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The death of a loved one - bereavement - is a universal experience that marks the human mental health condition. Grief - the cognitive, emotional, and behavioral responses to bereavement - is thus experienced by virtually everyone at some point in life, while mourning is a process through which grievers come to terms with the loss envisioning life without the deceased. Although distress subsides over time among most bereaved individuals, a minority will develop a condition recently identified as prolonged grief disorder (PGD). The present review provides a global perspective on bereavement, grief reactions, and PGD. Although the loss of a loved one and grief reactions are in general experienced consistently across different cultures, differences and variations in their expression may exist across cultures. Especially within specific populations that may be more at risk for PGD, possibly due to risk factors associated with the mechanisms of loss (e.g., refugees, migrants, and conflict survivors). The diagnostic criteria for PGD are mostly based on Western grieving populations, and cultural adaptations of PGD treatments are limited. Therefore, cross-cultural development and validation of PGD screening/assessment is critical to support future research on grief reactions and PGD, especially in non-Western contexts, and concerning the potential future global changes and challenges that appear to have a major impact on PGD. More transcultural research on PGD is needed to contextualize and will lead to culture-bound symptom identification of PGD, and the adaptation of current treatment protocols, which may ultimately improve health at the individual level, and health-care systems.

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Among the cultural conceptualizations of distress, susto is defined in the DSM-5 as "a cultural explanation of distress and misfortune in Latin America that refers to an illness attributed to a terrifying event that causes the soul to leave the body and leads to unhappiness and illness, as well as difficulties in performing key social functions" (American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: APA, p. 836). Thus, susto represents a cultural explanation that encompasses the symptoms of various mental disorders and physical diseases. We analyzed the descriptions of susto from different scientific fields and related them to definitions of DSM-5 syndromes. Three syndromic subtypes of susto show a symptomatic overlap with depression, post-traumatic stress disorder (PTSD) and somatic disorder. However, linguistic metaphors describing symptoms and perceived causes that are specific for Latin American culture support the concept of susto as a specific idiom of distress (e.g., loss of soul, shadow or ajayu; sunken, closed or white eyes; jumping and screaming in the night; being thrown to the ground). In addition, if diagnostic criteria are met for mental disorders, then susto describes a perceived cause of psychopathological states (e.g., depressive disorder, PTSD, somatic disorder, panic disorder, generalized anxiety disorder). Future research with people who have experienced susto is needed to clarify whether susto precedes the onset of other mental disorders (perceived cause) or whether it is a way of designating distress (idiom of distress).

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OBJECTIVE: This study aims to determine for Syrian refugee women in Turkey the effectiveness, feasibility, and acceptability of culturally adapted cognitive behavioral therapy (CA-CBT). METHOD: Participants were randomly allocated to receive either CA-CBT (n = 12) or treatment-as-usual (TAU; n = 11). We used the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL) to assess posttraumatic stress symptoms and anxious-depressive distress. CA-CBT was delivered through seven weekly group sessions. RESULTS: CA-CBT had a large effect on PTSD (HTQ d = 1.17) and nearly medium effect sizes for anxious-depressive distress (HSCL d = .40). There were also low drop-out rates and an absence of adverse events. CONCLUSIONS: Because CA-CBT greatly reduced PTSD symptoms as compared with TAU and had a low drop-out rate, no adverse events, and was deliverable in a short treatment frame (seven sessions) and in a group format, we conclude that the treatment is effective, acceptable, and feasible and has the potential for scalability. Clinical Impact Statement: A Syrian version of CA-CBT was effective (large effect sizes for the HTQ), feasible, and potentially scalable (easy application, conducted with trained facilitators, short-term therapy, group format), and acceptable (as evidenced by very low drop out and no adverse events). Thus, the Syrian version of CA-CBT appears to be a valuable psychological intervention for traumatized Syrian refugees, particularly given the lack of effective treatments for this group. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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The purpose of this study was to characterize trauma exposure and mental health burden among men who have sex with men (MSM) in Hanoi, Vietnam. Participants comprise 100 HIV-positive and 98 high-risk, HIV-negative MSM, ranging from 18 to 29 years of age. Data were collected using the Childhood Trauma Questionnaire, Traumatic Events Inventory, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and PTSD Symptom Scale. A subset of participants (n = 12) were also interviewed to evaluate community perception of the prevalence, causation, and available treatment options for mental health issues within the MSM community in Vietnam. In our sample, 23.2% reported having experienced moderate-to-severe childhood physical abuse; 18.7% physical neglect; 13.6% emotional abuse; 11.1% emotional neglect; and 26.8% sexual abuse. Such trauma exposure continued into adulthood and manifested most commonly in the form of interpersonal violence. Approximately 37.4% of the sample met the criteria for probable PTSD; 26.8% for moderate-to-severe depression; and 20.2% for moderate-to-severe anxiety. Neither exposure nor mental health burden differed by serostatus. Linear regression revealed that childhood emotional abuse was the only sub-type of trauma significantly associated with depression, anxiety, and PTSD symptoms. The majority of interviewees believed that mental health burden was higher among MSM relative to the general population and attributed this to their vulnerability to interpersonal violence and lack of available coping resources. However, few believed that these mental health issues warranted clinical attention, and only one participant was able to identify a mental health service provider. Our findings suggest that trauma exposure and mental health burden are prevalent among MSM, irrespective of serostatus, and much higher than what has been previously reported among the general population in Vietnam.

