Western conceptualizations and Eastern experience: a cross-cultural study of traumatic stress reactions among Tibetan refugees in India

Applicability of the Hebrew Bible to Post-traumatic Stress Disorder and Post-traumatic Growth

Since the new millennium, biblical scholars have begun to reread certain writings in the Hebrew Bible through the concepts of post-traumatic stress disorder and post-traumatic growth. Some scholars believe such a reading is legitimate, whereas others think it problematic, and still, others hold a midway perspective. This article argues for the midway, the position that accepts the applicability of the Hebrew Bible to today's psychological concepts but calls for caution. Because ancient Israelites reacted to traumatic events and distinguished the human mind from the body like modern people, it is reasonable to approach their thoughts and emotions in the Hebrew Bible through today's psychological concepts. However, the cultural differences between today's society and ancient Israelites in understanding and reacting to traumatic events should be considered.

Risk of psychopathology following traumatic events among immigrants and native-born persons in Denmark

PURPOSE

Immigrants may have increased risk of mental disorders compared with native-born persons. We aimed to expand the limited research on immigrants' posttraumatic psychopathology related to traumatic experiences in their country of resettlement.

METHODS

We obtained data from a cohort of Danish residents with ≥ 1 traumatic event recorded in health and administrative national registries during 1994-2016. We calculated risks of posttraumatic stress disorder (PTSD), depression, and substance use disorders (SUD) within 5 years post-trauma among native-born Danes and immigrants who had been in Denmark for ≥ 10 years at the time of their index trauma (including immigrants overall and immigrants from specific regions). Risks were compared via age- and sex-standardized risk ratios (SRR) with 95% confidence intervals (CI). We restricted to persons with no record of the disorder under investigation in the 10 years pre-trauma, and stratified by non-interpersonal (e.g., transport accidents) versus interpersonal trauma (e.g., assaults).

RESULTS

Following non-interpersonal trauma, immigrants were more likely than native-born Danes to be diagnosed with PTSD (SRR = 5.2, 95% CI 4.6, 5.9), about as likely to be diagnosed with depression (SRR = 0.98, 95% CI 0.92, 1.1), and less likely to be diagnosed with SUD (SRR = 0.89, 95% CI 0.82, 0.95). Results were similar following interpersonal trauma, except the SRR for PTSD was reduced in magnitude (SRR = 3.0, 95% CI 1.7, 5.4). There were differences by region of birth.

CONCLUSION

Immigrants to Denmark have higher risk of PTSD following traumatic experiences than do native-born Danes, possibly due to the combined influence of adverse pre-, peri-, and/or post-migration experiences.

Born in displacement: Psychosocial and mental health impacts of country of birth among urban Somali refugee youth

Urban refugees often face tremendous adversities during displacement that exacerbate mental health and psychosocial outcomes. Given the lack of research on how extended displacement affects mental health in urban refugee youth, this study examines the differential effects of country of birth on trauma exposure and psychosocial factors that influence mental health experiences among Somali refugee youth in urban Kenya (n = 303). Findings reveals that childhood trauma and impeded social functioning predicted mental health outcomes. Being born in Kenya was a significant predictor of poor mental health despite there being no significant difference in trauma exposures and psychosocial factors between Somali-born and Kenya-born youth. This difference can be attributed to prolonged displacement, disrupted development of cultural identity, and discrimination experienced in the host country. Given the widely devastating effects of childhood trauma and community violence, mental health interventions need to be two-prolonged: addressing and preventing intergenerational trauma sequelae through family-based interventions; and community-level programs and advocacy for safety and protection for the displaced. Our findings also emphasize that future interventions for urban refugee communities should be inclusive to all community members, considering shared vulnerability to community violence as well as intergenerational transmission of traumas through childhood adversities and lacking support.

Trauma exposure, social functioning, and common mental health disorders in Somali refugee male and female youth: An SEM analysis

Background:

Refugee youth often face numerous adversities before and during forced migration. Although experiences vary across settings and subpopulations, common mental disorders are prevalent among refugee youth who are displaced in low- and middle-income countries. It is important to examine how risk factors are intricately linked and contribute to common mental health issues to inform clinical practice and social policy.

Aims:

This study aims to test the pathways from risk factors previously identified as determinants of Somali refugee youth mental health (i.e. trauma exposure, substance use, social functioning, aggression) to symptoms of PTSD, depression, anxiety, and somatic pains.

Method:

We collected survey data in 2013, using snowball sampling to recruit Somali refugee youth (15–35 years old) living in Eastleigh, Kenya. We ran three structural equation models to assess paths from trauma exposure to mental health symptoms, through psychosocial factors including substance use, aggression, and functional impairment. We first conducted this analysis with a mixed-gender sample ( N = 305) and then assessed gender differences by running one model for male participants ( n = 124) and another for female participants ( n = 181).

Results:

In the mixed-gender sample, trauma exposure directly predicted substance use and both directly and indirectly predicted aggression, functional impairment, and mental health symptoms. Substance use directly predicted aggression and functional impairment, and substance use both directly and indirectly predicted mental health symptoms. The split-gender models revealed gender differences, with only functional impairment directly predicting mental health symptoms in the male sample and with many significant direct and indirect pathways in the female sample.

Conclusions:

This study shows the role of trauma exposure, substance use, aggression, and social functioning in determining mental health outcomes among refugee youth and how CMD symptoms are differently manifested across genders in this population.

Still Standing Inside: A Local Idiom Related to Trauma among Namibian Speakers of Khoekhoegowab

Euro-centric psychiatric conceptualizations often ignore the interplay of local with universal factors in psychological suffering. Emic, locally focused perspectives can enrich etic knowledge to provide culturally sensitive care and to better elucidate the role of culture in mental illness. This study explored the idiom Tsûsa ǃNaeǃkhais xa hâǃnâ/mâǃnâ/ǂgâǃnâhe hâ (a terrible event has entered a person and remains standing inside), which was understood to relate to experiences of trauma and post-traumatic stress, among speakers of Khoekhoegowab, a southern-African click language. Semi-structured interviews were conducted with 16 participants from six urban and rural communities in Namibia. Questions probed perceptions of the idiom in terms of etiology, course, and risk and resilience factors from a socio-ecological framework. Five key themes were identified using thematic analysis: origin in a shocking event; intrusive recurrence of memories, "it keeps on coming back"; the close interplay between mental and physical suffering; the importance of active engagement in healing through prayer and acceptance; and the role of the community in both alleviating and amplifying distress. Our findings highlight local norms and strategies for adaptive coping, and the benefits of exploring local idioms to elucidate the braiding together of universal and cultural elements in psychological distress.

