Trauma
Experiences, and
Depression
Eve Bernstein
Objective: toms
Posttraumatic
The
in Cambodian
Carison,
authors’
in a randomly
goal
selected
Ph.D.,
was
group
between the amount of trauma Data on traumatic experiences sion, and anxiety were collected
and Rhonda
to determine
scores These patients amount (Am
could
be classified
and symptom results indicate
J
from
clinical
in part, at the Sixth International Conference on Multiand Dissociative States, Chicago, 1 989. Received Aug. 2, 1 990; revision received March 1 9, 1 991; accepted April 29, 1991. From the Department of Psychology, Beloit College, and the Department of Counselor Education, University of North Carolina at Greensboro. Address reprint requests to Dr. Carlson, Department of
of measures Copyright
1548
Beloit
thank
College,
Sokhom
and interpreting © 1991
of trauma and
and
Ph.D.
psychiatric
to determine
multiple (86%) had high
American
700
College
Oum during
and
St.,
Beloit,
Nan
WI
Khoun
interviews.
Psychiatric
the
depression.
Association.
3511.
for translation
symp-
relationship Method: depreshad reset-
and severe traumas and of the subjects met DSMdissociation scores, and 40
Correlations
between
trauma
to large. Conclusions: who are not psychiatric
suffer from severe psychiatric symptoms and that there is a relationship of trauma they experienced and the severity of these symptoms. Psychiatry 1991; 148:148-11)
Presented, pie Personality
authors
levels
and among symptom scores were moderate a high proportion of Cambodian refugees
he experience of psychological trauma has long been thought to cause particular psychological symptoms (1). Van den Kolk (2) described the human response to overwhelming and uncontrollable life events as “remarkably consistent” (p. 2). Symptoms of anxiety, depression, and dissociation have been observed in groups such as war veterans, victims of natural disasters, and assault victims, and a cluster of anxiety symptoms has been identified that makes up the syndrome of posttraumatic stress disorder (PTSD). Cambodian refugees are among the groups who have experienced severe psychological trauma. They were survivors of a holocaust in which an estimated one to three million of a population of seven million Cambodians were killed (3). Cambodians who were not killed were removed from their homes and forced to work in labor camps. Most of those who were able to avoid on escape from the labor camps traveled on foot to Thailand to reach refugee camps. These treks were charactenized by extreme fear, danger, and deprivation. Life in Thai refugee camps was arduous, and there was con-
The
Refugees Rosser-Hogan,
refugees
experienced Forty-three 48 (96%)
T
Psychology,
Dissociation,
experienced and subsequent psychiatric symptoms. and symptoms of posttraumatic stress, dissociation, on 50 randomly selected Cambodian refugees who
as suffering
scores that
the
of Cambodian
tied in the United States. Results: Subjects showed high levels of all symptoms measured. III-R criteria for posttraumatic stress disorder, (80%)
Stress,
between
the
stant fear of disease and starvation. Cambodian refugees experienced severe traumas such as the death of spouses, children, relatives, and friends; witnessing the death and torture of others; being subject to severe physical and sexual violence; being forced to leave their homes; and losing all their possessions (3-5). Several studies have found that Cambodian refugees have experienced even more trauma than other Southeast Asian refugee groups (5, 6). Many studies have examined psychiatric symptoms in groups of Southeast Asian refugees who were psychiatnic patients. Several researchers have reported high levels of depression in Southeast Asian refugee patients (3, 5-7). Very high rates of PTSD have also been meported in groups of refugees who were psychiatric patients (3, 6-8). For example, in a group of 52 psychiatnc patients who were Southeast Asian refugees, 71 % met DSM-III criteria for a diagnosis of major affective disorder and 50% met DSM-III criteria for PTSD (6). Research is beginning to explore the relationship between traumatic experiences and psychiatric symptoms in refugee groups. In a recent study of several Southeast Asian refugee groups, Knoll et al. (7) found that widows and those who had had traumatic experiences had more psychiatric symptoms than others (7). Similarly, Mo!lica et a!. (6) found that refugee patients with PTSD reported having twice as many traumatic experiences as those without PTSD. Several authors (6, 8, 9) have commented on the importance of studying the prevalence of posttraumatic psychiatric symptoms in nonpatient groups of South-
Am
J Psychiatry
148:1
1, November
1991
EVE
east Asian refugees. Studies have shown high rates of posttnaumatic symptoms in nonpatient groups of refugees as well. In a study of Hmong refugees, Westermeyer et al. (10) found that 63% reported having mental or emotional problems since their arrival in the United States. This subgroup had significantly higher scones on every subscale of the SCL-90 than did Hmong refugees who did not report mental on emotional problems. In a study of 1,684 Southeast Asian refugees in California (5), more than 50% had high scones on two or more of four scales measuring anxiety, depression, difficulties in functioning due to emotional or nervous problems, and trouble with memory. Another largescale study of several Southeast Asian refugee groups (N=2,775) (9) found that 10% met criteria for PTSD. Clearly, a substantial proportion of refugees who have not sought psychiatric treatment have considerable psychological difficulties. The present study was undertaken to explore a numben of questions not yet addressed in a single study. We were interested in the amount of trauma experienced by Cambodian refugees who are not psychiatric patients and the severity of their psychiatric symptoms, particularly symptoms of PTSD and dissociation. In addition, we sought evidence that dissociation and PTSD symptoms are universal (cross-cultural) responses to trauma. We were also interested in the relationship between the amount of trauma experienced and subsequent psychiatnic symptoms. Finally, we wanted to examine the relationships among different types of symptoms in this traumatized group. We anticipated that the greaten range of trauma and symptoms shown by a nonpatient group (compared with a patient group) would make statistical analyses more meaningful.
