1. PTSD in Refugee Populations James Knowles Rustad University of Vermont College of Medicine Copyright 2006, James Knowles Rustad All Rights Reserved

2. Post-traumatic stress disorder Many trauma victims develop Post- traumatic Stress Disorder, hereinafter PTSD, which features symptoms such as hyper-arousal and avoidance of reminders of the trauma they experienced. People with PTSD see the world differently because the disorder distorts the normal appraisal process. Adapted from: Posttraumatic Stress Disorder. The Journal of Clinical Psychiatry, Vol. 58, Supplement #9 – 1997. Page 33. Author: Matthew J. Friedman, M.D., Ph.D.

3. Risk factors PTSD has a specific set of risk factors, some of which may require their own diagnostic interventions. These include prior traumatization, especially in childhood, personal or parental psychopathology (particularly parental PTSD), and personality traits such as harm avoidance. Adapted from: McFarlane, AC, Golier J, & Yehuda R (2002). Treatment Planning for Trauma Survivors with PTSD. In Yehuda R (ed.). Treating Trauma: Survivors with PTSD. (pp. 1-19). American Psychiatric Publishing. Washington,

4. Pathophysiology The person with PTSD pays a high price neurobiologically and psychologically because the balance between the HPA and adrenergic systems in PTSD is allostatic. Allostasis is defined as an abnormal steady state. Adapted from: Posttraumatic Stress Disorder. The Journal of Clinical Psychiatry, Vol. 58, Supplement #9 – 1997. Page 34. Author: Matthew J. Friedman, M.D., Ph.D.

5. Pathophysiology (continued) In PTSD, low steady-state cortisol levels are in balance with up-regulated glucocorticoid receptors, and high catecholamine levels lead to down- regulation of Beta and Alpha-2 adrenergic receptors. Adapted from: Posttraumatic Stress Disorder. The Journal of Clinical Psychiatry, Vol. 58, Supplement #9 – 1997. Page 34. Author: Matthew J. Friedman, M.D., Ph.D.

6. Cross-cultural perspective Ataques de nervios among Latin American cultures may be understood as a culturally patterned dissociative reaction to stress arising in a person predisposed by exposure to trauma during childhood. Adapted from Lewis-Fernandez R, Guarnaccia PJ, Patel S, Lizardi D, & Diaz N (2005). Ataque de Nervios: Anthropological, Epidemiological, and Clinical Dimensions of a Cultural Syndrome. In Georgiopoulos, AM & Rosenbaum JF (Ed.). (pp. 63-85). Perspectives in Cross-Cultural Psychiatry. Lippincott, Williams, and Wilkins. Philadelphia.

7. Cross-cultural (continued) There is a cultural perception that exists among some Latin Americans that mature social actors always need to be in control. This may account for the dissociative flavor to the illness and many times patients will say, ese no era yo, which translates that was not me. Adapted from Lewis-Fernandez R, Guarnaccia PJ, Patel S, Lizardi D, & Diaz N (2005). Ataque de Nervios: Anthropological, Epidemiological, and Clinical Dimensions of a Cultural Syndrome. In Georgiopoulos, AM & Rosenbaum JF (Ed.). (pp. 63-85). Perspectives in Cross-Cultural Psychiatry. Lippincott, Williams, and Wilkins. Philadelphia.

8. Cambodians Mental health clinicians working with Cambodian refugees in the 1980s observed different manifestations of distress following the trauma inflicted by the Khmer Rouge regime. Patients described themselves as thinking too much, which became known as the Cambodian sickness and bore similarities to PTSD. Adapted from: Van de Put WACM & Eisenbruch M. (2004). Internally Displaced Cambodians: Healing Trauma in Communities. In Miller, KE & Rasco, LM (ed.) (pp. 133-159). The Mental Health of Refugees. Ecological Approaches to Healing and Adaptation. Lawrence Erlbaum Associates Publishers. Mahwah NJ, London.

9. Cambodians (continued) The next stages of the illness were called small heart, which described a state of demoralization, and broken down heart-mind, which described worries leading to fragmented thoughts. The progression of mental deterioration described by many of these patients indicates a propensity for dissociation, or a lost and confused intellect or cognition. Adapted from: The Mental Health of Refugees. Ecological Approaches to Healing and Adaptation. Lawrence Erlbaum Associates Publishers. Mahwah NJ, London 2004. Page 137. Authors: Kenneth E. Miller and Lisa M. Rasco.