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Child trauma and posttraumatic stress in Cambodia is highly prevalent, perpetuated within a postwar sociocultural context. The examination of locally meaningful expressions of distress is needed to provide culturally sensitive assessment and treatment of trauma-affected Cambodian children. The acceptable, feasible, and sustainable incorporation of expressions of distress into assessment and intervention development relies on key mental health professionals operating in Cambodia, who can provide invaluable perspectives on child trauma experiences in this particular sociocultural context. In this study, qualitative interviews were conducted with 15 Cambodian mental health professionals (MHPs) who work directly with trauma-affected Cambodian children. MHPs were presented with seven key posttraumatic problems derived from previous qualitative interviews with Cambodian children and caregivers, and discussed 1) the causes of these problems, 2) the impact of the problem on the child or those around them, 3) the current treatment for the problem in Cambodia, and 4) recommended treatment. MHPs provided unique insights and perspectives of trauma-affected children in the Cambodian context regarding key target problems, including palpitations, difficulties in school, headache, and thinking too much, and highlighted future directions for assessment and intervention. Recommendations are discussed in regard to programming design and organizational training development to promote culturally salient, feasible, and sustainable mental health service provision in Cambodia.

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More than half of all children in Cambodia experience direct abuse and over 70% experience other traumatic events, which significantly increase their risks for a range of physical and mental health problems. Additionally, Cambodian children face longstanding sociopolitical, intergenerational, and cultural factors that compound the impact of other trauma. As a result, rates of posttraumatic stress symptoms among Cambodian youth are high. However, care providers often rely on Western-based nosology that does not account for culturally specific expressions of trauma. A greater understanding of culturally-salient expressions of distress can help inform diagnostic assessment accuracy and treatment effectiveness and monitoring. The current study utilized a qualitative design to interview 30 Cambodian caregivers of children with trauma experiences and 30 Cambodian children (ages 10-13 years) with trauma experiences to identify key local expressions of trauma. Findings reveal certain PTSD symptoms and culturally-specific frequent and severe trauma-related problems for Cambodian children and domains of functioning impacted by trauma. Certain symptoms seem particularly important to evaluate in this group, such as anger, physical complaints (e.g., headache and palpitations), and cognitive-focused complaints (in particular, "thinking too much"). All caregivers and children reported physical health as impacted by trauma-related problems, highlighting a particularly salient domain of functioning for this population. Expressions of distress explored in the current study are discussed in the context of assessment and intervention development to inform diagnostic and clinical efforts for those working with trauma-exposed Cambodian children.

