[Cultural expression of psychopathology]. / Culturele uitingsvormen van psychische aandoeningen.

Background  Psychiatry and psychology have struggled since their earliest development with the question whether psychopathology manifests itself identically around the world, and whether a disorder can be better understood from a biological or a socio-cultural perspective. Aim  To describe the culture and psychopathology debate based on recent developments in ICD and DSM, illustrated with depression and PTSD. Method  Clinical experience, previous publications in other languages, and a recent PubMed search on culture and psychopathology. Results  There is some consensus in worldwide studies on the universal manifestation of these two disorders. On the other hand, there is broad criticism due to three forms of bias: poor construct validity, looping effects and category truncation. DSM has developed concepts and tools that can enhance cultural competence in practice and in research. Conclusion  Researchers and practitioners should develop phenomenological skills to describe and incorporate the local expression of psychological problems into practice. And take into account the three forms of bias mentioned.

Intergenerational maltreatment in parent-child dyads from Burundi, Africa: Associations among parental depression and connectedness, posttraumatic stress symptoms, and aggression in children.

Studies investigating the associations between histories of childhood maltreatment (CM) in parent-child dyads have primarily involved samples from high-income countries; however, CM rates are higher in low- and middle-income countries. The present study aimed to examine the (a) association between maltreatment in parents and maltreatment of their children through risk (i.e., parent depression) and protective (i.e., parent-child connectedness) factors and (b) associations between CM in children with aggression through posttraumatic stress symptoms (PTSS) and peer/sibling victimization. Participants were 227 parent-child dyads from Burundi, Africa, a low-income country. Parents were 18 years of age or older, and children were 12-18 years (M = 14.76, SD = 1.88, 57.7% female). Among parents, 20.7%-69.5% of participants reported a history of physical and emotional abuse and neglect; among children, the rates of sexual, physical, and emotional abuse ranged from 14.5% to 89.4%. A history of CM in parents was associated with CM in children, B = 0.19, p < .01, and CM in parents was indirectly associated with CM in children through parent-child connectedness, ß = .04, 95% CI [.01, .10], and parental depression, ß = .08, 95% CI [.03, .15]. In children, maltreatment was positively associated with peer/sibling victimization, and CM was associated with aggression, ß = .07, 95% CI [.04, 0.11], through PTSS but not via peer/sibling victimization. Continued efforts to improve CM-related preventive strategies and the accessibility of prevention services are needed to reduce CM in low-income countries such as Burundi.

Assessing the factor structure of the Childhood Trauma Questionnaire, and cumulative effect of abuse and neglect on mental health among adolescents in conflict-affected Burundi.

The present study aimed to examine the factor structure of the Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998), highlight rates of abuse and neglect among Burundian adolescents, compare these rates with those found in high-income nations, and examine the cumulative effect of multiple types of abuse and neglect on depression and PTSD symptoms. Participants were 231 adolescents and youth (M=14.9, SD=1.99, 58.4% female) from five provinces of Burundi, a country in Central Africa affected by war and political violence. Translation and back-translation of the CTQ was carried out to obtain an adaptation of CTQ in Kirundi, the native language of Burundi. With the exception of one item on 'molestation' in the factor of sexual abuse, the five-factor structure of CTQ was obtained comprising latent factors, namely emotional, physical, and sexual abuse, and emotional and physical neglect. The rate of abuse and neglect ranged from 14.7-93.5% with more than 37% reporting 4 or more types of abuse and neglect experiences. Emotional abuse and neglect, and physical neglect were 2-3 times higher among Burundian adolescents when compared with studies from high-income countries using the CTQ. A cumulative effect of multiple types of abuse and neglect was found, such that, those with 4 or more types of maltreatment were higher on symptoms of depression and posttraumatic stress. Findings highlight the need for culturally sensitive, standardized, and validated measures and norms for gauging childhood maltreatment in Burundi and related need for preventative interventions on childhood maltreatment.

Intergenerational transmission of violence and resilience in conflict-affected Burundi: a qualitative study of why some children thrive despite duress.

