The Diagnosis and Treatment of Traumatized Refugees

1. The Diagnosis and Treatment of Traumatized Refugees Fern R. Hauck, MD, MS Essentials of Family Medicine II August 25, 2011

2. HL: Case Presentation • 32 year old Burmese man, came to Cville with wife and 4 children in 2007 • Was taken from home as young boy by Burmese army and forced to work for them • On guard duty one night, he and other boy fell asleep, when they were discovered by supervising soldiers, the other boy was killed and HL’s throat was slit, but he managed to escape • Fled and joined group of rebels in the woods, eventually went to refugee camp in Thailand, married, and emigrated here

3. HL (Continued) • Problems were apparent soon after arrival: patient had trouble keeping to work schedule, had marital problems, drinking, smoking, abusive towards children, threatened suicide requiring hospitalization (wife also had separate admission for same) identified during session at FSC • He talked of nightmares which were violent, full of blood • Certain sounds and smells reminded him of his war experience • Diagnosis?

4. ObjectivesTo Learn: • Criteria for diagnosing post-traumatic stress syndrome (PTSD) • Scales to measure symptoms and diagnose PTSD • Prevalence of PTSD • Course of PTSD • Challenges in assessment and treatment • Treatment approaches • Local resources

5. Sources Used in this Talk • Effective Treatments for PTSD. Foa EB, Keane TM, Friedman MJ, Cohen JA (Eds). New York: The Guilford Press, 2009. • Broken Spirits. The Treatment of Traumatized Asylum Seekers, Refugees, War and Torture Victims. Wilson JP, Drozdek (Eds). New York: Brunner-Routledge, 2004.

6. Normal Response to Extreme Circumstances vs. Psychological Pathology? • Refugees and asylum seekers evoke images that are filled with the anguish of exile and loss • The challenge for the clinician is to establish whether the distress and suffering of an individual is the expected normal response to the circumstances or whether the individual has developed a psychological disorder, triggered by the trauma and dislocation he or she has endured

7. Normal Response to Extreme Circumstances vs. Psychological Pathology? • Some argue that focusing on individual pathology has the potential of hiding the political and social realities of the refugees’ experience, thus diminishing the attention needed to address these root causes • Others argue that there is value in careful assessment and diagnosis of the psychological distress of refugees to help guide treatment and ease their suffering

8. PTSD • Prior traumatic experience drives the individual’s focus and preoccupation in the present, trapping him or her in the recurring suffering of the past. • DSM-IV-R (American Psychiatric Association) Criteria – 17 symptoms in 3 clusters: reliving or re-experiencing the traumatic event or frightening elements of it; avoiding and numbing thoughts, memories, people, and places associated with the event; and elevated arousal.

9. PTSD (Continued) • Often complicated by other associated features: • Guilt, dissociation, alterations in personality, and marked impairment in intimacy and attachment. • Comorbid disorders, such as depression, substance abuse, and other anxiety disorders • Suicide rates are high • Physical health complaints

10. PTSD (Continued) • First step in diagnosing PTSD is to establish that an individual has been exposed to an extreme stressor that satisfies the DSM definition of “trauma”. • Trauma is comprised of 3 elements: • Type of exposure (directly experienced or witnessed/ learned about it indirectly) • Event entailed life threat, serious injury, or threat to physical integrity • Event triggers an intense emotional response of fear, horror or helplessness • PTSD symptoms must have lasted at least 1 month to distinguish “normative reactions to stress” from a more chronic syndrome indicative of mental disorder

11. PTSD Measures • Many standardized scales have been developed and validated for PTSD: interviewer administered and self-administered • Harvard Trauma Questionnaire (HTQ) has been validated with several refugee populations, and translated into several languages

12. Harvard Trauma Questionnaire • HTQ is a checklist written by the Harvard Program in Refugee Trauma. It inquires about a variety of trauma events, as well as the emotional symptoms considered to be uniquely associated with trauma. • Currently there are six versions of this questionnaire: Vietnamese, Cambodian, Laotian, Japanese (for survivors of Kobe earthquake), Croatian Veterans' Version, Bosnian version. Recently adapted for use in Iraqi refugees.

