Symptoms of Distress

Refugees as a group experience multiple somatic (or physical) and psychological symptoms, which are often not specifically characteristic of posttraumatic stress disorder (PTSD), depression, or other psychiatric disorders.1-3  Best estimates are that up to 10% suffer diagnostic levels of PTSD and depression,4 and approximately 30% have high levels of distress that might require treatment.5  Estimates about the kind and prevalence of distressing symptoms experienced by refugees often come from research using questionnaires that allow a limited range of responses.  Many such questionnaires, called “instruments” when used for research, were developed using expert opinion in clinical samples and are used to assess specific western-defined health domains such as posttraumatic stress disorder (PTSD) or depression.6, 7  For example, a commonly used instrument, the Harvard Trauma Questionnaire, has a section listing 30 symptoms that were defined by clinicians.8  On the other hand, there are questionnaires that were developed by asking refugees about symptoms during qualitative research and conducting analyses to determine what symptoms are most valid, so these may be a more accurate reflection of symptoms experienced by refugees.  A number of studies or refugee populations have demonstrated a correlation between symptoms associated with depression and other western concepts of mental illness and symptoms correlated to western concepts.9-11

The New Mexico Refugee Symptom Checklist – 121 (NMRSCL-121), which was developed by community participatory methods with Vietnamese and Kurdish refugees, identified the broad range of bothersome and persistent symptoms experienced.12  Refugees identified 121 symptom items, and factor and reliability analyses showed that these symptoms clustered into 12 subscales: (1) PTSD and Depression, (2) Musculoskeletal, (3) Sensory, (4) Cardiopulmonary, (5) Gastrointestinal, (6) Anxiety, (7) Urinary, (8) Posttraumatic Vulnerability, (9) Neurological and Bleeding, (10) Skin Sensation, (11) Menstrual, and (12) Constitutional. Symptoms of western-defined PTSD and depression clustered together, suggesting they are similar, while there was a separate category of “posttraumatic vulnerability,” which is symptoms about anticipating more traumatic events and having anticipatory anxiety.  This shows that symptoms in refugees do not necessarily conform to current diagnostic structures, although this may be true for other populations too.  Refugees experienced on average 48 persistent and bothersome symptoms, with Kurdish refugees having more symptoms on average, perhaps owing to the fact that they were more recently resettled.  The symptoms experienced were both somatic and psychological, and all symptom types except the menstrual symptoms in women were correlated with other scales assessing depression, anxiety, and PTSD.

Demoralization may be a more parsimonious concept across emotional disturbances than western-defined psychiatric disorders and is often related to a sense of alienation.  Coined by Jerome Frank, demoralization “. . . results from persistent failure to cope with internally or externally induced stresses that the person and those close to him expect him to handle.  Its characteristic features, not all of which need to be present in any one person, are feelings of impotence, isolation, and despair…insofar as the meaning and significance of life derives from the individual’s ties with persons whose values he shares, alienation may contribute to a sense of the meaninglessness of life.”13  With alienation and a lack of belonging, refugees are prone to demoralization with or without psychiatric disturbances.  One study showed that refugees and migrants are often diagnosed with major depression, yet on the average do not benefit from a normal course of treatment.  However, data analyses suggested that demoralization was a preferable concept for many of the subjects rather than depression.14

In any case, symptoms of distress may be part of a mental disorder, which means that the symptoms are related to each other and impair the sufferer in daily life.  However, symptoms may also be signs of distress that are part of daily life and not a marker of an illness.  Because symptoms in refugees are highly prevalent owing to the stressful experiences they have endured, it is very important to carefully evaluate the source of symptoms and not quickly jump to conclusions that a psychiatric disorder is present, nor on the other hand ignore potential significant distress.

It is also important to understand that the symptoms presented are dependent on the health-care setting.  Most refugees who present to primary care and are eventually found to have anxiety and depression first present with somatic complaints.  And, if the refugee comes to understand his or her symptoms as “psychological” and agrees to see a mental health provider, then his or her presenting complaints are often ones of emotional and social distress. This pattern of presenting with somatic complaints in a medical setting and with psychological complaints in a mental health setting holds true not only for refugees, but also for most people around the world.15-17

References
1. APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth edition. Washington, D.C.: American Psychiatric Association; 1994.
2. Brett E, Spitzer R, William J. DSM-III-R criteria for post-traumatic stress disorder. American Journal of Psychiatry. 1988; 145: 1232-6.
3. Van der Kolk BA, Pelcovitz D, Roth S, Mandel FS, McFarlane A, Herman JL. Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. American Journal of Psychiatry. 1996; 153(7 Suppl): 83-93.
4. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005; 365(9467): 1309-14.
5. Hollifield M, Verbillis-Kolp S, Farmer B, Toolson EC, Woldehaimanot T, Yamazaki J, et al. The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. General Hospital Psychiatry. 2013; 35(2): 202-9.
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7. Punakami RI. Political violence and mental health. International Journal of Mental Health. 1989; 17: 3-15.
8. Mollica R. The Harvard Trauma Questionnaire Manual: Indochinese Versions: Harvard University; undated.
9. Kinzie JD, Manson SM, Vinh DT, Tolan NT, Anh B, Pho TN. Development and validation of a Vietnamese-language depression rating scale. American Journal of Psychiatry. 1982; 139(10): 1276-81.
10. Beiser M, Fleming JAE. Measuring Psychiatric Disorder among Southeast Asian refugees. Psychological Medicine. 1986; 16: 627-39.
11. Bolton P. Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. Journal of Nervous & Mental Disease. 2001; 189(4): 238-42.
12. Hollifield M, Warner TD, Krakow B, Jenkins J, Westermeyer J. The range of symptoms in refugees of war: the New Mexico Refugee Symptom Checklist-121. J Nerv Ment Dis. 2009; 197(2): 117-25.
13. Frank JD. Psychotherapy: the restoration of morale. Am J Psychiatry. 1974; 131(3): 271-4.
14. Briggs L, Macleod AD. Demoralisation–a useful conceptualisation of non-specific psychological distress among refugees attending mental health services. Int J Soc Psychiatry. 2006; 52(6): 512-24.
15. Harding TW, de Arango MV, Baltazar J, Climent CE, Ibrahim HH, Ladrido-Ignacio L, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med. 1980; 10(2): 231-41.
16. Katon W, Ries RK, Kleinman AM. The prevalence of somatization in primary care. Comprehensive Psychiatry. 1984; 25: 208-14.
17. Hollifield M, Katon W, Spain D, Pule L. Anxiety and depression in a village in Lesotho, Africa: a comparison with the U.S. British Journal of Psychiatry. 1990; 156: 343-50.