A Systematic Chart Review of Adults with Post-Traumatic Stress Disorder: Data from a Tertiary Care Psychiatry Center in India

BACKGROUND

Post-traumatic stress disorder (PTSD) is an understudied construct in the psychiatric setting. The majority of existing Indian studies on PTSD focus on the general population or disaster-stricken communities. Here, we present data from a five-year retrospective chart review from a tertiary care psychiatric center in India.

METHODS

Medical records of adult patients (≥18 years) who had attended psychiatry outpatient services between April 1, 2015 and March 31, 2020 (five years) and were diagnosed with PTSD, as per ICD-10 criteria, were reviewed (n = 113). The relevant sociodemographic and clinical details were extracted using a semistructured pro-forma.

RESULTS

The percentage of adult patients with PTSD diagnosis in the five years was 0.22%. PTSD was more common in females (n = 65, 57.5%). Most patients had interpersonal trauma (n = 85, 75.2%), specifically sexual abuse (n = 47, 41.6%). The median age of onset was 22 years. All the patients had re-experiencing symptoms, with an equally high rate of avoidance (n = 109, 96.5%) and arousal symptoms (n = 110, 97.3%). 82%(93) had a comorbid psychiatric disorder, with mood disorder being the most common (n = 44, 38.9%). Males had a higher rate of comorbid substance use disorder (n = 14, 29.2%) and depression (n = 20,42%), and females had a higher rate of comorbid dissociative disorder (n = 13,20%). Most of the patients received non-trauma-focused psychological interventions, and only 18% (20) received evidence-based trauma-focused psychological interventions.

CONCLUSION

Interpersonal trauma, specifically sexual abuse, largely contributes to PTSD among adults attending psychiatric services. The need for trauma-focused psychological interventions is underscored.

Risk and protective factors for comorbidity of PTSD, depression, and anxiety among Somali refugees in Kenya

Background:

Comorbid common mental disorders (CMDs) are pervasive in refugee populations. However, limited research has explored psychosocial factors for mental disorder comorbidity in Somali refugee samples.

Aims:

This study aims to explore potential risk and protective factors for comorbid depression-anxiety and comorbid depression-PTSD by examining associations between trauma exposure, psychosocial factors, and mental health symptoms among a sample of Somali refugees displaced in urban Kenya.

Methods:

We used snowball sampling to recruit Somali youth aged 15 to 35years( N = 250, n = 143 female, n = 88 male, n = 19 unknown gender). We measured 16 common types of trauma exposure and three psychosocial factors (endorsing violence, willingness to share problems, and symptom awareness) and used the HSCL-25 and PCL-C to capture individual and comorbid CMD symptoms, using guided cutoff points and/or algorithms. We then ran a series of logistic regression analyses to examine relationships between trauma exposure, psychosocial factors, and individual and comorbid CMD symptoms.

Results:

Findings showed that increased trauma exposure predicted symptoms of individual and comorbid CMDs. Increased symptom awareness and endorsement of violence predicted comorbid depression-PTSD and comorbid anxiety-depression symptoms, respectively. Willingness to share problems buffered depressive symptoms but did not predict comorbidity.

Conclusions:

These findings revealed the high CMD comorbidity prevalence with differential effects of trauma and psychosocial factors on individual or comorbid mental disorders. This study suggests a need for transdiagnostic approaches that cut across Western diagnostic boundaries and consider culturally responsive and relevant items for mental health measures.

Risk and protective factors for comorbidity of PTSD, depression, and anxiety among Somali refugees in Kenya

BACKGROUND

Comorbid common mental disorders (CMDs) are pervasive in refugee populations. However, limited research has explored psychosocial factors for mental disorder comorbidity in Somali refugee samples.

AIMS

This study aims to explore potential risk and protective factors for comorbid depression-anxiety and comorbid depression-PTSD by examining associations between trauma exposure, psychosocial factors, and mental health symptoms among a sample of Somali refugees displaced in urban Kenya.

METHODS

We used snowball sampling to recruit Somali youth aged 15 to 35years(N = 250,n = 143 female, n = 88 male, n = 19 unknown gender). We measured 16 common types of trauma exposure and three psychosocial factors (endorsing violence, willingness to share problems, and symptom awareness) and used the HSCL-25 and PCL-C to capture individual and comorbid CMD symptoms, using guided cutoff points and/or algorithms. We then ran a series of logistic regression analyses to examine relationships between trauma exposure, psychosocial factors, and individual and comorbid CMD symptoms.

RESULTS

Findings showed that increased trauma exposure predicted symptoms of individual and comorbid CMDs. Increased symptom awareness and endorsement of violence predicted comorbid depression-PTSD and comorbid anxiety-depression symptoms, respectively. Willingness to share problems buffered depressive symptoms but did not predict comorbidity.

CONCLUSIONS

These findings revealed the high CMD comorbidity prevalence with differential effects of trauma and psychosocial factors on individual or comorbid mental disorders. This study suggests a need for transdiagnostic approaches that cut across Western diagnostic boundaries and consider culturally responsive and relevant items for mental health measures.

Risk and Protective Factors for Common Mental Disorders among Urban Somali Refugee Youth

The purpose of this study was to explore exposure to trauma as well as demographic and psychosocial factors as predictors of mental health symptoms among Somali refugees in Kenya. Participants were recruited via snowball sampling to complete a survey and included 86 Somali refugee youth, aged 15 to 34 years, who were living in Eastleigh. We measured trauma using a total traumas experienced variable as well as four trauma types categories (pre-migration/migration trauma, post-migration trauma, family trauma, and individual trauma). We measured anxiety and depression symptoms using the Hopkins Symptom Checklist-25 (HSCL-25) and PTSD using the PTSD Check List - Civilian Version (PCL-C). We ran descriptive statistics followed by multiple linear regression models with trauma exposure, education, gender, and willingness to share problems as predictors of mental health symptoms. Out of 12 possible traumatic events, most participants (83.7%) reported experiencing at least one trauma, and participants reported experiencing an average of 3.76 total traumas. The regression models predicted between 11.5% and 35.5% of the variance of the mental health symptoms. Willingness to share problems was a significant predictor of decreased mental health symptoms in most models. These findings highlight the role of trauma exposure and psychosocial factors in predicting Somali refugee mental health and indicate that implementing programs to encourage problem sharing may help address Somali refugee mental health needs. Further research is needed to explore the differential impact of trauma exposure and various psychosocial factors on Somali refugee mental health.

