors for having PTSD, GAD or PD. CONCLUSION In individuals with a history of war-related trauma exposure, attention should be given to symptoms of GAD and PD, in addition to PTSD symptoms.
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Affiliation(s)
- Touraj Ayazi
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, PO Box 1171, Blindern, 0318 Oslo, Norway.
| | - Lars Lien
- National Center for Dual Diagnosis, Innlandet Hospital Trust, Furnesvegen 26, 2380 Brumunddal, Norway,Faculty of Public Health, Hedmark University College, PO Box 400, 2418 Elverum, Norway
| | - Arne Eide
- SINTEF Technology and Society, PO Box 124, Blindern, 0314 Oslo, Norway
| | - Leslie Swartz
- Alan J. Flisher Centre for Public Mental Health, Department of Psychology, Stellenbosch University, Private Bag X1, 7602 Matieland, South Africa
| | - Edvard Hauff
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, PO Box 1171, Blindern, 0318 Oslo, Norway,Division of Mental Health and Addiction, Department of Research and Development, Oslo University Hospital, Ulleval, Kirkeveien 166, Building 20, 0407 Oslo, Norway
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Hinton DE, Nickerson A, Bryant RA. Prolonged Grief in Cambodian Refugees Following Genocide: Rebirth Concerns and Avoidance of Reminders. JOURNAL OF LOSS & TRAUMA 2013. [DOI: 10.1080/15325024.2012.714218] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Saint Arnault D, Shimabukuro S. The Clinical Ethnographic Interview: a user-friendly guide to the cultural formulation of distress and help seeking. Transcult Psychiatry 2012; 49:302-22. [PMID: 22194348 PMCID: PMC3749914 DOI: 10.1177/1363461511425877] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transcultural nursing, psychiatry, and medical anthropology have theorized that practitioners and researchers need more flexible instruments to gather culturally relevant illness experience, meaning, and help seeking. The state of the science is sufficiently developed to allow standardized yet ethnographically sound protocols for assessment. However, vigorous calls for culturally adapted assessment models have yielded little real change in routine practice. This paper describes the conversion of the Diagnostic and Statistical Manual IV, Appendix I Outline for Cultural Formulation into a user-friendly Clinical Ethnographic Interview (CEI), and provides clinical examples of its use in a sample of highly distressed Japanese women.
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Bentley JA, Thoburn JW, Stewart DG, Boynton LD. The indirect effect of somatic complaints on report of posttraumatic psychological symptomatology among Somali refugees. J Trauma Stress 2011; 24:479-82. [PMID: 21755542 DOI: 10.1002/jts.20651] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Somali refugees are a growing population of displaced persons at risk for considerable traumatic exposure and its subsequent psychological symptomatology. Two hypotheses were proposed to evaluate the relationships between somatic complaints and posttraumatic psychological symptoms in a community-based sample of 74 adult Somali participants. As hypothesized, traumatic exposure predicted increased symptoms of posttraumatic stress disorder (PTSD; r = .64, p < .01), depression (r = .31, p < .01), and anxiety (r = .38, p < .01) in the basal model. In evaluation of the second hypothesis, somatic complaints were found to have a statistically significant indirect effect on the predictive relationship between traumatic life events and mood disturbance, accounting for 9% of the variance in depression and 14% of the variance in anxiety. However, somatic complaints failed to have an indirect effect on the relationship between traumatic exposure and symptoms of PTSD. Post hoc analyses revealed that, consistent with research conducted with nonrefugee populations, PTSD had a statistically significant indirect effect that accounted for 13% of the variance in the relationship between trauma and somatic complaints. These findings provide preliminary data regarding the influence of somatic complaints on the self-reported psychological symptoms of internationally displaced Somali refugees.
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Affiliation(s)
- Jacob A Bentley
- Department of Clinical Psychology, Seattle Pacific University, Seattle,WA 98119, USA.
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Nickerson A, Bryant RA, Silove D, Steel Z. A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clin Psychol Rev 2010; 31:399-417. [PMID: 21112681 DOI: 10.1016/j.cpr.2010.10.004] [Citation(s) in RCA: 313] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Revised: 10/22/2010] [Accepted: 10/29/2010] [Indexed: 12/01/2022]
Abstract
Despite much research evidence that refugees suffer from elevated rates of posttraumatic stress disorder (PTSD), relatively few studies have examined the effectiveness of psychological treatments for PTSD in refugees. The field of refugee mental health intervention is dominated by two contrasting approaches, namely trauma-focused therapy and multimodal interventions. This article firstly defines these two approaches, then provides a critical review of 19 research studies that have been undertaken to investigate the efficacy of these treatments. Preliminary research evidence suggests that trauma-focused approaches may have some efficacy in treating PTSD in refugees, but limitations in the methodologies of studies caution against drawing definitive inferences. It is clear that research assessing the treatment of PTSD in refugees is lagging behind that available for other traumatized populations. The review examines important considerations in the treatment of refugees. A theoretical framework is offered that outlines contextual issues, maintaining factors, change mechanisms and the distinctive challenges to traditional trauma-focused treatments posed by the needs of refugees with PTSD.
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Affiliation(s)
- Angela Nickerson
- School of Psychology, University of New South Wales, NSW 2052, Australia
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11
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Hooberman J, Rosenfeld B, Rasmussen A, Keller A. Resilience in trauma-exposed refugees: the moderating effect of coping style on resilience variables. THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY 2010; 80:557-563. [PMID: 20950296 DOI: 10.1111/j.1939-0025.2010.01060.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Research with survivors of torture has generated considerable variability in prevalence rates of posttraumatic stress disorder (PTSD). Multiple risk and resilience factors may affect this variability, increasing or decreasing the likelihood of experiencing psychological distress. This study sought to investigate the effect of several such resilience factors, coping style, social support, cognitive appraisals, and social comparisons on PTSD symptom severity. Furthermore, this study examined whether coping style moderated the relationship between resilience variables and PTSD symptoms. Seventy-five torture survivors completed an intake interview and several self-report measures upon entry into a treatment program for survivors of torture. Results indicated that emotion-focused coping styles significantly moderated the relationship between cognitive appraisal and social comparison variables and PTSD, and usually increased the likelihood of developing severe symptoms. These results indicate that the salience of resilience variables may differ depending on the individual's coping style, which present implications for clinical practice with torture survivors.
