The rights of the severely mentally ill in post-conflict societies.
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Female↗
Biomedical subjects
D Silove
Publications and source records attributed to D Silove.
Health and human rights of the East Timorese.
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Australia↗
Problems Tamil asylum seekers encounter in accessing health and welfare services in Australia.
Over the last decade, western countries have reduced their intake of refugees, even though a substantial number of persons continue to be displaced by war and persecution. At the same time, there has been a substantial increase in the number of asylum seekers who apply for refugee status after entering western countries without resettlement documents. Evidence is accruing that asylum seekers are at high risk to trauma-related psychiatric and physical disorders. Increasing concerns have been raised, therefore, about the difficulties that asylum seekers face in accessing health and welfare services. The present Australian-based volunteer study compared Tamil asylum seekers (n = 62) from Sri Lanka with compatriots (30 refugees; 62 immigrants) on a number of indices relating to difficulties accessing medical, counselling and welfare services. The majority of asylum seekers (>60%) reported serious difficulties accessing medical and dental services and a sizeable minority reported problems obtaining assistance with welfare (40%), counselling (34%), and charity (23%). Difficulties accessing medical and dental services consistently exceeded those reported by refugees and immigrants. In spite of the inevitable sampling limitations, the data support past research as well as clinical impressions in suggesting that asylum seekers are particularly disadvantaged in accessing health care services.
Adult↗
Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees, and immigrants.
Path analysis was used to examine the antecedents of posttraumatic stress (PTS) symptoms in Tamil asylum-seekers, refugees, and immigrants in Australia. The Harvard Trauma Questionnaire and a postmigration living difficulties questionnaire were completed by 62 asylum-seekers, 30 refugees, and 104 immigrants who responded to a mail-out. Demographic characteristics, residency status, and measures of trauma and postmigration stress were fitted to a structural model in PTS symptoms. Premigration trauma exposure accounted for 20% of the variance of PTS symptoms. Postmigration stress contributed 14% of the variance. Although limited by sampling constraints and retrospective measurement, the study supports the notion that both traumatic and posttraumatic events contribute to the expression of PTS symptoms.
Adult↗
Parental representations associated with adult separation anxiety and panic disorder--agoraphobia.
OBJECTIVE: Early bonding abnormalities have been associated with a range of anxiety and depressive disorders in adulthood, but no specific parental patterns have emerged for particular disorders. The present study investigated the possibility that parental overprotectiveness may be linked to a risk of separation anxiety (SA) in adulthood. METHOD: Two samples were recruited: volunteers (n = 34) whose major anxieties focused on separation concerns, and adult anxiety clinic patients (n = 37) who were diagnosed with panic disorder. Parental characteristics and early SA were assessed by dichotomising the combined sample first according to adult SA categorisation and then by panic disorder status. RESULTS: Subjects assigned to the adult SA category reported high levels of juvenile SA and exposure to maternal overprotectiveness, whereas patients diagnosed with panic disorder reported few differences in their bonding histories compared to residual anxious patients. CONCLUSIONS: The findings of this study suggest that early SA and parental overprotectiveness may not be associated with panic disorder per se, but rather with persisting SA symptoms in adulthood. The overlapping samples and retrospectivity of some measures are important limitations of the study.
Adult↗
The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework.
Torture is a complex trauma that often occurs within the context of widespread persecution and human rights violations. In addition, the nature of modern warfare is such that whole populations are at risk of suffering extensive trauma, injustices, loss, and displacement. Refugees, in particular, experience sequential stresses that may compound each other over prolonged periods of time. The present overview examines whether contemporary notions of trauma, and especially a focus on the category of posttraumatic stress disorder (PTSD), are adequate in assessing the multiple effects of such experiences. Recent studies are reviewed to indicate the strengths and limitations of current research approaches. Rates of PTSD in such studies have varied with relatively low rates being found in recent epidemiologic studies undertaken on refugee populations. It is suggested that a focus on intervening psychosocial adaptive systems may assist in delineating more clearly the pathways that determine whether traumatized persons achieve psychosocial restitution or are at risk of ongoing psychiatric disability. A model is proposed which suggests that torture and related abuses may challenge five core adaptive systems subserving the functions of "safety," "attachment," "justice," "identity-role," and "existential-meaning." It is argued that a clearer delineation of such adaptive systems may provide a point of convergence that may link research endeavors more closely to the subjective experience of survivors and to the types of clinical interventions offered by trauma treatment services.
