Posttraumatic stress disorder and prolonged grief in refugees exposed to trauma and loss

BMC Psychiatry

Richard A Bryant²  Derrick Silove¹  Zachary Steel¹  Fiona Maccallum²  Belinda J Liddell²  Angela Nickerson² 

[1] Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, Sydney NSW, 2052, Australia;School of Psychology, University of New South Wales, Sydney NSW 2052, Australia

关键词: War;    Refugees;    Grief;    Posttraumatic stress disorder;    Bereavement;    Trauma;   

Others  :  1123649
DOI  :  10.1186/1471-244X-14-106

 received in 2013-12-19, accepted in 2014-03-31,  发布年份 2014

【 摘 要 】

Background

While a large proportion of conflict-affected populations have been dually exposed to trauma and loss, there is inadequate research identifying differential symptom profiles related to bereavement and trauma exposure in these groups. The objective of this study were to (1) determine whether there are distinct classes of posttraumatic stress disorder (PTSD) and prolonged grief disorder (PGD) symptoms in bereaved trauma survivors exposed to conflict and persecution, and (2) examine whether particular types of refugee experiences and stressors differentially predict symptom profiles.

Methods

Participants were 248 Mandaean adult refugees who were assessed at an average of 4.3 years since entering Australia following persecution in Iraq. PTSD, PGD, trauma exposure, adjustment difficulties since relocation, and English proficiency were measured. Latent class analysis was used to elucidate symptom profiles of PTSD and PGD in this sample.

Results

Latent class analysis revealed four classes of participants: a combined PTSD/PGD class (16%), a predominantly PTSD class (25%), a predominantly PGD class (16%), and a resilient class (43%). Whereas membership in the PTSD/PGD class was predicted by exposure to traumatic loss, those in the PGD class were more likely to have experienced adaptation difficulties since relocation, and individuals in the PTSD class were more likely to have experienced difficulties related to loss of culture and support.

Conclusions

This study provides evidence that specific symptom patterns emerge following exposure to mass trauma and loss. These profiles are associated with distinct types of traumatic experiences and post-migration living difficulties. These results have substantial public health implications for assessment and intervention following mass trauma.