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Nickerson A, Bryant RA, Brooks R, Steel Z, Silove D. Fear of cultural extinction and psychopathology among Mandaean refugees: an exploratory path analysis. CNS Neurosci Ther 2010; 15:227-36. [PMID: 19691542 DOI: 10.1111/j.1755-5949.2009.00094.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The Mandaeans are a small religious community originating from Iraq and Iran who are facing the possibility of cultural extinction within the next few generations. This study aimed to examine the relationships between life experiences, psychopathology and fear of cultural extinction in Mandaean refugees. A survey was conducted of 315 adult Iraqi Mandaean refugees living in Australia. Past traumatic experiences and current resettlement difficulties were assessed. Mental health outcomes were also examined, including measures of posttraumatic stress disorder (PTSD) and depression. Fear of cultural extinction was measured by items developed in consultation with the Mandaean community. A path analysis was employed to investigate the relationship between trauma, living difficulties, PTSD, depression, and fear of cultural extinction. Results indicated that trauma and living difficulties impacted indirectly on fear of cultural extinction, while PTSD (and not depression) directly predicted levels of anxiety about the Mandaean culture ceasing to exist. The current findings indicate that past trauma and symptoms of posttraumatic stress contribute to fear of cultural extinction. Exposure to human rights violations enacted on the basis of religion has significant mental health consequences that extend beyond PTSD. The relationship between perception of threat, PTSD, and fear of cultural extinction is considered in the context of cognitive models of traumatic stress. Government immigration policy must prioritize the reunification of small, endangered groups to sustain cultural traditions. Treatment interventions implemented with cultural groups facing extinction should take into consideration anxiety about loss of culture.
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Affiliation(s)
- Angela Nickerson
- School of Psychology, University of New South Wales, NSW, Australia.
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Norton PJ, Weeks JW. A multi-ethnic examination of socioevaluative fears. J Anxiety Disord 2009; 23:904-8. [PMID: 19560315 PMCID: PMC2744744 DOI: 10.1016/j.janxdis.2009.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 05/27/2009] [Accepted: 05/28/2009] [Indexed: 11/18/2022]
Abstract
Established and emerging cognitive models of social anxiety have provided researchers and clinicians with a solid foundation for understanding and treating this phenomenon. Much of the support for these models, however, has been derived from predominantly Caucasian samples. While the evidence supports the concept of socioevaluative fears as being universal, ethnic/cultural influences can dramatically alter the cognitive profile of the fears. The purpose of this study was to examine the cross-ethnic equivalence of the bivalent fear of evaluation model of social anxiety among an ethnically diverse sample of 799 undergraduate students from the United States. A series of confirmatory factor analyses indicated good model fit for each of the ethnic groups examined, and that holding factor loadings and latent variances and covariances equivalent did not alter model fit significantly.
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Affiliation(s)
- Peter J Norton
- Department of Psychology, University of Houston, Houston, TX 77204-5022, USA.
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14
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Hinton DE, Rasmussen A, Nou L, Pollack MH, Good MJ. Anger, PTSD, and the nuclear family: a study of Cambodian refugees. Soc Sci Med 2009; 69:1387-94. [PMID: 19748169 DOI: 10.1016/j.socscimed.2009.08.018] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Indexed: 11/29/2022]
Abstract
This study profiles the family-directed anger of traumatized Cambodian refugees, all survivors of the Pol Pot genocide (1975-1979), who were patients at a psychiatric clinic in Lowell, MA, USA. We focus on the nuclear family (NF) unit, the NF unit defined as the patient's "significant other" (i.e. spouse or boyfriend/girlfriend) and children. Survey data were collected from a convenience sample of 143 Cambodian refugee patients from October 2006 to August 2007. The study revealed that 48% (68/143) of the patients had anger directed toward a NF member in the last month, with anger directed toward children being particularly common (64 of the 143 patients, or 49% [64/131] of the patients with children). NF-type anger was severe, for example, almost always resulting in somatic arousal (e.g., causing palpitations in 91% [62/68] of the anger episodes) and often in trauma recall and fears of bodily dysfunction. Responses to open-ended questions revealed the causes of anger toward a significant other and children, the content of anger-associated trauma recall, and what patients did to gain relief from anger. A type of cultural gap, namely, a linguistic gap (i.e., the parent's lack of English language skills and the child's lack of Khmer language skills), seemingly played a role in generating conflict and anger. NF-type anger was associated with PTSD presence. The effect of anger on PTSD severity resulted in part from anger-associated trauma recall and fears of bodily dysfunction, with 54% of the variance in PTSD severity explained by that regression model. The study: 1) suggests that among traumatized refugees, family-related anger is a major clinical concern; 2) illustrates how family-related anger may be profiled and investigated in trauma-exposed populations; and 3) gives insights into how family-related anger is generated in such populations.
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Affiliation(s)
- Devon E Hinton
- Massachusetts General Hospital, Harvard Medical School, Department of Psychiatry, Boston, USA.
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15
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Brown RA, Kuzara J, Copeland WE, Costello EJ, Angold A, Worthman CM. Moving from ethnography to epidemiology: lessons learned in Appalachia. Ann Hum Biol 2009; 36:248-60, 2 p following 260. [PMID: 19353406 DOI: 10.1080/03014460902832942] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Anthropologists are beginning to translate insights from ethnography into tools for population studies that assess the role of culture in human behavior, biology, and health. AIM We describe several lessons learned in the creation and administration of an ethnographically-based instrument to assess the life course perspectives of Appalachian youth, the Life Trajectory Interview for Youth (LTI-Y). Then, we explore the utility of the LTI-Y in predicting depressive symptoms, controlling for prior depressive symptoms and severe negative life events throughout the life course. SUBJECTS AND METHODS In a sample of 319 youths (190 White, 129 Cherokee), we tested the association between depressive symptoms and two domains of the LTI-Y - life course barriers and milestones. Longitudinal data on prior depressive symptoms and negative life events were included in the model. RESULTS The ethnographically-based scales of life course barriers and milestones were associated with unique variance in depressive symptoms, together accounting for 11% of the variance in this outcome. CONCLUSION When creating ethnographically-based instruments, it is important to strike a balance between detailed, participant-driven procedures and the analytic needs of hypothesis testing. Ethnographically-based instruments have utility for predicting health outcomes in longitudinal studies.
