Andrew Rasmussen

War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks.

This paper seeks to bridge the divisive split between advocates of trauma-focused and psychosocial approaches to understanding and addressing mental health needs in conflict and post-conflict settings by emphasizing the role that daily stressors play in mediating direct war exposure and mental health outcomes. The authors argue that trauma-focused advocates tend to overemphasize the impact of direct war exposure on mental health, and fail to consider the contribution of stressful social and material conditions (daily stressors). Drawing on the findings of recent studies that have examined the relationship of both war exposure and daily stressors to mental health status, a model is proposed in which daily stressors partially mediate the relationship of war exposure to mental health. Based on that model, and on the growing body of research that supports it, an integrative, sequenced approach to intervention is proposed in which daily stressors are first addressed, and specialized interventions are then provided for individuals whose distress does not abate with the repair of the social ecology.

Daily Stressors, War Experiences, and Mental Health in Afghanistan

Working in Afghanistans capital city of Kabul, the authors assessed the relative contribution of daily stressors and war-related experiences of violence and loss to levels of depression, PTSD, impaired functioning, and a culturally specific measure of general psychological distress. For women, daily stressors were a better predictor than war experiences of all mental health outcomes except for PTSD; for men, daily stressors were a better predictor of depression and functional impairment, while war experiences and daily stressors were similarly predictive of general distress. For men, daily stressors moderated the relationship between war experiences and PTSD, which was significant only under conditions of low daily stress. The studys implications for research and intervention in conflict and post-conflict settings are considered.

Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology

BACKGROUND Burgeoning global mental health endeavors have renewed debates about cultural applicability of psychiatric categories. This studys goal is to review strengths and limitations of literature comparing psychiatric categories with cultural concepts of distress (CCD) such as cultural syndromes, culture-bound syndromes, and idioms of distress. METHODS The Systematic Assessment of Quality in Observational Research (SAQOR) was adapted based on cultural psychiatry principles to develop a Cultural Psychiatry Epidemiology version (SAQOR-CPE), which was used to rate quality of quantitative studies comparing CCD and psychiatric categories. A meta-analysis was performed for each psychiatric category. RESULTS Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I(2) > 75%). Only general psychological distress had low heterogeneity (I(2) = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders. CONCLUSIONS Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.

Entering exile: Trauma, mental health, and coping among Tibetan refugees arriving in Dharamsala, India

Each year thousands of Tibetans escape Chinese-controlled Tibet. The authors present findings on the experiences, coping strategies, and psychological distress (depression, anxiety, somatization, and posttraumatic stress disorder) of 769 Tibetan refugees arriving in Dharamsala, India (2003-2004). Distress increased significantly with greater trauma exposure. However, despite a high prevalence of potentially traumatizing events, levels of psychological distress were extremely low. Coping activity (primarily religious) and subjective appraisals of trauma severity appeared to mediate the psychological effects of trauma exposure. The potential impact of other variables, including culturally determined attitudes about trauma and timing of assessment, are discussed.

Resilience in trauma-exposed refugees: the moderating effect of coping style on resilience variables.

Research with survivors of torture has generated considerable variability in prevalence rates of posttraumatic stress disorder (PTSD). Multiple risk and resilience factors may affect this variability, increasing or decreasing the likelihood of experiencing psychological distress. This study sought to investigate the effect of several such resilience factors, coping style, social support, cognitive appraisals, and social comparisons on PTSD symptom severity. Furthermore, this study examined whether coping style moderated the relationship between resilience variables and PTSD symptoms. Seventy-five torture survivors completed an intake interview and several self-report measures upon entry into a treatment program for survivors of torture. Results indicated that emotion-focused coping styles significantly moderated the relationship between cognitive appraisal and social comparison variables and PTSD, and usually increased the likelihood of developing severe symptoms. These results indicate that the salience of resilience variables may differ depending on the individuals coping style, which present implications for clinical practice with torture survivors.

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 subjective experience of trauma and subsequent PTSD in a sample of undocumented immigrants

Although a subjective component of trauma is commonly recognized in diagnosing posttraumatic stress disorder (PTSD), there are few studies that specifically address Criterion A2, and none addressing this issue among undocumented immigrants. We assessed 212 arriving undocumented immigrants with diverse trauma histories to investigate concordance between objective and subjective factors of trauma (Criteria A1 and A2) and across different types of trauma and PTSD. Concordance between Criteria A1 and A2 varied, with highest rates found for political violence. Interpersonal violence in general was associated with higher rates of PTSD. We identified a dose-response effect for PTSD, but this was not dependent on other events (i.e., other doses) meeting Criterion A2. Discussion focuses on Criterion A within the phenomenology of PTSD and the need to gauge subjective interpretations of trauma events among this population.

Posttraumatic idioms of distress among Darfur refugees: Hozun and Majnun

Although psychosocial programming is seen as essential to the humanitarian response to the Darfur conflict, aid groups lack culturally-appropriate assessment instruments for monitoring and evaluation. The current study used an emic-etic integrated approach to: (i) create a culturally-appropriate measure of distress (Study 1), and (ii) test the measure in structured interviews of 848 Darfuris living in two refugee camps in Chad (Study 2). Traditional healers identified two trauma-related idioms, hozun and majnun, which shared features with but were not identical to posttraumatic stress disorder and depression. Measures of these constructs were reliable and correlated with trauma, loss, and functional impairment. Exploratory factor analysis resulted in empirical symptom clusters conceptually parallel to general Western psychiatric constructs. Findings are discussed in terms of their implications for psychosocial programming.

The Validity and Clinical Utility of Post-traumatic Stress Disorder in Afghanistan

This study examined the validity and utility of PTSD among 320 adults in Afghanistan. Findings support the validity of PTSD in this cultural context: PTSD symptoms were highly prevalent, shared common variance, and correlated as expected with exposure to traumatic stress. However, only limited support was found for the clinical utility of PTSD. Other types of psychiatric symptomatology, including depression and a culturally specific measure of general distress, correlated more highly with traumatic stress than did PTSD; and PTSD accounted for limited variance in functioning beyond that explained by depression and general distress. Implications for research and intervention are considered.

The effects of torture-related injuries on long-term psychological distress in a Punjabi Sikh sample.

Torture survivors often report chronic debilitating physical and psychological distress. Prior research on the relationship between physical and psychological trauma suggests that the 2 are not independent. Injury sustained during torture may increase the likelihood of subsequent distress as either a moderator or mediator. For long-term psychopathology in a sample of Punjabi Sikh survivors of human rights violations (N = 116), chronic injuries mediated the path between torture and posttraumatic stress disorder, specifically the severity of numbing symptoms. Although injuries were associated with major depression, torture was not, and injuries did not moderate the relationship between major depression and torture. Chronic injuries may represent trauma severity or persistent traumatic cues. These findings emphasize connections between physical and psychological trauma and the importance of an interdisciplinary approach to torture treatment.