Publications by authors named "Devon E Hinton"

82 Publications

Auditory Hallucination Among Traumatized Cambodian Refugees: PTSD Association and Biocultural Shaping.

Authors:
Devon E Hinton

Cult Med Psychiatry 2021 Jan 1. Epub 2021 Jan 1.

Massachusetts General Hospital, Harvard Medical School, Center for Anxiety and Traumatic Stress Disorders, One Bowdoin Square, 6th Floor, Boston, MA, 02114, USA.

At a psychiatric refugee clinic for survivors of the Khmer Rouge genocide, a survey revealed that 42% (38/90) had auditory hallucinations (AHs) in the last month. Of those with AHs, 87% (33/38) had PTSD, whereas of those without AHs, 31% (16/52) had PTSD, giving a chi square of 27.8, p < .001, odds ratio 14.8 (4.8-45). Most AHs were of a "ghost summoning" (khmaoch hao), considered an exhortation to go with a ghost (e.g., hearing "Please come with me, younger sister"), experienced by 73% percent of patients with AHs. The voices were always exterior and usually loud and clear. AHs were heard most often during hypnagogia (i.e., upon falling asleep or awakening), experienced by 72% of patients with AHs, whereas 42% of patients with AHs experienced AHs when fully awake. AHs were almost always attributed to a ghost, giving rise to great fear: of having the "soul" called away or of being frightened to death. AH episodes almost always triggered trauma recall. AHs caused patients to undertake certain actions to address acute episodes and to prevent further ones. To illustrate these processes, cases are provided. AH appears to be a key part of the Cambodian bioculturally shaped trauma subjectivity.
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http://dx.doi.org/10.1007/s11013-020-09701-6DOI Listing
January 2021

Prevalence and Clinical Picture of Sleep Paralysis in a Polish Student Sample.

Int J Environ Res Public Health 2020 05 18;17(10). Epub 2020 May 18.

Behavioural and Clinical Neuroscience Institute and Department of Psychiatry, University of Cambridge, Cambridge, CB2 0QQ, UK.

Sleep paralysis (SP) is a psychobiological phenomenon caused by temporary desynchrony in the architecture of rapid eye movement (REM) sleep. It affects approximately 7.6% of the general population during their lifetime. The aim of this study was to assess (1) the prevalence of SP among Polish students in Lublin ( = 439) using self-reported online surveys, (2) the frequency of SP-related somatic and psychopathologic symptoms, and (3) the factors potentially affecting the occurrence of symptoms among people experiencing SP. We found that the incidence of SP in the Polish student population was slightly higher (32%) than the average prevalence found in other student populations (28.3%). The SP clinical picture was dominated by somatic symptomatology: 94% of respondents reported somatic symptoms (most commonly tachycardia, 76%), 93% reported fear (most commonly fear of death, 46%), and 66% reported hallucinations (most commonly visual hallucinations, 37%). The number of SP episodes was related to sleep duration and supine position during sleep. The severity of somatic symptoms correlated with lifestyle variables and anxiety symptomatology. Our study shows that a significant proportion of students experience recurrent SP and that this phenomenon is associated with fear and physical discomfort. The scale of the phenomenon requires a deeper analysis.
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http://dx.doi.org/10.3390/ijerph17103529DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7277803PMC
May 2020

Sleep paralysis in Italy: Frequency, hallucinatory experiences, and other features.

Transcult Psychiatry 2020 Mar 31:1363461520909609. Epub 2020 Mar 31.

Harvard Medical School.

Previous research has found supernatural beliefs about sleep paralysis (SP) to be very prevalent in Italy, with over one third of SP sufferers believing that their SP might have been caused by a supernatural creature known locally as the . The current study further examined features of SP in Italy. All participants had experienced SP at least once in their lifetime. Participants were recruited from the general population ( 67) in the region of Abruzzo. The Sleep Paralysis Experiences and Phenomenology Questionnaire (SP-EPQ) was orally administered to participants. As hypothesized, we found that Italians from the general population reported high lifetime rates of SP, prolonged duration of immobility during the event, and great fear of the experience (with as many as 42% of SP sufferers fearing that they could die from the experience), all of which were particularly elevated as compared to cultures where there are no such elaborate traditions of SP (e.g., Denmark). In addition, 78% of participants experienced some type of hallucination during their SP. The results we present here suggest that cultural beliefs about SP in Italy (e.g., as being caused by the , as reported elsewhere) potentially can profoundly shape certain aspects of the experience - a type of mind-body interaction.
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http://dx.doi.org/10.1177/1363461520909609DOI Listing
March 2020

Beliefs about sleep paralysis in Turkey: attack.

Transcult Psychiatry 2020 Mar 29:1363461520909616. Epub 2020 Mar 29.

Massachusetts General Hospital, Harvard Medical School.

