Jaswant Guzder

Common mental health problems in immigrants and refugees: general approach in primary care

Background: Recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care poses a challenge because of differences in language and culture and because of specific stressors associated with migration and resettlement. We aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care. Methods: We searched and compiled literature on prevalence and risk factors for common mental health problems related to migration, the effect of cultural influences on health and illness, and clinical strategies to improve mental health care for immigrants and refugees. Publications were selected on the basis of relevance, use of recent data and quality in consultation with experts in immigrant and refugee mental health. Results: The migration trajectory can be divided into three components: premigration, migration and postmigration resettlement. Each phase is associated with specific risks and exposures. The prevalence of specific types of mental health problems is influenced by the nature of the migration experience, in terms of adversity experienced before, during and after resettlement. Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. These issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations. Interpretation: Systematic inquiry into patients’ migration trajectory and subsequent follow-up on culturally appropriate indicators of social, vocational and family functioning over time will allow clinicians to recognize problems in adaptation and undertake mental health promotion, disease prevention or treatment interventions in a timely way.

Psychological risk factors for borderline personality disorder in female patients

The purpose of this study was to examine the role of several psychological risk factors, i.e., childhood sexual abuse (CSA) and its parameters, childhood physical abuse (PA), early separation or loss, and abnormal parental bonding, in borderline personality disorder (BPD). Women with personality disorders were divided into BPD (n = 78) and non-BPD (n = 72) groups. Risk factors were measured by a developmental interview and the Parental Bonding Index (PBI). The BPD group had a greater frequency of CSA, more severe CSA, as well as more PA, and a lower maternal affection score on the PBI. Only CSA was significant in the multivariate analysis. CSA is the risk factor that most strongly discriminates between BPD and non-BPD. However, CSA has low specificity to BPD, and only a subgroup reported severe abuse experiences.

Psychological risk factors for dissociation and self-mutilation in female patients with borderline personality disorder

The purposes of this study were to determine whether or not dissociation in female patients suffering from personality disorder is related to sexual and physical abuse or to abuse parameters and whether or not self-mutilation in the personality disorders is related to psychological risk factors or to dissociation. The sample was divided into 78 borderline and 72 nonborderline personality disorders. Psychological risk factors were measured through histories of childhood sexual abuse, physical abuse and separation or loss as well as scores on the Parental Bonding Index. Dissociation was measured by the Dissociative Experiences Scale. On the diagnostic interview, 48 subjects scored positive for self-mutilation. Dissociative Experiences Scale scores were associated with a borderline diagnosis but not with childhood sexual abuse or physical abuse. The parameters of abuse were not related to dissociation. Subjects who mutilated themselves had higher rates of both childhood sexual abuse and dissociation in univariate analyses. However, in multivariate analyses only diagnosis was significant. None of the other psychological risk factors were significantly linked to self-mutilation. The findings do not support theories that dissociation and self-mutilation in borderline personality disorder are associated with childhood trauma.

Risk Factors for Borderline Personality in Male Outpatients

The purpose of the study was to examine the role of several psychological risk factors-childhood sexual abuse (CSA) and its parameters, childhood physical abuse and its parameters, early separation or loss, and abnormal parental bonding-in male patients with borderline personality disorder (BPD). Subjects with personality disorders were divided into BPD (N = 61) and non-BPD (N = 60) groups. The risk factors were measured by a developmental interview and the Parental Bonding Index. The BPD group had a higher frequency of CSA, more severe CSA, a longer duration of physical abuse, increased rates of early separation or loss, and a higher paternal control score on the Parental Bonding Index. CSA and separation or loss were significant in the multivariate analysis. The risk factors suggest that trauma and loss, as well as problems with fathers, are important for the development of BPD in males.

Risk Factors for Borderline Pathology in Children

OBJECTIVE To examine risk factors associated with borderline pathology in latency-age children. METHOD The subjects were 98 children assessed for day treatment. Borderline subjects were identified in a chart review using the Child Diagnostic Interview for Borderlines, which divided the sample into borderline (n = 41) and nonborderline (n = 57) groups. Functional levels were assessed by Childrens Global Assessment Scale scores. The risk factors were also rated by chart review; all subjects were given a cumulative abuse score and a cumulative parental dysfunction score. RESULTS Both groups demonstrated severe functional impairment. The risk factors that differentiated the borderline group were sexual abuse, physical abuse, severe neglect, and parental substance abuse or criminality. Sexual abuse and severe neglect were significant in multivariate analysis. Cumulative abuse and cumulative parental dysfunction scores were both higher in the borderline group. CONCLUSIONS The findings indicate that the risk factors in borderline children are similar to those found in adults.

