Posttraumatic stress in emergency settings outside North America and Europe: A review of the emic literature

Abstract

Mental health professionals from North America and Europe have become common participants in postconflict and disaster relief efforts outside of North America and Europe. Consistent with their training, these practitioners focus primarily on posttraumatic stress disorder (PTSD) as their primary diagnostic concern. Most research that has accompanied humanitarian aid efforts has likewise originated in North America and Europe, has focused on PTSD, and in turn has reinforced practitioners’ assumptions about the universality of the diagnosis. In contrast, studies that have attempted to identify how local populations conceptualize posttrauma reactions portray a wide range of psychological states. We review this emic literature in order to examine differences and commonalities across local posttraumatic cultural concepts of distress (CCDs). We focus on symptoms to describe these constructs – i.e., using the dominant neo-Kraepelinian approach used in North American and European psychiatry – as opposed to focusing on explanatory models in order to examine whether positive comparisons of PTSD to CCDs meet criteria for face validity. Hierarchical clustering (Ward’s method) of symptoms within CCDs provides a portrait of the emic literature characterized by traumatic multifinality with several common themes. Global variety within the literature suggests that few disaster-affected populations have mental health nosologies that include PTSD-like syndromes. One reason for this seems to be the almost complete absence of avoidance as pathology. Many nosologies contain depression-like disorders. Relief efforts would benefit from mental health practitioners getting specific training in culture-bound posttrauma constructs when entering settings beyond the boundaries of the culture of their training and practice.

Post-conflict struggles as networks of problems: A network analysis of trauma, daily stressors and psychological distress among Sri Lankan war survivors

“…The fact that three items measuring avoidance and emotional numbing symptoms– i.e., avoidance due to fear, not visiting nearby relatives, lack of happiness – were highly central to the network is striking, given that avoidance and emotional numbing symptoms have not always been shown to be especially salient in non-Western contexts (Hinton & Lewis Fernandez, 2011) and particularly in non-Western emergency settings (Rasmussen, Keatley, & Joscelyne, 2014). These results indicate that at least in the Sri Lankan context, avoidance/numbing symptoms are closely associated to, and co-occur with many other symptoms, stressors and traumas.…”

Trauma-focused therapy for refugees: Meta-analytic findings.

“…Research on of the role of cultural factors in the treatment of refugee populations also is needed. Most refugees in the United States and other high income countries come from non-Western cultural backgrounds and may hold beliefs about the nature of symptoms and methods of healing that differ from those es poused in the Western mental health field (Rasmussen et al, 2014). Given the number of individuals from countries in the Middle East and Africa that have been forcibly displaced be cause of the ongoing conflicts (UNHCR, 2014), mental health research with these populations is particularly important.…”

How is depression experienced around the world? A systematic review of qualitative literature

“…Some researchers have combined etic and emic approaches in their study of depression, for example to inform existing (i.e. Western) scale adaptation (e.g., Applied Mental Health Research Group (AMHR), 2013; Haroz et al, 2014; Rasmussen et al, 2014a; Rasmussen et al, 2014b). These studies began with Western-developed instruments considered to have the best face validity based on local qualitative data, then augmented with context specific symptoms using the same qualitative data.…”

“…Findings from this review may help to improve cross-cultural measurement of depression. We intentionally used a neo-Kraepelinian approach (Compton and Guze, 1995; Rasmussen et al., 2014b) focusing solely on symptoms/features, in an effort to have our results inform self-report measurement instruments, as well as, Western psychiatric nosology as represented by the diagnostic criteria in the DSM. We intend that this review will encourage further relevant research contributing to a comprehensive picture of how depression presents and should be measured worldwide.…”