The present study examined explanations of sleep paralysis (SP) in Turkey. The participants were 59 college students recruited in İstanbul, Turkey, who had experienced SP at least once in their lifetime. Participants were administered the Sleep Paralysis Experiences and Phenomenology Questionnaire (SP-EPQ) in an interview. When asked whether they had heard of a name for SP, the vast majority (88%) mentioned the ""-a spirit-like creature rooted in Turkish folk tradition. Seventeen percent of the participants believed that their SP might have been caused by this supernatural creature. Thirty-seven percent of participants applied various supernatural and religious methods to prevent future SP attacks such as (supplicating to God), reciting the Quran, and wearing a (a type of talisman inscribed with Quranic verses). Case studies are presented to illustrate these findings. The constitutes a culturally specific, supernatural interpretation of the phenomenology of SP in Turkey.
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http://dx.doi.org/10.1177/1363461520909616DOI Listing
March 2020

Key expressions of trauma-related distress in Cambodian children: A step toward culturally sensitive trauma assessment and intervention.

Transcult Psychiatry 2020 Mar 16:1363461520906008. Epub 2020 Mar 16.

Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.

More than half of all children in Cambodia experience direct abuse and over 70% experience other traumatic events, which significantly increase their risks for a range of physical and mental health problems. Additionally, Cambodian children face longstanding sociopolitical, intergenerational, and cultural factors that compound the impact of other trauma. As a result, rates of posttraumatic stress symptoms among Cambodian youth are high. However, care providers often rely on Western-based nosology that does not account for culturally specific expressions of trauma. A greater understanding of culturally-salient expressions of distress can help inform diagnostic assessment accuracy and treatment effectiveness and monitoring. The current study utilized a qualitative design to interview 30 Cambodian caregivers of children with trauma experiences and 30 Cambodian children (ages 10-13 years) with trauma experiences to identify key local expressions of trauma. Findings reveal certain PTSD symptoms and culturally-specific frequent and severe trauma-related problems for Cambodian children and domains of functioning impacted by trauma. Certain symptoms seem particularly important to evaluate in this group, such as anger, physical complaints (e.g., headache and palpitations), and cognitive-focused complaints (in particular, "thinking too much"). All caregivers and children reported physical health as impacted by trauma-related problems, highlighting a particularly salient domain of functioning for this population. Expressions of distress explored in the current study are discussed in the context of assessment and intervention development to inform diagnostic and clinical efforts for those working with trauma-exposed Cambodian children.
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http://dx.doi.org/10.1177/1363461520906008DOI Listing
March 2020

A network analysis of culturally relevant anxiety sensitivity and posttraumatic stress disorder symptoms in Cambodians.

Transcult Psychiatry 2020 Mar 8:1363461520906005. Epub 2020 Mar 8.

University of Washington.

The Anxiety Sensitivity Index (ASI) measures fears of anxiety-related symptoms based on respondent beliefs about their harmfulness. This is the first network analysis of anxiety sensitivity and PTSD, and the first to explore an addendum of culturally salient fears in such an analysis. The purpose of our study was to test whether relations among PTSD symptoms and facets of anxiety sensitivity, observed clinically, can be visualized by this approach. Using network analysis, we examined in a Cambodian population the relationship of PTSD symptoms to the standard Anxiety Sensitivity Index (ASI) and to an ASI Cambodian Addendum (ASICA) that taps culturally salient fears of somatic symptoms among Cambodians not assessed in the standard ASI. Computing relative importance networks, we found that the ASI subscales, ASICA, and PTSD subscales were strongly interconnected, with the ASICA having the strongest outstrength centrality. In the network analysis of the ASI subscales, disaggregated ASICA, and PTSD subscales, several of the ASICA items had very high outstrength. The results show that fear of mental and physical symptoms of anxiety should be a key part of the evaluation of trauma-related disorder, and that those fears should be targeted. It also suggests the need for ASI addenda to assess concerns about anxiety symptoms salient for certain cultures that are not assessed by the standard ASI: among Cambodian populations, fear of cold hands and feet, "out of energy in the arms and legs," neck soreness, tinnitus, and dizziness on standing.
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http://dx.doi.org/10.1177/1363461520906005DOI Listing
March 2020

Local clinician perspectives on cause, impact, and treatment of key expressions of distress in Cambodian children.

Transcult Psychiatry 2020 Mar 1:1363461520905995. Epub 2020 Mar 1.

Harvard University.

