Patterns of symptomatology and patterns of torture and trauma experiences in resettled refugees

Local clinician perspectives on cause, impact, and treatment of key expressions of distress in Cambodian children

Child trauma and posttraumatic stress in Cambodia is highly prevalent, perpetuated within a postwar sociocultural context. The examination of locally meaningful expressions of distress is needed to provide culturally sensitive assessment and treatment of trauma-affected Cambodian children. The acceptable, feasible, and sustainable incorporation of expressions of distress into assessment and intervention development relies on key mental health professionals operating in Cambodia, who can provide invaluable perspectives on child trauma experiences in this particular sociocultural context. In this study, qualitative interviews were conducted with 15 Cambodian mental health professionals (MHPs) who work directly with trauma-affected Cambodian children. MHPs were presented with seven key posttraumatic problems derived from previous qualitative interviews with Cambodian children and caregivers, and discussed 1) the causes of these problems, 2) the impact of the problem on the child or those around them, 3) the current treatment for the problem in Cambodia, and 4) recommended treatment. MHPs provided unique insights and perspectives of trauma-affected children in the Cambodian context regarding key target problems, including palpitations, difficulties in school, headache, and thinking too much, and highlighted future directions for assessment and intervention. Recommendations are discussed in regard to programming design and organizational training development to promote culturally salient, feasible, and sustainable mental health service provision in Cambodia.

Trauma Exposures, Resilience Factors, and Mental Health Outcomes in Persons Granted Asylum in the U.S. for Claims Related to Domestic Violence and Persecution by Organized Gangs

Survivors of domestic violence (DV) and of violence perpetrated by organized gangs (GV) face barriers to legal protection under U.S. asylum law. We abstracted data from 132 affidavits based on forensic medical evaluations of asylum seekers granted legal protection in the U.S. on the basis of DV and/or GV. We described claimants’ trauma exposures and resilience factors and used multiple logistic regression to quantify associations with Diagnostic and Statistical Manual-5 (DSM-5) diagnoses and improvement in mental health. People seeking asylum based on DV and/or GV have endured multiple types of trauma with significant impacts on their mental health. New experiences of trauma following migration to the U.S. were common and associated with DSM-5 diagnoses. Conversely, resilience factors were associated with improved mental health. Policies that aim to reduce ongoing trauma in the U.S. and to bolster resilience factors may promote asylee mental health and well-being.

Predictors of Posttraumatic Stress Disorder, Anxiety, and Depression Symptoms in Survivors of Torture Living in the United States

A constellation of psychosocial factors contributes to the complex trauma symptoms that survivors of torture may experience. We examined the roles of pretrauma, peritrauma, and postmigration factors as predictors of posttraumatic stress disorder, depression, and anxiety in a sample of 101 culturally heterogeneous torture survivors residing in the United States. Predictors included demographic variables (sex, education, marital status), peritrauma torture type variables generated by principal components analysis (PCA), and postmigration variables (employment status, legal immigration status, and family separation). Of the torture factors identified through PCA (torture inflicted on the self and torture inflicted on family members), torture inflicted on the self significantly predicted anxiety. Undocumented legal status and female sex were related to poorer psychological outcomes. Results highlight the importance of considering postmigration factors, specifically legal status, rather than elements of the torture experience itself, in the delivery of trauma-informed psychological interventions and policy development for survivors of torture.

An investigation into the association of pre- and post-migration experiences on the self-rated health status among new resettled adult humanitarian refugees to Australia: a protocol for a mixed methods study

BACKGROUND

Refugees are one of the most vulnerable groups in our society. They are at risk of poor physical and mental health outcomes, much of this attributed to traumatic events prior to migration and the additional risk factors refugees face in the host nations. However, how migration factors shape the health of resettling refugees is not well understood. This study uses a mixed methods approach to examine how pre- and post-migration factors shape the self-rated health of resettling adult refugees in an effort to address the current knowledge gap.

