Roberto Lewis-Fernández

A Systematic Review of PTSD Prevalence and Trajectories in DSM-5 Defined Trauma Exposed Populations: Intentional and Non-Intentional Traumatic Events

Objective We conducted a systematic review of the literature to explore the longitudinal course of PTSD in DSM-5-defined trauma exposed populations to identify the course of illness and recovery for individuals and populations experiencing PTSD. Methods We reviewed the published literature from January 1, 1998 to December 31, 2010 for longitudinal studies of directly exposed trauma populations in order to: (1) review rates of PTSD in the first year after a traumatic event; (2) examine potential types of proposed DSM-5 direct trauma exposure (intentional and non-intentional); and (3) identify the clinical course of PTSD (early onset, later onset, chronicity, remission, and resilience). Of the 2537 identified articles, 58 articles representing 35 unique subject populations met the proposed DSM-5 criteria for experiencing a traumatic event, and assessed PTSD at two or more time points within 12 months of the traumatic event. Results The mean prevalence of PTSD across all studies decreases from 28.8% (range  = 3.1–87.5%) at 1 month to 17.0% (range  = 0.6–43.8%) at 12 months. However, when traumatic events are classified into intentional and non-intentional, the median prevalences trend down for the non-intentional trauma exposed populations, while the median prevalences in the intentional trauma category steadily increase from 11.8% to 23.3%. Across five studies with sufficient data, 37.1% of those exposed to intentional trauma develop PTSD. Among those with PTSD, about one third (34.8%) remit after 3 months. Nearly 40% of those with PTSD (39.1%) have a chronic course, and only a very small fraction (3.5%) of new PTSD cases appears after three months. Conclusions Understanding the trajectories of PTSD over time, and how it may vary by type of traumatic event (intentional vs. non-intentional) will assist public health planning and treatment.

Cultural psychiatry : theoretical, clinical, and research issues

As a discipline, cultural psychiatry has matured considerably in recent years and the ongoing quality of its theoretical, clinical, and research development holds great promise. The contemporary emphasis on culture as process permits a deeper analysis of the complexities of sociosomatics--the translation of meanings and social relations into bodily experience--and, thus, of the social course of illness. We also are learning a great deal more about cultural processes that affect therapy, including ethnopharmacologic and culturally valid family interventions that are directly relevant to patient care and mental health policy. And an important set of studies is examining the trauma experienced by refugees and immigrants. But at the same time many disquieting findings still point to the limited impact of cultural psychiatry on knowledge creation and clinical application in psychiatry. The failure of the cultural validation of DSM-IV is only the most dismaying. The persistent misdiagnosis of minority patients and the continued presence of racial bias in some treatment recommendations are also disheartening, as is the seeming contempt of many mainstream psychiatrists for culturally defined syndromes and folk healing systems. Widespread inattention to ethnic issues in medical ethics is another source of dismay. It is for these reasons that the culture of psychiatry itself becomes as important as the culture of patients as a topic for research and intervention. Most of the world still suffers from a terrible lack of basic mental health services, including life-saving medications and hospital beds. In the face of these limitations, and because of the increasing multicultural and pluralistic reality of contemporary life, the growing interpretive bridges linking indigenous systems of illness classification and healing to Western nosologies and therapeutic modalities become even more essential and the reluctance of mainstream clinicians to explore folk healing methods more incomprehensible. Psychiatry needs new ways of delivering culturally appropriate care to the disenfranchised and the destitute, for whom mainstream approaches are often too expensive, foreign, and centralized. As a profession, we also have much to learn from indigenous diagnosticians and therapists. Finally, psychosomatic, mind-brain, behavioral health, and psychopathologic investigations need to configure the social world in their paradigms of research if we are to understand better the sources and consequences of mental illness. Psychiatry can no more afford to be contextless than it can afford to be mindless or brainless.

The cultural formulation: a method for assessing cultural factors affecting the clinical encounter.

