The Prevalence of Posttraumatic Stress Clinical Significance Among Southeast J. David Laurie
All
nese
322
patients
refugees
of posttraumatic
were
Kinzie,
J. Moore,
M.D., James K. Boehnlein, M.D., Paul K. Leung, M.D., M.D., Crystal Riley, M.A., and Debra Smith, M.D.
at a psychiatric
surveyed stress
clinic
to determine
disorder
(PTSD).
not diagnosed at the time of initial tured reinterview was performed.
for
Indochi-
the presence If PTSD
was
evaluation, a strucSeventy percent of
the patients (N=226) met the criteria for a current diagnosis ofPTSD, and an additional 5% (N= 15) met the criteria for a past diagnosis. The Mein had the highest rate of PTSD (93 %) and the Vietnamese the lowest (54%). Of the patients with PTSD who were enrolled in the clinic before March 1 988, 46% (N= 87) were given a diagnosis of PTSD only after the reinterview. PTSD is a common disorder among Indochinese refugees, but the diagnosis is often difficult to make. (Am J Psychiatry 1990; 147:913-917)
T
he prevalence of posttraumatic stress disorder (PTSD) among traumatized victims of war or other disasters lacked extensive study before 1980. However, since then, with the acceptance of DSM-III and operational definitions of PTSD, an increasing number of studies, particularly of war veterans, have been recorded. One study of Vietnam veterans found PTSD rates of about 3.5% among nonwounded vetenans and 20% among wounded veterans (1). Other studies found PTSD in 40% of wounded Vietnam vetenans (2) and in about 50% of the prisoners of war (3). Rates of PTSD after natural disasters have generally been lower; for example, PTSD was found in only 3.3% of women and 0.7% of men after the Mount St. Helens volcano eruption in Washington state in 1980 (4). However, one study after a tornado disaster found PTSD in 59% of the affected population (5). By cornpanison, in a study using epidemiological catchment area data, the rate of PTSD in the community population was only 1% (1). Data have been slowly accumulating about psychi-
Received Sept. 5, 1989; revision received Dec. 13, 1989; accepted Jan. 1 1, 1990. From the Department of Psychiatry, Oregon Health Sciences University. Address reprint requests to Dr. Kinzie, Department of Psychiatry, UHN-80, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97201-3098. Copyright © 1 990 American Psychiatric Association.
Am
J
Psychiatry
147:7,
July
Disorder and Its Asian Refugees
1990
atnic disorders among refugees, especially those from Southeast Asia. Epidemiological survey data by GongGuy (6), Rumbaut (7), and Lin et al. (8) have shown high levels of distress and psychiatric needs. Clinical studies of Indochinese refugees have shown that depression was the most prevalent disorder (9); but among the Hmong of Laos there was a high nate of undiagnosable psychiatric disorders (10), and no PTSD symptoms were reported (1 1). PTSD was first described among Cambodian concentration camp sunvivons (12, 13). Other clinical reports have described the effects of trauma on Vietnamese and Laotians (1416). Mottica et at. (17) reported a PTSD prevalence of 50% among a Southeast Asian patient population of multiple ethnic groups. In a nonpatient community sample, a PTSD prevalence of SO% was found among Cambodian adolescents (18). A similar rate was reported among immigrants from Central America in a study that used a self-report survey (19). The present report concerns the DSM-III-R diagnosis of PTSD among an entire Indochinese clinic population of 322 patients.
METHOD Since 1978 the Department of Psychiatry at Oregon Health Sciences University has operated a program for Southeast Asian refugee patients. During this time, the Indochinese psychiatric program has evaluated oven 700 patients and currently has about 320 in treatment. The clinic medical staff includes four faculty psychiatnists and one senior resident, in addition to three Southeast Asian mental health counselors and four counselor trainees. The clinic staff has attempted to provide a medically oriented, culturally acceptable treatment for Indochinese refugees (9, 20). The major psychiatric effects of massive trauma, some psychotic reactions, psychotherapeutic approaches including group therapy, and drug therapy among Cambodian patients in our clinic have been described elsewhere (2 1-26). In March 1988 we turned our attention to detenmining the prevalence of PTSD among the entire Indochinese clinic population, not just the Cambodians. Our
913
PTSD
AMONG
TABLE
1. Current
SOUTHEAST
ASIAN
REFUGEES
and Past Diagnoses
of PTSD in a Clinic Population Vietnamese
Patient
Group
Admitted before March 1988 (N=243)a Original interview Reinterview With DSM-III-R checklist Patients admitted after March 1, 1988 (N=79y’ Total aln
March
1988
the
clinic
92
beg
N
%
Total N
53
58
-
13
-
-
-
40
-
-
16 69
46 54
35 127 an giving
each
new
patient
19 110 a thorough
RESULTS Demographic data revealed that the majority of all patients in all groups were women (66%, N213). The Mien were the oldest group (average age=54 years), but the entire population tended to be middleaged. Alt groups had arrived in the United States, on the average, in 1982 and had been patients in the clinic for 2 to 4 years; these data indicate the chronic nature of the symptoms. Depression was the most common non-PTSD diagnosis (81%, N262); about 16% (N 52) had schizophrenia. Antisocial and alcohol abuse disorders were very uncommon diagnoses in the clinic population. Our Vietnamese clinic patients included some mdividuals who had come to the United States soon after the collapse of Vietnam in 1975, but most patients had
Laotian PTSD
Mien PTSD
PTSD
N
%
Total N
84
92
20
65
40
82
-
-
4
-
-
2
-
-
-
9
-
-
36
-
89 92
11 31
91
prior impression was that PTSD was uncommon among the Vietnamese, Laotian, and Mien (Laotian hilt people) patients in the clinic, since it was rarely diagnosed. To determine its prevalence, all psychiatnists in the clinic were asked to systematically reintenview their patients with respect to severe on unusual trauma and subsequent symptoms; the psychiatrists used a DSM-III-R checklist that optimized intenrater reliability and the specificity of the PTSD diagnosis. In addition, the onset of the symptoms and the subsequent course were determined. Alt psychiatrists, with the exception of the senior resident, had worked with Indochinese refugees for at least 4 years; the three senion counselors had worked with them for at least 10 years, and the junior counselors, for at least 2 years. Analysis of the reinterview data allowed a current on past diagnosis of PTSD, and the data permitted a fuller description of the trauma among the refugees and the duration of its effects. It also showed a breakdown of the trauma by ethnic group. By comparing the diagnoses of all the established patients in the clinic before March 1988 with patients’ diagnoses based on the new evaluation, we could determine if only those with PTSD stayed as patients or if PTSD was equally preyalent among all patients.
