Transcript Diagnosis and Treatment of Traumatized Refugee Patients

The Diagnosis and Treatment
of Traumatized Refugees
Fern R. Hauck, MD, MS
Essentials of Family Medicine II
August 25, 2011
HL: Case Presentation
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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
HL (Continued)
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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
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He talked of nightmares which were violent, full of blood
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Certain sounds and smells reminded him of his war
experience
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Diagnosis?
Objectives
To Learn:
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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
Sources Used in this Talk
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Effective Treatments for PTSD. Foa EB, Keane
TM, Friedman MJ, Cohen JA (Eds). New York:
The Guilford Press, 2009.
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Broken Spirits. The Treatment of Traumatized
Asylum Seekers, Refugees, War and Torture
Victims. Wilson JP, Drozdek (Eds). New York:
Brunner-Routledge, 2004.
Normal Response to Extreme
Circumstances vs. Psychological
Pathology?
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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
Normal Response to Extreme
Circumstances vs. Psychological
Pathology?
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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
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.
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PTSD (Continued)
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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
PTSD (Continued)
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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
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PTSD symptoms must have lasted at least 1 month to
distinguish “normative reactions to stress” from a more
chronic syndrome indicative of mental disorder
PTSD Measures
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Many standardized scales have been
developed and validated for PTSD:
interviewer administered and selfadministered
 Harvard Trauma Questionnaire (HTQ) has
been validated with several refugee
populations, and translated into several
languages
Harvard Trauma Questionnaire
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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.
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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.
Harvard Trauma Questionnaire (Cont’d)
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Part I: Includes 46 to 82 traumatic events, Yes/No response to each question.
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Part II: Open-ended description of the most traumatic events.
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Part III, Asks about history of head injury.
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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.
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Should be administered by health care workers under the supervision and
support of a psychiatrist, medical doctor, and/or psychiatric nurse.
Prevalence of PTSD in Refugee
Populations
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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
Prevalence of PTSD in Refugee
Populations
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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
The Course of Posttraumatic Stress
Symptoms
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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
Challenges in Assessment
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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.
Challenges in Assessment and
Treatment
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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
Treatment
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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).
Treatment Resources
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Resources for assessment and treatment of
our refugee patients
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Psychiatry Team-Drs. Merkel and Hidalgo
Family Stress Clinic
Behavioral Medicine Clinic
Treatment Challenges Revisited
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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.
HL
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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!
Interlude
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Movie: Diary of Immaculée
Discussion
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Your own examples of patients you have
seen
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How can we best support each other in
caring for these emotionally challenging
patients?