Health-related quality of life of refugees: a systematic review of studies using the WHOQOL-Bref instrument in general and clinical refugee populations in the community setting

Purpose

To systematically review studies on HRQOL, measured by the WHOQOL-Bref instrument, of refugees in general and clinical populations who are settled in the community of the hosting country, and outline the differences in scores among the two population groups and across the four domains of WHOQOL-Bref (physical, psychological, social relationships and environment domain) as well as factors impacting those outcomes.

Methods

Several databases were systematically searched by using a broad search strategy. Additionally, a hand search for grey literature was performed. Studies had to comply with the following inclusion criteria: (a) population of refugees; (b) living in the community of the country of destination; (c) assessing HRQOL through the WHOQOL-Bref instrument.

Results

15 studies were identified and divided into two subgroups: (a) general population of refugees (b) clinical population of refugees, who were specifically selected for their mental status or because they had experienced relevant past traumas. Although we can outline common patterns among the two groups, in terms of domains scoring the highest and the lowest, heterogeneous values of HRQOL are observed across the studies included.

Conclusions

Individuals who were included in the clinical refugee group have a lower quality of life in respect to the general population of refugees. However, among the two groups different patterns can be outlined considering each domain of HRQOL: higher scores for the Physical and lower for the Environment domain when considering the general population of refugees and higher scores for the Environment and lower for the Psychological domain when referring to the clinical one. These lower scores are probably due to having a higher rate of mental distress and being more exposed to somatization, stigmatization and barriers to access the healthcare system of the hosting country.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00378-1.

Do somatic symptoms relate to PTSD and gender after earthquake exposure? A cross-sectional study on young adult survivors in Italy

OBJECTIVE

Increasing evidence confirms a strict relationship between mental disorders and physical health. Particularly, stressful life events and post-traumatic stress disorder (PTSD) have been closely correlated with various physical disorders and somatic symptoms, such as chronic pain, gastrointestinal disorders, and headaches. The aim of this study was to investigate the emergence of somatic symptoms in a sample of young adult survivors 21 months after exposure to the L'Aquila 2009 earthquake, with particular attention to PTSD and gender impact.

METHODS

Four hundred and fifty high-school senior students (253 male and 197 female) exposed to the 2009 L'Aquila earthquake, 21 months earlier, were enrolled and evaluated by the Trauma and Loss Spectrum Self-Report (TALS-SR), for symptomatological PTSD, and the Mood Spectrum Self-Report-Lifetime Version (MOODS-SR) "rhythmicity and vegetative functions" domain, for somatic symptoms.

RESULTS

Significantly higher rates of endorsement of the MOODS-SR somatic symptoms emerged in survivors with PTSD compared to those without. Females reported higher rates of endorsement of at least one MOODS-SR somatic symptom compared to males; however, a Decision Tree model and a two-way analysis of variance model confirmed a significant effect of PTSD only. A multivariate logistical regression showed a significant association between the presence of at least one MOOD-SR somatic symptom and re-experiencing and maladaptive coping TALS-SR domains.

CONCLUSION

This study corroborates a relevant impact of symptomatological PTSD, across both the genders, on somatic symptoms occurring in young adults after months from exposure to a massive earthquake.

Polyvictimization and mental health consequences of female genital mutilation/circumcision (FGM/C) among Somali refugees in Kenya

Female genital mutilation or circumcision (FGM/C) is a perilous social and cultural practice that affects the physical, mental, and psychological health of affected women. It is widespread around the world, affecting 200 million women and girls. This study aimed to explore the relation of FGM/C to mental and physical conditions in Somali refugees displaced in a low-resource setting, applying the concept of poly-victimization to reveal multifaceted trauma sequelae. Data for this cross-sectional study with 143 female Somali youth living in Eastleigh, Kenya were collected between April and May in 2013. FGM/C was strongly associated with negative physical and mental health outcomes, including post-traumatic stress disorder and depressive, anxiety, and somatic symptoms. Logistic regression analysis revealed that separation from a parent and poly-victimization experiences were significantly associated with FGM/C experience. The results also showed that FGM/C and other traumas did not occur singly but were indicative of cumulative adversities, especially for women who were socially vulnerable and marginalized. The results of this study highlight the practice of FGM/C in the context of other adverse living conditions of refugees and the importance of attending to other co-occurring risk factors that prevail with FGM/C practice in the ecological system of refugee forced migration.

REFUGEE MENTAL HEALTH AND HEALING: UNDERSTANDING THE IMPACT OF POLICIES OF RAPID ECONOMIC SELF-SUFFICIENCY AND THE IMPORTANCE OF MEANINGFUL WORK

Although refugees who are accepted for resettlement in a third country are guaranteed certain rights and experience safety from war and persecution, they face many mental health challenges. Using qualitative methods and constructivist grounded theory, we explored culturally-specific perspectives on trauma and recovery among Burundian, Congolese and Iraqi refugees resettled in the United States. Eighteen semi-structured interviews provided extensive data on the meaning of productivity and work, the ways in which they index normalcy and self-sufficiency, and how they create security that facilitates the healing process. Our inductive analyses revealed that participants emphasized the relationship between productivity and healing when they described recovery from trauma. Participants also discussed individual and structural facilitators and barriers to work. Finally, prominent themes emerged around gendered roles and expectations and the ways these function in refugee resettlement contexts that are shaped by policies that demand rapid economic self-sufficiency. Taken together, these findings suggest that policies that promote underemployment and foreclose opportunities for education and professional development may contribute negatively to refugee mental health, as well as keep refugees in poverty.