Adaptation, Psychological↗
Subpopulations of early separation anxiety: relevance to risk of adult anxiety disorders.
BACKGROUND: The present study aims to examine whether discrete subpopulations can be identified according to their levels of early separation anxiety (SA), and if so, whether such a typology of SA influences risk to particular adult anxiety disorders. METHODS: Mixture analysis was applied to early SA scores provided retrospectively by a composite group (n=1800) of adult community and patient samples. The distribution of adult anxiety diagnoses across the SA categories was assessed in a community (n=136) and a clinic (n=74) sample. RESULTS: The mixture analysis yielded two subpopulations according to SA scores. Odds ratios for assignment to the high SA category for the various anxiety disorders ranged from 3.6 to 6.7. A logistic regression analysis revealed that when comorbidity was taken into account, the panic disorder-agoraphobia (PD-Ag) group was the only anxiety disorder to be associated with the high SA category. CONCLUSION: Assignment to a high early SA category appears to increase risk to adult anxiety disorders, particularly PD-Ag. Several possible pathways may account for such a risk including the persistence of separation anxiety disorder into adulthood. LIMITATIONS: Assessment of early SA was made using a retrospective measure and the samples included groups which were known to have high SA scores. CLINICAL RELEVANCE: Only a subpopulation of anxiety sufferers may have elevated levels of SA. Identification of this group may be important for early detection and intervention.
Adult↗
Is posttraumatic stress disorder an overlearned survival response? An evolutionary-learning hypothesis.
Contemporary learning theories of posttraumatic stress disorder (PTSD) provide an explanation for the phobic avoidant features but do not account fully for the intrusive phenomena that are so characteristic of the disorder. This article hypothesizes that a primitive learning center in the limbic system rehearses traumatic memories immediately following exposure to trauma, thus inducing durable memories of the sources of novel threat. It is postulated that the mechanism developed during early evolution when, in the absence of cognitive mechanisms, automatic learning following single exposure to novel threat would have conferred survival value on the species. With evolution of the brain, a second cortical pathway developed for the cognitive processing of trauma memories. It is possible that synchrony between the two phylogentically distinct pathways may be lost in vulnerable individuals under conditions of extreme stress resulting in failure of cortical inhibition of limbic trauma rehearsal mechanisms. A mismatch between archaic biological mechanisms and novel cues in the modern environment also may play a role in triggering traumatic memories and associated fight and flight reactions. The intrusive phenomena of PTSD thus may reflect an "overlearned survival response" in those in whom the putative limbic rehearsal mechanism evades cortical control. The heuristic value and limitations of such an evolutionary-learning theory are discussed.
Animals↗
Psychosocial factors associated with depression: a study of socially disadvantaged women with young children.
This study aims to use valid measures to a) estimate the prevalence of depressive disorder and b) identify psychosocial factors associated with depression in a sample of socially disadvantaged women with children. One hundred ninety-three women, recruited through a doorknock of public housing estates completed an interview that included the Diagnostic Interview Schedule to identify cases of depression and the Mannheim Interview for Social Support. The women also completed self-report questionnaires assessing psychological morbidity, life events, perceptions of intimate relationships, and personality factors. The 6-month prevalence of major depression was 17% and the lifetime prevalence 29%. Major depression was associated with perceptions of low parental care during childhood and low care from current partner, vulnerable personality style, increased reporting of life events, and an unsatisfactory social support network.
Adolescent↗
Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and post-traumatic stress in Tamil asylum-seekers: comparison with refugees and immigrants.
Compared to research on displaced persons whose refugee status has been endorsed prior to arriving in Western countries, there is little systematic information available about levels of past trauma, postmigration living difficulties and psychiatric symptoms amongst asylum-seekers who claim refugee status only after arrival. Asylum-seekers, authorized refugees and immigrants of Tamil background were recruited by personal contact and mail-out in Sydney, Australia. A total of 62 subjects, constituting approximately 60% of the estimated pool of Tamil asylum-seekers, agreed to participate in the study. They returned statistically significantly higher scores than immigrants (n = 104) on measures of past trauma, symptoms of anxiety, depression and post-traumatic stress, and on all dimensions of postmigration difficulties. Asylum-seekers did not differ from refugees (n = 30) on measures of past trauma or psychiatric symptoms, but they scored higher on selective components of postmigration stress relating to difficulties associated with their insecure residency status. Although limited by sampling and diagnostic constraints, the present study suggests that asylum-seekers may be a high-risk group in relation to ongoing stress in the postmigration period.