【 授权许可】

   
2014 Nickerson et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Harbom L, Wallensteen P: Armed conflicts, 1946–2009. J Peace Res 2010, 47:501-509.
• [2]Fazel M, Wheeler J, Danesh J: Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet 2005, 365:1309-1314.
• [3]Steel Z, Chey T, Silove D, Marnane C, Bryant RA, Van Ommeren M: Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA 2009, 302(5):537-549.
• [4]Shear MK, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, Reynolds C, Lebowitz B, Sung S, Ghesquiere A, Gorscak B, Clayton P, Ito M, Nakajima S, Konishi T, Melhem N, Meert K, Schiff M, O'Connor MF, First M, Sareen J, Bolton J, Skritskaya N, Mancini AD, Keshaviah A: Complicated grief and related bereavement issues for DSM-5. Depress Anxiety 2011, 28(2):103-117.
• [5]Maercker A, Brewin CR, Bryant RA, Cloitre M, van Ommeren M, Jones LM, Humayan A, Kagee A, Llosa AE, Rousseau C, Somasundaram DJ, Souza R, Suzuki Y, Weissbecker I, Wessely SC, First MB, Reed GM: Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry 2013, 12:198-206.
• [6]Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, Raphael B, Marwit SJ, Wortman C, Neimeyer RA, Bonanno G, Block SD, Kissane D, Boelen P, Maercker A, Litz BT, Johnson JG, First MB, Maciejewski PK: Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med 2009, 6(8):e1000121.
• [7]Lichtenthal WG, Nilsson M, Kissane DW, Breitbart W, Kacel E, Jones EC, Prigerson HG: Underutilization of mental health services among bereaved caregivers with prolonged grief disorder. Psychiatr Serv 2011, 62(10):1225-1229.
• [8]Schaal S, Jacob N, Dusingizemungu JP, Elbert T: Rates and risks for prolonged grief disorder in a sample of orphaned and widowed genocide survivors. BMC Psychiatry 2010, 10:55. BioMed Central Full Text
• [9]Morina N, Rudari V, Bleichhardt G, Prigerson HG: Prolonged grief disorder, depression, and posttraumatic stress disorder among bereaved Kosovar civilian war survivors: a preliminary investigation. Int J Soc Psychiatry 2010, 56(3):288-297.
• [10]Craig CD, Sossou M-A, Schnak M, Essex H: Complicated grief and its relationship to mental health and well-being among Bosnian refugees after resettlement in the United States: implications for practice, policy, and research. Traumatology 2008, 14(4):103-115.
• [11]Ayer L, Danielson CK, Amstadter AB, Ruggiero K, Saunders B, Kilpatrick D: Latent classes of adolescent posttraumatic stress disorder predict functioning and disorder after 1 year. J Am Acad Child Adolesc Psychiatry 2011, 50(4):364-375.
• [12]Elhai JD, Naifeh JA, Forbes D, Ractliffe KC, Tamburrino M: Heterogeneity in clinical presentations of posttraumatic stress disorder among medical patients: testing factor structure variation using factor mixture modeling. J Trauma Stress 2011, 24(4):435-443.
• [13]Breslau N, Reboussin BA, Anthony JC, Storr CL: The structure of posttraumatic stress disorder: latent class analysis in 2 community samples. Arch Gen Psychiatry 2005, 62(12):1343-1351.
• [14]Steel Z, Silove D, Brooks R, Momartin S, Alzuhairi B, Susljik I: Impact of immigration detention and temporary protection on the mental health of refugees. Br J Psychiatry 2006, 188:58-64.
• [15]Nickerson A, Bryant RA, Steel Z, Silove D, Brooks R: The impact of fear for family on mental health in a resettled Iraqi refugee community. J Psychiatr Res 2010, 44:229-235.
• [16]Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J: The Harvard trauma questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis 1992, 180(2):111-116.
• [17]Steel Z, Silove D, Bird K, McGorry P, Mohan P: Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees and immigrants. J Trauma Stress 1999, 12:421-435.
• [18]Prigerson HG, Frank E, Kasl SV, Reynolds CF, Anderson B, Zubenko GS, Houck PR, George CJ, Kupfer DJ: Complicated grief and bereavement-related depression as distinct disorders: preliminary epirical validation in elderly bereaved spouses. Am J Psychiatr 1995, 152(1):22-30.
• [19]Mollica RF, Wyshak G, De Marneffe D, Khuon F, Lavelle J: Indochinese versions of the Hopkins symptom checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatr 1987, 144(4):497-500.
• [20]Silove D, Sinnerbrink I, Field A, Manicavasagar V, Steel Z: Anxiety, depression and PTSD in asylum-seekers: associations with pre-migration trauma and post-migration stressors. Br J Psychiatry 1997, 170:351-357.
• [21]Wylie E: Test and non-test assessment for the professional second language user. In Current developments and alternatives in language assessment. Edited by Huhta A, Kohonen V, Kurki-Suonio L, Luoma S. Finland: University of Jyvaskyla; 1996.
• [22]Bontempo R: Translation fidelity of psychological scales: an item response theory analysis of an individualism-collectivism scale. J Cross-Cult Psychol 1993, 24:1449-1166.
• [23]Muthén LK, Muthén BO: Mplus User's Guide. Sixth edition. Los Angeles, CA: Muthén & Muthén; 1998-2011.
