Psychotherapy for massively traumatized refugees: the therapist variable.

In the treatment of severe posttraumatic stress disorder (PTSD), much emphasis is put on techniques, especially behavioral therapies. Such techniques negate the importance of the therapist as an individual in the treatment of complex PTSD as presented in severely traumatized refugees. The specific difficulties encountered by this population and the therapist responses are discussed: the need to tell the trauma story and the therapist's ability to listen; the patient's need for constancy and therapist's ability to stay; the patient's need to give and the therapist's ability to receive; the patient's problem with evil and the therapist's ability to believe. Case examples illustrate the approach and then discuss how generalizable this experience is to other populations. Research implications are suggested.

Treating traumatized patients and victims of violence.

This chapter presents a thorough exposition of treating traumatized patients and victims of violence, addressing many aspects of trauma and victimization critical to a vast proportion of the work that mental health professionals find themselves doing.

A cross-cultural study of reactivation of posttraumatic stress disorder symptoms: American and Cambodian psychophysiological response to viewing traumatic video scenes.

A physiological hyperarousal state, which can be reactivated by traumatic stimuli, occurs frequently in patients with posttraumatic stress disorder (PTSD). The goals of this study were to determine whether physiological hyperarousal measured by increased heart rate is a specific response to reminders of a patient's own traumatic events or a more generalized hyperarousal state. Five brief videotape scenes of traumatic events (hurricane, auto accident, Cambodian refugee camp, domestic violence, and Vietnam War) were shown to two patient groups with PTSD (Vietnam veterans and Cambodian refugees) and three control groups (Vietnam veterans, Cambodian refugees, and nonpatient Americans). Observations of subjects' behavior, subjective ratings of distress, and heart rate change were recorded and evaluated. The results indicated that Cambodians with PTSD had the most reactions as measured by behavior and heart rate changes. These tended to occur during all scenes, not just the specific Cambodian scene, indicating a general nonspecific arousal. The Vietnam veterans had the fewest changes implying an inhibition of response. The control groups were intermediate in physiological response. The response in PTSD patients to reactivation scenes is complex and probably relates to type and degree of trauma, as well as to culture.

The history and future of cross-cultural psychiatric services.

With cultural issues prominent in the United States today and with ongoing rapid changes in health care management and delivery, this paper discusses the shift from a genetic-type psychiatry (i.e., assuming that humans the world over are no different, and will react to given stressors in life in the same manner) to one recognizing that cultural beliefs, mores, peer pressure, family expectations, and other ingredients operate in unique combinations in various cultures and ethnic groups. These social and cultural factors can and will impact treatment modalities and outcomes. Literature reviewed herein illustrates the progressive stages of awareness and incorporation of cultural differences and the many ways they impact treatment. Unfortunately, the rise in managed, rationed health care threatens the future of this progression. It is essential that culturally-based managed care programs be developed and funded to ensure the availability of cost-effective treatment, through an integrated system of services, to patients of all cultural and economic backgrounds.

A century of controversy surrounding posttraumatic stress stress-spectrum syndromes: the impact on DSM-III and DSM-IV.

The authors describe historical clinical reports that preceded the development of criteria for posttraumatic stress disorder (PTSD) and influenced the formation of PTSD in DSM-IV. These reports were identified from extensive search of 19th- and 20th-century American and European medical literature. Relevant findings from the most representative reports are described and discussed. Since the mid-19th century, clinical syndromes resembling PTSD have been described. However, understanding of PTSD has been complicated by questions of nomenclature, etiology, and compensation. Nomenclature placed PTSD syndromes under existing psychiatric disorders: traumatic hysteria, traumatic neurasthenia, or traumatic neurosis. Etiological issues have been concerned often solely with organic factors, pre-existing personality impairments, intrapsychiatric conflicts, and social factors. Only after World War II and the concentration camp experiences did the role of severe trauma in PTSD become recognized. Even though controversy remains, much progress in understanding PTSD has been made.

Screening for depression among newly arrived Vietnamese refugees in primary care settings.

A brief, culture-specific, self-report screening measure for depression, the Vietnamese Depression Scale, was used to determine the prevalence of depressive symptoms among 1,998 consecutive adult Vietnamese refugees who presented at 10 public health clinics within 2 months of their arrival in the United States. Of these patients, 6% met the criterion for a probable case of depression ("positive"). Being divorced, separated, or widowed and poorly educated were strongly associated with a greater likelihood of screening positive. Somatic complaints were common and induced considerable anxiety about physical health status. Nearly a third of the patients reported sadness and dysphoria; culture-specific symptoms of depression also were prevalent. Our findings document the feasibility of screening for depression using the Vietnamese Depression Scale among Vietnamese refugees, particularly in primary care settings where they are first likely to be seen by health professionals after arrival in their host country.

A prospective study of the natural course of alcoholism in a Native American village.

