This article describes a culturally sensitive questionnaire for the assessment of the effects of trauma in the Cambodian refugee population, the Cambodian Somatic Symptom and Syndrome Inventory (CSSI), and gives the results of a survey with the instrument. The survey examined the relationship of the CSSI, the two CSSI subscales, and the CSSI items to posttraumatic stress disorder (PTSD) severity and self-perceived functioning. A total of 226 traumatized Cambodian refugees were assessed at a psychiatric clinic in Lowell, MA, USA. There was a high correlation of the CSSI, the CSSI somatic and syndrome scales, and all the CSSI items to the PTSD Checklist (PCL), a measure of PTSD severity. All the CSSI items varied greatly across three levels of PTSD severity, and patients with higher levels of PTSD had very high scores on certain CSSI-assessed somatic items such as dizziness, orthostatic dizziness (upon standing), and headache, and on certain CSSI-assessed cultural syndromes such as khyâl attacks, "fear of fainting and dying upon standing up," and "thinking a lot." The CSSI was more highly correlated than the PCL to self-perceived disability assessed by the Short Form-12 Health Survey (SF-12). The study demonstrates that the somatic symptoms and cultural syndromes described by the CSSI form a central part of the Cambodian refugee trauma ontology. The survey indicates that locally salient somatic symptoms and cultural syndromes need be profiled to adequately assess the effects of trauma.

In this article we illustrate how we utilize acceptance and mindfulness techniques in our treatment (Culturally Adapted CBT, or CA-CBT) for traumatized refugees and ethnic minority populations. We present a Nodal Network Model (NNM) of Affect to explain the treatment's emphasis on body-centered mindfulness techniques and its focus on psychological flexibility. We explain the definition of mindfulness that guides our treatment, and we outline a typology of mindfulness states and show how many of the techniques in our treatment can be analyzed by these categories. We argue that acceptance and mindfulness are therapeutic for refugees and minority populations for several reasons. These include their increasing psychological flexibility, decreasing somatic distress, decreasing rumination, serving as emotion regulation techniques, decreasing the attentional bias to threat, and forming part of a new adaptive processing mode (which in CA-CBT centers on psychological flexibility). We describe the specific ways we teach acceptance and mindfulness with Latino and Southeast Asian refugee populations and present case examples of the treatment of a traumatized Latino and Cambodian patient.

Traumatized Cambodian refugees with PTSD often complain of khyâl attacks. The current study investigates khyâl attacks from multiple perspectives and examines the validity of a model of how khyâl attacks are generated. The study found that khyâl attacks had commonly been experienced in the previous 4 weeks and that their severity was strongly correlated with the severity of PTSD (PTSD Checklist). It was found that khyâl attacks were triggered by various processes--such as worry, trauma recall, standing up, going to a mall--and that khyâl attacks almost always met panic attack criteria. It was also found that during a khyâl attack there was great fear that death might occur from bodily dysfunction. It was likewise found that a complex nosology of khyâl attacks exists that rates the attacks on a scale of severity, that the severity determines how the khyâl attacks should be treated and that those treatments are often complex. As illustrated by the article, khyâl attacks constitute a key aspect of trauma ontology in this group, a culturally specific experiencing of anxiety and trauma-related disorder. The article also contributes to the study of trauma somatics, that is, to the study of how trauma results in specific symptoms in a specific cultural context, showing that a key part of the trauma-somatic reticulum is often a cultural syndrome.

This article explores the nightmares of Cambodian refugees in a cultural context, and the role of nightmares in the trauma ontology of this population, including their role in generating post-traumatic stress disorder (PTSD). Among Cambodian refugees attending a psychiatric clinic, we found that having a nightmare was strongly associated with having PTSD (chi(2) = 61.7, P < 0.001, odds ratio = 126); that nightmares caused much distress upon awakening, including panic attacks, fear of bodily dysfunction, flashbacks and difficulty returning to sleep; that nightmare content was frequently related to traumatic events; that nightmares resulted in a decrease in the sense of "concentric ontology security" (i.e., in an increased sense of physical and spiritual vulnerability in a culture that conceives of the self in terms of concentric, protective layers), including fears of being attacked by ghosts; and that nightmares frequently led to the performance of specific practices and rituals aiming to extrude and repel attacking forces and to create "protective layers." Cases are presented to illustrate these findings. The Discussion considers some treatment implications of the study.

Somatic symptoms are a common clinical presentation of distress among ethnic populations in the USA, particularly traumatized refugees. In this article, we apply a 'multiplex model' of bodily experience to explain how a somatic symptom is evoked, amplified, and generates distress, particularly distress related to post-traumatic stress disorder. We illustrate the multiplex model's applicability to acute episodes of tinnitus (i.e., a buzzing-like sound in the ear) among Cambodian refugees, a common symptom in that group. The article demonstrates the importance of carefully examining somatic symptoms and associated meanings in distressed ethnic populations, especially traumatized refugees, and aims to contribute to a medical anthropology of somatic symptoms.