Child trauma and posttraumatic stress in Cambodia is highly prevalent, perpetuated within a postwar sociocultural context. The examination of locally meaningful expressions of distress is needed to provide culturally sensitive assessment and treatment of trauma-affected Cambodian children. The acceptable, feasible, and sustainable incorporation of expressions of distress into assessment and intervention development relies on key mental health professionals operating in Cambodia, who can provide invaluable perspectives on child trauma experiences in this particular sociocultural context. In this study, qualitative interviews were conducted with 15 Cambodian mental health professionals (MHPs) who work directly with trauma-affected Cambodian children. MHPs were presented with seven key posttraumatic problems derived from previous qualitative interviews with Cambodian children and caregivers, and discussed 1) the causes of these problems, 2) the impact of the problem on the child or those around them, 3) the current treatment for the problem in Cambodia, and 4) recommended treatment. MHPs provided unique insights and perspectives of trauma-affected children in the Cambodian context regarding key target problems, including palpitations, difficulties in school, headache, and thinking too much, and highlighted future directions for assessment and intervention. Recommendations are discussed in regard to programming design and organizational training development to promote culturally salient, feasible, and sustainable mental health service provision in Cambodia.
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http://dx.doi.org/10.1177/1363461520905995DOI Listing
March 2020

Ghost Encounters Among Traumatized Cambodian Refugees: Severity, Relationship to PTSD, and Phenomenology.

Cult Med Psychiatry 2020 Sep;44(3):333-359

Center for Anxiety and Related Disorders, Boston University, Boston, USA.

Ghost encounters were found to be a key part of the trauma ontology among Cambodian refugees at a psychiatric clinic, a key idiom of distress. Fifty-four percent of patients had been bothered by ghost encounters in the last month. The severity of being bothered by ghosts in the last month was highly correlated to PTSD severity (r = .8), and among patients bothered by ghosts in the last month, 85.2% had PTSD, versus among those not so bothered, 15.4%, odds ratio of 31.8 (95% confidence level 11.3-89.3), Chi square = 55.0, p < .001. Ghost visitations occurred in multiple experiential modalities that could be classified into three states of consciousness: full sleep (viz., in dream), hypnagogia, that is, upon falling asleep or awakening (viz., in sleep paralysis [SP] and in non-SP hallucinations), and full waking (viz., in hallucinations, visual aura, somatic sensations [chills or goosebumps], and leg cramps). These ghost visitations gave rise to multiple concerns-for example, of being frightened to death or of having the soul called away-as part of an elaborate cosmology. Several heuristic models are presented including a biocultural model of the interaction of trauma and ghost visitation. An extended case illustrates the article's findings.
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http://dx.doi.org/10.1007/s11013-019-09661-6DOI Listing
September 2020

Dimensions of culturally sensitive CBT: Application to Southeast Asian populations.

Am J Orthopsychiatry 2019 ;89(4):493-507

Behavioural and Clinical Neuroscience Institute.

This article outlines key dimensions of culturally sensitive cognitive-behavioral therapy (CBT), and examines the application to Southeast Asian populations. Our treatment, culturally adapted (CA) multiplex CBT, was initially developed to treat traumatized Southeast Asian refugees, and has been shown to be efficacious for those and other groups. As described in the article, CA multiplex CBT is based on the multiplex model of distress generation and our conceptualization of key dimensions of culturally sensitive and effective treatment. We will describe why our CA-CBT may have applicability to Asian populations more generally, for example, due to its emphasis on mindfulness, contextual sensitivity (viz., flexibility), somatic complaint, and somatic-focused emotion regulation (e.g., applied stretching). We illustrate key dimensions of CA treatment, giving examples from how these principles are employed in CA multiplex CBT. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ort0000392DOI Listing
December 2019

Culturally sensitive assessment of anxious-depressive distress in the Cambodian population: Avoiding category truncation.

Transcult Psychiatry 2019 08 6;56(4):643-666. Epub 2019 Jun 6.

Kinder- und jugendpsychiatrische Tagesklinik Eutin.

In a large national survey in Cambodia (N = 2689), the present study investigated the prominence of certain culturally salient symptoms and syndromes in the general population and among those with anxious-depressive distress (as determined by the Hopkins Symptom Checklist-25, or HSCL). Using an abbreviated Cambodian Symptom and Syndrome Addendum (CSSA), we found that the CSSA complaints were particularly elevated among those with anxious-depressive distress. Those with anxious-depressive distress had statistically greater mean scores on all the CSSA items as well as severity of endorsement analyzed by percentage: among those with HSCL caseness, 75.3% were bothered "quite a bit" or "extremely" by "thinking a lot" (vs. 27.5% without caseness); 53.8% were bothered by "standing up and feeling dizzy" (vs. 13.8%); and 45.6% by blurry vision (vs. 16.8%). In a logistic regression analysis to predict anxious-depressive distress, 51% of the variance was accounted for by five predictors: "weak heart," "thinking a lot," dizziness, " hitting up from the stomach," and sleep paralysis. Using ROC analysis, a cut-off score of 1.81 on the CSSA was optimal as a screener to indicate anxious-depressive distress, giving a sensitivity of 0.86. The study results suggest that to avoid (i.e., the omission of key complaints that are part of an assessed distress domain) when profiling anxious-depressive distress among Cambodia population that items other than those in standard psychopathology measures should be assessed such as "thinking a lot," "weak heart," "blurry vision," and "dizziness upon standing up."
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http://dx.doi.org/10.1177/1363461519851609DOI Listing
August 2019

Caring for Families Separated by Changing Immigration Policies and Enforcement: A Cultural Psychiatry Perspective.