914
Asian Refugees
Cambodian PTSD
Total N
of Southeast
2
17 101 PTSD
eval uation
at the
N
13
8 21
tim e of original
%
Total N
N
%
38
95
73
14
12
86
68
54
50
93
assessment.
escaped as boat people in the late 1970s. Almost all of the Cambodians had lived in their homeland during the terrible Pot Pot years of 1975-1979, when there was widespread destruction of the culture and mass killing and death. The educational level of this group was low because of the singling out of leaders, teachens, businessmen, Buddhist monks, and intellectuals for execution. The Laotians represented a diversity of educational and social backgrounds. Most had gone to Thailand early after the fall of Laos and tended to have relatively fewer traumas related to war on their escape. The Mien, a highland tribe from Laos, originated as a minority group in China in the thirteenth century. Very few had a format education, and most had little prior experience with Western culture and technology. Their homeland was the location of constant but usually unreported fighting among the various Laotian factions and North Vietnamese. Their escape to Thailand usually had been very difficult. At one time Hmong tribesmen and their families had been more common in Oregon and as patients in the clinic, but because of out-of-state migration, very few remained. Table 1 presents the current and past prevalence of PTSD for each of the ethnic groups in the clinic, including the prevalence among patients admitted after March 1988. The tatter patients underwent a thorough evaluation for PTSD at the time of the original clinical assessment. Fifteen patients had a past diagnosis of PTSD but had improved to the point of no longer meeting the criteria. In other words, of the 241 patients who met the criteria for a lifetime diagnosis of PTSD, 94% (N226) stilt met the criteria. We compared patients with and without PTSD in the Vietnamese and Laotian groups. No such comparison is meaningful for the Cambodian and Mien groups because over 90% had PTSD. In both the Vietnamese and Laotian groups, women predominated among the PTSD patients, and all PTSD patients tended to be older than those without PTSD. PTSD was cleanly highly associated with depression and was infrequent among those with schizophrenia. The types of trauma endured by the refugee patients are shown in table 2. The trauma endured by the refugee patients stemmed from their experiences as Pot
Am
J
Psychiatry
147:7,
July
1990
KINZIE,
TABLE
2. Types of Trauma
Experienced
by 241
Southeast
Asian Refugees
BOEHNLEIN,
LEUNG,
ET
AL.
With PTSDa Total
Trauma Pol Pot concentration War-related trauma Civilian Combat Imprisonment Traumatic escape Trauma unrelated Total aThisix bSeven
Vietnamese
Cambodian
Laotian
Mien
N
0
101
0
0
101
0 0 0 0 0 101
9 1 2 4 11
25
27
64
camp
38 10 0 22 17 87
to war
patients experienced two or instances occurred in the United
more types States.
DISCUSSION
Am
J
most striking all Indochinese
Psychiatry
finding was the high rate of PTSD refugee patients in the clinic. To
I 47: 7, July
1990
72 12 4 55
36 26 4 1 20
35b
13
279’
100
of trauma.
Pot concentration camp internees (all Cambodians), war-related experiences either in combat on as civilians (Vietnamese, Laotian, and Mien), difficulties encountered during the escape from wan zones to refugee camps (Vietnamese, Laotian, and Mien), and trauma not related to war (before their arrival in the United States and sometimes preceding wan, in addition to trauma after their arrival in this country) (Vietnamese, Laotian, and Mien). The Pot Pot trauma occurred during the 4 years of the reign of terror in Cambodia. Separation of families, threats to life, forced labor, beatings, starvation, and the witnessing of deaths were common experiences of refugees. War-related traumas included bombings of villages and homes, witnessing deaths of family members, recovering the bodies of family members during the fighting, being direct targets of the soldiers of either side, with threats and the confiscation of property. Most of the patients in this group had experienced several of the types of traumas involved. Also included were 12 soldiers who had been in combat in Indochina and several who had been imprisoned under barbaric conditions after the fall of Vietnam. Among our patients it was primarily the Vietnamese boat people who had suffered multiple traumas during the escape from Vietnam. They were shot at and endured terrible treatment by pirates on the high seas or by the militia of other countries. Brutal robberies, rapes, murder, starvation, and even cannibalism were described. The Mien also suffered terribly during their escape, when they were the target of both local militia and armies. Trauma not specifically related to war included robbenies by gangs in Vietnam, severe and prolonged physical abuse of women by their husbands or employens, and, occasionally, rapes. A few described the source of their symptoms as trauma endured since their arrival in the United States.