METHOD Fifty adult subjects from a group of approximately 500 Cambodian refugees who had settled in Greensbono, N.C., between 1983 and 1985 participated in the study. Names of subjects were randomly selected from a list of all refugees resettled by a nonprofit social senvices agency. All came from mural areas and had no forma! education. Twenty-six subjects were women and 24 subjects were men. Subjects ranged in age from 21 to 65 years with a mean±SD age of 42± 10. Forty-nine subjects had never received any professional mental health care. All subjects participated voluntarily and gave fully informed consent. Data collection was accomplished during interviews in subjects’ homes by one of us (R.R-H.) with the help of a native Cambodian translator, both of whom were known and trusted by all subjects because they had worked with the nonprofit social services agency to nesettle the refugees when they first came to the area. Because most of the subjects were illiterate in their native language, all questions were read and reread to them in Cambodian. Data on experiences of trauma were collected by us-
AmJ
Psychiatry
148:11,
November
1991
BERNSTEIN
CARLSON
AND
RHONDA
ROSSER-HOGAN
ing the Post-Traumatic Inventory (5). This 23-item questionnaire in Cambodian has a dichotomous (yes/no) answer format and was designed to inquire about the particular kinds of traumatic experiences reported by Southeast Asian refugees. (Examples of items are provided in the Results section.) Two questions were not asked of the subjects because the answers were the same for all: all were known to have lost all personal property and all had spent 1 year on more in a refugee camp. A PTSD Checklist based on DSM-III-R diagnostic criteria for PTSD was created. For each symptom, subjects were asked to answer (yes or no) whether the symptom had happened to them recently. Five criteria were not included in the checklist because they were considered inappropriate to this group. Because of these omissions, the number of symptoms required to meet the criteria in the category of avoidance, detachment, and numbing was changed from three (out of seven) to two (out of three). Test-retest reliability of r=0.85 (p
Experiences, and
Depression
Eve Bernstein
Objective: toms
Posttraumatic
The
in Cambodian
Carison,
authors’
in a randomly
goal
selected
Ph.D.,
was
group
between the amount of trauma Data on traumatic experiences sion, and anxiety were collected
and Rhonda
to determine
scores These patients amount (Am
could
be classified
and symptom results indicate
J
from
clinical
in part, at the Sixth International Conference on Multiand Dissociative States, Chicago, 1 989. Received Aug. 2, 1 990; revision received March 1 9, 1 991; accepted April 29, 1991. From the Department of Psychology, Beloit College, and the Department of Counselor Education, University of North Carolina at Greensboro. Address reprint requests to Dr. Carlson, Department of
of measures Copyright
1548
Beloit
thank
College,
Sokhom
and interpreting © 1991
of trauma and
and
Ph.D.
psychiatric
to determine
multiple (86%) had high
American
700
College
Oum during
and
St.,
Beloit,
Nan
WI
Khoun
interviews.
Psychiatric
the
depression.
Association.
3511.
