Assessing symptom change in Southeast Asian refugee survivors of mass violence and torture

The authors' goal was to determine the levels of trauma and psychiatric symptoms in a randomly selected group of Cambodian refugees and to determine the relationship between the amount of trauma experienced and subsequent psychiatric symptoms. Data on traumatic experiences and symptoms of posttraumatic stress, dissociation, depression, and anxiety were collected on 50 randomly selected Cambodian refugees who had resettled in the United States. Subjects experienced multiple and severe traumas and showed high levels of all symptoms measured. Forty-three (86%) of the subjects met DSM-III-R criteria for posttraumatic stress disorder, 48 (96%) had high dissociation scores, and 40 (80%) could be classified as suffering from clinical depression. Correlations between trauma scores and symptom scores and among symptom scores were moderate to large. These results indicate that a high proportion of Cambodian refugees who are not psychiatric patients suffer from severe psychiatric symptoms and that there is a relationship between the amount of trauma they experienced and the severity of these symptoms.

The authors report on 404 Southeast Asian refugees seen at a community clinic. Approximately three-quarters of these patients met DSM-III criteria for major depressive episode, and 14% had posttraumatic stress disorder. Complaints of pain and sleep disturbances were the predominant presenting symptoms. Most of the men were married, but more than 40% of the women were widowed. Between 15% and 30% of the patients reported specific traumatic experiences either in their homeland or during their escape. Widowhood and such traumatic experiences were positively correlated with more symptoms of depression and anxiety.

Dr. Herman and Associates Reply

The purpose of this study was to examine factors predicting the development of posttraumatic stress symptoms after a traumatic event, the 1991 Oakland/Berkeley firestorm. The major predictive factors of interest were dissociative, anxiety, and loss of personal autonomy symptoms reported in the immediate aftermath of the fire; contact with the fire; and life stressors before and after the fire. Subjects were recruited from several sources so that they would vary in their extent of contact with the fire. Of 187 participants who completed self-report measures about their experiences in the aftermath of the firestorm, 154 completed a follow-up assessment. Of these 154 subjects, 97% completed the follow-up questionnaires 7-9 months after the fire. The questionnaires included measures of posttraumatic stress and life events since the fire. Dissociative and loss of personal autonomy symptoms experienced in the fire's immediate aftermath, as well as stressful life experiences occurring later, significantly predicted posttraumatic stress symptoms measured 7-9 months after the firestorm by a civilian version of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Impact of Event Scale. Dissociative symptoms more strongly predicted posttraumatic symptoms than did anxiety and loss of personal autonomy symptoms. Intrusive thinking differs from other kinds of posttraumatic symptoms in being related directly to the trauma and previous stressful life events. These findings suggest that dissociative symptoms experienced in the immediate aftermath of a traumatic experience and subsequent stressful experiences are indicative of risk for the later development of posttraumatic stress symptoms. Such measures may be useful as screening procedures for identifying those most likely to need clinical care to help them work through their reactions to the traumatic event and to subsequent stressful experiences.

Drs. Brown and Anderson and Dr. Sanders Reply

A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Dr. Gunderson Replies

The authors conducted a systematic analysis of quantitative research on religious variables found in four psychiatric journals between 1978 and 1982. Of the 2,348 psychiatric articles reviewed, 59 included a quantified religious variable. In this research, the religious variable chosen was most often a single static measure of religion rather than multiple dynamic measures. In addition, other available religious research was seldom cited. Comparison with systematic analyses of religious research in psychology and sociology suggests that psychiatric research lacks conceptual and methodological sophistication. The data suggest that the academic knowledge and skills needed to evaluate religion have not been absorbed into the psychiatric domain.