BACKGROUND: Research suggests that in environments where community conflict and violence are chronic or cyclical, caregiving can impact how children may begin to reproduce violence throughout the various stages of their lives. The aim of this study is to understand how caregiving affects processes of reproducing violence and resilience among children in conflict-affected Burundi. METHODS: We combined a socio-ecological model of child development with a child-actor perspective. We operationalized the core concepts 'vulnerable household', 'resilience', and 'caregiving' iteratively in culturally relevant ways, and put children's experiences at the center of the inquiry. We carried out a comparative case study among 74 purposively sampled vulnerable households in six collines in three communes in three provinces in the interior of Burundi. Burundian field researchers conducted three consecutive interviews; with the head of the household, the main caregiver, and a child. RESULTS: Our findings reveal a strong congruence between positive caregiving and resilience among children. Negative caregiving was related to negative social behavior among children. Other resources for resilience appeared to be limited. The overall level of household conditions and embedment in communities attested to a generalized fragile ecological environment. CONCLUSIONS: In conflict-affected socio-ecological environments, caregiving can impact children's functioning and their role in reproducing violence. Interventions that support caregivers in positive caregiving are promising for breaking cyclical violence.

Treatment processes of counseling for children in South Sudan: a multiple n=1 design.

Studies into treatment processes in low-income settings are grossly lacking, which contributes to the scarcity of evidence-based psychosocial treatment. We conducted multiple n=1 studies, with quantitative outcome indicators (depression-, PTSD- and anxiety- symptoms, hope) and qualitative process indicators (treatment- perceptions, content and progress) measured before, during and after counseling. We aimed to explore commonalities in treatment processes associated with change profiles within and between cases. The study was conducted in South Sudan with children aged between 10 and 15 years. Change profiles were associated with the quality of the counselor-client relationship (instilling trust and hope through self-disclosure, supportive listening and advice giving), level of client activation, and the ability of the counselor to match treatment strategies to the client's problem presentation (trauma- and emotional processing, problem solving, cognitive strategies). With limited time, due to restricted resources in low-income settings, training courses can now be better focused on key treatment processes.

[DSM-5 and culture]. / DSM-5 en cultuur.

BACKGROUND: The leading diagnostic classification system used in the Dutch mental health care system is the DSM-IV(Diagnostic and Statistical Manual of Mental Disorders). The next version, DSM-5, will probably be published in 2013. The new version aims to pay more attention to cultural diversity; this will have implications for treatment and research. AIM: To discuss the most important aspects of DSM-5 that have culture relevance. METHOD: A Medline search was conducted for the period 1990- 2011 on the basis of the search terms 'DSM', 'ICD', 'DSM-classification, 'psychiatric classification', 'psychiatric diagnosis', 'culture' and 'diversity'. RESULTS: Taking the example of depression and anxiety, one must conclude that the diagnostic system does not achieve its aims. It might be possible to compensate for this shortcoming by introducing a dimensional-categorical system. Such a system would be particularly important for cultural psychiatry and psychology in relation to matters such as subsyndromal symptom categories, experience of illness, behaviour during illness, the transition from normality to deviancy, culturally responsive research, and links to cultural neuroscience. CONCLUSION: It looks as if such a major paradigm shift will not occur until DSM-6.

Practice-driven evaluation of a multi-layered psychosocial care package for children in areas of armed conflict.

Psychosocial and mental health service delivery frameworks for children in low-income countries are scarce. This paper presents a practice-driven evaluation of a multi-layered community-based care package in Burundi, Indonesia, Sri Lanka and Sudan, through a set of indicators; (a) perceived treatment gains; (b) treatment satisfaction; (c) therapist burden; (d) access to care; (e) care package costs. Across four settings (n = 29,292 children), beneficiaries reported high levels of client satisfaction and moderate post-treatment problem reductions. Service providers reported significant levels of distress related to service delivery. Cost analyses demonstrated mean cost per service user to vary from 3.46 to 17.32 depending on country and specification of costs. The results suggest a multi-layered psychosocial care package appears feasible and satisfactory in reaching out to substantial populations of distressed children through different levels of care. Future replication should address therapist burden, cost reductions to increase sustainability and increase evidence for treatment efficacy.