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Clinical variation in the expression of panic disorder, depression and anxiety, and posttraumatic stress disorder (PTSD) has have been documented across cultures. However, local (emic) cultural models that explain how people make sense of their illness experiences remain relatively understudied in India among trauma-exposed populations. Further, the integration of emic findings into clinical care is limited, underscoring the need for emic perspectives following trauma to improve the development or adaptation of trauma-focused treatments in India. This study describes an emic explanatory model of distress, which includes idioms of distress, perceived causes of distress, and coping/help-seeking behaviors among Indian women from slums reporting gender-based violence. This explanatory model can be used as a culturally grounded way to develop clinical case conceptualizations to adapt and deliver psychological treatments for this under-served population.

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This article introduces Walking Corpse Syndrome, a common idiom of distress in Tamil Sri Lanka that is characterized by a variety of cognitive difficulties, feelings that an individual is functioning reflexively or impulsively, and acute attacks of dissociation that are accompanied with the sensation of empty-headedness. Walking Corpse Syndrome demonstrates some overlap with Western nosology, although it appears to be its own unique illness category, most likely of Ayurvedic provenance. The article comprises two studies. One is a secondary interview analysis of community members that aimed to identify the key symptoms of Walking Corpse Syndrome, allowing us to determine the local ethnopsychology of the syndrome and to elicit illustrative vignettes. The other study is a survey of Sri Lankan Tamil psychiatrists that aimed to investigate their understanding and experience of the disorder. This article outlines how, in certain cultural contexts, such syndromes emphasise the loss of attentional capacity and forgetfulness; it highlights the importance of "thinking a lot" as an idiom across cultures; and it details the many ways that Walking Corpse Syndrome is a key idiom of distress to assess in order to give adequate mental healthcare to Sri Lankan Tamil populations.

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At a psychiatric refugee clinic for survivors of the Khmer Rouge genocide, a survey revealed that 42% (38/90) had auditory hallucinations (AHs) in the last month. Of those with AHs, 87% (33/38) had PTSD, whereas of those without AHs, 31% (16/52) had PTSD, giving a chi square of 27.8, p < .001, odds ratio 14.8 (4.8-45). Most AHs were of a "ghost summoning" (khmaoch hao), considered an exhortation to go with a ghost (e.g., hearing "Please come with me, younger sister"), experienced by 73% percent of patients with AHs. The voices were always exterior and usually loud and clear. AHs were heard most often during hypnagogia (i.e., upon falling asleep or awakening), experienced by 72% of patients with AHs, whereas 42% of patients with AHs experienced AHs when fully awake. AHs were almost always attributed to a ghost, giving rise to great fear: of having the "soul" called away or of being frightened to death. AH episodes almost always triggered trauma recall. AHs caused patients to undertake certain actions to address acute episodes and to prevent further ones. To illustrate these processes, cases are provided. AH appears to be a key part of the Cambodian bioculturally shaped trauma subjectivity.

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The present study examined explanations of sleep paralysis (SP) in Turkey. The participants were 59 college students recruited in Istanbul, Turkey, who had experienced SP at least once in their lifetime. Participants were administered the Sleep Paralysis Experiences and Phenomenology Questionnaire (SP-EPQ) in an interview. When asked whether they had heard of a name for SP, the vast majority (88%) mentioned the "Karabasan"-a spirit-like creature rooted in Turkish folk tradition. Seventeen percent of the participants believed that their SP might have been caused by this supernatural creature. Thirty-seven percent of participants applied various supernatural and religious methods to prevent future SP attacks such as dua (supplicating to God), reciting the Quran, and wearing a musqa (a type of talisman inscribed with Quranic verses). Case studies are presented to illustrate these findings. The Karabasan constitutes a culturally specific, supernatural interpretation of the phenomenology of SP in Turkey.