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Affiliation(s)
- Ryan A Brown
- Human Development and Social Policy, Northwestern University, Chicago, IL 60208, USA.
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16
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Hinton DE, Hofmann SG, Pollack MH, Otto MW. Mechanisms of efficacy of CBT for Cambodian refugees with PTSD: improvement in emotion regulation and orthostatic blood pressure response. CNS Neurosci Ther 2009; 15:255-63. [PMID: 19691545 PMCID: PMC6494047 DOI: 10.1111/j.1755-5949.2009.00100.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Based on the results of a randomized controlled trial, we examined a model of the mechanisms of efficacy of culturally adapted cognitive-behavior therapy (CBT) for Cambodian refugees with pharmacology-resistant posttraumatic stress disorder (PTSD) and comordid orthostatic panic attacks (PAs). Twelve patients were in the initial treatment condition, 12 in the delayed treatment condition. The patients randomized to CBT had much greater improvement than patients in the waitlist condition on all psychometric measures and on one physiological measure-the systolic blood pressure response to orthostasis (d = 1.31)-as evaluated by repeated-measures MANOVA and planned contrasts. After receiving CBT, the Delayed Treatment Group improved on all measures, including the systolic blood pressure response to orthostasis. The CBT treatment's reduction of PTSD severity was significantly mediated by improvement in orthostatic panic and emotion regulation ability. The current study supports our model of the generation of PTSD in the Cambodian population, and suggests a key role of decreased vagal tone in the generation of orthostatic panic and PTSD in this population. It also suggests that vagal tone is involved in emotion regulation, and that both vagal tone and emotion regulation improve across treatment.
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Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, WACC 812, Boston, MA, USA.
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17
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Hinton DE, Hofmann SG, Pitman RK, Pollack MH, Barlow DH. The panic attack-posttraumatic stress disorder model: applicability to orthostatic panic among Cambodian refugees. Cogn Behav Ther 2008; 37:101-16. [PMID: 18470741 DOI: 10.1080/16506070801969062] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This article examines the ability of the panic attack-posttraumatic stress disorder (PTSD) model to predict how panic attacks are generated and how panic attacks worsen PTSD. The article does so by determining the validity of the panic attack-PTSD model in respect to one type of panic attack among traumatized Cambodian refugees: orthostatic panic (OP) attacks (i.e. panic attacks generated by moving from lying or sitting to standing). Among Cambodian refugees attending a psychiatric clinic, the authors conducted two studies to explore the validity of the panic attack-PTSD model as applied to OP patients (i.e. patients with at least one episode of OP in the previous month). In Study 1, the panic attack-PTSD model accurately indicated how OP is seemingly generated: among OP patients (N = 58), orthostasis-associated flashbacks and catastrophic cognitions predicted OP severity beyond a measure of anxious-depressive distress (Symptom Checklist-90-R subscales), and OP severity significantly mediated the effect of anxious-depressive distress on Clinician-Administered PTSD Scale severity. In Study 2, as predicted by the panic attack-PTSD model, OP had a mediational role in respect to the effect of treatment on PTSD severity: among Cambodian refugees with PTSD and comorbid OP who participated in a cognitive behavioural therapy study (N = 56), improvement in PTSD severity was partially mediated by improvement in OP severity.
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Affiliation(s)
- Devon E Hinton
- Southeast Asian Clinic, Arbour Counseling Services, Lowell, MA 02114, USA.
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Hinton DE, Hinton SD, Loeum RJR, Pich V, Pollack MH. The 'multiplex model' of somatic symptoms: application to tinnitus among traumatized Cambodian refugees. Transcult Psychiatry 2008; 45:287-317. [PMID: 18562496 DOI: 10.1177/1363461508089768] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Somatic symptoms are a common clinical presentation of distress among ethnic populations in the USA, particularly traumatized refugees. In this article, we apply a 'multiplex model' of bodily experience to explain how a somatic symptom is evoked, amplified, and generates distress, particularly distress related to post-traumatic stress disorder. We illustrate the multiplex model's applicability to acute episodes of tinnitus (i.e., a buzzing-like sound in the ear) among Cambodian refugees, a common symptom in that group. The article demonstrates the importance of carefully examining somatic symptoms and associated meanings in distressed ethnic populations, especially traumatized refugees, and aims to contribute to a medical anthropology of somatic symptoms.
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Hinton DE, Howes D, Kirmayer LJ. Toward a medical anthropology of sensations: definitions and research agenda. Transcult Psychiatry 2008; 45:142-62. [PMID: 18562491 DOI: 10.1177/1363461508089763] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this article, we outline the importance of a medical anthropology of sensations for theories of psychopathology and psychological healing. We define what is meant by ;sensation' (differentiating monomodal and polymodal sensations) and describe some of the mechanisms that generate and amplify sensations. We propose the heuristic use of the concepts of sensation schemas, sensation interpretants, and sensation scripts. We argue against the naive assumption that sensation experience is the same across cultures. Finally, we consider how healing may occur through 'sensation semiosis.'