[Cocaine use and sudden death: excited delirium syndrome]. / Cocaïnegebruik en plotseling overlijden: het geagiteerd-deliriumsyndroom.

Three patients, men aged 30, 33 and 32 years respectively, died in police custody in Amsterdam, the Netherlands. According to autopsy reports, all patients died from excited delirium syndrome induced by cocaine use. Excited delirium is a state of mental and physiological hyperarousal commonly associated with the use of cocaine. Patients suffering from excited delirium can be extremely hostile and violent. If a physical struggle arises with police or medical personnel, the episode can end in death due to adrenergic overstimulation. Patients in acute excited states should be regarded as a medical emergency with a serious mortality risk, and should be transferred to the hospital rather than the police station. Medical and police staff should aim to reduce confrontation. When patients are too agitated to cooperate, benzodiazepines should be used for sedation of the patient. Beta blockers and antipsychotic medication should not be administered, as these medications can exacerbate the fatal cardiac effects seen in excited delirium.

Screening for psychosocial distress amongst war-affected children: cross-cultural construct validity of the CPDS.

BACKGROUND: Large-scale psychosocial interventions in complex emergencies call for a screening procedure to identify individuals at risk. To date there are no screening instruments that are developed within low- and middle-income countries and validated for that purpose. The present study assesses the cross-cultural validity of the brief, multi-informant and multi-indicator Child Psychosocial Distress Screener (CPDS). METHODS: The CPDS data of total samples in targeted catchment areas of a psychosocial care program in four conflict-affected countries (Burundi n = 4193; Sri Lanka n = 2573; Indonesia n = 1624; Sudan n = 1629) were studied to examine the cross-cultural construct validity of the CPDS across settings. First, confirmatory factor analyses were done to determine the likelihood of pre-determined theory-based factor structures in each country sample. Second, multi-sample confirmatory factor analyses were done within each country sample to test measurement equivalence of the factor structure as a measure of construct validity. RESULTS: A 3-factor structure reflecting the theoretical premises of the instrument (e.g., child distress, child resilience and contextual factors) was found in the samples from Burundi, Sri Lanka and Indonesia, albeit with context specific deviations. The robustness of the 3-factor structure as an indicator of construct validity was confirmed within these three samples by means of multi-sample confirmatory factor-analyses. A 3-factor structure was not found in the Sudan sample. CONCLUSIONS: This study demonstrates the comparability of the assessment by the CPDS of the construct 'non-specific psychosocial distress' across three out of four countries. Robustness of the factor structure of the CPDS within different samples refers to the construct validity of the instrument. However, owing to context-specific deviations of inter-item relationships, the CPDS scores cannot be compared cross-culturally, a finding that confirms the need for attention to contextual factors when screening for non-specific psychosocial distress.

Migrant mental health: a model for indicators of mental health and health care consumption.

OBJECTIVE: This study explores the relationship between mental health and health care consumption among migrants in the Netherlands. DESIGN: Samples of the Turkish (n = 648), Moroccan (n = 102), and Surinamese (n = 311) populations in Amsterdam were examined. The study tested a hypothesized model of risk factors for psychiatric morbidity, indicators of well-being, and indicators of health care consumption. The model was specified on the basis of information from earlier research on the sample and literature on the topic. The model was tested and refined using structural equation modeling. MAIN OUTCOME MEASURES: Psychiatric morbidity and well-being measures were assessed with the CIDI 1.1 and MOS-sf-36 subscales, respectively. Health care consumption was assessed by the question "Have you ever consulted one or more of these professionals or health care facilities with respect to mental health problems or problems related to alcohol or drugs usage?" RESULTS: The primary result of this study was the confirmation that health care consumption among migrants is predicted by need and predisposition factors, such as health condition and sociodemographic characteristics. In addition, mental health care consumption of migrants is predicted by acculturation characteristics. This result suggests an effect of cultural and migrant-specific factors in help-seeking behavior and barriers to mental health care facilities. CONCLUSIONS: Findings confirm the existence of migrant-specific mechanisms in health care consumption. Mental health care professionals should be aware of these. However, ignoring common ground for interventions unnecessarily creates distance between migrant groups and between migrant and indigenous Dutch groups.

