Video: Trauma and Resilience
with Dr. Meb Rashid (Medical Director, The Crossroads Clinic, Women's College Hospital)
It's interesting. When we look at the rates of PTSD in refugee populations, you'll find that the rates really vary in the literature from very low numbers to very high numbers, which tells us that there's probably a problem with the methodology. And we can certainly see why when we look at those studies. Some use questionnaires, some are interview-based, some are cross-sectional, some will follow people for a long period of time. I think for me the important message is that, although the vast majority of people we see in our clinic are refugees and have suffered from immense trauma, not all of them are broken from that trauma. So we see a number of people who have lived through things that for many of us would be horrific but it's really quite, for me, inspiring to see how many of them arrive here and are really eager to put their lives back together. They're not suffering from those symptoms that really define things like posttraumatic stress disorder or depression. Now that's not to say they wouldn't have been affected by their trauma. The way they view the world, the way they look at relationships might be affected by what they've experienced, but it doesn't necessarily mean they're broken from it. So there was one very interesting study in the Journal of the American Medical Association that came out in the late 90s and it was after Rwanda and although we can look at the methodology and analyze that, I think what's most instructive for me was that they found rates of PTSD to be 25%, which are incredibly high in a population-based cohort. But given what people endured in a place like Rwanda where, you know, it's really in many ways a testimony of the worst things human beings can do to other human beings, 75% of people didn't have PTSD. And I think that's really an important message for those of us working with these populations to recognize that although everyone might be affected by their trauma, not everyone will be broken from it. And the vast majority of people will have actually processed it and be able to move on.
Assessment
When assessing for PTSD, it is important to keep in mind that the majority of those showing symptoms will recover without intervention (National Institute of Mental Health, 2019). Nevertheless, approximately one-third of clients may remain symptomatic for more than three years and are at a risk for secondary problems (Rousseau et al., 2011).
A number of screening instruments for PTSD in primary care settings are available; however, the majority of them have not been tested for diagnostic accuracy among immigrants and refugees (Wylie & al, 2018).
Two simple assessment tools that are commonly used:
- Primary Care Posttraumatic Stress Disorder (PC-PTSD) tool
- Breslau's seven-item scale
Other tools that may be helpful in an assessment include the PCL-C-17 for PTSD.
A number of issues can affect the assessment of PTSD in newcomers:
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Patient-determined pace of disclosure
Evidence-based clinical guidelines recommend that providers not routinely screen immigrants and refugees for exposure to traumatic events at the initial appointment.; pushing for disclosure of traumatic events in well-functioning individuals may result in more harm than good (Pottie et al., 2011). Providers should be alert for signs and symptoms of PTSD, such as recurrence of distressing memories of the traumatic event and/or sleep disturbance. When asked about their history of violence, newcomers must be allowed to provide details at their own pace and comfort level.
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Timing and severity of stressors
Questions about the duration, frequency and severity of stressors (e.g., exploring whether there was a single incident of trauma or prolonged, multiple incidents) might be helpful in better understand the severity of symptoms.
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Cultural differences in expressing psychological distress
PTSD is diagnosed if its DSM-5 criteria are met; this is a standard practice everywhere. Apart from the diagnosis, trauma can manifest and be expressed in different ways across cultures. For instance, avoidance of related stimuli and numbing of responsiveness seem to be less prevalent in some cultural groups. In other cases, newcomers may have unexplained somatic symptoms, such as headaches, stomachaches or back pain, instead of emotional complaints. These cultural differences may result in underdiagnosing PTSD in some migrant populations (Hinton & Lewis-Fernandez, 2010; CDC, 2011; APA, 2013; Kirmayer & Ryder, 2016).
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Function
Fulfilling the symptoms required in each of the categories for PTSD does not automatically result in a diagnosis of PTSD. The diagnosis also requires an evaluation of the capacity of the person to function.
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Fulfilling the symptoms required in each of the categories for PTSD does not automatically result in a diagnosis of PTSD. The diagnosis also requires an evaluation of the capacity of the person to function.