METHODS

This study will use a sequential explanatory mixed method study design. We begin by analyzing resettlement and health data from the 'Building a New Life In Australia' longitudinal study of humanitarian refugees resettled in Australia to identify significant associations between migration factors and refugee health. Then, a series of semi-structured interviews with resettled refugees will further explore the lived experiences of refugees with respect to the relationship between migration and refugee health. Finally, we will integrate both sets of findings to develop a detailed understanding of how and why migratory factors contribute to refugee health during resettlement.

DISCUSSION

There is a paucity of studies that examine the multidimensional nature of refugee health during resettlement and as a result, little is understood about their resettlement health needs. This information is required to inform existing or new resettlement interventions to help promote or improve refugee health. To overcome these limitations in the research knowledge, this study will use a mixture of study methods to illustrate the complex and multifaceted determinants of refugee health during resettlement in Australia.

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.

Beyond Asylum: Implications for Nursing and Health Care Delivery for Afghan Refugees in Australia

Descriptions of the refugee experience, together with an analysis of access, use, and appropriateness of mental and physical health services as perceived by members of the Afghan immigrant or refugee community living in New South Wales (NSW), Australia, are reported in this article. Using focus groups and semistructured interviews in a variety of settings, the study included 13 key informants and 25 general informants, together with health care agencies providing services to the Afghans and organizations providing resources. Analysis of interviews with Afghan people revealed a number of themes. These include emotional responses to trauma, migration, and resettlement experiences; culture-specific health maintenance strategies; barriers impeding access to and appropriateness of Australian health care services; and informant-suggested strategies to enhance accessibility and the appropriateness of health care and community services. These findings are significant and have relevance for improving the quality of culture-specific health care for the Afghan community in NSW Australia.

Trauma and PTSD rates in an irish psychiatric population: A comparison of native and immigrant samples

Although Western mental health services are increasingly finding themselves concerned with assisting traumatized individuals migrating from other countries, trauma and posttraumatic stress disorder (PTSD) are under-detected and undiagnosed in psychiatric populations. This study examined and compared rates of traumatic experiences, frequency of traumatic events, trauma symptomatology levels, rates of torture, rates of PTSD and chart documentation of trauma and PTSD between (a) Irish and migrant service-users and (b) forced migrant and voluntary migrant service-users in Dublin, Ireland. Data were gathered from 178 psychiatric outpatients attending using a sociodemographic questionnaire, the Harvard Trauma Questionnaire-Revised Cambodian Version and the SCID-I/P. A substantial number of service-users had experienced at least one lifetime trauma (71.3%), and a high percentage of both the Irish (47.4%) and migrant groups (70.3%) of service-users had experienced two or more events. Overall, analyses comparing rates between Irish, forced migrant and voluntary migrant service-users found that forced migrants displayed more traumatic life events, posttraumatic symptoms, and higher levels of PTSD than their voluntary migrant and Irish counterparts, with over 50% experiencing torture prior to arrival in Ireland. The lifetime rate of PTSD in the overall sample was 15.7% but only 53.57% of cases were documented in patient charts. The results of this study are informative about the nature and extent of the problem of trauma and PTSD among migrant mental health service users as well as highlighting the under-detected levels of trauma among native-born service users.

The mental health and psychosocial effects of organized violence: a qualitative study in northern Haiti

Historically, organized violence has been a chronic pervasive problem in Haiti. We set out to elicit Haitians' views on its effects to guide the development of interventions. In March 2006 we studied a population in the slum area of Cap-Haitien, Haiti's second largest city, and the nearby towns of Milot and Limbe. A convenience sample of adults was asked to free list all current problems affecting victims of organized violence. Two major categories emerged: psychological problems and financial problems. The psychological problems of "feeling startled and loss of self control," "sadness/grief," "continuing to suffer from reliving/reexperiencing past events," "problems in the head/mental problems," "deep suffering in the heart," and "thinking too much" emerged as themes from key-informant interviews. These may correspond to constructs of depression, dysthymia, and anxiety disorders including posttraumatic stress disorder in psychiatric nosology. The development of effective interventions can therefore consider those known to be effective for these problems in other settings. However in selecting interventions, considerations must also include local acceptability, perceived causes of problems, and their social effects.