[The effectiveness of mental health care in developing countries. Intervention and policy options at several levels]. / De effectiviteit van de geestelijke gezondheidszorg in ontwikkelingslanden. Interventiemogelijkheden en beleidsopties op verschillende niveaus.

BACKGROUND: In developing countries psychiatric disorders are a major cause of disability and reduced economic productivity. AIM: To present an overview of intervention and policy options in mental health care in developing countries. METHOD: We searched the literature using PubMed, supplementing our finding with what we have learned from experience in the field. RESULTS: Research data, though very limited, indicate that psychiatric disorders can be treated effectively in developing countries. Mental health care can be provided at three different levels: at the level of the existing health care system, at primary care level and at community level. We discuss interventions at each of these levels on the basis of three cases. CONCLUSION: More research is needed into the efficacy and cost-effectiveness of mental health care interventions in developing countries; research must be accompanied by the actual implementation of mental health programmes in these countries.

The deterioration and mobilization effects of trauma on social support: childhood maltreatment and adulthood military violence in a Palestinian community sample.

OBJECTIVES: To show that exposure to childhood maltreatment deteriorates, whereas exposure to adulthood military violence mobilizes social support; second, to show that associations between traumatic events and mental health problems are mediated through social support and, subsequently, adulthood military violence is associated with low level and childhood maltreatment with high level of mental health symptoms; third, to explore whether the moderating (protecting) effect of sufficient and satisfactory social support would differ among victims of childhood maltreatment and adulthood military violence. METHOD: The participants were a random-sample of Palestinian men and women (n=585) of 16-60 years of age. Exposure to military violence in adulthood was assessed by the Harvard Trauma Questionnaire (HTQ_I), and to childhood maltreatment by a 13-item questionnaire developed for the study. A Social Network Schedule was applied to assess the function, source, and satisfaction with social support, and the Revised SCL90-R Symptoms Checklist to assess mental health symptoms. RESULTS: Findings supported our hypothesis that exposure to childhood maltreatment was associated with low levels of social support, whereas exposure to adulthood military violence was associated with high levels of social support. Contrary to our second hypothesis, both childhood maltreatment and adulthood military violence were associated with high levels of mental health symptoms. Finally, high level and satisfactory social support moderated the association between exposure to military violence in adulthood and mental health symptoms, but not between childhood maltreatment and mental health symptoms. CONCLUSION: The findings emphasize that the nature of trauma, that is, whether familial or political, determines the availability of protective resources versus vulnerability, which should be considered when tailoring interventions to trauma victims.

[Many psychiatric disorders in Afghan refugees with residential status in Drenthe, especially depressive disorder and post-traumatic stress disorder]. / Veel psychiatrische stoornissen bij Afghaanse vluchtelingen met verblijfsstatus in Drenthe, met name depressieve stoornis en posttraumatische stresstoornis.

OBJECTIVE: To assess the prevalence of psychiatric disorders and help-seeking behaviour of Afghan refugees with a residence status in the province of Drenthe, the Netherlands. DESIGN: Cross-sectional prevalence study. METHOD: By means of a modified multiflex snowball sampling with 3 primary informants, 55 Afghan households in 16 towns and villages in Drenthe were selected. After informed consent had been obtained, 51 adults completed a sociodemographic questionnaire and a culturally validated shortened 'Composite international diagnostic interview' (CIDI), DSM-IV version. Help-seeking behaviour was recorded. RESULTS: Half of the sample had resided in the Netherlands for at least 3 years. There was a high level of education, an unemployment level of 88% and moderate to poor language skills in 92% of the respondents. The prevalence of psychiatric disorders was 65% (95% CI: 52-78); depressive disorder occurred in 57% and posttraumatic stress disorder in 35%. Psychopathological findings were related to poor language skills, a lower level of education and unemployment. A total of 56% received treatment from a general practitioner and 4% were under psychiatric treatment. CONCLUSIONS: The prevalence of psychiatric disorders among adult Afghan refugees in Drenthe with a residence status was considerably higher than among the general population in the Netherlands.