Acculturation↗
Compounding of premigration trauma and postmigration stress in asylum seekers.
Unauthorized immigrants arriving in Western countries increasingly are being subjected to stringent restrictions while their residency claims are assessed. The present study was a investigation of premigration exposure to organized violence and postmigration stressors in 40 individuals seeking asylum who were attending a community welfare center in Sydney, Australia. Almost 80% reported exposure to premigration trauma such as witnessing murders, having their lives threatened, being separated from family members, and brainwashing; 25% had been tortured. Asylum seekers reported a marked decline in socioeconomic status. Common ongoing sources of severe stress included fears of being repatriated, barriers to work and social services, separation from family, and issues related to the process of pursuing refugee claims. More than one third had problems obtaining health services in Australia--the same number who reported similar difficulties in their home countries. Although based on a selective and culturally heterogeneous sample, the results suggest that salient aspects of the asylum-seeking process may compound the stressors suffered by an already traumatized group.
Acculturation↗
The influence of culture on psychiatric assessment: the Vietnamese refugee.
The influence of culture on psychiatric diagnostic assessments remains controversial. The authors outline differences between the emic approach to assessment, which is informed by ethnographic concepts of the centrality of culture in shaping the psyche and its expressions, and the etic approach, which downplays cultural effects and focuses on the universal elements in manifestations of psychological distress. Based on the experience of assessing Vietnamese refugees in Australia, the authors explore semantic, contextual, and conceptual factors that may impede the psychiatric assessment of patients from other cultures. Areas of misinterpretation are illustrated using examples from the Vietnamese language. The authors discuss how variations in politicohistorical experiences within ethnic populations may result in differences in the modes of expressing and understanding mental illness. Recognition of the tension between etic and emic perspectives allows the clinician to draw on the most useful elements of each in assessing and treating individual patients.
Cross-Cultural Comparison↗
Satisfaction of Vietnamese patients and their families with refugee and mainstream mental health services.
OBJECTIVE: The study examined levels of satisfaction with mainstream mental health services and specialized mental health services for refugees among Vietnamese psychiatric patients and their relatives. Demographic, diagnostic, symptomatic, and service-related issues that might influence satisfaction were investigated. METHODS: Eighty-six Vietnamese patients were identified from case notes of mainstream inpatient services (N = 31), mainstream community services (N = 7), and a specialized refugee treatment unit (N = 48). During an interview, a scale measuring satisfaction with treatment as well as measures of anxiety, depression, and posttraumatic stress disorder was administered to them. A modified satisfaction scale was administered to 56 relatives. RESULTS: Patients and relatives were, on average, moderately satisfied with treatment. Patients expressed greater satisfaction with the specialized treatment unit for refugees than with mainstream services, a finding that was not influenced by diagnostic differences or symptom levels at the time patients responded. Further analyses controlling for multiple comparisons revealed that the extent of the information provided and the ease of negotiating changes in treatment were the most salient variables in distinguishing satisfaction levels across the two types of treatment centers. Patients' fluency in English and their relatives' level of education were inversely associated with satisfaction scores, tentatively suggesting that the greater the ability of patients and their families to evaluate services, the less likely they were to express satisfaction with treatment. CONCLUSIONS: Specialized mental health services for refugees may be more acceptable to refugee populations than their mainstream counterparts, perhaps because better communication with patients and their families is possible in the specialized services. Patients and families who are in a position to evaluate services fully are more likely to be critical of treatments offered.
Acculturation↗
Anxiety, depression and PTSD in asylum-seekers: assocations with pre-migration trauma and post-migration stressors.
BACKGROUND: Research into the mental health of refugees has burgeoned in recent times, but there is a dearth of studies focusing specifically on the factors associated with psychiatric distress in asylum-seekers who have not been accorded residency status. METHOD: Forty consecutive asylum-seekers attending a community resource centre in Sydney, Australia, were interviewed using structured instruments and questionnaires. RESULTS: Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were linked with both anxiety and depression. Thirty subjects (79%) had experienced a traumatic event such as witnessing killings, being assaulted, or suffering torture and captivity, and 14 subjects (37%) met full criteria for PTSD. A diagnosis of PTSD was associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom. CONCLUSIONS: Although based on correlational data derived from'a convenient' sample, our findings raise the possibility that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised.
Adult↗
Is there an adult form of separation anxiety disorder? A brief clinical report.