Our among
1 2 29 7
%
our knowledge, these rates are the highest reported in the literature for any group-even higher than those found in prisoners of wan (3) and in our own community studies of Cambodian adolescents (18). These high rates were found not only among adult Cambodians in the clinic (which we had known before this study) but also, unexpectedly, among the Mien, the Vietnamese, and the Laotians (see table 1). Because these high rates were unexpected and were found as the result of intensive interviewing to estabtish the diagnosis, we reexamined the diagnostic process and the cross-cultural diagnosis of PTSD. The psychiatnists in our clinic had all worked with Indochinese patients for many years, taking histories of trauma. Nevertheless, about half of the diagnoses were made only after the reinterview of the established patients, alt of whom had been in treatment for 2 to 4 years. The evaluation of traumatic events is often difficult to make because the victims may not report these events spontaneously, despite their clinical relevance (17, 27). In a cross-cultural setting it is sometimes difficult to do thorough evaluations because shame, toss of face, and psychic numbing add complexities to the task. Therefore, our systematic evaluation of trauma became necessary and gave us some surprising findings. We realized that in previous interviews, the patients had often minimized or completely ignored their past trauma, possibly because of shame or guilt (especially in nape cases), on more likely because they felt uncomfortable about discussing difficult life events with an American psychiatrist. For many patients, the continual experience of living in a war zone over several generations, together with cultural and religious belief systems that contributed to a rather fatalistic view of traumatic life events, may also have ted to the underreporting of symptoms. The disabling symptoms may not have been viewed by patients as a “problem” but merely as additional inconveniences in an already difficult life. Our patients’ stoicism and minimal outward emotional expression contributed to the undendiagnosis. However, factors involved in the psychiatrist’s style of interviewing could also account for the difficulty in making an accurate diagnosis. One factor may have been simply not asking about the trauma that the patients had endured.
915
PTSD
AMONG
SOUTHEAST
ASIAN
REFUGEES
As is clear from our data, many different types of trauma had occurred in the lives of the refugees. By not asking specifically about war or escape-related events or everyday trauma, the examiner could easily miss significant life experiences. Second, the psychiatrists may have become too accustomed to reports of massive trauma, such as that experienced by the Cambodians; this might (in fact, did) cause them to downplay the truly severe trauma of other refugee groups. Third, the process of the doctor-patient relationship in a cross-cultural situation may be a factor. Alt of our clinicians take an unhurried, unobtrusive clinical appnoach to diagnosis and treatment, as that is the expected process of all interpersonal relationships in Southeast Asian cultures. Moreover, trauma patients, regardless of culture, are particularly sensitive to the clinician’s probing of emotions and affects that they would prefer to avoid discussing. Therefore, a cautious, tentative, clinical and interpersonal style may inadvertently miss important diagnostic information. A final reason for missing a diagnosis was that key symptoms were not obvious, and patients themselves virtually never spontaneously reported them. Almost all had major depressive symptoms, but their voiced complaints were usually somatic: headaches, stomachaches, and poor steep. A sensitive interview usually revealed depressive symptoms and a depressed mood; this was followed by a diagnosis of major affective disorder, after which diagnostic procedures were prematurely discontinued. Without a reported history of trauma, the symptoms of PTSD were often never uncovered. Cleanly, sensitive interviewing by a psychiatrist experienced in both trauma and the treatment of refugees is necessary to make these major clinical diagnoses. A second major finding was the overwhelming vanety of traumas suffered by each ethnic group of Indochinese patients. The terrible events of the Pol Pot regime are well-documented. Clearly, PTSD should be a major diagnostic consideration among all Cambodian patients. The Vietnamese represent a more varied group. Despite the long and bitter military conflict in Vietnam and the well-known effects of the war on American combatants, there is little written of the effects on the civilian population. During almost 40 years of warfare, many, if not most, of the civilians were involved in its bloody and destructive effects. These effects seemed to be isolated incidents, but they left long-lasting impressions. The refugees’ descniptions of recovering family member’s bodies on the battlefield, of having houses blown apart with relatives stilt inside, of being held at gunpoint by Communists while their belongings were confiscated, and of fathers and brothers being marched off to unknown destinations cleanly are graphic examples of severe trauma. Even more distressing, perhaps, because of total helplessness, were the brutal attacks by pirates on the refugee boat people. Surprising among the Vietnamese were the high number of reports of trauma unrelated to war, particularly of severe wife abuse. These mci-
916
dents were often seen in arranged marriages that were established without love and lived without the possibility of separation or divorce. The problems of the Mien were revealing and tnoubling. These Laotian tnibespeople had often endured heavy fighting in their homelands and experienced threats from many sides, toss of life, frequent moves, and major disruption of their culture and economy. In addition, many patients had lost family members duning the bloody escape to a safe environment. Unsophisticated about Western ways, they often were unclear in presenting their symptoms and were suspicious of Western medicine. Among the Mein, symptoms of PTSD and depression are most frequently understood within an animist and supernatural belief system, so the concept of a Western physician being able to ameliorate these symptoms was initially foreign to them. Because so little information is available to Westerners about the cultural, military, and political events in the lives of the Mien, we have little knowledge of them. Diagnoses and treatment were very difficult, and an apparent unresponsiveness at the first interview often prevented us from taking a thorough history. Our lack of knowledge about the trauma also prevented us from clearly seeing the catastrophic stress. Of the 3 1 