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Previous research has found supernatural beliefs about sleep paralysis (SP) to be very prevalent in Italy, with over one third of SP sufferers believing that their SP might have been caused by a supernatural creature known locally as the Pandafeche. The current study further examined features of SP in Italy. All participants had experienced SP at least once in their lifetime. Participants were recruited from the general population (N = 67) in the region of Abruzzo. The Sleep Paralysis Experiences and Phenomenology Questionnaire (SP-EPQ) was orally administered to participants. As hypothesized, we found that Italians from the general population reported high lifetime rates of SP, prolonged duration of immobility during the event, and great fear of the experience (with as many as 42% of SP sufferers fearing that they could die from the experience), all of which were particularly elevated as compared to cultures where there are no such elaborate traditions of SP (e.g., Denmark). In addition, 78% of participants experienced some type of hallucination during their SP. The results we present here suggest that cultural beliefs about SP in Italy (e.g., as being caused by the Pandafeche, as reported elsewhere) potentially can profoundly shape certain aspects of the experience - a type of mind-body interaction.

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The Anxiety Sensitivity Index (ASI) measures fears of anxiety-related symptoms based on respondent beliefs about their harmfulness. This is the first network analysis of anxiety sensitivity and PTSD, and the first to explore an addendum of culturally salient fears in such an analysis. The purpose of our study was to test whether relations among PTSD symptoms and facets of anxiety sensitivity, observed clinically, can be visualized by this approach. Using network analysis, we examined in a Cambodian population the relationship of PTSD symptoms to the standard Anxiety Sensitivity Index (ASI) and to an ASI Cambodian Addendum (ASICA) that taps culturally salient fears of somatic symptoms among Cambodians not assessed in the standard ASI. Computing relative importance networks, we found that the ASI subscales, ASICA, and PTSD subscales were strongly interconnected, with the ASICA having the strongest outstrength centrality. In the network analysis of the ASI subscales, disaggregated ASICA, and PTSD subscales, several of the ASICA items had very high outstrength. The results show that fear of mental and physical symptoms of anxiety should be a key part of the evaluation of trauma-related disorder, and that those fears should be targeted. It also suggests the need for ASI addenda to assess concerns about anxiety symptoms salient for certain cultures that are not assessed by the standard ASI: among Cambodian populations, fear of cold hands and feet, "out of energy in the arms and legs," neck soreness, tinnitus, and dizziness on standing.

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Culturally adapted cognitive behavioral therapy (CA-CBT) is a well-evaluated, transdiagnostic group intervention for refugees that uses psychoeducation, meditation, and stretching exercises. In the current study, we added problem-solving training to CA-CBT and evaluated this treatment (i.e., CA-CBT+) in a randomized controlled pilot trial with a sample of Farsi-speaking refugees. Participants (N = 24) were male refugees diagnosed with DSM-5 PTSD, major depressive disorder, and anxiety disorders who were randomly assigned to either a treatment or waitlist control (WLC) condition. Treatment components were adapted both to the specific cultural background and the current social problems of asylum seekers. Assessments were performed pretreatment, 12-weeks posttreatment, and 1-year follow-up. The primary treatment outcome was the General Health Questionnaire (GHQ-28); secondary outcome measures included the Posttraumatic Stress Disorder Checklist, Patient Health Questionnaire, Somatic Symptom Scale, World Health Organization Quality of Life, and Emotion Regulation Scale. Eleven of 12 participants were randomized to CA-CBT+ completed treatment. Based on intent-to-treat data, large between-group effect sizes were seen at posttreatment in the GHQ-28, d = 3.0, and for most secondary outcome measures. Improvements for individuals in the treatment group decreased at 1-year follow-up, but effect sizes demonstrated continued large improvements on all measures as compared to pretreatment levels. In summary, CA-CBT+ led to large improvements in general psychopathological distress and quality of life, which were maintained in the long term. In addition, the dropout rate was very low, with delivery in group format. Thus, problem-solving training appears to be a promising addition to CA-CBT.