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Obsessive-compulsive symptoms and obsessive-compulsive disorder: a multiracial/ethnic analysis of a student population. J Nerv Ment Dis 2008; 196:456-61. [PMID: 18552622 DOI: 10.1097/nmd.0b013e3181775a62] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The Yale-Brown Obsessive-Compulsive Scale and the Padua Inventory Washington State University Revision are commonly used measures of obsessive-compulsive disorder. They have been shown to be reliable and valid with both clinical and nonclinical samples. However, their psychometrics have primarily been assessed using homogenous white samples. This is a concern because while some studies of anxiety measures among multiple racial and ethnic groups suggest equivalence (e.g., Norton, J Anxiety Dis. 2005;19:699-707), others report significant racial/ethnic differences and unequal predictive validity (e.g., Thomas et al., Assessment. 2000;7:247-258). This study examined 2 measures of obsessive-compulsive symptoms using a large sample of African American, white, Hispanic/Latino, Southeast Asian, and South Asian/East Indian students. Preliminary analyses indicated that Southeast and South Asian/East Indian participants reported significantly more symptoms on the Padua Inventory Washington State University Revision, although only South Asian/East Indian participants also reported a correspondingly higher rate of interference and distress associated with their symptoms. Comparable psychometric estimates were observed across all groups. Differences by race/ethnicity are discussed regarding potential variables that may act as moderators or mediators in addition to clinical and research implications.
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Abstract
Asylum seekers flee their countries in search of safety due to persecution at home. Characteristics were assessed of 134 consecutive asylum seekers who sought mental health services at a program caring for survivors of torture and refugee trauma, using a chart review of patients seen between January 1999 and December 2002. Two-thirds of the sample were female, and 82% came from Africa. Eighty-four percent of the sample reported a history of torture, and one-half experienced rape or attempted rape. Most common diagnoses included posttraumatic stress disorder and depression. Predictors of torture included: posttraumatic stress disorder [odds ratio (OR) = 4.93, p = 0.03], rape (OR = 4.23, p = 0.035), and political persecution (OR = 9.28, p = 0.006). Most common self-reported health problems were headaches (29.9%), sexual dysfunction (26.1%), chronic pain (12.7%), and gastrointestinal symptoms (11.2%).
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Dizziness- and Palpitations-predominant Orthostatic Panic: Physiology, Flashbacks, and Catastrophic Cognitions. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2007. [DOI: 10.1007/s10862-007-9059-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gastrointestinal-focused panic attacks among Cambodian refugees: associated psychopathology, flashbacks, and catastrophic cognitions. J Anxiety Disord 2007; 21:42-58. [PMID: 16650726 DOI: 10.1016/j.janxdis.2006.03.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2005] [Revised: 09/15/2005] [Accepted: 03/01/2006] [Indexed: 11/25/2022]
Abstract
Among Cambodian refugees attending a psychiatric clinic, we assessed psychopathology associated with gastrointestinal panic (GIP), and investigated possible causal mechanisms, including "fear of fear" and GIP-associated flashbacks and catastrophic cognitions. GIP (n=46) patients had greater psychopathology (Clinician-Administered PTSD Scale [CAPS] and Symptom Checklist-90-R [SCL]) and "fear of fear" (Anxiety Sensitivity Index [ASI]) than did non-GIP patients (n=84). Logistic regression revealed that general psychopathology (SCL; odds ratio=4.1) and fear of anxiety-related sensations (ASI; odds ratio=2.4) predicted the presence of GIP. Among GIP patients, a hierarchical regression revealed that GIP-associated trauma recall and catastrophic cognitions explained variance in GIP severity beyond a measure of general psychopathology (SCL). A mediational analysis indicated that SCL's effect on GIP severity was mediated by GIP-associated flashbacks and catastrophic cognitions.
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Hinton DE, Nguyen L, Pollack MH. Orthostatic Panic as a Key Vietnamese Reaction to Traumatic Events: The Case of September 11, 2001. Med Anthropol Q 2007; 21:81-107. [PMID: 17405699 DOI: 10.1525/maq.2007.21.1.81] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article discusses a culturally specific response to traumatic events: orthostatic panic attacks among Vietnamese refugees. We compared the rate and severity of orthostatic panic as well as the rates and severity of associated flashbacks a month before and a month after September 11, 2001. After that date, the rate and severity of orthostatic panic greatly increased, as did the rate and severity of associated flashbacks. The central role of orthostatic panic as a response to traumatic events is illustrated through a patient's vignette. An explanation of why September 11 so profoundly influenced this population is adduced, including an explanation of why it resulted in considerable worsening of orthostatic panic.
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Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, USA
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Hooberman JB, Rosenfeld B, Lhewa D, Rasmussen A, Keller A. Classifying the torture experiences of refugees living in the United States. JOURNAL OF INTERPERSONAL VIOLENCE 2007; 22:108-23. [PMID: 17151382 DOI: 10.1177/0886260506294999] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Few research studies have systematically categorized the types of torture experienced around the world. The purpose of this study is to categorize the diverse traumatic events that are defined as torture, and determine how these torture types relate to demographics and symptom presentation. Data for 325 individuals were obtained through a retrospective review of records from the Bellevue/NYU for Survivors of Torture. A factor analysis generated a model with five factors corresponding to witnessing torture of others, torture of family members, physical beating, rape/sexual assault, and deprivation/passive torture. These factors were significantly correlated with a number of demographic variables (sex, education, and region of origin). Post Traumatic Stress Disorder, anxiety, and depression symptoms were significantly correlated with the rape factor but no other factors were uniquely associated with psychological distress. The results offer insight into the nature of torture and differences in responses.