Posttraumatic stress disorder (PTSD) symptoms were assessed by using the Clinician-Administered PTSD Scale (CAPS) in a consecutive sample of Cambodian refugees attending a psychiatric clinic in the United States. Psychometric properties of the translated CAPS and severity of PTSD-related symptoms were examined. The CAPS demonstrated adequate psychometric properties, including coefficient alpha (92) and item-total correlations (48-85). Of the sample 56% (101/179) met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for current PTSD. Those patients who met criteria for current PTSD had significantly higher CAPS total scores (M = 65.3, SD = 18.1) than those who did not meet the criteria (M = 13.9, SD = 16.7).

The authors outline six steps to develop culturally sensitive treatment for traumatized refugees, which focus on somatic symptoms. Among Cambodian refugees with posttraumatic stress disorder, the authors describe a somatic presentation (viz., neck-focused panic attacks) that forms a key aspect of trauma-related disorder, how those panic attacks are generated, and a treatment that specifically targets those panic attacks. Evidence of treatment efficacy is provided through a multiple-baseline, across-subjects design (N = 3), and one treatment case is described to illustrate clinical presentation and treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Among Cambodian refugees with panic disorder (N = 208), we performed two factor analyses, one with the ASI, another with an Augmented ASI (consisting of the 16-item ASI supplemented with a 9-item addendum that assesses additional Cambodian concerns about anxiety-related sensations). The principal component analysis of the ASI yielded a 3-factor solution (I, “Weak Heart Concerns”; II, “Social Concerns”; III, “Control Concerns”); the Augmented ASI, a 4-factor solution: I, “Wind Attack Concerns”; II, “Weak Heart Concerns”; III, “Social Concerns”; and IV, “Control Concerns.” The item clustering within the factor solution of both the ASI and Augmented ASI illustrates the role of cultural syndromes in generating fear of mental and bodily events.

Consecutive Cambodian refugees attending a psychiatric clinic were assessed for the presence and severity of current tinnitus (i.e., at least one episode in the last month). Fifty percent (52/104) of surveyed patients had tinnitus. Among the tinnitus patients, posttraumatic stress disorder (PTSD) rates were significantly more elevated than among nontinnitus patients (OR=13.5; 95% CI=5.8 to 39.4), as were Clinician-Administered PTSD Scale (CAPS) scores. In a hierarchical regression among tinnitus patients (n=52), tinnitus-related trauma associations and catastrophic cognitions accounted for variability in CAPS severity beyond a measure of tinnitus severity. Among tinnitus patients, tinnitus-related trauma associations and catastrophic cognitions mediated the effect of tinnitus severity on CAPS severity.

Consecutive Cambodian refugees (N = 100) attending a psychiatric clinic were assessed for the presence and severity of current orthostatic panic (OP), which is defined as panic triggered by standing up. The patients with current OP (n = 36) had significantly greater psychopathology than patients without current OP. During OP, trauma associations and catastrophic cognitions were common. Negative affectivity's impact on OP severity was significantly mediated (Sobel test; Baron & Kenny, 1986 ) by orthostasis-associated flashbacks and catastrophic cognitions. In the care of traumatized Cambodian refugees, OP—including associated flashbacks and catastrophic cognitions—should be specifically assessed and treated.

Among a psychiatric population of Cambodian refugees ( N = 100), 42% had current - i.e. at least once in the last year - sleep paralysis (SP). Of those experiencing SP, 91% (38/42) had visual hallucinations of an approaching being, and 100% (42/42) had panic attacks. Among patients with post-traumatic stress disorder (PTSD; n = 45), 67% (30/45) had SP, whereas among those without PTSD, only 22.4% (11/45) had SP (χ2 = 20.4, p < .001). Of the patients with PTSD, 60% (27/45) had monthly episodes of SP. The Cambodian panic response to SP seems to be greatly heightened by elaborate cultural ideas - with SP generating concerns about physical status, ‘good luck’ status,‘bad luck’ status, sorcery assault, and ghost assault - and by trauma associations to the figure seen in SP. Case vignettes illustrate cultural beliefs about, and trauma resonances of, SP. A model to explain the high rate of SP in this population is presented. SP is a core aspect of the Cambodian refugees response to trauma; when assessing Cambodian refugees, and traumatized refugees in general, clinicians should assess for its presence.

