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.

Testimony Therapy With Ritual: A Pilot Randomized Controlled Trial.

Testimony therapy can provide low-cost, brief, simple, and culturally adaptable psychosocial services in low-income countries (Agger, Raghuvanshi, Khan, Polatin, & Laursen, 2009). Nonetheless, there have been no well-controlled studies of testimony therapy. We report the analyses of a randomized controlled trial designed to assess the effectiveness of testimony therapy plus a culturally adapted ceremony in reducing mental health symptoms among Khmer Rouge torture survivors from across Cambodia. Using multilevel modeling, we compared symptoms of posttraumatic stress disorder, anxiety, and depression between a treatment (n = 45) and a control group (n = 43) at baseline, 3 months, and 6 months. We found that testimony therapy plus ceremony significantly reduced symptoms of posttraumatic stress disorder (d = 0.49), anxiety (d = 0.44), and depression (d = 0.53).

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.

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.