Trauma and loss as determinants of medically unexplained epidemic illness in a Bhutanese refugee camp.

BACKGROUND: We sought to identify personal factors that placed people at risk during an epidemic of medically unexplained illness in a Bhutanese refugee camp in southeastern Nepal. METHODS: We conducted a case-control study, involving 68 cases and 66 controls. Caseness was defined as experiencing at least one attack of medically unexplained fainting or dizziness during the time of the epidemic. We performed hierarchical logistic regression analysis to identify significant predictors of case status. RESULTS: In terms of Western psychiatric constructs, the illness involved somatoform symptoms of both acute anxiety and dissociation. Sixty per cent reported visual and 28% reported auditory hallucinatory experiences. Cases and controls were similar on all demographic variables, school performance, number of attacks witnessed and psychopathology before the onset of the epidemic. Recent loss, early loss, childhood trauma and pulse-rate were predictors of case status. CONCLUSION: We identified trauma, early loss and, especially, recent loss as predictors of attacks during medically unexplained epidemic illness in a Bhutanese refugee community.

Lifetime events and posttraumatic stress disorder in 4 postconflict settings.

CONTEXT: Little is known about the impact of trauma in postconflict, low-income countries where people have survived multiple traumatic experiences. OBJECTIVE: To establish the prevalence rates of and risk factors for posttraumatic stress disorder (PTSD) in 4 postconflict, low-income countries. DESIGN, SETTING, AND PARTICIPANTS: Epidemiological survey conducted between 1997 and 1999 among survivors of war or mass violence (aged >/=16 years) who were randomly selected from community populations in Algeria (n = 653), Cambodia (n = 610), Ethiopia (n = 1200), and Gaza (n = 585). MAIN OUTCOME MEASURE: Prevalence rates of PTSD, assessed using the PTSD module of the Composite International Diagnostic Interview version 2.1 and evaluated in relation to traumatic events, assessed using an adapted version of the Life Events and Social History Questionnaire. RESULTS: The prevalence rate of assessed PTSD was 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza. Conflict-related trauma after age 12 years was the only risk factor for PTSD that was present in all 4 samples. Torture was a risk factor in all samples except Cambodia. Psychiatric history and current illness were risk factors in Cambodia (adjusted odds ratio [OR], 3.6; 95% confidence interval [CI], 2.3-5.4 and adjusted OR,1.6; 95% CI, 1.0-2.7, respectively) and Ethiopia (adjusted OR, 3.9; 95% CI, 2.0-7.4 and adjusted OR, 1.8; 95% CI, 1.1-2.7, respectively). Poor quality of camp was associated with PTSD in Algeria (adjusted OR, 1.8; 95% CI, 1.3-2.5) and in Gaza (adjusted OR, 1.7; 95% CI, 1.1-2.8). Daily hassles were associated with PTSD in Algeria (adjusted OR, 1.6; 95% CI, 1.1-2.4). Youth domestic stress, death or separation in the family, and alcohol abuse in parents were associated with PTSD in Cambodia (adjusted OR, 1.7; 95% CI, 1.1-2.6; adjusted OR, 1.7; 95% CI, 1.0-2.8; and adjusted OR, 2.2; 95% CI, 1.1-4.4, respectively). CONCLUSIONS: Using the same assessment methods, a wide range of rates of symptoms of PTSD were found among 4 low-income populations who have experienced war, conflict, or mass violence. We identified specific patterns of risk factors per country. Our findings indicate the importance of contextual differences in the study of traumatic stress and human rights violations.

Psychiatric disorders among tortured Bhutanese refugees in Nepal.