Psychiatr Serv 2018 12 20;69(12):1200-1203. Epub 2018 Aug 20.

Dr. Kohrt is with the Department of Psychiatry, George Washington University, Washington, D.C. Dr. Lu is with the Department of Psychiatry and Behavioral Sciences, University of California, Davis. Dr. Wu is with the Department of Child and Adolescent Psychiatry and Dr. Hinton is with the Department of Psychiatry, both at Massachusetts General Hospital and Harvard Medical School, Boston. Dr. Aggarwal and Dr. Lewis-Fernández are with the Department of Psychiatry, Columbia University, and with New York State Psychiatric Institute, New York. Dr. Parekh is with the Division of Diversity and Health Equity, American Psychiatric Association, Washington, D.C. Dr. Rousseau is with the Department of Psychiatry, McGill University, Montreal. The authors are members or guests of the Cultural Psychiatry Committee of the Group for the Advancement of Psychiatry. Dr. Kohrt is the project coordinator and Dr. Lewis-Fernández is the committee chair. Dr. Lewis-Fernández is also editor of this column.

Recent changes in U.S. immigration policies and enforcement have precipitated a 300% rise in arrests and planned deportations. Although some family members face deportation, other family members may have state-sanctioned status. Such mixed status puts hundreds of thousands of families at risk of forced separation and associated mental health problems. Building on cross-cultural work with refugee families and other groups and on work with families separated by parental incarceration, the authors provide recommendations to guide clinicians working with families who are separated or who fear separation. Mental health problems among separated families can in part be addressed through identifying the origins of distress, elucidating family structures and roles, strengthening communication practices, linking with legal and economic resources, and facilitating decision making through distress reduction.
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http://dx.doi.org/10.1176/appi.ps.201800076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382597PMC
December 2018

A group mental health randomized controlled trial for female refugees in Malaysia.

Am J Orthopsychiatry 2019 23;89(6):665-674. Epub 2018 Jul 23.

Department of Global Health and Social Medicine, Harvard Medical School.

Forcibly displaced persons confront multiple stressors while awaiting permanent asylum or resettlement and often experience high levels of emotional distress. This study assessed an 8-week somatic-focused culturally adapted cognitive-behavioral therapy (CBT) group intervention with 39 female refugees from Afghanistan living in Kuala Lumpur, Malaysia. Twenty-nine participants were randomly assigned to treatment conditions, resulting in 20 participants in two separate treatment groups and 9 in a waitlist control group. An additional 10 participants were not randomly assigned and therefore were treated as an additional treatment group and analyzed separately. A three-group piecewise linear growth model was specified in Mplus using Bayesian estimation. Dependent variables included emotional distress, anxiety, depression, posttraumatic stress, and social support. From baseline to posttreatment assessments, initial intervention participants experienced significant declines in emotional distress (b = -16.90, p < .001), anxiety (b = -.80, p < .001), depression (b = -.59, p < .001), and posttraumatic stress (b = -.24, p < .05). Gains were maintained three months posttreatment, with similar trends observed among nonrandomized participants. Subsequent to receiving treatment, the waitlist control participants also showed significant declines in emotional distress (b = -20.88, p < .001), anxiety (b = -1.10, p < .001), depression (b = -.79, p < .001), and posttraumatic stress scores (b = -.82, p < .001). Comparing the treatment groups to the waitlist control group revealed large effect sizes: Cohen's d was 2.14 for emotional distress, 2.31 for anxiety, 2.42 for depression, and 2.07 for posttraumatic stress. Relevant public health findings include low drop out, group format, and facilitation by a trained community member. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ort0000346DOI Listing
April 2020

Culturally Sensitive Assessment of Anxious-Depressive Distress in Vietnam: Avoiding Category Truncation.

Transcult Psychiatry 2018 06 6;55(3):384-404. Epub 2018 Apr 6.

Da Nang Psychiatric Hospital.

The present study investigated what complaints are prominent in psychologically distressed Vietnamese in Vietnam beyond standard symptoms assessed by Western diagnostic instruments for anxiety and depression. To form the initial Vietnamese Symptom and Cultural Syndrome Addendum (VN SSA), we reviewed the literature, consulted experts, and conducted focus groups. The preliminary VN SSA was then used in a general survey (N = 1004) of five provinces in Vietnam. We found that the VN SSA items were highly and significantly correlated with a measure of anxious-depressive psychopathology (a composite measure of the General Anxiety Disorder-7; Posttraumatic Diagnostic Scale; and Patient Health Questionnaire-9). The VN SSA item most highly correlated to anxious-depressive psychopathology was "thinking a lot" ( r = .54), reported by 15.8% of the sample. Many other symptoms in the addendum also were prominent, such as orthostatic dizziness (i.e., dizziness upon standing up; r = .41), reported by 22.9% of the sample. By way of comparison, somatic complaints more typically assessed to profile Western anxious-depressive distress, such as palpitations, were less prominent, as evidenced by being less strongly correlated to Western psychiatric symptoms and being less frequent (e.g., palpitations: r = .31, 7.1% of the sample). Study results suggest that to avoid category truncation when profiling anxious-depressive distress among Vietnamese that items other than those in standard psychopathology measures should also be assessed.
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http://dx.doi.org/10.1177/1363461518764500DOI Listing
June 2018

Cultural Adaptations of Cognitive Behavioral Therapy.