Laotian patients, 1 1 described a significant nonwan or escaperelated trauma. A significant clinical finding was the chronicity of the symptoms of PTSD. Most patients’ trauma had occurred 10 to 15 years before the current study. Howeven, only a few patients (6%) had recovered, i.e., had a past diagnosis, but no longer met the criteria for PTSD. Most patients continued to have symptoms, and those with a current diagnosis of PTSD reported no decrease in symptoms. lndeed, many patients had recently reported an increase in symptoms related to stressors experienced in the United States. These included accidents observed on experienced, exposure to crime, anniversary reactions, and a normal life change (children leaving home). We have previously reported on the chronic and sometimes episodic nature of PTSD in refugees (21, 28). At first we thought that the chronic symptoms among patients led to the high prevalence of PTSD among the clinic population. That is, those with PTSD stayed as patients and those without PTSD improved and were discharged. However, the proportion of patients with PTSD was about the same in the groups admitted after and before March 1988 (67% versus 77%). It appeared that PTSD was very common among the Indochinese patients, both new and established. Our data show demographic correlations in regard to the prevalence of PTSD in the Vietnamese and Laotian groups. Advanced age, female gender, and the diagnosis of depression correlated with a higher prevatence of the disorder in these groups. Further studies are needed to determine if these factors influence the development of PTSD. The diagnosis of PTSD has important clinical impli-
AmJPsychiatry
147:7,July
1990
KINZIE,
cations. It helps the clinician understand and empathize with the patient’s life and problems. It can unify an often confusing and changing symptom pattern characterized by affective instability and marked reactivity to minimal stress. For the patients, a review of the traumatic life experiences can help them understand their losses and reactions. Their responses can be placed in the context of a normal reaction to abnormal situations. They can move out of the “crazy patient” role into a survivor role, even if an impaired one. This is particularly important in Asian cultures, which place a great stigma on mental illness. The diagnosis results in a change in therapy. Unlike depression, which would be expected to improve after treatment, PTSD among refugees is a chronic disorder. Clinicians must plan for long-term treatment, with a slow response and frequent setbacks during times of stress. This understanding removes many pressures for a rapid cure, which in itself may provoke further PTSD symptoms. It also removes the threat of abandonment, which may occur in short-term therapies. The use of a combination of tnicyctic antidepressants and clonidine has been helpful in reducing intrusive symptoms as welt as depressive ones (26). After the diagnosis of PTSD was made among patients in our clinic, clonidine was added to their treatment. Almost universally, the patients reported a reduction in nightmares, irritability, and startle responses. It is difficult to separate these effects from those associated with a change in the focus of psychotherapy, but the addition of clonidine to an antidepressant is a potentially useful approach in treating this difficult problem. Studying the prevalence of PTSD in a clinical population does not answer the questions about its prevatence in the community sample at large, i.e., among all refugees. It is probable that those with severe symptoms or impairment have become patients. Clearly, further epidemiotogicat studies among refugees are indicated, including PTSD as a diagnostic consideration and the development of appropriate techniques to make this difficult diagnosis in cross-cultural groups. More and more, the traumas of Indochinese wars are becoming clear. Americans have slowly adjusted to the Vietnam wan veteran and his or hen problems. Now the civilian victims of that conflict are becoming evident as traumatized refugees. The Indochinese refugees have problems due not only to loss, displacement, and refugee status, but also to the effects of hornible, man-made traumas.
response
S.
4.
Am
Psychiatry
147:7,
July
5, O’Brien a natural
KF: Acute disaster.
New
J
DC,
posttraumatic Nerv Ment
Methods American
stress disorder Dis 1987; 175:
Gong-Guy E: California Assessment. Oakland, ices, California State
85-76282A-2,
Southeast Asian Mental Health Needs Asian Community Mental Health ServDepartment of Mental Health Contract
1985
Rumbaut RG: Mental health and the refugee experience: a comparative study of Southeast Asian refugees, in Southeast Asian Mental Health: Treatment, Prevention, Services, Training, and Research. Edited by Owan TC, Bliatot B, Lin K-M, et al. Rockville, Md, NIMH, 1985 8. Lin KM, Tozuma L, Masuda M: Adaptional problems of Vietnamese refugees. Arch Gen Psychiatry 1979; 36:955-961 9. Kinzie JD, Manson SM: Five years’ experience with Indochinese refugee patients. J Operational Psychiatry 1983; 14:105-111 10. Westermeyer J: DSM-III psychiatric disorders among Hmong refugees in the United States: a point prevalence study. Am J Psychiatry 1988; 145:197-202 I 1. Glassman JN: PTSD in refugees (letter). Am J Psychiatry 1988; 14:1486-1487 12. Kinzie JD, Fredrickson RH, Ben R, et al: Posttraumatic stress disorder among survivors of Cambodian concentration camps. Am J Psychiatry 1984; 141:645-650 13. Boehnlein JK, Kinzie JD, Ben R, et al: One-year follow-up study of posrtraumatic stress disorder among survivors of Cambodian concentration camps. Am J Psychiatry 1985; 142:956-959 14. Kleinman 5: Trauma and its ramifications in Vietnamese victims of piracy. Jefferson J Psychiatry 1987; 5:3-15 IS. Mollica RF: The trauma story: the psychiatric case of refugee survivors of violence and torture, in Post-Traumatic Therapy and Victims of Violence. Edited by Oehberg R. New York, Brunner/Mazel, 1988 16. Freimer N, Lu F, Chen J: Posttraumatic stress and conversion disorders in a Laotian refugee veteran: use of amobarbital interview. J Nerv Ment Dis 1989; 177:432-433 17. Mollica RF, Wyshak G, Lavelle J: The psychosocial impact of war trauma and torture on Southeast Asian refugees. Am J Psychiatry 1987; 144:1567-1572 18. Kinzie JD, Sack W, Angell R, et al: The psychiatric effects of massive trauma on Cambodian children, I: the children. J Am Acad Child Psychiatry 1986; 25:370-376 19. Cervantes RC, de Synder UNS, Padella AM: Posttraumatic stress in immigrants from Central America and Mexico. Hosp Community Psychiatry 1989; 40:6 15-6 19 20. Kinzie JD, Tran KA, Breckenridge A, et al: An indochinese refugee psychiatric clinic: culturally accepted treatment approaches. Am J Psychiatry 1980; 137:1429-1432 21.
