Symptom Presentation and Symptom Meaning Among Traumatized Cambodian Refugees: Relevance to a Somatically Focused Cognitive-Behavior Therapy

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Abstract

Among psychologically distressed Cambodian refugees, somatic complaints are particularly prominent. Cambodians interpret anxiety-related somatic sensations in terms of “Wind” (khyâl), an ethnophysiology that gives rise to multiple catastrophic interpretations; and they have prominent trauma-memory associations to anxiety-related somatic symptoms. In this article, we detail some of the common sensation-related dysphoric networks of Cambodian refugees, focusing on catastrophic cognitions and trauma associations. We argue that delineating symptom-related dysphoric networks is crucial to successfully adapt cognitive-behavioral interventions to treat panic disorder and posttraumatic stress disorder among Cambodian refugees, and that such an approach may be useful for the culturally sensitive adaptation of cognitive-behavior therapy for other traumatized non-Western groups.

Section snippets

The Somatization of Trauma-Related Distress Among Cambodian Refugees: The Role of Cultural Syndromes and Ethnophysiology

To understand a particular group’s catastrophic cognitions about anxiety symptoms, one must research (a) its anxiety-related cultural syndromes, determining whether these cause syndrome-generated catastrophic cognitions, and (b) its ethnophysiological models of how anxiety symptoms occur, determining whether these cause ethnophysiology-generated catastrophic cognitions (Hinton et al., 2005, Hinton et al., 2006). In the following section, we will illustrate how Cambodian cultural syndromes about

Trauma Associations to Somatic Symptoms

As is clear, cognitive-behavioral interventions adopt a tactic far different from cultural expectation; hence, the cognitive-behavior therapist faces the task of shifting beliefs about the appropriate response to these symptoms. However, attending to symptom interpretation—in terms of the pathomechanics of Wind—provides only a partial picture of anxiety-related distress in Cambodian patients. The meaning of these sensations in relation to trauma memories also needs to be considered. As

Metaphoric Resonances to Somatic Symptoms

Hayes, Strosahl, and Wilson (1999, p. 39) demonstrate the importance of semantic networks—e.g., the metaphoric and literal meaning of the word “trapped”—in the formation of panic-related conditioning. Often a somatic symptom will have correlated metaphors of distress; these metaphors, which vary by culture, guide somatization and affect the selection—as a result of emotional valences and meaning—of the symptom of anxious concern (e.g., cardiophobia, Eifert, 1992; see too, Kirmayer, 1984).

Sensation-Related Catastrophic Cognitions, Trauma Associations, and Metaphors

Cambodians may face a particularly vicious “one-two-three punch” of associations to the somatic sensations of anxiety (Hinton et al., in press, Hinton et al., 2006): first, fear of the potentially dire implications of “heart weakness” and of dysregulation of Wind flow; second, tragic and overwhelming memories of distant traumas; and third, the evocation of metaphoric resonances to the sensation, bringing to mind current life distress, such as unpaid bills and a gang-involved child.

Anger

Several studies illustrate that anger plays an important role in the psychopathology of Southeast Asian refugees. Abe, Zane, and Chun (1994) found that Southeast Asian patients with PTSD demonstrated significantly higher scores on the Anger Reaction Index than patients without PTSD, including higher levels of both expressed and experienced anger. Similarly, in a study of Vietnamese refugees using the Symptom Checklist (SCL), of the 9 items that were able to differentiate between patients with

Assessing Cambodian Refugees Using Standardized and Culturally Sensitive Measures

Below we will review measures that have been validated among Cambodian populations, and suggest others that may be useful in assessment.

Concluding comments: somatic-focused CBT for traumatized refugees

Among Cambodian refugees, symptom presentations tend to be somatic, and the meaning and interpretation appears to be richly dependent on culture-related beliefs, as in the Wind ethnophysiology and associated worries about the dangers of Wind blockade. Attending to these beliefs, and the cultural expectations for treatment, helps the cognitive-behavior therapists to better design cognitive and exposure interventions to alleviate fears underlying PTSD and panic. Anger and guilt also represent

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