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Sleep paralysis (SP) is a psychobiological phenomenon caused by temporary desynchrony in the architecture of rapid eye movement (REM) sleep. It affects approximately 7.6% of the general population during their lifetime. The aim of this study was to assess (1) the prevalence of SP among Polish students in Lublin (n = 439) using self-reported online surveys, (2) the frequency of SP-related somatic and psychopathologic symptoms, and (3) the factors potentially affecting the occurrence of symptoms among people experiencing SP. We found that the incidence of SP in the Polish student population was slightly higher (32%) than the average prevalence found in other student populations (28.3%). The SP clinical picture was dominated by somatic symptomatology: 94% of respondents reported somatic symptoms (most commonly tachycardia, 76%), 93% reported fear (most commonly fear of death, 46%), and 66% reported hallucinations (most commonly visual hallucinations, 37%). The number of SP episodes was related to sleep duration and supine position during sleep. The severity of somatic symptoms correlated with lifestyle variables and anxiety symptomatology. Our study shows that a significant proportion of students experience recurrent SP and that this phenomenon is associated with fear and physical discomfort. The scale of the phenomenon requires a deeper analysis.

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Ghost encounters were found to be a key part of the trauma ontology among Cambodian refugees at a psychiatric clinic, a key idiom of distress. Fifty-four percent of patients had been bothered by ghost encounters in the last month. The severity of being bothered by ghosts in the last month was highly correlated to PTSD severity (r = .8), and among patients bothered by ghosts in the last month, 85.2% had PTSD, versus among those not so bothered, 15.4%, odds ratio of 31.8 (95% confidence level 11.3-89.3), Chi square = 55.0, p < .001. Ghost visitations occurred in multiple experiential modalities that could be classified into three states of consciousness: full sleep (viz., in dream), hypnagogia, that is, upon falling asleep or awakening (viz., in sleep paralysis [SP] and in non-SP hallucinations), and full waking (viz., in hallucinations, visual aura, somatic sensations [chills or goosebumps], and leg cramps). These ghost visitations gave rise to multiple concerns-for example, of being frightened to death or of having the soul called away-as part of an elaborate cosmology. Several heuristic models are presented including a biocultural model of the interaction of trauma and ghost visitation. An extended case illustrates the article's findings.

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This article outlines key dimensions of culturally sensitive cognitive-behavioral therapy (CBT), and examines the application to Southeast Asian populations. Our treatment, culturally adapted (CA) multiplex CBT, was initially developed to treat traumatized Southeast Asian refugees, and has been shown to be efficacious for those and other groups. As described in the article, CA multiplex CBT is based on the multiplex model of distress generation and our conceptualization of key dimensions of culturally sensitive and effective treatment. We will describe why our CA-CBT may have applicability to Asian populations more generally, for example, due to its emphasis on mindfulness, contextual sensitivity (viz., flexibility), somatic complaint, and somatic-focused emotion regulation (e.g., applied stretching). We illustrate key dimensions of CA treatment, giving examples from how these principles are employed in CA multiplex CBT. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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In a large national survey in Cambodia (N = 2689), the present study investigated the prominence of certain culturally salient symptoms and syndromes in the general population and among those with anxious-depressive distress (as determined by the Hopkins Symptom Checklist-25, or HSCL). Using an abbreviated Cambodian Symptom and Syndrome Addendum (CSSA), we found that the CSSA complaints were particularly elevated among those with anxious-depressive distress. Those with anxious-depressive distress had statistically greater mean scores on all the CSSA items as well as severity of endorsement analyzed by percentage: among those with HSCL caseness, 75.3% were bothered "quite a bit" or "extremely" by "thinking a lot" (vs. 27.5% without caseness); 53.8% were bothered by "standing up and feeling dizzy" (vs. 13.8%); and 45.6% by blurry vision (vs. 16.8%). In a logistic regression analysis to predict anxious-depressive distress, 51% of the variance was accounted for by five predictors: "weak heart," "thinking a lot," dizziness, "khyâl hitting up from the stomach," and sleep paralysis. Using ROC analysis, a cut-off score of 1.81 on the CSSA was optimal as a screener to indicate anxious-depressive distress, giving a sensitivity of 0.86. The study results suggest that to avoid category truncation (i.e., the omission of key complaints that are part of an assessed distress domain) when profiling anxious-depressive distress among Cambodia population that items other than those in standard psychopathology measures should be assessed such as "thinking a lot," "weak heart," "blurry vision," and "dizziness upon standing up."