BACKGROUND: The impact of torture on the distribution of psychiatric disorders among refugees is unknown. METHODS: We surveyed a population-based sample of 418 tortured and 392 nontortured Bhutanese refugees living in camps in Nepal. Trained interviewers assessed International Classification of Diseases, 10th Revision (ICD-10) disorders through structured diagnostic psychiatric interviews. RESULTS: Except for male sex, history of torture was not associated with demographics. Tortured refugees, compared with nontortured refugees, were more likely to report 12-month ICD-10 posttraumatic stress disorder, persistent somatoform pain disorder, and dissociative (amnesia and conversion) disorders. In addition, tortured refugees were more likely to report lifetime posttraumatic stress disorder, persistent somatoform pain disorder, affective disorder, generalized anxiety disorder, and dissociative (amnesia and conversion) disorders. Tortured women, compared with tortured men, were more likely to report lifetime generalized anxiety disorder, persistent somatoform pain disorder, affective disorder, and dissociative (amnesia and conversion) disorders. CONCLUSIONS: Among Bhutanese refugees, the survivors had higher lifetime and 12-month rates of ICD-10 psychiatric disorder. Men were more likely to report torture, but tortured women were more likely to report certain disorders. The results indicate the increased need for attention to the mental health of refugees, specifically posttraumatic stress disorder, persistent somatoform pain disorder, and dissociative (amnesia and conversion) disorders among those reporting torture.

Schizophrenia among Surinamese in the Netherlands: high admission rates not explained by high emigration rates.

BACKGROUND: A high risk of schizophrenia has been found among Caribbean immigrants in the Netherlands and Great Britain. One hypothesis to explain these findings is that patients with a diagnosis of schizophrenia or patients with symptoms of psychosis not specifically diagnosed, emigrate more than the general population. Such selection might account for high rates of Surinamese patients with a diagnosis of schizophrenia in Netherlands psychiatric hospitals. We examined this hypothesis. METHODS: The files of patients with schizophrenia or patients suffering from unspecified psychosis were selected from the archives of the National Psychiatric Hospital in Surinam. These patients were traced to investigate patterns of emigration. Data from the Central Bureau for Statistics in the Netherlands and from the Central Population Bureau in Surinam provided the percentage of the general Surinamese population that emigrated to the Netherlands. The difference between the two percentages was evaluated using the chi-squared test. Using the same method the percentage of remigration from the Netherlands among Surinamese patients was compared with the percentage of remigration among the general Surinamese population. RESULTS: Surinamese patients with schizophrenia or unspecified psychosis did not emigrate more frequently to the Netherlands compared with the general Surinamese population. They did remigrate significantly more frequently. CONCLUSION: High migration rates do not explain the high hospital admission rates for schizophrenia among Surinamese in the Netherlands.

Shipboard techniques based on flow injection analysis for measuring dissolved Fe, Mn and Al in seawater.

An overview is presented of sampling techniques and flow injection analysis (FIA) methods for low concentrations of Fe, Mn and Al in filtered seawater. On the basis of sampling procedures, filtration techniques, accuracy, blanks, detection limits, intercalibration results and oceanographic consistency, the feasibility of these FIA methods was evaluated. It was found that these metals could be measured on board with a minimum risk of contamination and with good accuracy even at low subnanomolar levels (<0.5 nM). Results for reference seawater were in the case of Fe-FIA and Mn-FIA in excellent agreement with the certified values. Data from samples analyzed by Fe-FIA and by cathodic stripping voltametry (CSV) compared well, as did Mn-FIA and GFAAS. All three methods gave results that were mostly in good agreement with data from the same ocean regions published by other research groups. Two different types of surface water sampling were also tested and compared, namely conventional hand filling of a sample bottle from a rubber dinghy away from the ship, and underway pumping of seawater using a 'tow fish'. The latter method gave the best results. Also, conventional membrane filtration and cartridge filtration for large volume filtration were compared using Fe and Al data from water column samples. Good agreement was found for both filter types, although for defining dissolved metal species the latter filter type was preferred.