OBJECTIVE: The aim of this clinical report is to investigate whether symptoms of separation anxiety disorder can occur in adulthood. CLINICAL PICTURE: Three cases are described to illustrate that adults may experience: wide-ranging separation anxiety symptoms, such as extreme anxiety and fear, when separated from major attachment figures; avoidance of being alone; and fears that harm will befall those close to them. Symptoms of panic appeared to be secondary to separation anxiety, and none of the patients fulfilled criteria for dependent personality disorder. TREATMENT: Group cognitive behavioural treatment focusing on preventing panic attacks and generalised anxiety did not appear to have an impact on core separation anxiety symptoms. OUTCOME: Exacerbations of separation anxiety appeared to be closely linked to actual or threatened ruptures to primary bonds. CONCLUSIONS: Separation anxiety disorder may be a neglected diagnosis in adulthood. Formal nosological systems such as the DSM may need to be revised to incorporate adult manifestations of the disorder.
Adult↗
Ethical considerations in the management of asylum seekers on hunger strike.
Hunger strikes have confronted physicians with complex ethical dilemmas throughout history. Asylum seekers under threat of forced repatriation have emerged as a new category of hunger strikers, posing novel challenges for management. The management of 3 Cambodian asylum seekers on hunger strike admitted to a hospital in Sydney, New South Wales, Australia, posted important ethical dilemmas for the physicians and mental health experts involved in their care. Several factors confounded the task of assessment and decision making, including language and cultural barriers, the patients' past exposure to persecution by authorities, and the complexities of the legal procedures being pursued. Different rules appeared to govern the actions of the hunger strikers, the medical team, and the immigration authorities, creating a ¿malignant triangle¿ of mounting confrontation. Recent recommendations for the management of asylum-seeking hunger strikers include the appointment of an external physician of confidence and the writing of a confidential advance directive specifying the hunger striker's wishes about resuscitation in the event of collapse. In addition, we consider the value of constituting an ad hoc ethics committee to advise the responsible physician on points of conflict in managing the hunger strike. The advantages and limitations of these proposals in relation to the particular cultural, historical, and contextual issues relevant to asylum seekers are examined herein.
Advance Directives↗
Anxiety and depression in general practice patients: prevalence and management.
OBJECTIVE: To determine the prevalence of anxiety and depression in general practice patients and assess management of these conditions by general practitioners (GPs). METHOD: A random sample of 212 GPs were approached to be interviewed and to conduct a patient survey and audit on 50 consecutive patient consultations during 1993. PARTICIPANTS: 117 GPs (55% response rate) and 4867 patients (85%) who completed questionnaires suitable for analysis. SETTING: General practices in two areas (divisions of general practice) in Sydney, New South Wales. RESULTS: Thirty-six per cent of patients had abnormal scores on a General Health Questionnaire (GHQ-12); they were more likely to be women or to be unemployed. Twenty per cent of these patients had been treated for depression or anxiety in the previous 12 months; 52% were prescribed drug therapy, and were more likely to be older, male or unemployed. Seventy per cent of patients reported having been offered therapy by their GP that did not involve drugs. Twenty-four per cent had been referred to another health professional; they were more likely to be younger, or men, or patients attending their usual doctor. CONCLUSIONS: A brief screening instrument may improve GPs' detection rate of patients with anxiety or depression. The high prevalence of these conditions in unemployed people deserves particular attention by GPs. Both drug and non-drug therapies are being more appropriately applied in general practice than previously.
Adult↗
Pathological gambling: forensic issues.
OBJECTIVE: The aim of this paper is to review the literature describing the hypothesised link between crime and pathological gambling and its relevance to arguments of diminished responsibility. METHOD: An attempt was made to include all publications in the psychiatry and psychology literature which made reference to pathological gambling and criminal behaviours. Given the limited research in this field, specific unpublished conference papers were also included in the review. RESULTS: Evidence supports the contention that pathological gamblers are at high risk for committing criminal offences in order to maintain their habitual gambling behaviours. An antisocial personality disorder while acting to increase the risk factor is in itself an insufficient explanation for the observed link. As a result of the acceptance of pathological gambling as a psychiatric disorder, the judicial system is being increasingly confronted with an argument of diminished responsibility for gambling-related offences committed by pathological gamblers. CONCLUSION: A diagnosis of pathological gambling does not diminish legal responsibility but is a factor that should be considered in sentencing. Referral to psychiatric services reduces the risk of recidivism.
Adolescent↗