Causal beliefs regarding schizophrenia and help-seeking behaviors among patients with schizophrenia and family caregivers attending psychiatric clinics in Cambodia.

Schizophrenia often follows a chronic or recurrent course, placing an immense burden on patients and their families. Mental health services in Cambodia are still highly limited, thus there is a major treatment gap. It is common that people consult traditional healers (Kru Khmer) and monks. In this culture, people who receive psychiatric medical treatment are expected to exhibit higher mental health literacy, but little is known about this factor. In this study, we interviewed 59 patients with schizophrenia and 59 family caregivers attending psychiatric clinics in Cambodia. Through qualitative analysis using a thematic analysis approach, we extracted eight themes of causal beliefs regarding schizophrenia: (1) spiritual beliefs, (2) cultural symptoms, (3) physical problems, (4) heredity, (5) substance abuse, (6) traumatic events, (7) stress in human relationships or in one's social environment, and (8) socioeconomic position. We found that "thinking too much" (kit chroeun) and "worrying too much" (prouy / barom chroeun), cultural idioms of distress, were recognized as causal factors of schizophrenia by both parents and family caregivers. Some participants were aware of the possible causal factors in light of the latest psychiatry findings, such as genetic factors and childhood trauma. Our data show that causal beliefs are not a decisive factor in shortening the duration of untreated psychosis (DUP). In Cambodia, where the treatment for schizophrenia is pluralistic, we suggest that it is crucial to embed the meaning of psychiatric treatment into local meaning worlds for better help-seeking behaviors.

Key expressions of trauma-related distress in Cambodian children: A step toward culturally sensitive trauma assessment and intervention.

More than half of all children in Cambodia experience direct abuse and over 70% experience other traumatic events, which significantly increase their risks for a range of physical and mental health problems. Additionally, Cambodian children face longstanding sociopolitical, intergenerational, and cultural factors that compound the impact of other trauma. As a result, rates of posttraumatic stress symptoms among Cambodian youth are high. However, care providers often rely on Western-based nosology that does not account for culturally specific expressions of trauma. A greater understanding of culturally-salient expressions of distress can help inform diagnostic assessment accuracy and treatment effectiveness and monitoring. The current study utilized a qualitative design to interview 30 Cambodian caregivers of children with trauma experiences and 30 Cambodian children (ages 10-13 years) with trauma experiences to identify key local expressions of trauma. Findings reveal certain PTSD symptoms and culturally-specific frequent and severe trauma-related problems for Cambodian children and domains of functioning impacted by trauma. Certain symptoms seem particularly important to evaluate in this group, such as anger, physical complaints (e.g., headache and palpitations), and cognitive-focused complaints (in particular, "thinking too much"). All caregivers and children reported physical health as impacted by trauma-related problems, highlighting a particularly salient domain of functioning for this population. Expressions of distress explored in the current study are discussed in the context of assessment and intervention development to inform diagnostic and clinical efforts for those working with trauma-exposed Cambodian children.

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.

Factors Affecting the Help-Seeking Behaviours of Patients with Schizophrenia in Rural Cambodia.

In low- and middle-income countries in Asia, the use of supernatural, religious, and magical approaches to mental illness is widespread. We aimed to document the help-seeking behaviours and barriers to effective mental healthcare in the case of a psychiatric patient in rural Cambodia. The present case report describes the pathway that a patient with schizophrenia utilised to receive effective treatment in a rural area. First, the patient was taken by his parents to a pagoda. Subsequently, they took him to the home of a Kru Khmer (a Cambodian traditional healer). Nevertheless, his condition did not improve, and after seeing this, a neighbour suggested to his mother that they visit the provincial hospital. The patient received a diagnosis after an assessment by the hospital psychiatrist. Following several months of treatment with medication, the patient no longer exhibited paranoid behaviour. In this case, the patient's and his family's beliefs are strongly related to help-seeking behaviour toward medical care among psychiatric patients. To promote timely visits to the hospital, it is crucial to clarify and understand the type of beliefs held by psychiatric patients and their families. Besides, an educational approach to the beliefs is essential for shortening the duration of untreated illness.