Psychiatr Clin North Am 2017 12 19;40(4):701-714. Epub 2017 Sep 19.

Department of Psychology, The University of Tulsa, 800 South Tucker Drive, Tulsa, OK 74104, USA.

In increasingly multicultural societies, cognitive behavioral therapy (CBT) must be made appropriate for diverse groups. This article examines cultural adaptations of CBT, focusing on anxiety and depressive disorders. The article presents a culturally informed, transdiagnostic model of how anxious-depressive distress is generated and culturally shaped. Guided by this model, it discusses how interventions can be designed to decrease anxiety-type and depressive-type psychopathology in a culturally sensitive way. It describes such concepts as explanatory model bridging, cultural grounding, and contextual sensitivity.
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http://dx.doi.org/10.1016/j.psc.2017.08.006DOI Listing
December 2017

Migraine-Like Visual Auras Among Traumatized Cambodians with PTSD: Fear of Ghost Attack and Other Disasters.

Cult Med Psychiatry 2018 Jun;42(2):244-277

Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands.

This article profiles visual auras among traumatized Cambodian refugees attending a psychiatric clinic. Thirty-six percent (54/150) had experienced an aura in the previous 4 weeks, almost always phosphenes (48% [26/54]) or a scintillating scotoma (74% [40/54]). Aura and PTSD were highly associated: patients with visual aura in the last month had greater PTSD severity, 3.6 (SD = 1.8) versus 1.9 (SD = 1.6), t = 10.2 (df = 85), p < 0.001, and patients with PTSD had a higher rate of visual aura in the last month, 69% (22/32) versus 13% (7/55), odds ratio 15.1 (5.1-44.9), p < 0.001. Patients often had a visual aura triggered by rising up to the upright from a lying or sitting position, i.e., orthostasis, with the most common sequence being an aura triggered upon orthostasis during a migraine, experienced by 60% of those with aura. The visual aura was often catastrophically interpreted: as the dangerous assault of a supernatural being, most commonly the ghost of someone who died in the Pol Pot period. Aura often triggered flashback. Illustrative cases are provided. The article suggests the existence of local biocultural ontologies of trauma as evinced by the centrality of visual auras among Cambodian refugees.
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http://dx.doi.org/10.1007/s11013-017-9554-7DOI Listing
June 2018

Platzschwindel, agoraphobia and their influence on theories of anxiety at the end of the nineteenth century: theories of the role of biology and 'representations' (Vorstellungen).

Hist Psychiatry 2016 Dec 22;27(4):425-442. Epub 2016 Jul 22.

Massachusetts General Hospital, Boston, USA.

During the 1860s, Berlin's exterior physiognomy transformed radically. The city eroded the surrounding rural areas, and the frontiers of the old city centre were abolished. These transformations led to the disappearance of the visible frontiers that once demarcated the limits of the old residential Prussian city. In this context, the description of the clinical picture of agoraphobia by the Berlin psychiatrist Carl Westphal in 1872 marked a turning point, not only in psychiatric theories on anxiety but also in the conceptualization of our experience of space. In this paper, the authors trace the emergence of a new psychology-neurology episteme during the last third of the nineteenth century; and they argue that such an episteme became possible once the relations between anxiety and modern city-scape had been clearly articulated.
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http://dx.doi.org/10.1177/0957154X16657710DOI Listing
December 2016

The Flexibility Hypothesis of Healing.

Cult Med Psychiatry 2017 Mar;41(1):3-34

McGill University, Montreal, QC, Canada.

Theories of healing have attempted to identify general mechanisms that may work across different modalities. These include altering expectations, remoralization, and instilling hope. In this paper, we argue that many forms of healing and psychotherapy may work by inducing positive psychological states marked by flexibility or an enhanced ability to shift cognitive sets. Healing practices may induce these states of cognitive and emotional flexibility through specific symbolic interventions we term "flexibility primers" that can include images, metaphors, music, and other media. The flexibility hypothesis suggests that cognitive and emotional flexibility is represented, elicited, and enacted through multiple modalities in healing rituals. Identifying psychological processes and cultural forms that evoke and support cognitive and emotional flexibility provides a way to understand the cultural specificity and potential efficacy of particular healing practices and can guide the design of interventions that promote resilience and well-being.
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http://dx.doi.org/10.1007/s11013-016-9493-8DOI Listing
March 2017

A Transcultural Model of the Centrality of "Thinking a Lot" in Psychopathologies Across the Globe and the Process of Localization: A Cambodian Refugee Example.