for translation
symp-
relationship Method: depreshad reset-
and severe traumas and of the subjects met DSMdissociation scores, and 40
Correlations
between
trauma
to large. Conclusions: who are not psychiatric
suffer from severe psychiatric symptoms and that there is a relationship of trauma they experienced and the severity of these symptoms. Psychiatry 1991; 148:148-11)
Presented, pie Personality
authors
levels
and among symptom scores were moderate a high proportion of Cambodian refugees
he experience of psychological trauma has long been thought to cause particular psychological symptoms (1). Van den Kolk (2) described the human response to overwhelming and uncontrollable life events as “remarkably consistent” (p. 2). Symptoms of anxiety, depression, and dissociation have been observed in groups such as war veterans, victims of natural disasters, and assault victims, and a cluster of anxiety symptoms has been identified that makes up the syndrome of posttraumatic stress disorder (PTSD). Cambodian refugees are among the groups who have experienced severe psychological trauma. They were survivors of a holocaust in which an estimated one to three million of a population of seven million Cambodians were killed (3). Cambodians who were not killed were removed from their homes and forced to work in labor camps. Most of those who were able to avoid on escape from the labor camps traveled on foot to Thailand to reach refugee camps. These treks were charactenized by extreme fear, danger, and deprivation. Life in Thai refugee camps was arduous, and there was con-
The
Refugees Rosser-Hogan,
refugees
experienced Forty-three 48 (96%)
T
Psychology,
Dissociation,
experienced and subsequent psychiatric symptoms. and symptoms of posttraumatic stress, dissociation, on 50 randomly selected Cambodian refugees who
as suffering
scores that
the
of Cambodian
tied in the United States. Results: Subjects showed high levels of all symptoms measured. III-R criteria for posttraumatic stress disorder, (80%)
Stress,
between
the
stant fear of disease and starvation. Cambodian refugees experienced severe traumas such as the death of spouses, children, relatives, and friends; witnessing the death and torture of others; being subject to severe physical and sexual violence; being forced to leave their homes; and losing all their possessions (3-5). Several studies have found that Cambodian refugees have experienced even more trauma than other Southeast Asian refugee groups (5, 6). Many studies have examined psychiatric symptoms in groups of Southeast Asian refugees who were psychiatnic patients. Several researchers have reported high levels of depression in Southeast Asian refugee patients (3, 5-7). Very high rates of PTSD have also been meported in groups of refugees who were psychiatric patients (3, 6-8). For example, in a group of 52 psychiatnc patients who were Southeast Asian refugees, 71 % met DSM-III criteria for a diagnosis of major affective disorder and 50% met DSM-III criteria for PTSD (6). Research is beginning to explore the relationship between traumatic experiences and psychiatric symptoms in refugee groups. In a recent study of several Southeast Asian refugee groups, Knoll et al. (7) found that widows and those who had had traumatic experiences had more psychiatric symptoms than others (7). Similarly, Mo!lica et a!. (6) found that refugee patients with PTSD reported having twice as many traumatic experiences as those without PTSD. Several authors (6, 8, 9) have commented on the importance of studying the prevalence of posttraumatic psychiatric symptoms in nonpatient groups of South-
Am
J Psychiatry
148:1
1, November
1991
EVE
east Asian refugees. Studies have shown high rates of posttnaumatic symptoms in nonpatient groups of refugees as well. In a study of Hmong refugees, Westermeyer et al. (10) found that 63% reported having mental or emotional problems since their arrival in the United States. This subgroup had significantly higher scones on every subscale of the SCL-90 than did Hmong refugees who did not report mental on emotional problems. In a study of 1,684 Southeast Asian refugees in California (5), more than 50% had high scones on two or more of four scales measuring anxiety, depression, difficulties in functioning due to emotional or nervous problems, and trouble with memory. Another largescale study of several Southeast Asian refugee groups (N=2,775) (9) found that 10% met criteria for PTSD. Clearly, a substantial proportion of refugees who have not sought psychiatric treatment have considerable psychological difficulties. The present study was undertaken to explore a numben of questions not yet addressed in a single study. We were interested in the amount of trauma experienced by Cambodian refugees who are not psychiatric patients and the severity of their psychiatric symptoms, particularly symptoms of PTSD and dissociation. In addition, we sought evidence that dissociation and PTSD symptoms are universal (cross-cultural) responses to trauma. We were also interested in the relationship between the amount of trauma experienced and subsequent psychiatnic symptoms. Finally, we wanted to examine the relationships among different types of symptoms in this traumatized group. We anticipated that the greaten range of trauma and symptoms shown by a nonpatient group (compared with a patient group) would make statistical analyses more meaningful.
METHOD Fifty adult subjects from a group of approximately 500 Cambodian refugees who had settled in Greensbono, N.C., between 1983 and 1985 participated in the study. Names of subjects were randomly selected from a list of all refugees resettled by a nonprofit social senvices agency. All came from mural areas and had no forma! education. Twenty-six subjects were women and 24 subjects were men. Subjects ranged in age from 21 to 65 years with a mean±SD age of 42± 10. Forty-nine subjects had never received any professional mental health care. All subjects participated voluntarily and gave fully informed consent. Data collection was accomplished during interviews in subjects’ homes by one of us (R.R-H.) with the help of a native Cambodian translator, both of whom were known and trusted by all subjects because they had worked with the nonprofit social services agency to nesettle the refugees when they first came to the area. Because most of the subjects were illiterate in their native language, all questions were read and reread to them in Cambodian. Data on experiences of trauma were collected by us-
AmJ
Psychiatry
148:11,
November
1991
BERNSTEIN
CARLSON
AND
RHONDA
ROSSER-HOGAN
ing the Post-Traumatic Inventory (5). This 23-item questionnaire in Cambodian has a dichotomous (yes/no) answer format and was designed to inquire about the particular kinds of traumatic experiences reported by Southeast Asian refugees. (Examples of items are provided in the Results section.) Two questions were not asked of the subjects because the answers were the same for all: all were known to have lost all personal property and all had spent 1 year on more in a refugee camp. A PTSD Checklist based on DSM-III-R diagnostic criteria for PTSD was created. For each symptom, subjects were asked to answer (yes or no) whether the symptom had happened to them recently. Five criteria were not included in the checklist because they were considered inappropriate to this group. Because of these omissions, the number of symptoms required to meet the criteria in the category of avoidance, detachment, and numbing was changed from three (out of seven) to two (out of three). Test-retest reliability of r=0.85 (p