Potentially traumatic experiences of seafarers

Background

The aim of the present study is to assess the extent to which seafarers had been affected by severe mental stress situations and what possible psychological effects they may have.

Methods

During the voyages of 22 German ships, a psychologically trained investigator interviewed 323 seafarers about severe mental stress or potentially traumatic events on board (participation rate 88.5%). Furthermore, a psychologist conducted semi-standardized interviews in 12 shipping companies and in 8 stations of the German Seafarers’ Mission on seafarers’ traumatic experiences.

Results

Of the seafarers surveyed on board, 116 (35.9%) experienced ship wrecks/severe accidents and 55 (17.0%) piracy on board. Experiences with stowaways were indicated by 126 seafarers (39.0%). Repeatedly having to unintentionally think about these events, being reminded of them by certain noises, smells, etc., or often dreaming of them were after-effects in 97 (83.6%) of the affected seafarers after ship wrecks/serious personal accidents on board and in 42 crew members (76.4%) after threats of piracy. Experiences of threat from stowaways had particularly affected non-European seafarers or ratings.

According to the interviews with the shipping companies, a total of 14 deaths occurred in the last 3 years in the 12 interviewed shipping companies (due to heart attacks (3), severe cancer (3), very serious accidents (3), suicides (2) and 3 with unknown causes of death). In relation to the container ships of the investigated shipping companies, these frequencies correspond to a mortality rate of 78.4 per 100,000 seafarer years.

According to the interviews in 8 Seafarers’ Missions, these organizations are in charge of emergency counselling in the form of crisis intervention when a seafarer has experienced serious psychological stress.

Discussion

A serious injury or even the death of a member is a serious psychological stress experience for the other crew members in the closed social system on board. These events are particularly distressing for Filipino seafarers with their strong sociocentric bonds and religious values. Priestly support is often required in order to stabilize the Filipino crew members.

Conclusion

As a preventive measure, psychoeducation for seafarers should be established for coping with extreme mental stress situations.

Posttraumatic stress disorder following the 2008 Wenchuan earthquake: A 10-year systematic review among highly exposed populations in China

BACKGROUND

The 2008 Wenchuan earthquake was unprecedented in Chinese history both in terms of the magnitude of the quake itself and the scale of human suffering. Following the disaster, researchers reported on a wide range of mental health outcomes, especially posttraumatic stress disorder (PTSD). In this review, we assess the cumulative body of research evidence about PTSD across the first 10 years following the earthquake.

METHODS

We searched the literature in the PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) databases (from May 2008 to February 2018) using Wenchuan earthquake and PTSD as keywords.

RESULTS

We selected 58 relevant studies. Published findings from the selected period suggested a substantial burden of PTSD on highly exposed survivors. Studies have found that symptoms of PTSD have been associated with a range of risk factors, including sociodemographic factors, trauma exposure characteristics, post-disaster cognitive and emotional states, and social support. Studies have explored the factor structure of PTSD in the affected Chinese population, and researchers have developed a Chinese self-report measure of PTSD symptoms. Several treatments for PTSD have been evaluated, including some indigenous intervention methods.

LIMITATIONS

Only a relatively small number of the studies used longitudinal assessments, and the consistency and effectiveness of measurement tools for PTSD require further exploration. More rigorous investigations of the effectiveness of interventions for the prevention and treatment of PTSD are needed.

CONCLUSION

The 10-year body of literature is important for the future deployment of disaster relief and an increased understanding of PTSD in China.

Japanese Students Do See the Value of Asking About Child Abuse and Trauma in the Research Setting

Despite evidence regarding the impact of childhood abuse perpetrated by close others, or high betrayal trauma, a number of barriers continue to impede research efforts, including concerns that research may do more harm than good. Research conducted with Western samples has indicated that contrary to such concerns, participants rate the benefit of participating in trauma research as outweighing costs, even when they have a history of high betrayal trauma. Certain non-Western values, such as interpersonal harmony, could play a role in perceptions regarding trauma research participation. The current study evaluated perceptions of 79 Japanese undergraduate students who participated in an online study of child abuse. Japanese students rated the importance of participating in trauma research as greater than any immediate distress it caused. Interpersonal harmony was not related to perceptions of participating in trauma research, nor was a history of high betrayal child trauma. Taken together, these findings support continued research on childhood abuse in non-Western samples.

UCLA PTSD reaction index for DSM-5 (PTSD-RI-5): a psychometric study of adolescents sampled from communities in eleven countries

Background: Children and adolescents are often exposed to traumatic events, which may lead to the development of posttraumatic stress disorder (PTSD). It is therefore important for clinicians to screen for potential symptoms that can be signs of PTSD onset. PTSD in youth is a worldwide problem, thus congruent screening tools in various languages are needed. Objective: The aim of this study was to test the general psychometric properties of the Traumatic Stress Disorder Reaction Index for children and adolescents (UCLA PTSD) Reaction Index for DSM-5 (PTSD-RI-5) in adolescents, a self-report instrument intended to screen for trauma exposure and assess PTSD symptoms. Method: Data was collected from 4201 adolescents in communities within eleven countries worldwide (i.e. Brazil, Bulgaria, Croatia, Indonesia, Montenegro, Nigeria, Palestine-Gaza, Philippines, Portugal, Romania, and Serbia). Internal consistency, discriminant validity, and a confirmatory factor analysis of a four-factor model representing the main DSM-5 symptoms of the PTSD-RI-5 were evaluated. Results: The PTSD-RI-5 total score for the entire sample shows very good reliability (α = .92) as well as across all countries included (α ranged from .90 to .94). The correlations between anxiety/depressive symptoms and the PTSD-RI-5 scores were below .70 indicating on good discriminant validity. The four-factor structure of the scale was confirmed for the total sample and data from six countries. The standardized regression weights for all items varied markedly across the countries. The lack of a common acceptable model across all countries prevented us from direct testing of cross-cultural measurement invariance. Conclusions: The four-factor structure of the PTSD-RI-5 likely represents the core PTSD symptoms as proposed by the DSM-5 criteria, but there could be items interpreted in a conceptually different manner by adolescents from different cultural/regional backgrounds and future cross-cultural evaluations need to consider this finding.