• [24]Burnstein M, Georgiades K, Lamers F, Swanson SJ, Cui L, He JP, Avenevoli S, Merikangas KR: Empirically derived subtypes of lifetime anxiety disorders: developmental and clinical correlates in US adolescence. J Consult Clin Psychol 2012, 80:102-115.
• [25]Steenkamp MM, Nickerson A, Maguen S, Nash WP, Litz BT: Latent classes of PTSD symptoms in Vietnam Veterans. Behav ModifIn press
• [26]Rosenblatt PC: Grief across cultures: a review and research agenda. In Handbook of bereavement research and practice: Advances in theory and intervention. Edited by Stroebe MS, Hansson RO, Schut H, Stroebe W. Washington DC: American Psychological Association; 2008:207-222.
• [27]Baures MM: Letting go of bitterness and hate. J Humanist Psychol 1996, 36:75-90.
• [28]Hagengimana A, Hinton DE: Ihahamuka, a Rwandan syndrome of response to the genocide: blocked flow, spirit assault, and shortness of breath. In Culture and panic disorder. Edited by Hinton DE, Good BJ. Stanford: Stanford University Press; 2009:205-229.
• [29]Rothbaum BO, Foa EB, Riggs DS, Murdock T, Walsh W: A prospective examination of post-traumatic stress disorder in rape victims. J Trauma Stress 1992, 5(3):455-475.
• [30]Bonanno GA, Boerner K, Wortman CB: Trajectories of grieving. In Handbook of bereavement research and practice: Advances in theory and intervention. Edited by Stroebe MS, Hansson RO, Schut H, Stroebe W. Washington DC: American Psychological Association; 2008:287-307.
• [31]Mollica RF, McInnes K, Poole C, Tor S: Dose-effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. Br J Psychiatry 1998, 173:482-488.
• [32]Van Ommeren M, De Jong JT, Sharma B, Komproe I, Thapa SB, Cardena E: Psychiatric disorders among tortured Bhutanese refugees in Nepal. Arch Gen Psychiat 2001, 58:475-482.
• [33]Neria Y, Litz BT: Bereavement by traumatic means: the complex synergy of trauma and grief. J Loss Trauma 2004, 9:73-88.
• [34]Nickerson A, Bryant RA, Brooks R, Steel Z, Silove D: Fear of cultural extinction and psychopathology among Mandaean refugees: an exploratory path analysis. CNS Neurosci Ther 2009, 15(3):227-236.
• [35]Newmarker C: Survival of ancient faith threatened by fighting in Iraq. Associated Press; 2007. http://www.washingtonpost.com/wp-dyn/content/article/2007/02/09/AR2007020901687.html webcite
• [36]Eisenbruch M: From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Soc Sci Med 1991, 33(6):673-680.
• [37]Ott CH: The impact of complicated grief on mental and physical health at various points in the bereavement process. Death Stud 2003, 27(3):249-272.
• [38]Boelen PA: Personal goals and prolonged grief disorder symptoms. Clin Psychol Psychother 2011, 18(6):439-444.
• [39]Tomarken A, Holland J, Schachter S, Vanderwerker L, Zuckerman E, Nelson C, Coups E, Ramirez PM, Prigerson H: Factors of complicated grief pre-death in caregivers of cancer patients. Psychooncology 2008, 17(2):105-111.
• [40]Steel Z, Silove D, Phan T, Bauman A: Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study. Lancet 2002, 360:1056-1062.
• [41]Takeuchi DT, Zane N, Hong S, Chae DH, Gong F, Gee GC, Walton E, Sue S, Alegria M: Immigration-related factors and mental disorders among Asian Americans. Am J Public Health 2007, 97(1):84-90.
• [42]Hauff E, Vaglum P: Organised violence and the stress of exile: predictors of mental health in a community cohort of Vietnamese refugees three years after resettlement. Br J Psychiatry 1995, 166(3):360-367.
• [43]Nickerson A, Steel Z, Bryant R, Brooks R, Silove D: Change in visa status amongst Mandaean refugees: relationship to psychological symptoms and living difficulties. Psychiatry Res 2011, 187(1–2):267-274.
• [44]Laban CJ, Gernaat HB, Komproe IH, Schreuders BA, De Jong JT: Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. J Nerv Ment Dis 2004, 192(12):843-851.
• [45]Prigerson HG, Maciejewski PK, Reynolds CF 3rd, Bierhals AJ, Newsom JT, Fasiczka A, Frank E, Doman J, Miller M: Inventory of complicated grief: a scale to measure maladaptive symptoms of loss. Psychiatry Res 1995, 59(1–2):65-79.
• [46]Shoeb M, Weinstein H, Mollica RF: The Harvard trauma questionnaire: adapting a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Iraqi refugees. Int J Soc Psychiatry 2007, 53(5):447-463.
• [47]Ichikawa M, Nakahara S, Wakai S: Cross-cultural use of the predetermined scale cutoff points in refugee mental health research. Soc Psychiatry Psychiatr Epidemiol 2006, 41(3):248-250.
• [48]Prigerson H, Ahmed I, Silverman GK, Saxena AK, Maciejewski PK, Jacobs SC, Kasl SV, Aqeel N, Hamirani M: Rates and risks of complicated grief among psychiatric clinic patients in Karachi, Pakistan. Death Stud 2002, 26(10):781-792.
• [49]Nickerson A, Bryant RA, Silove D, Steel Z: A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clin Psychol Rev 2011, 31(3):399-417.