22.
23.
Kinzie JD: The psychiatric effects of massive trauma on Cambodian refugees, in Human Adaptation to Extreme Stress: From the Holocaust to Vietnam. Edited by Wilson JP, Harel Z, Kahana B. New York, Plenum, 1988 Kinzie JD, Boehnlein JK: Post-traumatic psychosis among Cambodian refugees. J Traumatic Stress 1989; 2:185-198 Kinzie JD, Fleck J: Psychotherapy with severely traumatized refugees. Am J Psychother 1987; 41:82-94 Boehnlein JK: Culture and society in posttraumatic stress disorder: implications for psychotherapy. Am J Psychother 1987;
41:519-530
Helzer JE, Robin L, McEvoy C: Post-traumatic stress disorders in the general population. N EngI J Med 1987; 317:1630-1 634 Pitman RK, Altman B, MackIm ML: Prevalence of posttraumatic stress disorder in wounded Vietnam veterans. Am J Psychiatry 1989; 146:667-669 Speed N, Engdahl B, Schwartz J, et al: Post-traumatic stress disorder as a consequence of POW experience. J Nerv Ment Dis 1989; 177:147-153 Shore JH, Tatum EL, Volimer WM: The Mount St Helens stress
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of
Studies:
Washington,
ET AL.
7.
25.
3.
Madakasya in victims
Stress JH.
LEUNG,
286-290 6.
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2.
in Disaster
and Findings. Edited by Shore Psychiatric Press, 1986
24.
1.
syndrome,
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26.
Kinzie JD, Leung P, Bui A, et al: Group therapy with Southeast Asian refugees. Community Ment Health J 1988; 24:157-166 KinzieJD, Leung P: Clonidine in Cambodian patients with posttraumatic stress disorder. J Nerv Ment Dis 1989; 177:546-550
27.
Westermeyer
28.
chiatric 249 Kinzie
JD,
Cambodian Child
J, Wahmenholm
patient.
Adolesc
Hosp
Sack
W,
young
K: Assessing
Community Angell
people
Psychiatry
R, et aI:
1989;
A three-year
traumatized 1989;
the victimized
Psychiatry
as children.
psy-
40:245-
follow-up of J Am Acad
28:501-504
917
All
nese
322
patients
refugees
of posttraumatic
were
Kinzie,
J. Moore,
M.D., James K. Boehnlein, M.D., Paul K. Leung, M.D., M.D., Crystal Riley, M.A., and Debra Smith, M.D.
at a psychiatric
surveyed stress
clinic
to determine
disorder
(PTSD).
not diagnosed at the time of initial tured reinterview was performed.
for
Indochi-
the presence If PTSD
was
evaluation, a strucSeventy percent of
the patients (N=226) met the criteria for a current diagnosis ofPTSD, and an additional 5% (N= 15) met the criteria for a past diagnosis. The Mein had the highest rate of PTSD (93 %) and the Vietnamese the lowest (54%). Of the patients with PTSD who were enrolled in the clinic before March 1 988, 46% (N= 87) were given a diagnosis of PTSD only after the reinterview. PTSD is a common disorder among Indochinese refugees, but the diagnosis is often difficult to make. (Am J Psychiatry 1990; 147:913-917)
T
he prevalence of posttraumatic stress disorder (PTSD) among traumatized victims of war or other disasters lacked extensive study before 1980. However, since then, with the acceptance of DSM-III and operational definitions of PTSD, an increasing number of studies, particularly of war veterans, have been recorded. One study of Vietnam veterans found PTSD rates of about 3.5% among nonwounded vetenans and 20% among wounded veterans (1). Other studies found PTSD in 40% of wounded Vietnam vetenans (2) and in about 50% of the prisoners of war (3). Rates of PTSD after natural disasters have generally been lower; for example, PTSD was found in only 3.3% of women and 0.7% of men after the Mount St. Helens volcano eruption in Washington state in 1980 (4). However, one study after a tornado disaster found PTSD in 59% of the affected population (5). By cornpanison, in a study using epidemiological catchment area data, the rate of PTSD in the community population was only 1% (1). Data have been slowly accumulating about psychi-
Received Sept. 5, 1989; revision received Dec. 13, 1989; accepted Jan. 1 1, 1990. From the Department of Psychiatry, Oregon Health Sciences University. Address reprint requests to Dr. Kinzie, Department of Psychiatry, UHN-80, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97201-3098. Copyright © 1 990 American Psychiatric Association.
Am
J
Psychiatry
147:7,
July
Disorder and Its Asian Refugees
1990
atnic disorders among refugees, especially those from Southeast Asia. Epidemiological survey data by GongGuy (6), Rumbaut (7), and Lin et al. (8) have shown high levels of distress and psychiatric needs. Clinical studies of Indochinese refugees have shown that depression was the most prevalent disorder (9); but among the Hmong of Laos there was a high nate of undiagnosable psychiatric disorders (10), and no PTSD symptoms were reported (1 1). PTSD was first described among Cambodian concentration camp sunvivons (12, 13). Other clinical reports have described the effects of trauma on Vietnamese and Laotians (1416). Mottica et at. (17) reported a PTSD prevalence of 50% among a Southeast Asian patient population of multiple ethnic groups. In a nonpatient community sample, a PTSD prevalence of SO% was found among Cambodian adolescents (18). A similar rate was reported among immigrants from Central America in a study that used a self-report survey (19). The present report concerns the DSM-III-R diagnosis of PTSD among an entire Indochinese clinic population of 322 patients.
