Download 1st ptsd and cb and cs sudanese

Cross-Cultural Perceptions:
Posttraumatic Stress Disorder
(PTSD)
and
“Cultural Bereavement”
Definition of “Trauma”
“Trauma” was initially a medical term referring
to a wound. However, it also began to be
used to refer to an emotional wound.
By definition, emotional trauma is "emotional
shock producing a lasting effect on a person"
(Oxford, 1980, s.v. "trauma").
Trauma definition
We all use the word "trauma" in every day
language to mean a highly stressful event.
But the key to understanding traumatic events
is that it refers to extreme stress that
overwhelms a person's ability to cope.
There are no clear divisions between stress
which leads to trauma and that which leads to
adaptation.
Psychological and physiological
Although we are talking about psychological
trauma, it is also important to keep in mind
that stress reactions are clearly physiological
as well.
Trauma definition
Psychological trauma is the unique individual
experience of an event or enduring conditions, in
which:
1. The individual's ability to integrate (coping) his/her
emotional experience is overwhelmed, or
2. The individual experiences (subjectively) a threat to
life, bodily integrity, or sanity. (Pearlman &
Saakvitne, 1995, p. 60)
Exposure to potentially Traumatic
Situations vs
“Being Traumatized”
Trauma is defined by the subjective experience
of the survivor.
Two people could undergo the same event and
one person might be traumatized, while the
other person remained relatively unscathed.
Trauma is subjective
It is not possible to make blanket
generalizations such that "X is traumatic for
all who go through it" or "event Y was not
traumatic because no one was physically
injured."
You cannot assume that the details or meaning
of an event that are most distressing for one
person will be same for another person.
What is PTSD?
PTSD is a concept introduced by the American
Psychological Association, first appearing in 1980
(see DSM III-IV),
And based on specific symptom patterns found
among some survivors of traumatic experiences in
the US (initially Vietnam war veterans) and
elsewhere.
PTSD
Post Traumatic Stress Disorder (PTSD)
– is considered a normal reaction to a
potentially traumatic event such as war,
torture, rape, natural disasters, etc.
However, it is still classified as a “mental
disorder” within the DSM system.
Who develops PTSD?
PTSD may affect some persons whose
coping mechanisms are overwhelmed,
but not everyone exposed to a certain
event will go on to develop PTSD,
…just as not everyone will become
“traumatized” by virtue merely of having
lived through or witnessed violence.
DSM IV
PTSD is characterized by intrusive,
hyper-aroused, and avoidant
symptoms related to the original
(potentially traumatic) stressor.
PTSD is an Anxiety Disorder in the DSM IV
classification.
PTSD Symptom Prevalence:
Several studies, including those in post-conflict
settings, indicate that approximately 25-33%
of persons exposed to an extreme
stressor/ violence experience will go on to
develop PTSD symptoms (Breslau et al 1991,
Kilpatrick et al 1992).
Aprox 70% of persons exposed to a traumatic stressor
will NOT develop PTSD symptoms. This may point
to a certain level of inherent resilience/ coping
skills among the majority.
Co-morbid Disorders
The two most frequently co-morbid (occurring at the
same time) disorders with PTSD are substance
abuse and major depression, both of which may be
accompanied by a high risk of suicide.
80% of persons with long-term PTSD suffer from
depression, another anxiety disorder, or substance
abuse (International Society for Traumatic Stress Studies, 2000).
Who is most likely to develop PTSD
symptoms?
 those who experience greater stressor
magnitude, intensity, and duration;
 those who experience stressors with a sexual
assault component;
 those with limited social support;
 those with a social environment that
produces shame, guilt, stigmatization, or
self-hatred;
 those with concurrent stressful life events.
PTSD Cluster Symptoms
(A, B, C, D):
A. STRESSOR – exposure to (an extreme)
stressor outside the range of “normal human
experience”.
B. INTRUSIVE
 Having nightmares
 “Flashbacks”/ invasive memories of the event
PTSD Symptoms cont.
C. AVOIDANT/ NUMBING
 Trouble remembering
 Avoiding people or places that are reminders
 Numb, unable to feel any emotions (joy or pain)
 Sense of foreshortened future
D. (Hyper) AROUSAL
 Feeling “jumpy” all of the time, exaggerated
startle response
 Difficulty concentrating
 Difficulty sleeping
 Bursts of anger, yelling or crying frequently
Includes impaired functioning/subjective
distress – symptoms must be present for 1 month
The diagnosis of PTSD means that symptoms are
interfering significantly with relationships or work
(as confirmed by the subjective perception of the
person), and that overall functioning of the
individual has been reduced.