Cult Med Psychiatry 2016 Dec;40(4):570-619

Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands.

We present a general model of why "thinking a lot" is a key presentation of distress in many cultures and examine how "thinking a lot" plays out in the Cambodian cultural context. We argue that the complaint of "thinking a lot" indicates the presence of a certain causal network of psychopathology that is found across cultures, but that this causal network is localized in profound ways. We show, using a Cambodian example, that examining "thinking a lot" in a cultural context is a key way of investigating the local bio-cultural ontology of psychopathology. Among Cambodian refugees, a typical episode of "thinking a lot" begins with ruminative-type negative cognitions, in particular worry and depressive thoughts. Next these negative cognitions may induce mental symptoms (e.g., poor concentration, forgetfulness, and "zoning out") and somatic symptoms (e.g., migraine headache, migraine-like blurry vision such as scintillating scotomas, dizziness, palpitations). Subsequently the very fact of "thinking a lot" and the induced symptoms may give rise to multiple catastrophic cognitions. Soon, as distress escalates, in a kind of looping, other negative cognitions such as trauma memories may be triggered. All these processes are highly shaped by the Cambodian socio-cultural context. The article shows that Cambodian trauma survivors have a locally specific illness reality that centers on dynamic episodes of "thinking a lot," or on what might be called the "thinking a lot" causal network.
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http://dx.doi.org/10.1007/s11013-016-9489-4DOI Listing
December 2016

Lifetime presence and rates of sleep paralysis in Denmark of ethnic Danes and non-ethnic Danes.

Psychiatry Clin Neurosci 2016 Jun 8;70(6):253. Epub 2016 Apr 8.

Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Massachusetts, USA.

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http://dx.doi.org/10.1111/pcn.12385DOI Listing
June 2016

Somatic Symptoms Mediate the Relationship Between Trauma During the Arab Spring and Quality of Life Among Tunisians.

J Nerv Ment Dis 2016 Feb;204(2):153-5

*Department of Psychiatry, Université de Toulouse, France; †Department of Psychology, University of Calgary, Canada; ‡Massachusetts General Hospital and §Harvard Medical School, Boston, MA; ∥Department of Psychology, Université de Toulouse, France; ¶Centre Hospitalier Esquirol, Department of Psychiatry; and #INSERM, UMR 1094, Department of Tropical Neuroepidemiology, Limoges, France.

This study examined the relationship between peritraumatic reactions, posttraumatic stress disorder (PTSD) symptoms, somatic complaints, and quality of life in Tunisians exposed to the events of the Arab Spring. Participants (n = 60) completed an online survey 1 year after the events, assessing peritraumatic distress, peritraumatic dissociation, PTSD symptoms, somatic complaints, and physical and mental quality of life. Results showed that peritraumatic dissociation was independently associated with increased PTSD symptoms and somatic complaints 12 months after the events. Multiple mediator mediation analyses revealed that somatic complaints (not PTSD symptoms) were the only independent mediators of the relationships between peritraumatic dissociation and both physical and mental quality of life. Assessing peritraumatic dissociation soon after trauma exposure among the North African population might help identify individuals at risk for PTSD. Furthermore, the impact of trauma on quality of life may be better explained by somatic complaints than PTSD symptoms among North Africans.
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http://dx.doi.org/10.1097/NMD.0000000000000446DOI Listing
February 2016

"Thinking too much": A systematic review of a common idiom of distress.

Soc Sci Med 2015 Dec 21;147:170-83. Epub 2015 Oct 21.

Department of Psychiatry, Massachusetts General Hospital, 15 Parkman Street, WACC 812, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.

Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.
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http://dx.doi.org/10.1016/j.socscimed.2015.10.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4689615PMC
December 2015

Sleep Paralysis Among Egyptian College Students: Association With Anxiety Symptoms (PTSD, Trait Anxiety, Pathological Worry).

J Nerv Ment Dis 2015 Nov;203(11):871-5

*Center for Brain and Cognition, UC San Diego, La Jolla, CA; and ‡Massachusetts General Hospital/Harvard Medical School, Boston, MA.

Among Egyptian college students in Cairo (n = 100), this study examined the relationship between sleep paralysis (SP) and anxiety symptoms, viz., posttraumatic stress disorder (PTSD), trait anxiety, and pathological worry. SP rates were high; 43% of participants reported at least one lifetime episode of SP, and 24% of those who reported at least one lifetime episode had experienced four or more episodes during the previous year. Fourteen percent of men had experienced SP as compared to 86% of women. As hypothesized, relative to non-SP experiencers, participants who had SP reported higher symptoms of PTSD, trait anxiety, and pathological worry. Also, as hypothesized, the experiencing of hypnogogic/hypnopompic hallucinations during SP, even after controlling for negative affect, was highly correlated with symptoms of PTSD and trait anxiety. The study also investigated possible mechanisms by examining the relationship of hallucinations to anxiety variables.
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http://dx.doi.org/10.1097/NMD.0000000000000382DOI Listing
November 2015

Cultural Explanations of Sleep Paralysis in Italy: The Pandafeche Attack and Associated Supernatural Beliefs.