Trauma-Informed Psychoeducation for Somali Refugee Youth in Urban Kenya: Effects on PTSD and Psychosocial Outcomes

The current study developed and implemented a trauma-informed psychoeducation (TIPE) intervention that is culturally relevant to urban Somali refugees in Nairobi, Kenya. A total of 141 Somali refugee youth completed 12 sessions of peer-led TIPE intervention. A series of pre- and post-tests revealed that TIPE made positive impacts on PTSD symptoms and psychosocial factors, with a differential effect observed according to baseline PTSD symptom report. Participants with high baseline PTSD scores (i.e. above clinical threshold) reported a significant decrease in PTSD symptoms and increase in perceived social support. In the meantime, those with no to mild baseline PTSD symptoms showed an increase in self-awareness of trauma responses and thus PTSD symptom report within the range of normalcy. This research supports the effect of a culturally relevant psychoeducation intervention in addressing the high mental health and psychosocial needs of the marginalized urban Somali refugee community in low resource settings.

Fear of violence during armed conflict: Social roles and responsibilities as determinants of fear

This article investigates the prevalence and determinants of fear as a consequence of living through armed conflict. We use survey data from Nepal during the armed conflict (1996-2006) to examine how trauma, sex and gender, age, marriage, and household size affect fear of violence. We also disaggregate types of worry, and find substantial variance on whether respondents were more concerned about livelihood consequences of conflict than physical danger. We supplement quantitative analyses with discussion of in-depth interviews from the study area on these same topics. Overall, our results highlight the enduring impact of gender roles in Nepal and that conflict might disproportionately affect those who are already vulnerable and have greater social responsibilities. This article provides a unique comparison between fear of violence during armed conflict in a low-income country to the fear of crime literature based in high-income countries.

An Investigation into Suicides Among Bhutanese Refugees Resettled in the United States Between 2008 and 2011

An increase of Bhutanese refugee suicides were reported in the US between 2009 and 2012. This investigation examined these reported suicides in depth to gain a better understanding of factors associated with suicide within this population. The study employed 14 psychological autopsies to elicit underlying motivations and circumstances for self-inflicted death and to identify potential future avenues for prevention and intervention among refugee communities. Disappointment with current (un)employment, lack of resettlement services and social support, and frustrations with separation from family were believed to contribute to suicidal acts. Suicide within refugee populations may be connected with experiences of family withdrawal, integration difficulties, and perceived lack of care. It is important to assess the effectiveness of improving refugee services on the mental health of migrants. More research is needed in order to better understand, and respond to, suicide in resettled populations.

Measuring self-rated health status among resettled adult refugee populations to inform practice and policy - a scoping review

BACKGROUND

The health status of refugees is a significant factor in determining their success in resettlement and relies heavily on self-rated measures of refugee health. The selection of robust and appropriate self-rated health measurement tools is challenging due to the number and methodological variation in the use of assessment tools across refugee health studies. This study describes the existing self-report health measures which have been used in studies of adult refugees living in the community to allow us to address the challenges of selecting appropriate assessments to measure health within refugee groups.

METHODS

Electronic databases of Ovid Medline, CINAHL, SCOPUS, Embase and Scopus.

RESULTS

This review identified 45 different self-rated health measurements in 183 studies. Most of the studies were cross sectional explorations of the mental health status of refugees living in community settings within Western nations. A third of the tools were designed specifically for use within refugee populations. More than half of the identified measurement tools have been evaluated for reliability and/or validity within refugee populations. Much variation was found in the selection, development and testing of measurement tools across the reviewed studies.

CONCLUSION

This review shows that there are currently a number of reliable and valid tools available for use in refugee health research; however, further work is required to achieve consistency in the quality and in the use of these tools. Methodological guidelines are required to assist researchers and clinicians in the development and testing of self-rated health measurement tools for use in refugee research.

Plausibility Judgments of Atypical Symptoms Across Cultures: an Explorative Study Among Western and Non-Western Experts

Symptom validity tests (SVTs) are predicated on the assumption that overendorsement of atypical symptoms flags symptom exaggeration (i.e., questionable symptom validity). However, few studies have explored how practitioners from different cultural backgrounds evaluate such symptoms. We asked professionals working in Western (n = 56) and non-Western countries (n = 37) to rate the plausibility of uncommon symptoms taken from the Structured Inventory of Malingered Symptomatology (SIMS), dissociative symptoms from the Dissociative Experience Scale (DES-T), and standard symptoms (e.g., anxiety, depression) from the Brief Symptom Inventory-18 (BSI-18). Western and non-Western experts gave similar plausibility ratings to atypical, dissociative, and standard symptoms: both groups judged BSI-18 symptoms as significantly more plausible than either dissociative or atypical symptoms, while the latter two categories did not differ. Our results suggest that the strategy to detect symptom exaggeration by exploring overendorsement of atypical items might work in a non-western context as well.

Bibliometric analysis of medicine - related publications on refugees, asylum-seekers, and internally displaced people: 2000 - 2015

BACKGROUND

Wars and violent domestic conflicts have forced millions of people to move outside their homes. Meeting the basic health needs of those people requires an understanding of research activity and research output on this topic. The objective of this study was to shed light on the quantity and impact of medicine - related publications on refugees, asylum seekers and internally displaced people (IDP).

METHOD

Scopus database was used to retrieve required data. Specifically, the number of publications, top productive countries and institutions, highly cited articles, citation analysis, international collaboration, and journals involved in publishing articles on refugees, asylum seekers and IDP were reviewed and analyzed. The time span for the study was set from year 2000 to 2015.

RESULTS

Two thousands five hundred and thirty publications were retrieved. The h-index of retrieved articles was 64. A steep rise in number of publications was noticed after 2011. Top productive countries were the United States of America, Australia and the United Kingdom. The American public health institute (Centers for Disease Control and Prevention) and the United Nations refugee agency were among the top active organizations on this topic. Active journals in publishing on health of refugees, asylum seekers and IDP were those on mental health, psychology, public health and general medicine. Publications on Somali, Afghani, Iraqi, and Syrian refugees received a significant share of medicine-related publications. Analysis of publications based on region showed that publications on refugees from Middle East is rising sharply and is approaching those on African refugees.