We examined the therapeutic efficacy of a culturally adapted cognitive-behavior therapy for Cambodian refugees with treatment-resistant posttraumatic stress disorder (PTSD) and comordid panic attacks. We used a cross-over design, with 20 patients in the initial treatment (IT) condition and 20 in delayed treatment (DT). Repeated measures MANOVA, Group & times; Time ANOVAs, and planned contrasts indicated significantly greater improvement in the IT condition, with large effect sizes (Cohen's d) for all outcome measures: Anxiety Sensitivity Index (d = 3.78), Clinician-Administered PTSD Scale (d = 2.17), and Symptom Checklist 90-R subscales (d = 2.77). Likewise, the severity of (culturally related) neck-focused and orthostasis-cued panic attacks, including flashbacks associated with these subtypes, improved across treatment.

We examined the psychometric properties and factor structure of a Cambodian translation of the Anxiety Sensitivity Index (ASI) and an Augmented ASI (the ASI supplemented with a 9-item addendum that assesses additional Cambodian concerns about anxiety-related sensations). Both the ASI and the Augmented ASI distinguished among three diagnostic groups: highest score, PTSD with panic disorder (PP group); next, panic disorder without PTSD (P group); and then, other disorders than PTSD or panic disorder (O group). In the discriminant function analysis using the Augmented ASI, the best classificatory predictor (PP vs. P vs. O) was an Addendum item (“It scares me when I stand up and feel dizzy”). The principal component analysis (oblimin rotation) of the ASI yielded a 3-factor solution (I, Weak Heart Concerns; II, Control Concerns; III, Social Concerns) and of the Augmented ASI, a 4-factor solution (I, Weak Heart Concerns; II, Control Concerns; III, Wind Attack Concerns; IV, Social Concerns). The item clustering within the factor solution of both the ASI and Augmented ASI illustrates the role of cultural syndromes in generating fear of mental and bodily events.

Consecutive Cambodian refugees attending a psychiatric clinic were assessed for the presence and severity of current--i.e., at least one episode in the last month--neck-focused panic. Among the whole sample (N=130), in a logistic regression analysis, the Anxiety Sensitivity Index (ASI; odds ratio=3.70) and the Clinician-Administered PTSD Scale (CAPS; odds ratio=2.61) significantly predicted the presence of current neck panic (NP). Among the neck panic patients (N=60), in the linear regression analysis, NP severity was significantly predicted by NP-associated flashbacks (beta=.42), NP-associated catastrophic cognitions (beta=.22), and CAPS score (beta=.28). Further analysis revealed the effect of the CAPS score to be significantly mediated (Sobel test [Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182]) by both NP-associated flashbacks and catastrophic cognitions. In the care of traumatized Cambodian refugees, NP severity, as well as NP-associated flashbacks and catastrophic cognitions, should be specifically assessed and treated.

Among Cambodian refugees attending a psychiatric clinic (n = 100), 49% (491 100) had at least one episode of sleep paralysis (SP) in the previous 12 months. The annual and monthly SP prevalences were much higher in posttraumatic stress disorder (PTSD) than in non-PTSD patients. Among the PTSD patients, 65% (30/46) bad monthly episodes of SP versus 14.85% (8/54) among non-PTSD patients (X-2 [2, n = 100] = 26.78, P<.001). Moreover, patients with SP in the last month (n = 30) versus those without SP had much higher PTSD severity scores. In the entire sample In = 100), the PTSD severity scores correlated significantly with the rate of SP in the last month. During SP, Cambodian refugees usually hallucinated an approaching figure (90%, 44/49). The rate of SP-associated and post-SP panic attacks was high, indicating the great distress caused by the phenomenon. SP seems to be a core aspect of the Cambodian refugee's response to trauma. When treating Cambodian refugees, and traumatized refugees in general, clinicians should assess for its presence. Depression and Anxiety 22:47-51, 2005. (c) 2005 Wiley-Liss, Inc.

Olfactory panic attacks have not been systematically assessed in a psychiatric population by any previous studies. Among Cambodian refugees attending a psychiatric clinic, the present investigation determines the following: (a) 1-month current prevalence of olfactory-triggered panic attacks, (b) associated psychopathology (Hopkins Symptom Checklist and the Structured Clinical Interview for DSM-IV-diagnosed posttraumatic stress disorder [PTSD]), and (c) frequency in events of olfactory panic of catastrophic cognitions (Panic Attack Cognitions Scale [PACQ]) and flashbacks (Clinician-Administered PTSD flashback scale). Forty-five percent of 100 consecutive psychiatric patients were found to have suffered an olfactory-triggered panic attack in the previous month; having current olfactory panic attacks was highly correlated with psychopathology (e.g., to PTSD diagnosis: and chi(2)=50.0; df=1; p<.001); and during olfactory-triggered panic attacks, catastrophic cognitions and flashbacks were common. Possible mechanisms for generation of high rates of olfactory-triggered panic attacks in this population are discussed (the "traumatic memory/catastrophic cognitions/interoceptive conditioning/escalating arousal" or "TCIE" model of panic generation) as are treatment implications.