School-Based Prevention Programs for Refugee Children

Because refugee families tend to underutilize mental health services, schools have a key mediation role in helping refugee children adapt to their host country and may become the main access point to prevention and treatment services for mental health problems. Many obstacles hamper the development of school-based prevention programs. Despite these difficulties, a review of existing school-based prevention programs points to a number of promising initiatives that are described in this article. More interdisciplinary work is needed to develop and evaluate rigorously joint school-based education and mental health initiatives that can respond to the diverse needs of refugee children.

Psychological Risk Factors for Borderline Pathology in School-Age Children

OBJECTIVE To determine whether children with borderline pathology have a specific pattern of psychological risk factors. METHOD The subjects were 94 school-age children in day treatment, divided into borderline (n = 41) and nonborderline (n = 53) groups using the child version of the Retrospective Diagnostic Interview for Borderlines. All children were assessed using the Child Behavior Checklist, the Schedule for Affective Disorders and Schizophrenia for School-Age Children, and the Psychosocial Questionnaire. Parental pathology was assessed by a computerized version of the Structured Clinical Interview for DSM-III-R. RESULTS Children with borderline pathology had higher rates of physical abuse, sexual abuse, severe neglect, as well as family breakdown and parental criminality. In multivariate analyses, the discriminating factors were sexual abuse and parental criminality. Borderline pathology was highly comorbid with conduct disorder, but most of these results remained significant in reanalyses comparing children with and without conduct disorder. CONCLUSIONS Borderline pathology in children has a unique pattern of risk factors not accounted for by conduct disorder alone.

Defense styles, hostility, and psychological risk factors in male patients with personality disorders

The purpose of this study was to compare ratings of defense styles and hostility in male patients with personality disorders, to determine whether either of these is related to a borderline diagnosis, or to specific psychological risk factors. Subjects with personality disorders were divided into borderline personality disorder (BPD) (N = 61) and non-BPD (N = 60) groups and were given both the Defense Style Questionnaire (DSQ) and the Buss-Durkee Guilt-Hostility Inventory (BDHI). Risk factors were measured by a developmental interview and by the Parental Bonding Index. The BPD group reported more maladaptive and image distorting defenses on the DSQ, as well as higher ratings on the BDHI. Ratings on both dependent measures were strongly related to diagnosis, and more weakly to measures of psychological risk factors. Thus, in men with personality disorders, immature defense styles and high levels of hostility are strongly associated with a borderline diagnosis.

Diatheses and stressors in borderline pathology of childhood: the role of neuropsychological risk and trauma

OBJECTIVE To determine the relative contributions of neuropsychological deficits and psychosocial stressors to the presence of borderline pathology in children. METHOD The subjects were 86 school-age children (75 males, 11 females) referred for psychiatric day treatment. Thirty-five of the children met criteria for borderline pathology. Data on psychosocial risk factors were obtained for each child from a questionnaire completed by members of the childs clinical team and were based on interviews with parents and children, as well as reports from schools and social agencies. Neuropsychological measures included computerized versions of the Wisconsin Card Sorting Test and the Continuous Performance Test. RESULTS Both deficits in executive function and psychological trauma made significant and independent contributions to the variance in borderline pathology. Inclusion of both sets of risk factors produced a model that explained 48% of the variance in borderline diagnosis. CONCLUSIONS Both environmental risks and neurobiological vulnerability should be taken into account to understand the etiology of borderline pathology in children.

Training clinicians in cultural psychiatry: a Canadian perspective.

ObjectivesThe authors summarize the pedagogical approaches and curriculum used in the training of clinicians in cultural psychiatry at the Division of Social and Transcultural Psychiatry, McGill University.MethodWe reviewed available published and unpublished reports on the history and development of training in cultural psychiatry at McGill to identify the main orientations, teaching methods, curriculum, and course content. Student evaluations of teaching were reviewed. The training strategies and curriculum are related to the larger social context of Canadian society including the history of migration, current demography, and policies of multiculturalism.ResultsThe McGill program includes core teaching, clinical rotations, an intensive summer program, and annual Advanced Study Institutes. The interdisciplinary training setting emphasizes general knowledge rather than specific ethnocultural groups, including: understanding the cultural assumptions implicit in psychiatric theory and practice; exploring the clinician’s personal and professional identity and social position; evidence-based conceptual frameworks for understanding the interaction of culture and psychopathology; learning to use an expanded version of the cultural formulation in DSM-IV for diagnostic assessment and treatment planning; and developing skills for working with interpreters and culture-brokers, who mediate and interpret the cultural meaning and assumptions of patient and clinician.ConclusionAn approach to cultural psychiatry grounded in basic social science perspectives and in trainees’ appreciation of their own background can prepare clinicians to respond effectively to the changing configurations of culture, ethnicity, and identity in contemporary health care settings.