METHOD Since 1978 the Department of Psychiatry at Oregon Health Sciences University has operated a program for Southeast Asian refugee patients. During this time, the Indochinese psychiatric program has evaluated oven 700 patients and currently has about 320 in treatment. The clinic medical staff includes four faculty psychiatnists and one senior resident, in addition to three Southeast Asian mental health counselors and four counselor trainees. The clinic staff has attempted to provide a medically oriented, culturally acceptable treatment for Indochinese refugees (9, 20). The major psychiatric effects of massive trauma, some psychotic reactions, psychotherapeutic approaches including group therapy, and drug therapy among Cambodian patients in our clinic have been described elsewhere (2 1-26). In March 1988 we turned our attention to detenmining the prevalence of PTSD among the entire Indochinese clinic population, not just the Cambodians. Our
913
PTSD
AMONG
TABLE
1. Current
SOUTHEAST
ASIAN
REFUGEES
and Past Diagnoses
of PTSD in a Clinic Population Vietnamese
Patient
Group
Admitted before March 1988 (N=243)a Original interview Reinterview With DSM-III-R checklist Patients admitted after March 1, 1988 (N=79y’ Total aln
March
1988
the
clinic
92
beg
N
%
Total N
53
58
-
13
-
-
-
40
-
-
16 69
46 54
35 127 an giving
each
new
patient
19 110 a thorough
RESULTS Demographic data revealed that the majority of all patients in all groups were women (66%, N213). The Mien were the oldest group (average age=54 years), but the entire population tended to be middleaged. Alt groups had arrived in the United States, on the average, in 1982 and had been patients in the clinic for 2 to 4 years; these data indicate the chronic nature of the symptoms. Depression was the most common non-PTSD diagnosis (81%, N262); about 16% (N 52) had schizophrenia. Antisocial and alcohol abuse disorders were very uncommon diagnoses in the clinic population. Our Vietnamese clinic patients included some mdividuals who had come to the United States soon after the collapse of Vietnam in 1975, but most patients had
Laotian PTSD
Mien PTSD
PTSD
N
%
Total N
84
92
20
65
40
82
-
-
4
-
-
2
-
-
-
9
-
-
36
-
89 92
11 31
91
prior impression was that PTSD was uncommon among the Vietnamese, Laotian, and Mien (Laotian hilt people) patients in the clinic, since it was rarely diagnosed. To determine its prevalence, all psychiatnists in the clinic were asked to systematically reintenview their patients with respect to severe on unusual trauma and subsequent symptoms; the psychiatrists used a DSM-III-R checklist that optimized intenrater reliability and the specificity of the PTSD diagnosis. In addition, the onset of the symptoms and the subsequent course were determined. Alt psychiatrists, with the exception of the senior resident, had worked with Indochinese refugees for at least 4 years; the three senion counselors had worked with them for at least 10 years, and the junior counselors, for at least 2 years. Analysis of the reinterview data allowed a current on past diagnosis of PTSD, and the data permitted a fuller description of the trauma among the refugees and the duration of its effects. It also showed a breakdown of the trauma by ethnic group. By comparing the diagnoses of all the established patients in the clinic before March 1988 with patients’ diagnoses based on the new evaluation, we could determine if only those with PTSD stayed as patients or if PTSD was equally preyalent among all patients.
914
Asian Refugees
Cambodian PTSD
Total N
of Southeast
2
17 101 PTSD
eval uation
at the
N
13
8 21
tim e of original
%
Total N
N
%
38
95
73
14
12
86
68
54
50
93
assessment.
escaped as boat people in the late 1970s. Almost all of the Cambodians had lived in their homeland during the terrible Pot Pot years of 1975-1979, when there was widespread destruction of the culture and mass killing and death. The educational level of this group was low because of the singling out of leaders, teachens, businessmen, Buddhist monks, and intellectuals for execution. The Laotians represented a diversity of educational and social backgrounds. Most had gone to Thailand early after the fall of Laos and tended to have relatively fewer traumas related to war on their escape. The Mien, a highland tribe from Laos, originated as a minority group in China in the thirteenth century. Very few had a format education, and most had little prior experience with Western culture and technology. Their homeland was the location of constant but usually unreported fighting among the various Laotian factions and North Vietnamese. Their escape to Thailand usually had been very difficult. At one time Hmong tribesmen and their families had been more common in Oregon and as patients in the clinic, but because of out-of-state migration, very few remained. Table 1 presents the current and past prevalence of PTSD for each of the ethnic groups in the clinic, including the prevalence among patients admitted after March 1988. The tatter patients underwent a thorough evaluation for PTSD at the time of the original clinical assessment. Fifteen patients had a past diagnosis of PTSD but had improved to the point of no longer meeting the criteria. In other words, of the 241 patients who met the criteria for a lifetime diagnosis of PTSD, 94% (N226) stilt met the criteria. We compared patients with and without PTSD in the Vietnamese and Laotian groups. No such comparison is meaningful for the Cambodian and Mien groups because over 90% had PTSD. In both the Vietnamese and Laotian groups, women predominated among the PTSD patients, and all PTSD patients tended to be older than those without PTSD. PTSD was cleanly highly associated with depression and was infrequent among those with schizophrenia. The types of trauma endured by the refugee patients are shown in table 2. The trauma endured by the refugee patients stemmed from their experiences as Pot
Am
J
Psychiatry
147:7,
July
1990
KINZIE,
TABLE
2. Types of Trauma
Experienced
by 241
Southeast
Asian Refugees
BOEHNLEIN,
LEUNG,
ET
AL.