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The most common mental health problems among adolescents are anxiety and mood disorders. While disorder-specific cognitive behavior therapy (CBT) is effective for each of these conditions, the comorbidity between anxiety and mood disorders indicates a need for the development of evidence-based transdiagnostic treatments. To examine the efficacy of culturally adapted transdiagnostic CBT (CA-CBT) in reducing symptoms of anxiety and depression in treatment-resistant Turkish adolescents, 13 adolescent participants with anxiety or mood disorders who were treatment resistant received 10 sessions of CA-CBT in group format. The main outcome measures were the Screen for Childhood Child Anxiety Related Disorders (SCARED), Beck Depression Inventory (BDI), and the Turkish Symptom and Syndrome Addendum (TSSA), which were assessed at baseline, posttreatment, and at 2-month follow-up. At posttreatment, there were large effect sizes for all measures: depression scores (BDI, d = .9), anxiety scores (SCARED, d = 1.1), and the Turkish Symptom and Syndrome Addendum (TSSA, d = 1.6). Moreover, at 2-month follow-up, depression and anxiety symptoms were either maintained or continued to improve such that from pretreatment to follow-up the effect sizes were as follows: depression scores (BDI, d = 1.4), anxiety scores (SCARED, d = 1.7), and the Turkish Symptom and Syndrome Addendum (TSSA, d = 2.4). In addition, there were no dropouts across treatment. This open trial suggests that CA-CBT is effective in reducing anxiety and depression symptoms and that the treatment is well accepted. A full randomized controlled trial to verify the effectiveness of transdiagnostic CA-CBT in similar populations is needed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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Forcibly displaced persons confront multiple stressors while awaiting permanent asylum or resettlement and often experience high levels of emotional distress. This study assessed an 8-week somatic-focused culturally adapted cognitive-behavioral therapy (CBT) group intervention with 39 female refugees from Afghanistan living in Kuala Lumpur, Malaysia. Twenty-nine participants were randomly assigned to treatment conditions, resulting in 20 participants in two separate treatment groups and 9 in a waitlist control group. An additional 10 participants were not randomly assigned and therefore were treated as an additional treatment group and analyzed separately. A three-group piecewise linear growth model was specified in Mplus using Bayesian estimation. Dependent variables included emotional distress, anxiety, depression, posttraumatic stress, and social support. From baseline to posttreatment assessments, initial intervention participants experienced significant declines in emotional distress (b = -16.90, p < .001), anxiety (b = -.80, p < .001), depression (b = -.59, p < .001), and posttraumatic stress (b = -.24, p < .05). Gains were maintained three months posttreatment, with similar trends observed among nonrandomized participants. Subsequent to receiving treatment, the waitlist control participants also showed significant declines in emotional distress (b = -20.88, p < .001), anxiety (b = -1.10, p < .001), depression (b = -.79, p < .001), and posttraumatic stress scores (b = -.82, p < .001). Comparing the treatment groups to the waitlist control group revealed large effect sizes: Cohen's d was 2.14 for emotional distress, 2.31 for anxiety, 2.42 for depression, and 2.07 for posttraumatic stress. Relevant public health findings include low drop out, group format, and facilitation by a trained community member. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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Recent changes in U.S. immigration policies and enforcement have precipitated a 300% rise in arrests and planned deportations. Although some family members face deportation, other family members may have state-sanctioned status. Such mixed status puts hundreds of thousands of families at risk of forced separation and associated mental health problems. Building on cross-cultural work with refugee families and other groups and on work with families separated by parental incarceration, the authors provide recommendations to guide clinicians working with families who are separated or who fear separation. Mental health problems among separated families can in part be addressed through identifying the origins of distress, elucidating family structures and roles, strengthening communication practices, linking with legal and economic resources, and facilitating decision making through distress reduction.

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