10. Specialization It is advisable for psychiatrists and counselors to develop expertise working with refugees from specific nations. While it is impossible to learn everything there is to know about a particular culture, the experience of their clinical interactions with a particular population can enrich their fund of knowledge about that group and allow them to find their own niche as a practitioner.

11. Specialization (continued) If there are experts on treating patients from certain populations, it would then be easier to triage medical resources following a disaster or a political upheaval necessitating immigration from a certain geographical region.

12. Focus on Family The lack of focus on family hampers Western medicines ability to care for the refugee population. For example, Bosnian refugees feel disconnected from traditional clinic based mental health services due to the lack of emphasis upon family. Adapted from: Weine S, Feetham S, Kulauzovic Y, Besic S, Lezic A, Mujagic A, Muzurovic J, Spahovic D, Zhubi M, Rolland J, & Pavkovic I. (2004). Bosnian and Kosovar Refugees in the United States: Family Interventions in a Services Framework. In Miller, KE & Rasco, LM (ed.) (pp. 263-293). The Mental Health of Refugees. Ecological Approaches to Healing and Adaptation. Lawrence Erlbaum Associates Publishers. Mahwah NJ, London.

13. Family (continued) It is important to understand the social impact of a disease and realize that it affects the patients entire family and does not occur on an isolated basis. Training specialists in family therapy would be one avenue to approach this deficit in our health care system.

14. Loss of home The first association that people make when they think of refugees is to trauma rather than loss of home. However, the only condition universal among refugees is the loss of home. Adapted from: Papadopoulos RK. (2002). Refugees, home and trauma. In Papadopoulos, RK (ed.) (pp. 9-39). Therapeutic Care for Refugees: No place like home. Karnac. London, NY.

15. Loss of home (continued) It is important to foster an understanding of what the patient liked and disliked about the place they used to live and help keep reminders of the most positive aspects of their past existence. This is as simple as helping them find stores that stock their favorite foods or helping them access newspapers and magazines from their country of origin.

16. Community Connecting them with the greater community of their culture is often helpful, as is keeping them involved in cultural activities such as music performances and art displays. Interconnectedness with community is a real way to provide meaning and structure in peoples lives and improve mental health.

17. Adjustment to new surroundings Finding out what refugees enjoy and dislike about their present surroundings is also a good way to help improve their lives. The clinician may even be able to impact their present surroundings in a positive way by suggesting an alternate route to work, or a better place to shop in the new area.

18. Sources Friedman, MJ, Posttraumatic Stress Disorder. (1997). The Journal of Clinical Psychiatry, Vol. 58, Supplement #9 - 1997. McFarlane, AC, Golier J, & Yehuda R (2002). Treatment Planning for Trauma Survivors with PTSD. In Yehuda R (ed.). Treating Trauma: Survivors with PTSD. (pp. 1-19). American Psychiatric Publishing. Washington, London. Lewis-Fernandez R, Guarnaccia PJ, Patel S, Lizardi D, & Diaz N (2005). Ataque de Nervios: Anthropological, Epidemiological, and Clinical Dimensions of a Cultural Syndrome. In Georgiopoulos, AM & Rosenbaum JF (Ed.). (pp. 63-85). Perspectives in Cross-Cultural Psychiatry. Lippincott, Williams, and Wilkins. Philadelphia.

19. Sources (continued) Van de Put WACM & Eisenbruch M. (2004). Internally Displaced Cambodians: Healing Trauma in Communities. In Miller, KE & Rasco, LM (ed.) (pp. 133-159). The Mental Health of Refugees. Ecological Approaches to Healing and Adaptation. Lawrence Erlbaum Associates Publishers. Mahwah NJ, London. Weine S, Feetham S, Kulauzovic Y, Besic S, Lezic A, Mujagic A, Muzurovic J, Spahovic D, Zhubi M, Rolland J, & Pavkovic I. (2004). Bosnian and Kosovar Refugees in the United States: Family Interventions in a Services Framework. In Miller, KE & Rasco, LM (ed.) (pp. 263-293). The Mental Health of Refugees. Ecological Approaches to Healing and Adaptation. Lawrence Erlbaum Associates Publishers. Mahwah NJ, London. Papadopoulos RK. (2002). Refugees, home and trauma. In Papadopoulos, RK (ed.) (pp. 9-39). Therapeutic Care for Refugees: No place like home. Karnac. London, NY.