This study examines the natural course of alcoholism in a Native American village. We found that the remission rates of alcoholism were quite similar despite the different methods used: life histories (SADS-L interview) showed a 63% remission rate; a 19-year follow-up prospective showed 60% in remission; and following a cohort of all those who developed alcoholism in the village over the previous 19 years revealed a 60.9% remission rate. The data also showed vast differences in drinking problems between men and women. In the span of 19 years, the differences of point prevalence rates of alcoholism between men and women have jumped from that of two times (52% vs 26%) to five times (36.4% vs 7%). Furthermore, the results showed women had a higher rate of alcohol abuse (8.4% vs 3.6%) and a far higher remission rate (82% vs 52%) when compared to men. Three-fourths of the men in the studied sample had a lifetime history of alcohol dependence. They usually began drinking in their teens and developed dependency by their early twenties. About half stopped after an average of 15 years of drinking. The majority (83%) of the subjects who stopped drinking did so spontaneously or for specific personal-related reasons rather than because they received alcohol treatment.

Criterion validity of the Center for Epidemiologic Studies Depression Scale in a population sample from an American Indian village.

The criterion validity of the Center for Epidemiologic Studies Depression Scale (CES-D) is examined in 120 adult Northwest Coast American Indians. The criterion was a DSM-III-R diagnosis derived from the Lifetime version of the Schedule for Affective Disorders and Schizophrenia. Sensitivity for major depression was 100% (95% confidence limits 36%, 100%); specificity was 82.1% (75.1%; 89%). For a broad category of depressive disorders (n = 9), sensitivity was 77.8% and specificity was 84.7%. Cut points based on receiver operating characteristic analyses did not greatly improve the performance of the CES-D. The use of factor scores instead of total scores made little difference.

A 6-year follow-up study of Cambodian refugee adolescents traumatized as children.

Seventy-three percent of a sample of 46 Cambodian youth interviewed in 1984 and 1987 were reinterviewed in 1990 as part of a pretest for a multisite study of Cambodian refugee trauma now under way. An additional sample of convenience of 38 youth were also interviewed to determine reliability and validity of the diagnostic instruments chosen for the larger study. The DSM-III-R diagnosis of post-traumatic stress disorder (PTSD) was found to persist, but the symptoms appeared less intense over time. In contrast, the prevalence of depression dropped markedly since 1987. Subjects remained largely free of comorbid conditions. Diagnostic reliability and validity were satisfactory. The follow-up sample appeared to be functioning well despite their PTSD profiles. The findings are discussed in light of several current controversies surrounding the concept and measurement of PTSD.

Prevalence of depressive symptoms among established Vietnamese refugees in the United States: detection in a primary care setting.

OBJECTIVE: To determine the prevalence of depressive symptoms among Vietnamese refugees who have lived in the United States for at least two months. DESIGN: A prospective and descriptive study using the Vietnamese Depression Scale (VDS). Scores of > or = 13 on the VDS were considered indicative of depression. SETTING: Ten public health clinics in four states. PATIENTS/PARTICIPANTS: Four hundred seventy-six consecutive adult Vietnamese refugees presenting for primary care. INTERVENTIONS: The VDS, an 18-item culture-specific self-report measure, was used to screen for depressive symptoms. MEASUREMENTS AND MAIN RESULTS: Twenty percent of these patients had scores of 13 or above. Although being female; being older; being divorced, separated, or widowed; and being poorly educated were significant univariate risk factors for screening positive, only the latter two were significant in a multivariate model. Physical complaints were common and induced considerable anxiety about health status, but psychological and emotional symptoms were even more prevalent. Patients scoring 13 or higher had a higher rate of endorsement for every item in the scale than did those scoring lower than 13. CONCLUSIONS: This study substantiates the feasibility and importance of screening for depressive symptoms among Vietnamese refugees, particularly in primary care settings where they are most likely to seek care for both medical and psychological problems.

Psychotherapy of the victims of massive violence: countertransference and ethical issues.

Psychotherapy with severely traumatized patients is a long, draining process that often produces strong countertransference reactions. It is difficult to therapeutically and ethically handle these personal responses. We feel that at different stages in therapy different ethical principles should guide the therapy. At the early stages, fidelity and nonmaleficence should be the guiding principles. As trust and confidence develop, therapists may have more personal freedom to act; beneficence, i.e., providing specific confident care then becomes the primary ethical principle. In later stages of therapy, promoting the principles of autonomy and justice come into play. As therapy further progresses, therapists' own needs, the principle of self-interest, may be utilized in the therapeutic relationship. Throughout therapeutic contacts with traumatized patients, therapists need to monitor their own needs, and find appropriate ways outside of therapy to cope with these often intense feelings. Continuing to feel therapeutically competent and ethically grounded, yet maintaining the personal strength and balance to treat traumatized patients, pose major challenges for therapists.

Improving quality assurance through psychiatric mortality and morbidity conferences in a university hospital.