Cult Med Psychiatry 2015 Dec;39(4):651-64

Massechustest General Hospital and Harvard Medical School, Boston, MA, USA.

The current study examines cultural explanations regarding sleep paralysis (SP) in Italy. The study explores (1) whether the phenomenology of SP generates culturally specific interpretations and causal explanations and (2) what are the beliefs and local traditions associated with such cultural explanations. The participants were Italian nationals from the general population (n = 68) recruited in the region of Abruzzo, Italy. All participants had experienced at least one lifetime episode of SP. The sleep paralysis experiences and phenomenology questionnaire were orally administered to participants. We found a multilayered cultural interpretation of SP, namely the Pandafeche attack, associated with various supernatural beliefs. Thirty-eight percent of participants believed that this supernatural being, the Pandafeche-often referred to as an evil witch, sometimes as a ghost-like spirit or a terrifying humanoid cat-might have caused their SP. Twenty-four percent of all participants sensed the Pandafeche was present during their SP. Strategies to prevent Pandafeche attack included sleeping in supine position, placing a broom by the bedroom door, or putting a pile of sand by the bed. Case studies are presented to illustrate the study findings. The Pandafeche attack thus constitutes a culturally specific, supernatural interpretation of the phenomenology of SP in the Abruzzo region of Italy.
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http://dx.doi.org/10.1007/s11013-015-9442-yDOI Listing
December 2015

The "Thinking a Lot" Idiom of Distress and PTSD: An Examination of Their Relationship among Traumatized Cambodian Refugees Using the "Thinking a Lot" Questionnaire.

Med Anthropol Q 2015 Sep 14;29(3):357-80. Epub 2015 Apr 14.

Amsterdam Institute for Social Science Research, University of Amsterdam.

"Thinking a lot" (TAL)—also referred to as "thinking too much"—is a key complaint in many cultural contexts, and the current article profiles this idiom of distress among Cambodian refugees. The article also proposes a general model of how TAL generates various types of distress that then cause PTSD-type psychopathology, a model we refer to as the TAL-PTSD model. As tested in this Cambodian refugee sample, the model is supported by the following: (1) the close connection of TAL to PTSD as shown by odds ratio (OR = 19.6), correlation (r = .86), and factor loading; and (2) the mediation of most of the effect of TAL on PTSD by TAL-caused somatic symptoms, catastrophic cognitions, trauma recall, insomnia, and irritability. The questionnaire used in the present study is provided and can be used to examine TAL in other cultural and global contexts to advance the study of this commonly encountered distress form.
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http://dx.doi.org/10.1111/maq.12204DOI Listing
September 2015

Cross-cultural aspects of anxiety disorders.

Curr Psychiatry Rep 2014 Jun;16(6):450

Department of Psychology, Boston University, 648 Beacon Street, 6th Floor, Boston, MA, 02215-2002, USA,

A person's cultural background influences the experience and expression of emotions. In reviewing the recent literature on cross-cultural aspects of anxiety disorders, we identified some culturally related ethnopsychology/ethnophysiology factors (the culture's conceptualizations of how the mind and body function) and contextual factors that influence anxiety disorders. Ethnopsychology/ethnophysiology factors include the person's ideas about the mental and bodily processes (and their interaction), whereas contextual factors are associated with the social norms and rules that may contribute to anxiety, including individualism vs. collectivism and self-construals. From the perspective of ethnopsychology/ethnophysiology and contextual factors, we will discuss "khyâl cap" ("wind attacks"), taijin kyofusho, and ataques de nervios, three prominent examples of culture-specific expressions of anxiety disorders that have all been included in the DSM-5 list of cultural concepts of distress.
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http://dx.doi.org/10.1007/s11920-014-0450-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037698PMC
June 2014

Dreams of the dead among Cambodian refugees: frequency, phenomenology, and relationship to complicated grief and posttraumatic stress disorder.

Death Stud 2013 Sep;37(8):750-67

Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.

The authors investigated the importance of dreams of the deceased in the experiencing of prolonged grief (PG) and posttraumatic stress disorder (PTSD) among Cambodian refugees who survived the Pol Pot genocide (1975-1979). Such dreams were frequent in the last month (52% of those surveyed), and most often involved a relative who died in the Pol Pot period. Past month frequency was correlated with PG severity (r = .59) and PTSD severity (r = .52). The dreams were almost always deeply upsetting because the dreams indicated the deceased to be in a difficult spiritual state. Dreams of the deceased as a central component of PG and PTSD among Cambodian refugees is discussed.
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http://dx.doi.org/10.1080/07481187.2012.692457DOI Listing
September 2013

Social anxiety disorder in DSM-5.