CONCLUSION

Bibliometric analysis reveals that research publications on refugees have been increasing in a dramatic way and articles are being published in journals with high impact factor and international reputation, not only in general medicine and public health, but also mental health and psychology journals. Analysis of publications related to refugees can be helpful to international health agencies and governments not only to document the psychological trauma of fled people, but also to identify best mental health programs to face the consequences of wars and aggression that led to this refugee crisis.

The Relationship Between Post-Migration Stress and Psychological Disorders in Refugees and Asylum Seekers

Refugees demonstrate high rates of post-traumatic stress disorder (PTSD) and other psychological disorders. The recent increase in forcible displacement internationally necessitates the understanding of factors associated with refugee mental health. While pre-migration trauma is recognized as a key predictor of mental health outcomes in refugees and asylum seekers, research has increasingly focused on the psychological effects of post-migration stressors in the settlement environment. This article reviews the research evidence linking post-migration factors and mental health outcomes in refugees and asylum seekers. Findings indicate that socioeconomic, social, and interpersonal factors, as well as factors relating to the asylum process and immigration policy affect the psychological functioning of refugees. Limitations of the existing literature and future directions for research are discussed, along with implications for treatment and policy.

Somatic Symptoms Mediate the Relationship Between Trauma During the Arab Spring and Quality of Life Among Tunisians

This study examined the relationship between peritraumatic reactions, posttraumatic stress disorder (PTSD) symptoms, somatic complaints, and quality of life in Tunisians exposed to the events of the Arab Spring. Participants (n = 60) completed an online survey 1 year after the events, assessing peritraumatic distress, peritraumatic dissociation, PTSD symptoms, somatic complaints, and physical and mental quality of life. Results showed that peritraumatic dissociation was independently associated with increased PTSD symptoms and somatic complaints 12 months after the events. Multiple mediator mediation analyses revealed that somatic complaints (not PTSD symptoms) were the only independent mediators of the relationships between peritraumatic dissociation and both physical and mental quality of life. Assessing peritraumatic dissociation soon after trauma exposure among the North African population might help identify individuals at risk for PTSD. Furthermore, the impact of trauma on quality of life may be better explained by somatic complaints than PTSD symptoms among North Africans.

Impact of asylum interviews on the mental health of traumatized asylum seekers

BACKGROUND

Asylum interviews within the asylum procedure are associated with psychological stress for traumatized asylum seekers. This study investigates the impact of asylum interviews on the mental health in a sample of 40 traumatized asylum seekers. The comparison group consisted of refugees (N=10) that had not been invited to an asylum interview. Additionally, the moderating effects of trial-related variables such as perceived justice of the trial, stress of giving testimony, and stress of waiting for the asylum interview were examined.

METHOD

Participants were assessed on average 10 days before (t1) and 16 days after (t2) the asylum interview. Chi-square tests for dichotomous and categorical variables were used to compare the descriptive statistics of the two groups. To investigate symptom changes from t1 to t2, paired t-tests were calculated. The magnitude of effects was measured by Cohen's effect size d within groups. Hierarchical regression analyses were conducted for demographic and trial variables predicting posttraumatic intrusions, avoidance, and hyperarousal.

RESULTS

Data showed a significant increase in posttraumatic intrusions and a significant decrease in posttraumatic avoidance and hyperarousal symptoms from t1 to t2. No significant symptom changes in the posttraumatic stress disorder subscales were found in the comparison group. The results of hierarchical regression analyses revealed perceived justice of the interview to predict the increase of intrusions and the number of experienced traumata and testimony stress to predict posttraumatic avoidance.

CONCLUSIONS

The present findings underline the stressful impact of asylum interviews on traumatized refugees. They indicate that the asylum interview might decrease posttraumatic avoidance and trigger posttraumatic intrusions, thus highlight the importance of ensuring that the already vulnerable group of traumatized refugees needs to be treated with empathy during their asylum interview.

Factor structure of PTSD, and relation with gender in trauma survivors from India

BACKGROUND

The factor structure of posttraumatic stress disorder (PTSD) has been extensively studied in Western countries. Some studies have assessed its factor structure in Asia (China, Sri Lanka, and Malaysia), but few have directly assessed the factor structure of PTSD in an Indian adult sample. Furthermore, in a largely patriarchal society in India with strong gender roles, it becomes imperative to assess the association between the factors of PTSD and gender.

OBJECTIVE

The purpose of the present study was to assess the factor structure of PTSD in an Indian sample of trauma survivors based on prevailing models of PTSD defined in the DSM-IV-TR (APA, 2000), and to assess the relation between PTSD factors and gender.

METHOD

The sample comprised of 313 participants (55.9% female) from Jammu and Kashmir, India, who had experienced a natural disaster (N=200) or displacement due to cross-border firing (N=113).

RESULTS

Three existing PTSD models-two four-factor models (Emotional Numbing and Dysphoria), and a five-factor model (Dysphoric Arousal)-were tested using Confirmatory Factor Analysis with addition of gender as a covariate. The three competing models had similar fit indices although the Dysphoric Arousal model fit significantly better than Emotional Numbing and Dysphoria models. Gender differences were found across the factors of Re-experiencing and Anxious arousal.

CONCLUSIONS

Findings indicate that the Dysphoric Arousal model of PTSD was the best model; albeit the fit indices of all models were fairly similar. Compared to males, females scored higher on factors of Re-experiencing and Anxious arousal. Gender differences found across two factors of PTSD are discussed in light of the social milieu in India.

Developing a Chinese PTSD Inventory (CPI) based on interviews with earthquake victims in Sichuan

Although some of the self-report scales for posttraumatic stress disorder (PTSD) are available in Chinese and are currently in use in China, cultural limitations exist. An indigenous Chinese PTSD self-rating scale-the Chinese PTSD Inventory (CPI)-has been developed. The item generation of the CPI was based on interviews of Sichuan earthquake victims. Exploratory factor analysis was conducted on a sample of 313 earthquake victims, acquiring five factors with 27 items: Intrusion, Avoidance, Hyperarousal, Dysphoria, and Somatization. Another sample of 227 debris-flow victims was administered the 27-item CPI. It demonstrated high internal consistency and test-retest reliability, and the result of confirmatory factor analysis indicated a good fit for the five-factor model.