To make quality assurance more outcome oriented, the department of psychiatry in a university hospital developed a program of psychiatric mortality and morbidity conferences for reviewing cases with undesirable outcomes. The conference combines aspects of a traditional medical mortality and morbidity conference with features of utilization review and risk management. Case review is focused on mortality, morbidity, or specific indicators developed by the departmental services involved and on a determination of whether an adverse outcome was avoidable, possibly avoidable, or unavoidable. The authors summarize the 100 cases reviewed in the first seven months. They believe the focus on outcome gives the method a useful role in quality assurance; advantages include its recognizable contributions to continuing education and training.

Use of the CES-D in an American Indian village.

In this paper, we examine the performance of a pencil-and-paper screening questionnaire on depressive symptoms (the Center for Epidemiologic Studies Depression Scale, or CES-D) in a sample of 120 adult American Indians belonging to a single Northwest Coast tribe. Results of factor analyses suggest that somatic complaints and emotional distress are not well differentiated from each other in this population. CES-D scores (which have shown good sensitivity and specificity for depressive disorders in this sample) also show weak and apparently nonsignificant trends to be elevated in the presence of other psychiatric diagnoses (including alcoholism) or general impairment. However, because of the use of a convenience sample (rather than a probability sample), analyses of associations between study factors--including comorbidity--are liable to produce spurious results due to selection bias (including Berkson bias). On this basis, we suggest that the use of probability samples should assume a high priority in cross-cultural studies. The study of the entire population of interest is another solution to the sampling problem, particularly in small communities.

Psychiatric epidemiology of an Indian village. A 19-year replication study.

This 1988 study reports the point and lifetime prevalence of psychiatric disorders, using DSM-III-R criteria, of a sample (approximately 25%) of adult members of an Indian village previously studied in 1969. The basic instrument was the Schedule for Affective Disorders and Schizophrenia, augmented by available medical information and administered by experienced psychiatrists. Subjects were interviewed and results were weighed for the age- and sex-distributed population. The results indicated a high point prevalence of alcohol dependence (32.8%), with a lifetime prevalence of 72.8%, among males. The lifetime prevalence of affective disorders among women was also high (36.8%), but less so among men (19.3%). When compared with the DSM-III-R diagnoses of the 1969 study, the point prevalence rates of alcohol dependence and abuse disorders fell from 39% to 21%. Also, fewer subjects were judged to be psychiatrically impaired. Even though the prevalence of psychiatric disorders was lower in the current study, the rates for alcohol disorders and affective disorders were still far higher than those reported in Epidemiologic Catchment Area studies. Alcohol dependence (especially among young men) and affective disorder (among women) were major problems.

The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees.

All 322 patients at a psychiatric clinic for Indochinese refugees were surveyed to determine the presence of posttraumatic stress disorder (PTSD). If PTSD was not diagnosed at the time of initial evaluation, a structured reinterview was performed. Seventy percent of the patients (N = 226) met the criteria for a current diagnosis of PTSD, and an additional 5% (N = 15) met the criteria for a past diagnosis. The Mein had the highest rate of PTSD (93%) and the Vietnamese the lowest (54%). Of the patients with PTSD who were enrolled in the clinic before March 1988, 46% (N = 87) were given a diagnosis of PTSD only after the reinterview. PTSD is a common disorder among Indochinese refugees, but the diagnosis is often difficult to make.

Clonidine in Cambodian patients with posttraumatic stress disorder.

Some symptoms of posttraumatic stress disorder (PTSD) are related to central nervous system adrenergic hyperarousal. It has been suggested that an adrenergic receptor-blocker could be used to diminish, if not alleviate, the target symptoms of PTSD. Severely traumatized Cambodian refugee patients (N = 68) who suffered from chronic PTSD and major depression improved symptomatically when treated with a combination of clonidine and imipramine. A prospective pilot study of nine patients using this combination of an alpha-2 adrenergic agonist and a tricyclic antidepressant resulted in improved symptoms of depression in six patients, five to the point that DSM-III-R diagnoses were no longer met. The average decrease in the Hamilton Rating Scale for Depression score was 16. PTSD global symptoms improved in six patients but only in two to the point that DSM-III-R diagnoses were not met. There was no further sleep disorder in five and the frequency of nightmares lessened in seven patients. Startle reaction improved only in four patients; avoidance behavior showed little improvement in any of the nine. The imipramine-clonidine combination was well tolerated and presents a promising treatment for severely depressed and traumatized patients, although further studies are needed.

A three-year follow-up of Cambodian young people traumatized as children.

Twenty-seven Cambodian young people, who were severely traumatized at ages 8 to 12, were followed up 3 years after an original study. A structured interview and self-rating scales showed that post-traumatic stress disorders (PTSD) were still highly prevalent (48%). Depression existed in 41%. Those with PTSD differed significantly from those without PTSD on the Global Adjustment Scale, the Social Adjustment Scale, the Beck Depression Inventory, and the Impact of Event Scale. Eight subjects had PTSD at both interviews, while 11 had none at either time. Eight showed a variable course. Avoidance behavior was highly prevalent, even among those without PTSD diagnosis. Although functioning relatively well, these youths continued to show symptoms related to their trauma of 8 to 12 years before.