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.

Screening for Torture: A Narrative Checklist Comparing Legal Definitions in a Torture Treatment Clinic

Torture has been defined most precisely in legal contexts. Practitioners who work with torture survivors and researchers who study torture have frequently cited legal definitions, particularly those in the United States' Torture Victims Relief Act, the United Nations Convention against Torture, or the World Medical Association's Declaration of Tokyo. Few practitioners have operationalized these definitions and applied them in their practice. We describe how a New York City torture treatment clinic used a coding checklist that operationalizes the definitions, and present results. We found that in practice these definitions were nested; that using guidelines for applying the definitions in practice altered the number of cases meeting criteria for these definitions; and that the severity of psychological symptoms did not differ between those who were tortured and those who were not under any definition. We propose theoretical and practical implications of these findings.

Gender differences in victims of war torture: Types of torture and psychological consequences

Background/Aim. Torture for political reasons is an extreme violence in interpersonal relations resulting in not only acute psychiatric disorders but also very often in very severe and far reaching negative consequences for the overall psychosocial functioning of a victim. The aim of this study was to investigate gender differences in types of torture and psychological consequences in subjects who experienced war torture. Methods. A sample (410 men and 76 women) included clients of 'Centre for rehabilitation of torture victims - IAN, Belgrade' who experienced torture in prisons and concentration camps during civil wars in ex-Yugoslavia 1991-1995 and 1999. Types of Torture Questionnaire with 81 items was used for collecting data about forms of torture. Symptom Checklist 90-Revised (SCL-90- R) was used for assessing type and intensity of psychological symptoms, and Impact of Event Scale (IES) was used to estimate posttraumatic complaints. Results. A gender difference was found for 33 types of torture: 28 more frequent in men, and 5 in women. Factor analysis of torture types revealed three factors explaining 29% of variance: 'common torture', 'sadistic torture', and 'sexual torture'. Discriminant analysis revealed significant gender difference concerning the factors. 'Common torture' and 'sadistic torture' were more prominent in men, and 'sexual torture' was more present in women. Higher scores on depression, anxiety, somatization, interpersonal sensitivity and obsessive-compulsive dimensions on SCL-90-R were found in women. General score and scores of subscales (intrusion and avoidance) on IES were significantly higher in women. Conclusion. Women exposed to war torture experienced less torture techniques and shorter imprisonment than men, but had more frequent and severe symptoms of posttraumatic stress disorder and other psychological symptoms. Gender differences in posttraumatic symptomatology can not be explained exclusively by gender differences in types of torture found in this study.

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.

Access to mental health for asylum seekers in the European Union. An analysis of disparities between legal rights and reality

The article explores some of the issues surrounding access to mental health care for asylum seekers, using Belgium as a case in point. Asylum and immigration issues have become increasingly pressing in Europe, with member states seeking a common European Asylum System and establishing minimum standards for the reception of asylum seekers. The EU measures have fallen short of providing and implementing clear guidelines. Significant discrepancies continue to exist between member states, notably policies on health care for refugees, and in particular mental healthcare. Access to mental health care is identified as crucial, yet for many the right to access is theoretical only, and in reality care is often inaccessible. Access should refer not only to the availability, but also the quality and efficacy of care. Refugees are a particularly vulnerable population, and access in the fullest sense of the term should be an essential element in the reception of asylum seekers.

The range of symptoms in refugees of war: the New Mexico Refugee Symptom Checklist-121

The range of symptoms experienced by refugees of war has not been empirically assessed. The New Mexico Refugee Symptom Checklist-121 (NMRSCL-121) was developed utilizing established guidelines and evaluated for its psychometric properties. Community-dwelling Kurdish and Vietnamese refugees reported 48 (SD = 31) persistent and bothersome somatic and psychological symptoms on the NMRSCL-121. Internal consistency and test-retest reliability for the total scale and for most subscales were acceptable, and construct and concurrent validity for the NMRSCL-121 data was shown. There were modest ethnic group differences on symptom severity and psychometric properties of NMRSCL-121 subscales. The NMRSCL-121 produces reliable and valid assessments of a wide range of symptoms in 2 broad community samples of displaced adult refugees.