13. Part I: Includes 46 to 82 traumatic events, Yes/No response to each question. Part II: Open-ended description of the most traumatic events. Part III, Asks about history of head injury. Part IV: 16 DSM-IV PTSD questions and 24 additional symptom items that focus on the impact of trauma on an individual's perception of his/her ability to function in everyday life. In HPRT's experience, these symptoms are extremely important because traumatized people are usually more concerned about social functioning than about emotional distress. Should be administered by health care workers under the supervision and support of a psychiatrist, medical doctor, and/or psychiatric nurse. Harvard Trauma Questionnaire (Cont’d)

14. Prevalence of PTSD in Refugee Populations • Studies to assess PTSD among refugees have shown rates that far exceed those found in nonwar-affected communities of the West • Prevalence rates have varied between 15% and 47%. • In contrast, prevalence of PTSD in Western countries ranges from 1.3 to 8%. • Note: discrepancy in depression is even greater, with most refugee populations showing prevalence rates many times higher

15. Prevalence of PTSD in Refugee Populations • Dose-response relationship between trauma and PTSD, regardless of cultural setting: the greater the number of traumatic events, the more intense their symptoms of PTSD. • Certain traumas are particularly pathogenic, e.g., torture results in greater levels of psychiatric morbidity

16. The Course of Posttraumatic Stress Symptoms • Most persons exposed to trauma will experience stress responses (sleep disturbances, hyperarousal, startle reactions, etc.) • Most survivors overcome these early symptoms, but a minority continue to have persistent psychosocial disability • Long-term follow up studies (only a few so far) have shown that symptoms diminish gradually, the longer people are here the more improved their symptoms, as long as their environment is welcoming and affords opportunities to participate freely in the host society. Only a very small minority remain symptomatic. • Post-migration stresses can perpetuate trauma related symptoms

17. Challenges in Assessment • Diagnosis is a subtle process that depends on careful use of words and nuances of understanding • Questions and responses can get lost in translation, with meaning altered • Words for emotion are frequently not directly translatable • Patients may not be aware of their behaviors (e.g., an individual who has been tortured may choose a very restricted lifestyle, because choice may be a reminder of punishment where any action lead to punishment.) Such patterns of behavior may not be recognized by patient, and direct questioning may not yield accurate responses.

18. Challenges in Assessment and Treatment • Balance between recognizing and understanding the unique aspects of different cultures with the universality of responses to stress across all cultures • There is a significant association between perceived health status, psychological sx, and disability in refugees. • Limitations of language and culture make affective interventions difficult • Children are very susceptible to PTSD and other comorbid psychological disorders. Strong correlation between children’s diagnosis of psychological disorder and parental distress

19. Treatment • Individual therapy: attitude of love and compassion, respect for the rage of refugees, and interest in their doubts and uncertainties. They need to feel safe and secure. (Example: patient I observed in Minnesota Trauma Center-she would only be interviewed outside, because of fear of small, closed in spaces) • Group therapy, art and music therapy (especially for children) • Community interventions (e.g., identify strengths of the refugee community, work with representatives to develop their own programs and interventions).

20. Treatment Resources • Resources for assessment and treatment of our refugee patients • Psychiatry Team-Drs. Merkel and Hidalgo • Family Stress Clinic • Behavioral Medicine Clinic

21. Treatment Challenges Revisited • It is very difficult emotionally to care for people who have experienced extreme trauma and torture. In some cases the therapists can develop symptoms of PTSD. • Important to get support from colleagues and supervisors, behavioral clinicians, others.

22. HL • Treatment: • Patient and his wife prescribed Paxil • Family referred to Child Protective Services and Department of Social Services • All family members received counseling from Charlottesville League of Therapists, support from all these agencies, intensive case management • All family members are doing much better—these interventions worked!

23. Interlude • Movie: Diary of Immaculée

24. Discussion • Your own examples of patients you have seen • How can we best support each other in caring for these emotionally challenging patients?