In order to receive a diagnosis of PTSD, the
symptom pattern related to avoidance, arousal,
and intrusive behaviors and feelings must have
been present for at least 1 month.
Onset of symptoms
Symptoms can appear immediately after exposure
or years later in response to a “trigger”.
Example, adult survivors of childhood abuse with
children…
Following onset, symptoms are usually characterized
as chronic and recurrent for the majority of those
with PTSD if left untreated. A few will however,
spontaneously recover without treatment.
Ethno-cultural Research
Several studies and existing biological
research suggest there is a universal
biological response to traumatic events
(A. Marsella et al 1993).
For example, intrusive thoughts/memories or
“flashbacks” may transcend culture.
Ethno-cultural Research
However,
Avoidance/ numbing and arousal symptoms
may be more specific to various cultural
groups;
Some cultural groups may be more likely to
describe physical symptoms (somatic
complaints);
Ethno-cultural Research
Ethno-cultural factors appear to play more of a
role in individual vulnerability to PTSD (ieprevalence rates within various cultures).
People from some cultures may be more
resilient, have better coping skills or
protective factors.
Some cultures also vary in PTSD treatment
responsiveness (ex: CBT).
Criticisms of PTSD Diagnosis
(see Summerfield, D.)
Labels people as “mentally ill” when they are not.
It is a culturally specific concept that supports culturally
specific interventions based on biomedical systems that
are stigmatizing (ie – “disorder”).
People from some cultures do not respond well to some
types of interventions that arise from this diagnosis (ex:
success of cognitive and behavioral therapy).
Just because we can ID similar symptom patterns does
not mean that these symptoms have the same meaning
in different cultures. What about the symptoms we can’t
ID (using DSM descriptions)?
Criticisms of PTSD Diagnosis (cont.):
It attempts to replace traditional indigenous
knowledge and meaning systems with an
alternative “truth” (cultural imperialism).
Focuses on the individual self to the exclusion
of the communal context. The individual
receives the diagnosis, not the family or
community system.
An Alternative:
Cultural Bereavement
The term was initially introduced by M.
Eisenbruch in 1991 during research with
Cambodian refugees:
Toward a culturally sensitive DSM: Cultural
bereavement in Cambodian refugees and
the traditional healer as taxonomist.
Cultural Bereavement
Is suggested that although the symptoms of CB
may resemble PTSD to some extent, is not
intended to be an alternative DSM diagnosis, but
a term used to describe a part of a healthy
rehabilitative response to multiple loss,
migration and acculturation pressures at a
community level.
Attempts to give voice to alternative perspectives
and provide a “culturally correct taxonomy”.
Cultural Bereavement
Symptoms result from loss of home, identity,
cultural values, social networks,
institutions, routines and surroundings,
acculturative stress and pressures of
adaptation….not necessarily only from
exposure to what we usually consider to be
an initially (single) traumatic stressor.
Cultural Bereavement - Symptoms:
1.
2.
3.
4.
5.
6.
7.
8.
Continuing to “live in the past”;
Visitation by supernatural forces when asleep or
awake;
Feelings of Guilt;
Trying to hold onto memories of the past;
(But) experiencing pain if memories of the past
intrude into daily life;
Yearning to complete obligations to the dead;
Constantly struggling with various anxieties, morbid
thoughts and (uncontrollable) anger;
Inability to function well in daily tasks due to the
above.
Friedman and Jaranson in The Applicability of
PTSD to Refugees conclude:
“We believe that (cultural bereavement) is
complementary but certainly not an appropriate
substitute for a PTSD focus…having reviewed
criticisms of the PTSD model, we can not find any
reason to reject it….concerns are easily
incorporated into a clinical approach to refugees
based on the PTSD model…we believe it offers a
useful conceptual and theoretic approach to the
psychological impact of trauma on refugees from
all ethnocultural backgrounds.”
Do you agree?
1. Case Study: review the criteria for a PTSD diagnosis
and the criteria for cultural bereavement.
2. How would you conceptualize the symptom patterns
exhibited by the client in the case study?
3. What implications might the conceptual framework
you chose to embrace have for survivors selfperception and treatment interventions?