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Schulz PM, Huber LC, Resick PA. Practical Adaptations of Cognitive Processing Therapy with Bosnian Refugees: Implications for Adapting Practice to a Multicultural Clientele. COGNITIVE AND BEHAVIORAL PRACTICE 2006. [DOI: 10.1016/j.cbpra.2006.04.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hinton DE, Safren SA, Pollack MH, Tran M. Cognitive-Behavior Therapy for Vietnamese Refugees With PTSD and Comorbid Panic Attacks. COGNITIVE AND BEHAVIORAL PRACTICE 2006. [DOI: 10.1016/j.cbpra.2006.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hinton DE, Otto MW. Symptom Presentation and Symptom Meaning Among Traumatized Cambodian Refugees: Relevance to a Somatically Focused Cognitive-Behavior Therapy. COGNITIVE AND BEHAVIORAL PRACTICE 2006; 13:249-260. [PMID: 19823603 PMCID: PMC2759766 DOI: 10.1016/j.cbpra.2006.04.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Among psychologically distressed Cambodian refugees, somatic complaints are particularly prominent. Cambodians interpret anxiety-related somatic sensations in terms of "Wind" (khyâl), an ethnophysiology that gives rise to multiple catastrophic interpretations; and they have prominent trauma-memory associations to anxiety-related somatic symptoms. In this article, we detail some of the common sensation-related dysphoric networks of Cambodian refugees, focusing on catastrophic cognitions and trauma associations. We argue that delineating symptom-related dysphoric networks is crucial to successfully adapt cognitive-behavioral interventions to treat panic disorder and posttraumatic stress disorder among Cambodian refugees, and that such an approach may be useful for the culturally sensitive adaptation of cognitive-behavior therapy for other traumatized non-Western groups.
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Affiliation(s)
- Devon E Hinton
- Massachusetts General Hospital and Harvard Medical School
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Hinton DE, Pich V, Safren SA, Pollack MH, McNally RJ. Anxiety sensitivity among Cambodian refugees with panic disorder: A factor analytic investigation. J Anxiety Disord 2006; 20:281-95. [PMID: 16564433 DOI: 10.1016/j.janxdis.2005.02.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Revised: 01/20/2005] [Accepted: 02/14/2005] [Indexed: 11/25/2022]
Abstract
Among Cambodian refugees with panic disorder (N = 208), we performed two factor analyses, one with the ASI, another with an Augmented ASI (consisting of the 16-item ASI supplemented with a 9-item addendum that assesses additional Cambodian concerns about anxiety-related sensations). The principal component analysis of the ASI yielded a 3-factor solution (I, "Weak Heart Concerns"; II, "Social Concerns"; III, "Control Concerns"); the Augmented ASI, a 4-factor solution: I, "Wind Attack Concerns"; II, "Weak Heart Concerns"; III, "Social Concerns"; and IV, "Control Concerns." The item clustering within the factor solution of both the ASI and Augmented ASI illustrates the role of cultural syndromes in generating fear of mental and bodily events.
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Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 15 Parkman Street, WACC 812, Boston, MA 02114, USA.
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Hinton DE, Chhean D, Pich V, Um K, Fama JM, Pollack MH. Neck-focused panic attacks among Cambodian refugees; a logistic and linear regression analysis. J Anxiety Disord 2006; 20:119-38. [PMID: 16464700 DOI: 10.1016/j.janxdis.2005.02.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Revised: 01/20/2005] [Accepted: 02/22/2005] [Indexed: 11/18/2022]
Abstract
Consecutive Cambodian refugees attending a psychiatric clinic were assessed for the presence and severity of current--i.e., at least one episode in the last month--neck-focused panic. Among the whole sample (N=130), in a logistic regression analysis, the Anxiety Sensitivity Index (ASI; odds ratio=3.70) and the Clinician-Administered PTSD Scale (CAPS; odds ratio=2.61) significantly predicted the presence of current neck panic (NP). Among the neck panic patients (N=60), in the linear regression analysis, NP severity was significantly predicted by NP-associated flashbacks (beta=.42), NP-associated catastrophic cognitions (beta=.22), and CAPS score (beta=.28). Further analysis revealed the effect of the CAPS score to be significantly mediated (Sobel test [Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182]) by both NP-associated flashbacks and catastrophic cognitions. In the care of traumatized Cambodian refugees, NP severity, as well as NP-associated flashbacks and catastrophic cognitions, should be specifically assessed and treated.
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Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 812, Boston, MA 02114, USA.
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Hinton DE, Chhean D, Pich V, Hofmann SG, Barlow DH. Tinnitus among Cambodian refugees: relationship to PTSD severity. J Trauma Stress 2006; 19:541-6. [PMID: 16929509 DOI: 10.1002/jts.20138] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Consecutive Cambodian refugees attending a psychiatric clinic were assessed for the presence and severity of current tinnitus (i.e., at least one episode in the last month). Fifty percent (52/104) of surveyed patients had tinnitus. Among the tinnitus patients, posttraumatic stress disorder (PTSD) rates were significantly more elevated than among nontinnitus patients (OR=13.5; 95% CI=5.8 to 39.4), as were Clinician-Administered PTSD Scale (CAPS) scores. In a hierarchical regression among tinnitus patients (n=52), tinnitus-related trauma associations and catastrophic cognitions accounted for variability in CAPS severity beyond a measure of tinnitus severity. Among tinnitus patients, tinnitus-related trauma associations and catastrophic cognitions mediated the effect of tinnitus severity on CAPS severity.
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Affiliation(s)
- Devon E Hinton
- Southeast Asian Clinic, Arbour Counseling Services, Lowell, Massachusetts General Hospital, Boston 02114, and Harvard Medical School, Cambridge, MA, USA.
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Hinton DE, Sinclair SJ, Chung RCY, Pollack MH. The SF-36 Among Cambodian and Vietnamese Refugees: An Examination of Psychometric Properties. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2006. [DOI: 10.1007/s10862-006-9022-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hinton DE, Hinton L, Tran M, Nguyen L, Hsia C, Pollack MH. Orthostatically induced panic attacks among Vietnamese refugees: associated psychopathology, flashbacks, and catastrophic cognitions. Depress Anxiety 2006; 23:113-5. [PMID: 16402369 DOI: 10.1002/da.20154] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Hinton DE, Pich V, Chhean D, Pollack MH, McNally RJ. Sleep paralysis among Cambodian refugees: association with PTSD diagnosis and severity. Depress Anxiety 2006; 22:47-51. [PMID: 16094659 DOI: 10.1002/da.20084] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Among Cambodian refugees attending a psychiatric clinic (n=100), 49% (49/100) had at least one episode of sleep paralysis (SP) in the previous 12 months. The annual and monthly SP prevalences were much higher in posttraumatic stress disorder (PTSD) than in non-PTSD patients. Among the PTSD patients, 65% (30/46) had monthly episodes of SP versus 14.85% (8/54) among non-PTSD patients (chi2[2, n=100]=26.78, P<.001). Moreover, patients with SP in the last month (n=30) versus those without SP had much higher PTSD severity scores. In the entire sample (n=100), the PTSD severity scores correlated significantly with the rate of SP in the last month. During SP, Cambodian refugees usually hallucinated an approaching figure (90%, 44/49). The rate of SP-associated and post-SP panic attacks was high, indicating the great distress caused by the phenomenon. SP seems to be a core aspect of the Cambodian refugee's response to trauma. When treating Cambodian refugees, and traumatized refugees in general, clinicians should assess for its presence.