Depress Anxiety 2014 Jun 2;31(6):472-9. Epub 2014 Jan 2.

Department of Psychology, Adult Anxiety Clinic, Temple University, Philadelphia, Pennsylvania.

With the publication of DSM-5, the diagnostic criteria for social anxiety disorder (SAD, also known as social phobia) have undergone several changes, which have important conceptual and clinical implications. In this paper, we first provide a brief history of the diagnosis. We then review a number of these changes, including (1) the primary name of the disorder, (2) the increased emphasis on fear of negative evaluation, (3) the importance of sociocultural context in determining whether an anxious response to a social situation is out of proportion to the actual threat, (4) the diagnosis of SAD in the context of a medical condition, and (5) the way in which we think about variations in the presentation of SAD (the specifier issue). We then consider the clinical implications of changes in DSM-5 related to these issues.
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http://dx.doi.org/10.1002/da.22231DOI Listing
June 2014

Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology.

Int J Epidemiol 2014 Apr 23;43(2):365-406. Epub 2013 Dec 23.

Duke Global Health Institute, Department of Psychiatry and Behavioral Sciences, Durham, NC, USA, Department of Psychology, Fordham University, New York, USA, Department of Anthropology, Department of Epidemiology, Emory University, Atlanta, GA, USA, Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA, Department of Psychology, Tribhuvan University, Kirtipur, Nepal, Butabika National Referral Mental and Teaching Hospital, Kampala, Uganda, AISSR, University of Amsterdam, The Netherlands and Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Background: Burgeoning global mental health endeavors have renewed debates about cultural applicability of psychiatric categories. This study's goal is to review strengths and limitations of literature comparing psychiatric categories with cultural concepts of distress (CCD) such as cultural syndromes, culture-bound syndromes, and idioms of distress.

Methods: The Systematic Assessment of Quality in Observational Research (SAQOR) was adapted based on cultural psychiatry principles to develop a Cultural Psychiatry Epidemiology version (SAQOR-CPE), which was used to rate quality of quantitative studies comparing CCD and psychiatric categories. A meta-analysis was performed for each psychiatric category.

Results: Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I(2) > 75%). Only general psychological distress had low heterogeneity (I(2) = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders.

Conclusions: Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.
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http://dx.doi.org/10.1093/ije/dyt227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3997373PMC
April 2014

Local responses to trauma: symptom, affect, and healing.

Transcult Psychiatry 2013 Oct;50(5):607-21

Harvard University.

This article provides an introduction to the thematic issue of Transcultural Psychiatry on local responses to trauma. To illustrate how local responses to trauma may be therapeutic, we consider the multiple dimensions or domains that may be targeted by healing rituals and interventions. We then outline a theoretical model of the generation of trauma-related symptoms and distress. We present the multiplex model of symptom generation which posits multiple cognitive, social, and physiological mechanisms by which various triggers can lead to severe distress among trauma victims in acute episodes, and which may be targeted in treatment. More persistent forms of distress can be explained in terms of the effects of persistent mood states and associated modes of cognitive processing and behavior that render individuals vulnerable to chronic symptoms and acute exacerbations. The beneficial effects of healing rituals and interventions may occur, in part, by inducing positive affective states associated with a flexible mind-set. We conclude by summarizing some of the contributions of the papers in this issue to understanding local therapeutic processes of healing.
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http://dx.doi.org/10.1177/1363461513506529DOI Listing
October 2013

Explanations of sleep paralysis among Egyptian college students and the general population in Egypt and Denmark.

Transcult Psychiatry 2014 Apr 1;51(2):158-75. Epub 2013 Oct 1.

University of California at San Diego.

This cross-cultural study compared explanations of sleep paralysis (SP) in two countries and two groups with different levels of education in one country. Comparisons were made between individuals having experienced SP at least once in a lifetime from Cairo, Egypt (n = 89), Copenhagen, Denmark (n = 59), and the American University in Cairo, Egypt (n = 44). As hypothesized, participants from the general Egyptian population were more likely to endorse supernatural causal explanation of their SP compared to participants from Denmark; participants from the American University in Cairo were less likely to endorse supernatural causes of their SP compared to participants from the general Egyptian population. Moreover, participants from the American University in Cairo were marginally significantly more likely to endorse supernatural causes of their SP compared to participants from Denmark. Additionally, we explored which culturally bound explanations and beliefs about SP existed in Egypt and Denmark. We found that nearly half (48%) of the participants from the general Egyptian population believed their SP to be caused by the Jinn, a spirit-like creature with roots in Islamic tradition, which constitutes a culturally bound interpretation of the phenomenology of SP in this region of the world. Case studies are presented to illustrate these findings.
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http://dx.doi.org/10.1177/1363461513503378DOI Listing
April 2014