The authors examined the effect of patients' style of clinical presentation on primary care physicians' recognition of depression and anxiety. The subjects were 685 patients attending family medicine clinics on self-initiated visits. They completed structured interviews assessing presenting complaints, self-report measures of symptoms and hypochondriacal worry, the Diagnostic Interview Schedule (DIS), and the Center for Epidemiologic Studies Depression Scale (CES-D). Physician recognition was determined by notation of any psychiatric condition in the medical chart over the ensuing 12 months. The authors identified three progressively more persistent forms of somatic presentations, labeled "initial," "facultative," and "true" somatization. Of 215 patients with CES-D scores of 16 or higher, 80% made somatized presentations; of 75 patients with DIS-diagnosed major depression or anxiety disorder, 76% made somatic presentations. Among patients with DIS major depression or anxiety disorder, somatization reduced physician recognition from 77%, for psychosocial presenters, to 22%, for true somatizers. The same pattern was found for patients with high CES-D scores. In logistic regression models education, seriousness of concurrent medical illness, hypochondriacal worry, and number of lifetime medically unexplained symptoms each increased the likelihood of recognition, while somatized presentations decreased the rate of recognition. While physician recognition of psychiatric distress in primary care varied widely with different criteria for recognition, the same pattern of reduction of recognition with increasing level of somatization was found for all criteria. In contrast, hypochondriacal worry and medically unexplained somatic symptoms increased the rate of recognition.

The authors systematically examine the concept of boundaries and boundary violations in clinical practice, particularly as they relate to recent sexual misconduct litigation. They selectively review the literature on the subject and identify critical areas that require explication in terms of harmful versus nonharmful boundary issues short of sexual misconduct. These areas include role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context. Heightened awareness of the concepts of boundaries, boundary crossings, and boundary violations will both improve patient care and contribute to effective risk management.

The author reviewed the literature published since 1972 concerning restraint and seclusion. The review began with a computerized literature search. Further sources were located through citations from articles identified in the original search. The author synthesized the contents of the articles reviewed using the categories of indications and contraindications; rates of seclusion and restraint as well as demographic, clinical, and environmental factors that affect these rates; effects on patients and staff; implementation; and training. The literature on restraint and seclusion supports the following. 1) Seclusion and restraint are basically efficacious in preventing injury and reducing agitation. 2) It is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint. 3) Restraint and seclusion have deleterious physical and psychological effects on patients and staff, and the psychiatric consumer/survivor movement has emphasized these effects. 4) Demographic and clinical factors have limited influence on rates of restraint and seclusion. 5) Local nonclinical factors, such as cultural biases, staff role perceptions, and the attitude of the hospital administration, have a greater influence on rates of restraint and seclusion. 6) Training in prediction and prevention of violence, in self-defense, and in implementation of restraint and/or seclusion is valuable in reducing rates and untoward effects. 7) Studies comparing well-defined training programs have potential usefulness.

Allegations of psychiatric misdiagnosis of black patients are supported by only a few examples of such errors, but there is a modest body of circumstantial evidence suggesting that black patients run a higher risk of being misdiagnosed than white patients. The author reviews the studies providing such evidence and concludes that greater awareness among clinicians and research into more appropriate diagnostic criteria for black patients are desirable.

The authors report the latest findings from a 32-year longitudinal study of 269 back-ward patients from Vermont State Hospital. This intact cohort participated in a comprehensive rehabilitation program and was released to the community in a planned deinstitutionalization effort during the mid-1950s. At their 10-year follow-up mark, 70% of these patients remained out of the hospital but many were socially isolated and many were recidivists. Twenty to 25 years after their index release, 262 of these subjects were blindly assessed with structured and reliable protocols. One-half to two-thirds of them had achieved considerable improvement or recovery, which corroborates recent findings from Europe and elsewhere.

Research on the epidemiology of bulimia nervosa has focused largely on the prevalence of the disorder. As methods have improved, consensus has increased regarding the prevalence rate among adolescent and young adult women--about 1%. However, the accuracy of this figure and its clinical significance must be questioned. In this synthesis of the epidemiological work to date, the authors review the literature from a clinical and research perspective. They recommend a shift in emphasis away from studies of the distribution of the disorder toward studies of the determinants of the whole spectrum of the disturbance that exists in the community.

This review of the descriptive literature on borderline patients indicates that accounts of such patients vary depending upon who is describing them, in what context, how the samples are selected, and what data are collected. The authors identify six features that provide a rational means for diagnosing borderline patients during an initial interview: the presence of intense affect, usually depressive or hostile; a history of impulsive behavior; a certain social adaptiveness; brief psychotic experiences; loose thinking in unstructured situations; and relationships that vacillate between transient superficiality and intense dependency. Reliable identification of these patients will permit better treatment planning and clinical research.