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Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Hinton DE, Chhean D, Pich V, Pollack MH, Orr SP, Pitman RK. Assessment of posttraumatic stress disorder in Cambodian refugees using the Clinician-Administered PTSD Scale: psychometric properties and symptom severity. J Trauma Stress 2006; 19:405-9. [PMID: 16788999 DOI: 10.1002/jts.20115] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Posttraumatic stress disorder (PTSD) symptoms were assessed by using the Clinician-Administered PTSD Scale (CAPS) in a consecutive sample of Cambodian refugees attending a psychiatric clinic in the United States. Psychometric properties of the translated CAPS and severity of PTSD-related symptoms were examined. The CAPS demonstrated adequate psychometric properties, including coefficient alpha (.92) and item-total correlations (.48-.85). Of the sample 56% (101/179) met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for current PTSD. Those patients who met criteria for current PTSD had significantly higher CAPS total scores (M = 65.3, SD = 18.1) than those who did not meet the criteria (M = 13.9, SD = 16.7).
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Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, 15 Parkman Street, WACC 812, Boston, MA 02114, USA.
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Morissette SB, Spiegel DA, Heinrichs N. Sensation-Focused Intensive Treatment for panic disorder with moderate to severe agoraphobia. COGNITIVE AND BEHAVIORAL PRACTICE 2005. [DOI: 10.1016/s1077-7229(05)80036-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hinton DE, Pich V, Safren SA, Pollack MH, McNally RJ. Anxiety sensitivity in traumatized Cambodian refugees: A discriminant function and factor analytic investigation. Behav Res Ther 2005; 43:1631-43. [PMID: 16239155 DOI: 10.1016/j.brat.2005.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2004] [Revised: 09/09/2004] [Accepted: 09/22/2004] [Indexed: 11/30/2022]
Abstract
We examined the psychometric properties and factor structure of a Cambodian translation of the Anxiety Sensitivity Index (ASI) and an Augmented ASI (the ASI supplemented with a 9-item addendum that assesses additional Cambodian concerns about anxiety-related sensations). Both the ASI and the Augmented ASI distinguished among three diagnostic groups: highest score, PTSD with panic disorder (PP group); next, panic disorder without PTSD (P group); and then, other disorders than PTSD or panic disorder (O group). In the discriminant function analysis using the Augmented ASI, the best classificatory predictor (PP vs. P vs. O) was an Addendum item ("It scares me when I stand up and feel dizzy"). The principal component analysis (oblimin rotation) of the ASI yielded a 3-factor solution (I, Weak Heart Concerns; II, Control Concerns; III, Social Concerns) and of the Augmented ASI, a 4-factor solution (I, Weak Heart Concerns; II, Control Concerns; III, Wind Attack Concerns; IV, Social Concerns). The item clustering within the factor solution of both the ASI and Augmented ASI illustrates the role of cultural syndromes in generating fear of mental and bodily events.
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Affiliation(s)
- Devon E Hinton
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Hinton DE, Chhean D, Pich V, Safren SA, Hofmann SG, Pollack MH. A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: a cross-over design. J Trauma Stress 2005; 18:617-29. [PMID: 16382423 DOI: 10.1002/jts.20070] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We examined the therapeutic efficacy of a culturally adapted cognitive-behavior therapy for Cambodian refugees with treatment-resistant posttraumatic stress disorder (PTSD) and comordid panic attacks. We used a cross-over design, with 20 patients in the initial treatment (IT) condition and 20 in delayed treatment (DT). Repeated measures MANOVA, Group & times; Time ANOVAs, and planned contrasts indicated significantly greater improvement in the IT condition, with large effect sizes (Cohen's d) for all outcome measures: Anxiety Sensitivity Index (d = 3.78), Clinician-Administered PTSD Scale (d = 2.17), and Symptom Checklist 90-R subscales (d = 2.77). Likewise, the severity of (culturally related) neck-focused and orthostasis-cued panic attacks, including flashbacks associated with these subtypes, improved across treatment.
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Affiliation(s)
- Devon E Hinton
- Southeast Asian Clinic, Arbour Counseling Services, Lowell, Massachusetts, USA.
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Orthostatically induced panic attacks among cambodian refugees: Flashbacks, catastrophic cognitions, and associated psychopathology. COGNITIVE AND BEHAVIORAL PRACTICE 2005. [DOI: 10.1016/s1077-7229(05)80052-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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40
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Hinton DE, Nguyen L, Tran M, Quinn S. Weak kidney and panic attacks in a traumatized Vietnamese male. Cult Med Psychiatry 2005; 29:125-35. [PMID: 16108206 DOI: 10.1007/s11013-005-4626-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA.
