Archive for the 'panic disorder' Category

Publication: Review of posttraumatic cultural concepts of distress

Although not every human culture would recognize psychological terms as we use them in North America and Europe, every culture has ways of talking about how individuals feel, and every culture has terms that describe extreme and abnormal versions of these feelings. Cultural concepts of distress are those culturally-specific ways that people from within a given group express their psychological distress. For example, Cambodians talk about a khyal attack” as an experience whereby “wind” that flows naturally through the body (akin to chi in Chinese medicine) is blocked from exiting, causing problems that Western psychologists would call symptoms of panic attack (if you’re at all curious, you really should visit the website dedicated to explaining khyal attack).

A couple of colleagues and I recently published a review in Social Science and Medicine of the symptoms that are included in the various ways that different cultures think about the emotional distress following trauma. Our review included 55 studies and identified 116 different cultural concepts of distress. We categorized these concepts based on their symptoms (using hierarchical cluster analysis), and found that the 116 concepts could be described in four basic categories: (1) somatic dysphoria, which largely concerned bodily complaints; (2) behavioral disturbances, “odd” behavior (relative to cultural norms), (3) anxious dysphoria, which as its name implies included lots of anxiety; and (4) depression, which was surprisingly similar to depression as it appears in North American and European medicine. Notably, none of these groups of concepts looked like the psychological disorder that most mental health professionals in North America and Europe think of when they think about trauma — posttraumatic stress disorder, or PTSD.

Of course there are all sorts of limitations to our review, and some would argue that the way we categorized cultural concepts of distress using symptoms alone misses the point of the diversity of these concepts globally (which is broader concerning explanations for distress than it is concerning symptoms). Others would argue that PTSD is actually somewhere in the mix of concepts we reviewed. I’d like to think our review is a starting point for discussion of these issues, rather than a definitive answer to any of these questions.

You can find a link to the publication in Social Science and Medicine here.

NPR puts mental health after buildings in Haiti; now we’re getting it

This morning, bleary eyed and half asleep, I turned on National Public Radio’s Morning Edition, as I do pretty much every morning of the week. Following a feature on structural instability of buildings in Port Au Prince, Haiti, Alix Spiegel reported on the field of disaster mental health. Usually popular depictions of my field make me cringe — stories of mass trauma, generations of psychological damage, and heroic psychologists healing the unthinkable are everywhere these days — but today I was delightfully surprised.

They came after the Oklahoma City bombing, and flooded Sri Lanka in the wake of the South Asian tsunami. They came in droves to New York after 9/11. And according to Richard Mollica, a professor at Harvard who’s spent his life researching mental health responses to natural and man-made disasters, mental health professionals will soon come to Haiti as well.

“There’s going to be many, many, many, many hundreds of organization—– big, little and small—– doing mental health work in Haiti, “ Mollica says. “ And they will all have their own agenda, and their own donors, and their own goals.”

All will come with the best of intentions, says Mollica, but the work of a mental health professional in the aftermath of a major disaster like Haiti’s isn’t always clear. The science of how to treat psychological trauma is still very much evolving.

“Mental health has had a hard time figuring out how to fit in with the medical response,” says Mollica. Apparently while mending a broken leg is a straight forward process, mending a broken heart is much more fraught.

Okay, so “broken heart” is not what psychologists treat (usually), but other than that, the story’s pretty good. Why? First, as you can read above, the primary issue is coordination of services, as outlined by Richard Mollica (Harvard luminary in disaster mental health). Second, the piece provides a healthy dose of criticism of how our field’s embrace of PTSD as the main trauma-related problem led us to limit our thinking for what we should do (from Sandro Galea, PTSD research wunderkind). Third (and related to the second), there’s a good discussion of critical incident stress debriefing (mistakenly referred to as simply “debriefing”), which may have resulted in more people developing PTSD than would have if they had simply been left alone. Finally, as Dr. Mollica points out, psychological first aid is really more like social work 101:

The funny thing about “psychological first aid” though, is that there’s very little that’s particularly “psychological” about it. Mollica says it’s mostly very practical, basic social work.

“You can’t find your son? Well, this is who you need to talk to at the Red Cross to find your son. You don’t have enough water for tonight? This is who you need to talk to to get water for yourself.”

A couple weeks ago, I wrote in these blog pages that we really haven’t gotten much further than this. This is still true, but there is, according to Charles Marmar in an NYU Psychiatry Grand Rounds a few weeks ago, work afoot to test a behavioral treatment for the acute phase of trauma reactions (disclosure: Dr. Marmar is one of my bosses, and I like the guy). Based on  cognitive behavioral treatment for panic attacks, this treatment would involve anxiety reduction through brief education about reactions to trauma, breathing control, muscle relaxation, and thought stopping (a basic CBT technique). It would not involve reviewing or processing the trauma expereince, contraindicated in the acute posttrauma phase (the problem with critical incident stress debriefing).

In his talk, Marmar emphasized what Mollica alluded to this morning: “Mental health intervention the absence of basic needs is generally not effective.” So let’s make extra sure that mental health relief provided to Haiti follows material relief (as it did on NPR this morning).


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