With PTSDa Total
Trauma Pol Pot concentration War-related trauma Civilian Combat Imprisonment Traumatic escape Trauma unrelated Total aThisix bSeven
Vietnamese
Cambodian
Laotian
Mien
N
0
101
0
0
101
0 0 0 0 0 101
9 1 2 4 11
25
27
64
camp
38 10 0 22 17 87
to war
patients experienced two or instances occurred in the United
more types States.
DISCUSSION
Am
J
most striking all Indochinese
Psychiatry
finding was the high rate of PTSD refugee patients in the clinic. To
I 47: 7, July
1990
72 12 4 55
36 26 4 1 20
35b
13
279’
100
of trauma.
Pot concentration camp internees (all Cambodians), war-related experiences either in combat on as civilians (Vietnamese, Laotian, and Mien), difficulties encountered during the escape from wan zones to refugee camps (Vietnamese, Laotian, and Mien), and trauma not related to war (before their arrival in the United States and sometimes preceding wan, in addition to trauma after their arrival in this country) (Vietnamese, Laotian, and Mien). The Pot Pot trauma occurred during the 4 years of the reign of terror in Cambodia. Separation of families, threats to life, forced labor, beatings, starvation, and the witnessing of deaths were common experiences of refugees. War-related traumas included bombings of villages and homes, witnessing deaths of family members, recovering the bodies of family members during the fighting, being direct targets of the soldiers of either side, with threats and the confiscation of property. Most of the patients in this group had experienced several of the types of traumas involved. Also included were 12 soldiers who had been in combat in Indochina and several who had been imprisoned under barbaric conditions after the fall of Vietnam. Among our patients it was primarily the Vietnamese boat people who had suffered multiple traumas during the escape from Vietnam. They were shot at and endured terrible treatment by pirates on the high seas or by the militia of other countries. Brutal robberies, rapes, murder, starvation, and even cannibalism were described. The Mien also suffered terribly during their escape, when they were the target of both local militia and armies. Trauma not specifically related to war included robbenies by gangs in Vietnam, severe and prolonged physical abuse of women by their husbands or employens, and, occasionally, rapes. A few described the source of their symptoms as trauma endured since their arrival in the United States.
Our among
1 2 29 7
%
our knowledge, these rates are the highest reported in the literature for any group-even higher than those found in prisoners of wan (3) and in our own community studies of Cambodian adolescents (18). These high rates were found not only among adult Cambodians in the clinic (which we had known before this study) but also, unexpectedly, among the Mien, the Vietnamese, and the Laotians (see table 1). Because these high rates were unexpected and were found as the result of intensive interviewing to estabtish the diagnosis, we reexamined the diagnostic process and the cross-cultural diagnosis of PTSD. The psychiatnists in our clinic had all worked with Indochinese patients for many years, taking histories of trauma. Nevertheless, about half of the diagnoses were made only after the reinterview of the established patients, alt of whom had been in treatment for 2 to 4 years. The evaluation of traumatic events is often difficult to make because the victims may not report these events spontaneously, despite their clinical relevance (17, 27). In a cross-cultural setting it is sometimes difficult to do thorough evaluations because shame, toss of face, and psychic numbing add complexities to the task. Therefore, our systematic evaluation of trauma became necessary and gave us some surprising findings. We realized that in previous interviews, the patients had often minimized or completely ignored their past trauma, possibly because of shame or guilt (especially in nape cases), on more likely because they felt uncomfortable about discussing difficult life events with an American psychiatrist. For many patients, the continual experience of living in a war zone over several generations, together with cultural and religious belief systems that contributed to a rather fatalistic view of traumatic life events, may also have ted to the underreporting of symptoms. The disabling symptoms may not have been viewed by patients as a “problem” but merely as additional inconveniences in an already difficult life. Our patients’ stoicism and minimal outward emotional expression contributed to the undendiagnosis. However, factors involved in the psychiatrist’s style of interviewing could also account for the difficulty in making an accurate diagnosis. One factor may have been simply not asking about the trauma that the patients had endured.