Treating survivors of torture and refugee trauma: a preliminary case series using qigong and t'ai chi

OBJECTIVES

This paper seeks to explore the potential value of qigong and t'ai chi practice as a therapeutic intervention to aid in the treatment of survivors of torture and refugee trauma.

DESIGN

The common effects of torture and refugee trauma are surveyed with a focus on post-traumatic stress disorder. An alternative theoretical framework for conceptualizing and healing trauma is presented. Evidence is reviewed from the scientific literature that describes how qigong and t'ai chi have been used in studies of the general population to alleviate symptoms that are also expressed in torture survivors. Observations are presented from a combined, simplified qigong and t'ai chi intervention with a convenience sample of four refugee survivors of torture.

RESULTS

Preliminary observations from four cases and a review of the literature support the potential efficacy of incorporating qigong and t'ai chi into the treatment of survivors of torture and refugee trauma.

CONCLUSIONS

The incorporation of qigong and t'ai chi into the treatment of torture survivors, within a new framework for healing trauma, merits further investigation.

Classifying the torture experiences of refugees living in the United States

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.

The experience of mental death: The core feature of complex posttraumatic stress disorder

Exposure to extreme interpersonal stress, exemplified by the experience of torture, represents a threat to the psychological integrity of the victim. The experience is likely to result in mental death, in the loss of the victim's pretrauma identity. Mental death is characterized by loss of core beliefs and values, distrust, and alienation from others, shame and guilt, and a sense of being permanently damaged. Mental death is a primary feature of a distinct posttrauma syndrome, complex posttraumatic stress disorder (PTSD), which is refractory to standard exposure therapies. We identify cognitive mechanisms that mediate the symptoms of complex PTSD, and suggest how current treatments need to be modified to obtain enhanced treatment outcomes.

Refugee intake: reflections on inequality

BACKGROUND

Refugees represent one of the most marginalized populations with generally poor health outcomes and requirements often very different from, and in excess of, the populations in the countries of asylum. It stands to reason that countries that accept refugees should have the resources to support them. Although governments in industrialised countries are often vociferous about the generosity of their support for refugees, the appearance is that it is the poorest nations that bear the greatest burden. This has important implications for the allocation of resources to support the health and welfare needs of refugees. The distribution of refugees globally and the wealth of the countries of asylum are examined in this paper.

METHOD

Data on the numbers of refugees accepted in each country were obtained from the United Nations High Commissioner for Refugees. These were used to analyse the 'fairness' of the distribution of refugees according to the economic capacity of the host countries.

FINDINGS

A similar distribution of refugees prevails in the poorest quintile of countries and in the richest. Although there is considerable between-country variation, when account is taken of economic capacity, the poorest countries bear the greatest burden.

INTERPRETATION

The distribution of refugees is in stark contrast to the humanitarian rhetoric of the industrialized countries. The implications of the inequitable distribution on health cannot be overemphasized.

Traumatic events and physical health in a New Zealand community sample

Traumatic event exposure and physical health were examined in a community-residing sample of 1,500 New Zealand adults. Half (51%) reported past traumatic event exposure, 9% reported recent (past 12 months) trauma exposure, and 40% reported no exposure. After adjusting for gender, ethnic, and age differences, those experiencing crime and accident trauma exhibited significantly deteriorated physical health, as measured by current physical symptoms, chronic medical conditions, and chronic limitations in daily functioning. Further research is required to assess the influence of traumatic events on the physical health among adults from other countries, and to evaluate the factors that may mediate or moderate this relationship for different subgroups of the New Zealand population. Limitations of this study are outlined.