The growing cultural pluralism of US society requires clinicians to examine the impact of cultural factors on psychiatric illness, including on symptom presentation and help-seeking behavior. In order to render an accurate diagnosis across cultural boundaries and formulate treatment plans acceptable to the patient, clinicians need a systematic method for eliciting and evaluating cultural information in the clinical encounter. This article describes one such method, the Cultural Formulation model, expanding on the guidelines published in DSM-IV. It consists of five components, assessing cultural identity, cultural explanations of the illness, cultural factors related to the psychosocial environment and levels of functioning, cultural elements of the clinician–patient relationship, and the overall impact of culture on diagnosis and care. We present a brief historical overview of the model and use a case scenario to illustrate each of its components and the substantial effect on illness course and treatment outcome of implementing the model in clinical practice.

Toward a Puerto Rican Popular Nosology: Nervios and Ataque de Nervios

This paper is about naming illnesses—about who determines what categories are used and the implications of these determinations. The central concerns of medical/psychiatric anthropology have been to understand popular categories of and systems for classification of illness, to examine the relationship of illness categories to cultural understandings of the body, and to interpret the role of categories of illness in mediating between the personal and social spheres. At the same time, the paper also discusses the interplay of popular categories and psychiatric diagnoses. This paper examines the multiple experiences of nervios among Puerto Ricans in Puerto Rico and New York City. Our contention is that nervios is more than a diffuse idiom of distress, and that there are different categories and experiences of nervios which provide insights into how distress is experienced and expressed by Puerto Ricans and point to different social sources of suffering. The data in this paper come from the responses to a series of open-ended questions which tapped into peoples general conceptions of nervios and ataques de nervios. These questions were incorporated into follow-up interviews to an epidemiological study of the mental health of adults in Puerto Rico. The results suggest ways to incorporate these different categories of nervios into future research and clinical work with different Latino groups in the United States and in their home countries.

National trends in ethnic disparities in mental health care.

Objective:To compare trends in office-based treatment of mental disorders between Hispanics and non-Hispanics. Design, Setting, and Participants:Analysis of a nationally representative sample of visits to office-based physicians conducted between 1993 and 2002 (N = 251,905). Visits were grouped into 3 discrete time periods, 1993–1996, 1997–1999 and 2000–2002. Main Outcome Measures:Rate of diagnosis, type of mental health visit, type of treatment received (medication or psychotherapy), rate of psychotropic medications prescription, and specialty of the treating physician. Results:From 1993–1996 to 2000–2002, the proportion of office visits in which mental health care was provided decreased for Hispanics from 12.2% to 11.7% while it increased from 13.1% to 15.7% for non-Hispanics (P < 0.05). Visits with a diagnosis of mental disorder decreased from 5.2% to 5.1% in Hispanics but increased from 6.0% to 8.8% in non-Hispanics (P < 0.05). Visits resulting in prescription of a psychotropic medication decreased from 10.2% to 9.3% in Hispanics, while they increased from 10.2% to 12.5% in non-Hispanics (P < 0.05). Psychotherapy visits decreased from 2.4% to 1.3% in Hispanics (P < 0.05), whereas they remained constant (2.5%) in non-Hispanics. Visits to a psychiatrist decreased from 2.5% to 1.3% in Hispanics (P < 0.05), while they increased (nonsignificantly) from 3.1% to 3.5% for non-Hispanics. Most differences persisted after adjusting for age and insurance status. Conclusions:From 1993 to 2002, there was an increase in mental health care disparities between Hispanics and non-Hispanics treated by office-based physicians. Improvement of the mental health care for Hispanics continues to be an important public health priority, with clear opportunities and challenges for health care policy-makers and practitioners.