Effects of post-migration factors on PTSD outcomes among immigrant survivors of political violence

This study examined the predictors of posttraumatic stress disorder (PTSD) in a clinical sample of 875 immigrant survivors of political violence resettled in the United States, with a specific aim of comparing the relative predictive power of pre-migration and post-migration experiences. Results from a hierarchical OLS regression indicated that pre-migration experiences such as rape/sexual assault were significantly associated with worse PTSD outcomes, as were post-migration factors such as measures of financial and legal insecurity. Post-migration variables, which included immigration status in the US, explained significantly more variance in PTSD outcomes than premigration variables alone. Discussion focused on the importance of looking at postmigration living conditions when treating trauma in this population.

Life stress as a determinant of emotional well-being: development and validation of a Spanish-Language Checklist of Stressful Life Events

Objectives: To develop a screening instrument for investigating the prevalence and impact of stressful life events in Spanish-speaking Peruvian adults. Background: Researchers have demonstrated the causal connection between life stress and psychosocial and physical complaints. The need for contextually relevant and updated instruments has been also addressed. Methods: A sequential exploratory design combined qualitative and quantitative information from two studies: first, the content validity of 20 severe stressors (N = 46); then, a criterion-related validity process with affective symptoms as criteria (Hopkins Symptom Checklist (HSCL-25), N = 844). Results: 93% of the participants reported one to eight life events (X = 3.93, Mdn = 3, SD = 7.77). Events increase significantly until 60 years of age (Mdn = 6). Adults born in inland regions (Mdn = 4) or with secondary or technical education (Mdn = 5) reported significantly more stressors than participants born in Lima or with higher education. There are no differences by gender. Four-step hierarchical models showed that life stress is the best unique predictor (β) of HSCL anxiety, depression and general distress (p < .001). Age and gender are significant for the three criteria (p < .01, p < .001); lower education and unemployment are significant unique predictors of general distress and depression (p < .01; p < .05). Previously, the two-factor structure of the HSCL-25 was verified (Satorra-Bentler chi-square, root-mean-square error of approximation = 0.059; standardized root-mean-square residual = 0.055). Conclusion: The Spanish-Language Checklist of Stressful Life Events is a valid instrument to identify adults with significant levels of life stress and possible risk for mental and physical health (clinical utility).

High prevalence of anxiety disorders among adolescent Tibetan refugees

INTRODUCTION

Psychiatric disturbance has been shown to result from stress associated with events related to being a refugee. Children of refugees also experience significant stress but little is known about the prevalence of psychiatric disorders in this group. This survey explores the prevalence of psychiatric disorders in a Tibetan refugee enclave in rural North India.

METHODS

A prevalence survey was conducted using the Beck Anxiety Inventory (BAI) to determine the prevalence of anxiety amongst the Tibetan community. Three hundred fifty forms were distributed amongst the students; 335 were completed of which 300 were considered suitable to be collated and analysed.

RESULTS

The results revealed that 21% of the study population had significant levels of anxiety classed as moderate or severe using the BAI. Late adolescents had higher levels of significant moderate and severe anxiety than early and middle adolescents x(2) = 92.95 (P < 0.0001). Female participants had higher levels of moderate and severe anxiety but this was not statistically significant (x(2) = 1.286, P = 0.2568).

CONCLUSION

There were high rates of anxiety in this study of Tibetan school aged children. School based anxiety prevention programmes and other interventions should be considered in such vulnerable populations especially amongst females and late adolescents who are disproportionately affected. These findings indicate a need for further evaluation of young Tibetan refugees for definitive diagnosis of anxiety disorders, specific phobias, social anxiety, post traumatic stress disorders and other anxiety disorders.

Culture and Posttraumatic Stress Disorder (PTSD): A Proposed Conceptual Framework

It is widely accepted that the understanding of any psychological disorder needs to be contextualised within cultural parameters. The notion that current diagnostic taxonomies are not always universally applicable does not mean that all symptoms are not applicable. We present a framework that is aimed at being a starting point from which to delineate universal and culture specific elements of PTSD. The framework follows the possible influence of cultural factors on (a) the formation of an intrusive memory, (b) an understanding of how such a memory becomes pathological, and (c) how symptoms are expressed from the intrusive memory core of PTSD. While the framework presents certain elements (e.g. intrusive memory and core schemas) as centrally important, the focus is on a heuristic framework that allows for the study of the dynamic interaction between potentially universal and cultural factors and how this interaction may produce the symptom profile generally seen with PTSD. Tentative recommendations are made for a research agenda and are presented after a brief exploration of the strengths and weaknesses of such a framework.

The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5

BACKGROUND

There is considerable debate about the cross-cultural applicability of the posttraumatic stress disorder (PTSD) category as currently specified. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds. This review examines various types of cross-cultural validity of the PTSD criteria as defined in DSM-IV-TR, and presents options and preliminary recommendations to be considered for DSM-5.

METHODS

Searches were conducted of the mental health literature, particularly since 1994, regarding cultural-, race-, or ethnicity-related factors that might limit the universal applicability of the diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria for DSM-5.

RESULTS

Substantial evidence of the cross-cultural validity of PTSD was found. However, evidence of cross-cultural variability in certain areas suggests the need for further research: the relative salience of avoidance/numbing symptoms, the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms. This review also indicates the need to modify certain criteria, such as the items on distressing dreams and on foreshortened future, to increase their cross-cultural applicability. Text additions are suggested to increase the applicability of the manual across cultural contexts: specifying that cultural syndromes-such as those indicated in the DSM-IV-TR Glossary-may be a prominent part of the trauma response in certain cultures, and that those syndromes may influence PTSD symptom salience and comorbidity.

CONCLUSIONS

The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

Posttraumatic stress and growth among Tibetan refugees: the mediating role of cognitive-emotional regulation strategies

This study examined posttraumatic stress (PTS) and posttraumatic growth (PTG) among 226 Tibetan refugees across two generations. Additional objectives were to (i) examine the sex and generation differences on the scores of trauma, PTS, and PTG, (ii) explore the relationship between traumatic experiences, PTS and PTG, and (iii) investigate the mediating effect of cognitive-emotional regulation strategies between the traumatic experiences and PTS as well as PTG. Females scored higher on trauma, PTS, and PTG. The trauma, PTS, and PTG scores of the two generations were significantly different. Acceptance and putting into perspective partially mediated the relationship between traumatic experience and PTS. Positive refocusing, refocus on planning, putting into perspective, and catastrophisizing partially mediated the relationship between traumatic experiences and PTG.