Quality of life and its social determinants for patients with schizophrenia and family caregivers in Cambodia.

Due to inadequate human and financial resource support, the development of mental health services in Cambodia has been undertaken by various non-governmental organizations (NGOs). Schizophrenia is the most common functional psychotic disorder, causing severe and chronic symptoms, and the programs provided by the NGOs should have enhanced the quality of life (QoL) of patients and their caregivers; however, epidemiological research, which is a driving force behind the recognition of mental health as a global public health concern, is lacking for schizophrenia in Cambodia. This study therefore aimed to create QoL evaluation questionnaires available in Khmer (the Cambodian language) for patients with schizophrenia and family caregivers, and to identify the social determinants and predictors of their QoL. This cross-sectional study recruited 59 patients and 59 caregivers attending three clinics operated by two NGOs: the Transcultural Psychosocial Organization (TPO) Cambodia and the Supporters for Mental Health (SUMH) Cambodia. We conducted linguistic validation of the Schizophrenia Quality of Life Questionnaire 18-item version (S-QoL 18) and the Schizophrenia Caregiver Questionnaire (SCQ), then analyzed correlations between the QoL dimensions and socio-demographic factors. The main findings of this study were as follows: 1) the newly created Khmer versions of S-QoL 18 and SCQ are relatively good psychometric tools that are suitable for research to identify patients' and caregivers' needs to improve their QoL; and 2) engaging in paid work or being of the post-Khmer Rouge generation results in higher QoL for patients, but having low household economic status or being affected by chronic disease leads to lower QoL for family caregivers. These findings are useful for enabling community mental health professionals and aid organizations to create programs to lessen the patient and caregiver burden in Cambodia. Further research is necessary to develop practical projects that will improve patients' and caregivers' QoL in various clinical settings in Cambodia.

Prolonged grief following the recent death of a daughter among mothers who experienced distal losses during the Khmer Rouge era: Validity of the prolonged grief construct in Cambodia.

This study addressed the validity of the prolonged grief (PG) construct in a Cambodian context. Eighty mothers who lost a young adult daughter stemming from a crowd stampede incident during the annual water festival were interviewed at the six-month post-loss point along with a control group of similarly aged women who were not recently bereaved. Both groups were assessed for PG, PTSD, anxiety, and depression symptoms and well as for the number of distal losses experienced during the Khmer Rouge (KR) regime - knowing that all the women were old enough to have lived through the KR regime. Support for the discriminant validity of PG was shown in a factor analysis in which its core symptoms were distinguished from anxiety, depression, and PTSD symptoms. Also, support was found for its incremental validity as shown in the unique sensitivity of PG in distinguishing the two groups when controlling for the other symptoms. Lastly, a positive relationship was found between the number of distal deaths experienced during the KR regime and PG symptom severity among the group of recently bereaved mothers, providing support for the predictive validity of PG. Implications as well as study limitations are discussed.

Labor migration and mental health in Cambodia: a qualitative study.

Labor migration is thought to have significant mental and physical health impacts, given the risks for exploitation and abuse of migrant workers, particularly among those in semiskilled and unskilled positions, although empirical data are limited. This qualitative study, conducted in July 2010 in Banteay Meanchey Province, Cambodia, focused on psychosocial and mental health signs and symptoms associated with labor migration among Cambodian migrant workers to Thailand. Two qualitative methods identified a number of mental health problems faced by Cambodian migrant workers in Thailand, including the presence of anxiety and depression-like problems among this population, described in local terminology as pibak chet (sadness), keut chreun (thinking too much), and khval khvay khnong chet (worry in heart). Key informants revealed the extent to which psychosocial well-being is associated with conditions of poverty, including debt and lack of access to basic services.