Methodological Challenges in Cross-Cultural Mental Health Research

The article discusses some of the main challenges involved in carrying out culturally informed mental health research and the usefulness of a cross-cultural approach to psychiatric epidemiology, focusing on its benefits for hypothesis formulation, the ascertainment of etiologies and risk factors, and the creation of policies for illness prevention. Also described is the ongoing theoretical debate regarding the extent to which cultural diversity should be incorporated directly into research methodologies used in the assessment of psychopathology. Specifically, how much local cultural diversity can be incorporated into an established diagnostic instrument before the degree of alteration renders the instrument incapable of measuring the original constructs for which it was designed? Some of the most salient methodological challenges encountered in cross-cultural research, and how several researchers have tried to resolve them are also discussed, e.g. definition of what constitutes a case and what constitutes outcome; maintaining meaning and procedural equivalence throughout the translation and cultural adaptation of diagnostic instruments; and ensuring that the significance of various sociodemographic factors is actually equivalent across the different cultural samples studied. Finally, the article discusses several directions for future research offering examples from research carried out in Puerto Rico.

Assessing Diversity among Latinos: Results from the NLAAS

This article provides a profile of a range of important variables for assessing diversity among different Latino groups from the National Latino and Asian American Study (NLAAS). The NLAAS is a nationally representative study of the mental health needs and mental health services use of the Latino population of the United States. The NLAAS employs a stratified area probability sampling design. There are 2,554 respondents in the Latino portion of the NLAAS. The article demonstrates through a detailed presentation of a wide range of variables the diverse experiences of Latino groups in their encounters with U.S. culture. Language use and migration experiences show considerable variability within and across Latino groups and are promising areas for analysis of their mental health consequences.

Idioms of Distress Among Trauma Survivors: Subtypes and Clinical Utility

In this introduction to the Special Issue on Trauma and Idioms of Distress, we provide an overview of the concept and typology of “idioms of distress,” focusing particularly on their clinical utility. This includes the role of idioms as indicators of trauma exposure, of various types of psychopathology and of levels of distress, risk and functioning. It likewise includes the fact that idioms of distress may profoundly influence the personal meaning of having a trauma-related disorder, may shape the interpersonal course of the disorder and may pattern help-seeking and self-treatment. Finally, it illustrates the fact that idioms may also help clinicians understand sufferers’ views of the causes of their distress, constitute key therapeutic targets and help increase therapeutic empathy and treatment adherence. This special issue focuses on the role played by idioms of distress in the local trauma ontology, the associations between the idioms and psychiatric disorders occurring in the context of trauma and the mechanisms by which the idioms profoundly influence the personal and interpersonal course of trauma-related disorders.

Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V†

This review covers the literature since the publication of DSM‐IV on the diagnostic criteria for panic attacks (PAs) and panic disorder (PD). Specific recommendations are made based on the evidence available. In particular, slight changes are proposed for the wording of the diagnostic criteria for PAs to ease the differentiation between panic and surrounding anxiety; simplification and clarification of the operationalization of types of PAs (expected vs. unexpected) is proposed; and consideration is given to the value of PAs as a specifier for all DSM diagnoses and to the cultural validity of certain symptom profiles. In addition, slight changes are proposed for the wording of the diagnostic criteria to increase clarity and parsimony of the criteria. Finally, based on the available evidence, no changes are proposed with regard to the developmental expression of PAs or PD. This review presents a number of options and preliminary recommendations to be considered for DSM‐V. Depression and Anxiety, 2010.

Positive Tertiary Appraisals and Posttraumatic Stress Disorder in U.S. Male Veterans of the War in Vietnam: The Roles of Positive Affirmation, Positive Reformulation, and Defensive Denial.

A 70.9% majority of the U.S. male veterans in a nationwide sample appraised the impact of their service in Vietnam on their present lives as mainly positive. A substantial minority, 41.7%, judged the effects to be highly salient. With controls on level of exposure to war-zone stressors measured with data from military records, the valence and salience of these appraisals are investigated in relation to posttraumatic stress disorder (PTSD) and other indicators of wartime and postwar functioning. The results are consistent with the hypothesis that mainly positive tertiary appraisals are affirmations of successful wartime and postwar adaptation rather than defensive denials related to maladaptive outcomes. The possibility that mainly positive tertiary appraisals also contribute to successful postwar adaptation is discussed.