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Hinton DE, Pich V, Chhean D, Pollack MH. 'The ghost pushes you down': sleep paralysis-type panic attacks in a Khmer refugee population. Transcult Psychiatry 2005; 42:46-77. [PMID: 15881268 DOI: 10.1177/1363461505050710] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Among a psychiatric population of Cambodian refugees (N = 100), 42% had current--i.e. at least once in the last year--sleep paralysis (SP). Of those experiencing SP, 91% (38/42) had visual hallucinations of an approaching being, and 100% (42/42) had panic attacks. Among patients with post-traumatic stress disorder (PTSD; n = 45), 67% (30/45) had SP, whereas among those without PTSD, only 22.4% (11/45) had SP (chi2 = 20.4, p < .001). Of the patients with PTSD, 60% (27/45) had monthly episodes of SP. The Cambodian panic response to SP seems to be greatly heightened by elaborate cultural ideas--with SP generating concerns about physical status, 'good luck' status, 'bad luck' status, sorcery assault, and ghost assault--and by trauma associations to the figure seen in SP. Case vignettes illustrate cultural beliefs about, and trauma resonances of, SP. A model to explain the high rate of SP in this population is presented. SP is a core aspect of the Cambodian refugees response to trauma; when assessing Cambodian refugees, and traumatized refugees in general, clinicians should assess for its presence.
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Affiliation(s)
- Devon E Hinton
- Massachusetts General Hospital, Harvard Medical School, USA.
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Hinton DE, Pham T, Tran M, Safren SA, Otto MW, Pollack MH. CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: a pilot study. J Trauma Stress 2004; 17:429-33. [PMID: 15633922 PMCID: PMC2748790 DOI: 10.1023/b:jots.0000048956.03529.fa] [Citation(s) in RCA: 126] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We examined the feasibility, acceptability, and therapeutic efficacy of a culturally adapted cognitive-behavior therapy (CBT) for twelve Vietnamese refugees with treatment-resistant posttraumatic stress disorder (PTSD) and panic attacks. These patients were treated in two separate cohorts of six with staggered onset of treatment. Repeated measures Group x Time ANOVAs and between-group comparisons indicated significant improvements, with large effect sizes (Cohen's d) for all outcome measures: Harvard Trauma Questionnaire (HTQ; d = 2.5); Anxiety Sensitivity Index (ASI: d = 4.3); Hopkins Symptom Checklist-25 (HSCL-25), anxiety subscale (d = 2.2); and Hopkins Symptom Checklist-25, depression subscale (d = 2.0) scores. Likewise, the severity of (culturally related) headache-and orthostasis-cued panic attacks improved significantly across treatment
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Affiliation(s)
- Devon E Hinton
- Southeast Asian Clinic, Arbour Counseling Services, Lowell, Massachusetts, USA.
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Hinton DE, Pich V, Chhean D, Pollack MH, Barlow DH. Olfactory-triggered panic attacks among Cambodian refugees attending a psychiatric clinic. Gen Hosp Psychiatry 2004; 26:390-7. [PMID: 15474639 DOI: 10.1016/j.genhosppsych.2004.04.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2004] [Accepted: 04/22/2004] [Indexed: 11/26/2022]
Abstract
Olfactory panic attacks have not been systematically assessed in a psychiatric population by any previous studies. Among Cambodian refugees attending a psychiatric clinic, the present investigation determines the following: (a) 1-month current prevalence of olfactory-triggered panic attacks, (b) associated psychopathology (Hopkins Symptom Checklist and the Structured Clinical Interview for DSM-IV-diagnosed posttraumatic stress disorder [PTSD]), and (c) frequency in events of olfactory panic of catastrophic cognitions (Panic Attack Cognitions Scale [PACQ]) and flashbacks (Clinician-Administered PTSD flashback scale). Forty-five percent of 100 consecutive psychiatric patients were found to have suffered an olfactory-triggered panic attack in the previous month; having current olfactory panic attacks was highly correlated with psychopathology (e.g., to PTSD diagnosis: and chi(2)=50.0; df=1; p<.001); and during olfactory-triggered panic attacks, catastrophic cognitions and flashbacks were common. Possible mechanisms for generation of high rates of olfactory-triggered panic attacks in this population are discussed (the "traumatic memory/catastrophic cognitions/interoceptive conditioning/escalating arousal" or "TCIE" model of panic generation) as are treatment implications.
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Affiliation(s)
- Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Hinton D, Pich V, Chhean D, Pollack M. Olfactory-triggered panic attacks among Khmer refugees: a contextual approach. Transcult Psychiatry 2004; 41:155-99. [PMID: 15446720 PMCID: PMC2791797 DOI: 10.1177/1363461504043564] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
One hundred Khmer refugees attending a psychiatric clinic were surveyed to determine the prevalence of olfactory-triggered panic attacks as well as certain characteristics of the episodes, including trigger (i.e. type of odor), frequency, length, somatic symptoms, and the rate of associated flashbacks and catastrophic cognitions. Forty-five of the 100 patients had experienced an olfactory-triggered panic attack in the last month. Trauma associations and catastrophic cognitions (e.g. fears of a 'wind attack', 'weakness', and 'weak heart') were common during events of olfactory panic. Several case examples are presented. A multifactorial model of the generation of olfactory panic is adduced. The therapeutic implications of this model for the treatment of olfactory panic are discussed.
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Affiliation(s)
- Devon Hinton
- Department of Psychiatry, Massachusetts General Hospital, Harvard University, USA.
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Hinton D, Hinton S, Pham T, Chau H, Tran M. 'Hit by the wind' and temperature-shift panic among Vietnamese refugees. Transcult Psychiatry 2003; 40:342-76. [PMID: 14649850 DOI: 10.1177/13634615030403003] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surveying 60 Vietnamese patients with either current or past post-traumatic stress disorder, this article aims to phenomenologically characterize the syndrome of 'hit by the wind' in a multidimensional manner. This includes determining the patient conceptualization of the disorder, profiling 'hit by the wind' episodes suffered by patients in the previous month, and presenting case vignettes. Eighteen of the 60 patients (30%) suffered at least one episode of 'hit by the wind' in the last month; all 18 patients had at least one episode of 'hit by the wind' in the last month that met panic attack criteria. For the 18 patients, 33 episodes of'hit by the wind' that met panic attack criteria were experienced in the previous month. For these 33 episodes, the most frequently reported DSM-IV panic attack symptoms were chills (100%; 33/33) and dizziness (88%; 29/33). Flashbacks played a role in the 'hit by the wind' episodes for 5 of the 18 patients (28%). In the discussion, a model of how the syndrome of 'hit by the wind' generates panic is adduced; also, possible Chinese origins of the disorder are discussed.