Baksbat (broken courage): a trauma-based cultural syndrome in Cambodia.

Whether posttraumatic stress disorder (PTSD) sufficiently explains and encompasses the symptoms experienced by people from non-Western cultures is debatable. The etymological, social, and historical contexts of idioms of distress experienced by Khmer, known as baksbat, were studied through interviews with 53 Cambodian experts. Phey-khlach (double fear), bor-veas-cheas-chgnay (wishing that the trauma would go away), dam-doeum-kor (planting a kapok tree-remaining mute), chos-nhorm (submissive, easily giving in), kob yobal (ideas are buried), and loss of togetherness, were all identified as specific symptoms of baksbat. Similarities and differences between symptoms of baksbat, PTSD, anxiety, and depression indicate that baksbat is a Cambodian idiom of distress with sufficient characteristics to be recognized as a formal cultural trauma syndrome distinct from PTSD. Increased awareness of its criteria and phenomenology may help clinicians provide appropriate support for traumatized Cambodians.

Prolonged grief disorder three decades post loss in survivors of the Khmer Rouge regime in Cambodia.

BACKGROUND: During the Khmer Rouge (KR) regime from 1975 to 1979 millions of Cambodians were confronted with the death or murder of family members. The long-term psychological consequences of these traumatic losses have not yet been investigated. The purpose of this study was to determine the rate and potential predictors of prolonged grief disorder (PGD) in survivors of the KR regime. METHOD: The Inventory of Complicated Grief-Revised (ICG-R) was administered in a sample of N=775 Cambodians in face-to-face interviews who had lost at least one family member during the KR regime. Symptoms of PTSD were assessed with the PTSD Checklist-Civilian Version and symptoms of depression and anxiety with the Hopkins Symptom Checklist-25. RESULTS: The prevalence of PGD in the sample was 14.3%. PGD was moderately associated with symptoms of depression, anxiety and PTSD. The loss of a spouse, a child, or a parent was associated with higher symptom severity of PGD than was the loss of a sibling or distant relatives. PGD was predicted by the relationship to the deceased and symptoms of depression and PTSD. LIMITATIONS: Limitations of the study include the non-random sampling recruitment. The ICG-R has not been validated for use in Cambodia. CONCLUSIONS: The vast majority of Cambodians lost family members during the KR regime. Even three decades later, PGD was prevalent in a substantial proportion of the present sample and related to other psychiatric disorders. The results underline the importance of examining PGD in studies of war-related psychological impairment.

Baksbat (broken courage): the development and validation of the inventory to measure baksbat, a Cambodian trauma-based cultural syndrome of distress.

This article outlines the development and validation of an inventory measuring a Cambodian cultural syndrome of distress called 'baksbat' (broken courage). The inventory development phase involved ethnographic interviews with a preliminary group of 53 experts having knowledge or experience of baksbat. The initial ethnographically derived inventory with 32 items was developed and administered to a second group of 390 consecutive patients to assess factor loadings. The validation phase used confirmatory factor analysis (CFA) to test goodness-of-fit of four hypothesized factor models of the newly developed inventory in a third group of 159 participants. CFA confirms three-factor models that have the best goodness-of-fit, thus a 24-item baksbat inventory clustering of three-symptom categories was developed. Multiple regression, which assesses the relationship between the dependent variable (PTSD) and a subcluster of baksbat inventory (predictors), shows baksbat inventory accounts for 47 % of the total variance of symptoms in PTSD (R (2) = .47). Of the three-symptom clusters, 'psychological distress' shows significant contribution to the total variance of symptoms in PTSD (ß = .63, p < .001). Of significance, some symptoms of baksbat were independent from symptoms of PTSD with isolated symptoms that are culturally specific. These preliminary findings suggest that baksbat could be a potential Cambodian trauma-based syndrome with its own culturally validated inventory.