915
PTSD
AMONG
SOUTHEAST
ASIAN
REFUGEES
As is clear from our data, many different types of trauma had occurred in the lives of the refugees. By not asking specifically about war or escape-related events or everyday trauma, the examiner could easily miss significant life experiences. Second, the psychiatrists may have become too accustomed to reports of massive trauma, such as that experienced by the Cambodians; this might (in fact, did) cause them to downplay the truly severe trauma of other refugee groups. Third, the process of the doctor-patient relationship in a cross-cultural situation may be a factor. Alt of our clinicians take an unhurried, unobtrusive clinical appnoach to diagnosis and treatment, as that is the expected process of all interpersonal relationships in Southeast Asian cultures. Moreover, trauma patients, regardless of culture, are particularly sensitive to the clinician’s probing of emotions and affects that they would prefer to avoid discussing. Therefore, a cautious, tentative, clinical and interpersonal style may inadvertently miss important diagnostic information. A final reason for missing a diagnosis was that key symptoms were not obvious, and patients themselves virtually never spontaneously reported them. Almost all had major depressive symptoms, but their voiced complaints were usually somatic: headaches, stomachaches, and poor steep. A sensitive interview usually revealed depressive symptoms and a depressed mood; this was followed by a diagnosis of major affective disorder, after which diagnostic procedures were prematurely discontinued. Without a reported history of trauma, the symptoms of PTSD were often never uncovered. Cleanly, sensitive interviewing by a psychiatrist experienced in both trauma and the treatment of refugees is necessary to make these major clinical diagnoses. A second major finding was the overwhelming vanety of traumas suffered by each ethnic group of Indochinese patients. The terrible events of the Pol Pot regime are well-documented. Clearly, PTSD should be a major diagnostic consideration among all Cambodian patients. The Vietnamese represent a more varied group. Despite the long and bitter military conflict in Vietnam and the well-known effects of the war on American combatants, there is little written of the effects on the civilian population. During almost 40 years of warfare, many, if not most, of the civilians were involved in its bloody and destructive effects. These effects seemed to be isolated incidents, but they left long-lasting impressions. The refugees’ descniptions of recovering family member’s bodies on the battlefield, of having houses blown apart with relatives stilt inside, of being held at gunpoint by Communists while their belongings were confiscated, and of fathers and brothers being marched off to unknown destinations cleanly are graphic examples of severe trauma. Even more distressing, perhaps, because of total helplessness, were the brutal attacks by pirates on the refugee boat people. Surprising among the Vietnamese were the high number of reports of trauma unrelated to war, particularly of severe wife abuse. These mci-
916
dents were often seen in arranged marriages that were established without love and lived without the possibility of separation or divorce. The problems of the Mien were revealing and tnoubling. These Laotian tnibespeople had often endured heavy fighting in their homelands and experienced threats from many sides, toss of life, frequent moves, and major disruption of their culture and economy. In addition, many patients had lost family members duning the bloody escape to a safe environment. Unsophisticated about Western ways, they often were unclear in presenting their symptoms and were suspicious of Western medicine. Among the Mein, symptoms of PTSD and depression are most frequently understood within an animist and supernatural belief system, so the concept of a Western physician being able to ameliorate these symptoms was initially foreign to them. Because so little information is available to Westerners about the cultural, military, and political events in the lives of the Mien, we have little knowledge of them. Diagnoses and treatment were very difficult, and an apparent unresponsiveness at the first interview often prevented us from taking a thorough history. Our lack of knowledge about the trauma also prevented us from clearly seeing the catastrophic stress. Of the 3 1 Laotian patients, 1 1 described a significant nonwan or escaperelated trauma. A significant clinical finding was the chronicity of the symptoms of PTSD. Most patients’ trauma had occurred 10 to 15 years before the current study. Howeven, only a few patients (6%) had recovered, i.e., had a past diagnosis, but no longer met the criteria for PTSD. Most patients continued to have symptoms, and those with a current diagnosis of PTSD reported no decrease in symptoms. lndeed, many patients had recently reported an increase in symptoms related to stressors experienced in the United States. These included accidents observed on experienced, exposure to crime, anniversary reactions, and a normal life change (children leaving home). We have previously reported on the chronic and sometimes episodic nature of PTSD in refugees (21, 28). At first we thought that the chronic symptoms among patients led to the high prevalence of PTSD among the clinic population. That is, those with PTSD stayed as patients and those without PTSD improved and were discharged. However, the proportion of patients with PTSD was about the same in the groups admitted after and before March 1988 (67% versus 77%). It appeared that PTSD was very common among the Indochinese patients, both new and established. Our data show demographic correlations in regard to the prevalence of PTSD in the Vietnamese and Laotian groups. Advanced age, female gender, and the diagnosis of depression correlated with a higher prevatence of the disorder in these groups. Further studies are needed to determine if these factors influence the development of PTSD. The diagnosis of PTSD has important clinical impli-
AmJPsychiatry
147:7,July
1990
KINZIE,
cations. It helps the clinician understand and empathize with the patient’s life and problems. It can unify an often confusing and changing symptom pattern characterized by affective instability and marked reactivity to minimal stress. For the patients, a review of the traumatic life experiences can help them understand their losses and reactions. Their responses can be placed in the context of a normal reaction to abnormal situations. They can move out of the “crazy patient” role into a survivor role, even if an impaired one. This is particularly important in Asian cultures, which place a great stigma on mental illness. The diagnosis results in a change in therapy. Unlike depression, which would be expected to improve after treatment, PTSD among refugees is a chronic disorder. Clinicians must plan for long-term treatment, with a slow response and frequent setbacks during times of stress. This understanding removes many pressures for a rapid cure, which in itself may provoke further PTSD symptoms. It also removes the threat of abandonment, which may occur in short-term therapies. The use of a combination of tnicyctic antidepressants and clonidine has been helpful in reducing intrusive symptoms as welt as depressive ones (26). After the diagnosis of PTSD was made among patients in our clinic, clonidine was added to their treatment. Almost universally, the patients reported a reduction in nightmares, irritability, and startle responses. It is difficult to separate these effects from those associated with a change in the focus of psychotherapy, but the addition of clonidine to an antidepressant is a potentially useful approach in treating this difficult problem. Studying the prevalence of PTSD in a clinical population does not answer the questions about its prevatence in the community sample at large, i.e., among all refugees. It is probable that those with severe symptoms or impairment have become patients. Clearly, further epidemiotogicat studies among refugees are indicated, including PTSD as a diagnostic consideration and the development of appropriate techniques to make this difficult diagnosis in cross-cultural groups. More and more, the traumas of Indochinese wars are becoming clear. Americans have slowly adjusted to the Vietnam wan veteran and his or hen problems. Now the civilian victims of that conflict are becoming evident as traumatized refugees. The Indochinese refugees have problems due not only to loss, displacement, and refugee status, but also to the effects of hornible, man-made traumas.
response
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Psychiatry
147:7,
July
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