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Hinton D, Hsia C, Um K, Otto MW. Anger-associated panic attacks in Cambodian refugees with PTSD; a multiple baseline examination of clinical data. Behav Res Ther 2003; 41:647-54. [PMID: 12732373 DOI: 10.1016/s0005-7967(02)00035-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Despite the increasing recognition of the importance of anger as a key aspect of post-traumatic stress disorder (PTSD), the presence of anger-induced panic attacks has been understudied in traumatized groups. The present investigation determines the prevalence of anger-associated panic attacks among Cambodian refugees suffering from PTSD. Specific characteristics of these episodes that were examined included frequency, symptoms, and cognitions (in particular, fear of death from bodily dysfunction). In a survey of 100 Khmer patients suffering PTSD, 58% reported anger-associated panic attacks in the last month. These attacks occurred at a mean rate of 6.2 attacks a month and were characterized by extreme arousal and in 81% of these cases, fears of death due to bodily dysfunction during the anger-induced panic. Mechanisms for this high rate of fear of death during anger arousal are discussed with a focus on culture-specific catastrophic cognitions.
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Affiliation(s)
- D Hinton
- Massachusetts General Hospital & Harvard Medical School, Revere, MA, USA.
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Hagengimana A, Hinton D, Bird B, Pollack M, Pitman RK. Somatic panic-attack equivalents in a community sample of Rwandan widows who survived the 1994 genocide. Psychiatry Res 2003; 117:1-9. [PMID: 12581815 PMCID: PMC2772881 DOI: 10.1016/s0165-1781(02)00301-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The present study is the first to attempt to determine rates of panic attacks, especially 'somatically focused' panic attacks, panic disorder, symptoms of post-traumatic stress disorder (PTSD), and depression levels in a population of Rwandans traumatized by the 1994 genocide. The following measures were utilized: the Rwandan Panic-Disorder Survey (RPDS); the Beck Depression Inventory (BDI); the Harvard Trauma Questionnaire (HTQ); and the PTSD Checklist (PCL). Forty of 100 Rwandan widows suffered somatically focused panic attacks during the previous 4 weeks. Thirty-five (87%) of those having panic attacks suffered panic disorder, making the rate of panic disorder for the entire sample 35%. Rwandan widows with panic attacks had greater psychopathology on all measures. Somatically focused panic-attack subtypes seem to constitute a key response to trauma in the Rwandan population. Future studies of traumatized non-Western populations should carefully assess not only somatoform disorder but also somatically focused panic attacks.
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Affiliation(s)
| | - Devon Hinton
- Corresponding author. Revere Counseling Center, 265 Beach Street, Revere, MA 02151, USA. Tel.: +1-617-738-9055; fax: +1-781-286-5636. (D. Hinton)
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Abstract
According to the Khmer conception, a person suffering 'weak heart' (khsaoy beh daung) has episodes of palpitations on slight provocation (e.g. triggered by orthostasis, anger, a noise, worry, an odor or exercise) and runs the risk of dying of heart arrest during these periods of palpitations; too, the sufferer typically has other symptoms attributed to the purported cardiac dysfunction: fatigue, shortness of breath, and orthostatic dizziness. Many Khmer refugees suffer this cultural syndrome, an anxious-dysphoria ontology, most probably of French colonial provenance. The syndrome demonstrates considerable overlap with those Western illness categories that feature panic attacks, in particular post-traumatic stress disorder (PTSD) and panic disorder. In a psychiatric clinic survey, 60 percent (60/100) of those assessed believed themselves to currently suffer 'weak heart'; 90 percent (54/60) of those considering themselves to suffer from 'weak heart' thought that palpitations (e.g., those resulting from a loud noise or orthostasis) might result in death. The article illustrates the profoundly culturally constructed nature of 'cardiac sensations,' located in a specific historical trajectory and episteme; too, the article suggests that trauma may result more in panic disorder than 'PTSD' when autonomic arousal symptoms (in the present case, palpitations) are considered potentially life-threatening.
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Hinton D, Nathan M, Bird B, Park L. Panic probes and the identification of panic: a historical and cross-cultural perspective. Cult Med Psychiatry 2002; 26:137-53. [PMID: 12211322 DOI: 10.1023/a:1016359531483] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This article reviews the historical development of the category of panic disorder in the United States, particularly the shifting perspectives on both what causes panic and how the presence of panic should be determined. The notion that panic attacks of a panic-disorder type must be "out of the blue" and "unexpected," except in the case of triggering by a particular place (i.e., agoraphobia), is critiqued. The authors illustrate that a meaningful epidemiological determination of panic rates in other cultural groups must be preceded by a detailed ethnography that ascertains the catastrophic cognitions, core symptoms, and typical cues of panic attacks in that particular context.
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Affiliation(s)
- Devon Hinton
- Department of Psychiatry, Massachusetts General Hospital, Harvard University, Boston, USA
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Hinton D, Hinton S. Panic disorder, somatization, and the new cross-cultural psychiatry: the seven bodies of a medical anthropology of panic. Cult Med Psychiatry 2002; 26:155-78. [PMID: 12211323 DOI: 10.1023/a:1016374801153] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This article aims to adduce a framework that will allow for the cross-cultural study of panic disorder. The authors take sensation as the key unit of analysis, aiming to contribute to a medical anthropology of sensation. The seven analytic perspectives that are suggested in the article are the following: the full spectrum of panic attack sensations (the sensation body), the biological generation of panic sensations (the biological body), sensation as invoking an ethnophysiology (the ethnophysiological body), sensation as metaphor (the metaphoric body), sensation as invoking the landscape (the landscape body), sensation as invoking catastrophic cognitions (the catastrophic cognitions body), and sensation as invoking memory (the memory-associational body).
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Affiliation(s)
- Devon Hinton
- Dept. of Psychiatry, Massachusetts General Hospital, Harvard University, Boston, USA
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