A randomized trial of a reconciliation workshop with and without PTSD psychoeducation in Burundian sample

Posttraumatic stress disorder (PTSD) psychoeducation is increasingly offered in diverse cultural settings. As the literature offers theoretical arguments for why such information might be normalizing and distress-reducing, or might risk morbid suggestion of greater vulnerability, a two-sided hypothesis was proposed to examine the specific effect of PTSD psychoeducation. Participants of a trauma healing and reconciliation intervention in Burundi were randomized to conditions with and without PTSD psychoeducation, or to a waitlist control. Both interventions reduced symptoms more than the waitlist. Participants in the condition without psychoeducation experienced a greater reduction in PTSD symptoms relative to other conditions. Findings are discussed in relationship to intervention development for traumatic stress in nonindustrialized and culturally diverse settings.

Traumatic events and mental health in the community: a New Zealand study

BACKGROUND

Adverse mental health effects in response to a variety of distressing events in specific populations are well documented. However, comparatively little research has been conducted within large community samples outside North America.

AIMS

To assess the prevalence and psychological impact of specific traumatic events in a New Zealand community sample.

METHODS

Prevalence and psychological impact of 12 traumatic events was examined in a community sample of 1,500 New Zealand adults using a three-stage cluster sampling method. Traumatic events, psychological distress, psychological well-being, and post-traumatic stress disorder symptoms were assessed using modified versions of the Traumatic Stress Schedule, Mental Health Inventory, and Civilian Mississippi Scale. The effects of age, gender and ethnicity were controlled for while assessing impact of traumatic events.

RESULTS

Sixty-one per cent of the sample experienced trauma events in their lifetime, with 9% experiencing events in the past year. Accident-related events were most common in the present sample. Violent crime produced the greatest impact. Tests of interactions involving age, gender, and ethnicity were not significant.

CONCLUSIONS

New Zealand community-residing individuals experience post-traumatic stress symptoms, reduced psychological well-being, and increased psychological distress following the experience of violent crime and accidents specifically. Study limitations and suggestions for future research are discussed.

Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement - an epidemiological study

Background

The aim of this study was to establish the prevalence of posttraumatic stress disorder (PTSD) and depression among Rwandese and Somali refugees resident in a Ugandan refugee settlement, as a measure of the mental health consequences of armed conflict, as well as to inform a subsequent mental health outreach program. The study population comprised a sample from 14400 (n = 519 Somali and n = 906 Rwandese) refugees resident in Nakivale refugee settlement in South Western Uganda during the year 2003.

Methods

The Posttraumatic Diagnostic Scale (PDS) and the Hopkins Symptom Checklist 25 were used to screen for posttraumatic stress disorder and depression.

Results

Thirty two percent of the Rwandese and 48.1% of the Somali refugees were found to suffer from PTSD. The Somalis refugees had a mean of 11.95 (SD = 6.17) separate traumatic event types while the Rwandese had 8.86 (SD = 5.05). The Somalis scored a mean sum score of 21.17 (SD = 16.19) on the PDS while the Rwandese had a mean sum score of 10.05 (SD = 9.7).

Conclusion

Mental health consequences of conflict remain long after the events are over, and therefore mental health intervention is as urgent for post-conflict migrant populations as physical health and other emergency interventions. A mental health outreach program was initiated based on this study.

Avoidance symptoms and assessment of posttraumatic stress disorder in Arab immigrant women

This study investigates whether the avoidance symptom criterion required for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) diagnosis of posttraumatic stress disorder (PTSD) is overly conservative. Arab immigrant women (N = 453), many of whom reported experiencing multiple traumatic events, completed the Posttraumatic Diagnostic Scale in Arabic as part of a face to face interview. Analyses indicated all but one avoidance symptom was reported less frequently than reexperiencing and arousal symptoms. However, those who fully met reexperiencing, avoidance, and arousal symptom criteria had worse symptom severity and functioning than those who fully met reexperiencing and arousal symptom criteria, but only partially met avoidance symptom criterion. Study findings support importance of the PTSD avoidance symptom criterion.

Shattered Shangri-la: differences in depressive and anxiety symptoms in students born in Tibet compared to Tibetan students born in exile

OBJECTIVE

As a result of ongoing political tensions within Tibetan regions of the People's Republic of China, several thousand Tibetans escape across the Himalayas every year to seek refuge in India and Nepal. Prior studies have found a high prevalence of depressive and anxiety symptoms in these refugees, many of whom are young and have been exposed to significant trauma. However, it is not known whether depressive and anxiety symptoms are more prevalent in these refugees than in ethnic Tibetans born and raised in the relative political and social stability of exile communities in North India and Nepal.

METHODS

We conducted a cross-sectional survey of a convenience sample of 319 students attending school at the Tibetan Children's Villages in Northern India to test the a priori hypothesis that adolescents and young adults who escaped from Tibet to India would demonstrate increased depressive and anxiety symptoms when compared to ethnic Tibetans born and raised in exile. The Hopkins Symptom Checklist-25 (HSCL-25) was used to measure depressive and anxiety symptoms. In addition, demographic information on age, sex, country of birth and frequency of family contact was collected.

RESULTS

Students born in Tibet had higher mean HSCL-25 depressive and anxiety symptom scores than did ethnic Tibetans born in exile. Female students demonstrated higher depressive and anxiety scores, as did those with limited contact with immediate family. After adjusting for sex, age and frequency of family contact, being born in Tibet was associated with increased HSCL-25 depressive and anxiety symptom scores (depression: F[2, 316] = 29.96, P < 0.0001; anxiety: F[4, 316] = 43.57, P < 0.0001).

CONCLUSIONS

The experience of being raised in Tibet and escaping to India appears to be a risk factor for increased depressive and anxiety symptoms when compared to being born and raised within an exile community in India or Nepal.