Orthostatic Panic as a Key Vietnamese Reaction to Traumatic Events: The Case of September 11, 2001

This article discusses a culturally specific response to traumatic events: orthostatic panic attacks among Vietnamese refugees. We compared the rate and severity of orthostatic panic as well as the rates and severity of associated flashbacks a month before and a month after September 11, 2001. After that date, the rate and severity of orthostatic panic greatly increased, as did the rate and severity of associated flashbacks. The central role of orthostatic panic as a response to traumatic events is illustrated through a patient's vignette. An explanation of why September 11 so profoundly influenced this population is adduced, including an explanation of why it resulted in considerable worsening of orthostatic panic.

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

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.

Modifying Exposure-Based CBT for Cambodian Refugees with Posttraumatic Stress Disorder

Cambodian refugees represent a severely traumatized population living in the United States. In this paper, we describe the modification of a cognitive-behavior therapy program to facilitate delivery of an exposure-based treatment for posttraumatic stress disorder while addressing some of the challenges brought by differences in language and culture between providers and patients. Our treatment modifications include the use of metaphors and culturally relevant examples to aid the communication of core concepts by interpreters, an emphasis on teaching the "process" of exposure therapy rather than relying on specific exposure practice in the group setting, a focus on interoceptive exposure to allow more effective group practice and to address culturally specific symptom interpretations, attention to the way in which treatment procedures interacted with culturally specific beliefs, and efforts to integrate treatment services within the community. Although data are limited, results to date suggest that this modified treatment was acceptable to patients and offered benefits on the order of large effect sizes.

Anxiety sensitivity among Cambodian refugees with panic disorder: A factor analytic investigation

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.

Neck-focused panic attacks among Cambodian refugees; a logistic and linear regression analysis

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.

Tinnitus among Cambodian refugees: relationship to PTSD severity

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.

Sleep paralysis among Cambodian refugees: association with PTSD diagnosis and severity

Among Cambodian refugees attending a psychiatric clinic (n=100), 49% (49/100) 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) had monthly episodes of SP versus 14.85% (8/54) among non-PTSD patients (chi2[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 (n=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.

Assessment of posttraumatic stress disorder in Cambodian refugees using the Clinician-Administered PTSD Scale: psychometric properties and symptom severity

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).

Anxiety sensitivity in traumatized Cambodian refugees: A discriminant function and factor analytic investigation

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.

A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: a cross-over design

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.

'The ghost pushes you down': sleep paralysis-type panic attacks in a Khmer refugee population

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 (chi2 = 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.

Stage-specific toxicity of cypermethrin to medaka (Oryzias latipes) eggs and embryos using a refined methodology for an in vitro fertilization bioassay

Using original artificial fertilization methods with medaka (Oryzias latipes), the effects of exposure to cypermethrin on gametes, fertilization, and embryonic development were investigated. The relative sensitivity was studied with 96-hour duration, 24-hour renewal exposures to six nominal concentrations of cypermethrin ranging from 3.1 100.0 microg cypermethrin/L. Tests were initiated at different developmental stages: unfertilized egg (stage 0), late morula (stage 9), eminence of swim bladder (stage 29), and maximum flexion of the atrioventricular region (stage 34). Cypermethrin did not affect the fertilization process. Predominant sublethal effects in embryos included transient visceral edemas intimately associated to the gall bladder with subsequent pericardial edemas. Other sublethal effects were observed in surviving larvae and included spastic movements with or without ability to respond to stimulus (>/=6.3 microg cypermethrin/L), spinal curvatures, and delayed or absence of swim bladder inflation (>/=12.5 microg cypermethrin/L). The exposure of the gametes (stage 0) or animals during earlier embryonic development (stages 9 or 29) was not a critical window for cypermethrin exposure. Although the incidence of edemas in embryos occurred mainly during exposure of these early developmental stages, embryo and larva lethality and the incidence of transient sublethal effects in hatchlings showed that the later exposure window (stage 34) was the most sensitive. The stage 34 group involved advanced organogenetic stages in which the chorion partially degraded before hatching. Our studies reinforced the idea that a combination of morphologic and functional impairment evaluation is a more sensitive response to developmental toxicants than morphologic defects alone.

CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: a pilot study

We examined the feasibility, acceptability, and therapeutic efficacy of a culturally adapted cognitive-behavior therapy (CBT) for twelve Vietnamese refugees with treatment-resistant posttraumatic stress disorder (PTSD) and panic attacks. These patients were treated in two separate cohorts of six with staggered onset of treatment. Repeated measures Group x Time ANOVAs and between-group comparisons indicated significant improvements, with large effect sizes (Cohen's d) for all outcome measures: Harvard Trauma Questionnaire (HTQ; d = 2.5); Anxiety Sensitivity Index (ASI: d = 4.3); Hopkins Symptom Checklist-25 (HSCL-25), anxiety subscale (d = 2.2); and Hopkins Symptom Checklist-25, depression subscale (d = 2.0) scores. Likewise, the severity of (culturally related) headache-and orthostasis-cued panic attacks improved significantly across treatment

Olfactory-triggered panic attacks among Cambodian refugees attending a psychiatric clinic

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.

Carcinogen induced unscheduled DNA synthesis in mouse hepatocytes

Mouse primary liver cell cultures were examined for evidence of unscheduled DNA synthesis (UDS) following treatment with the carcinogens; dimethylnitrosamine (DMNA), diethylnitrosamine (DENA), 2-acetylaminofluorene (2-AAF), N-methyl-N'-nitro-N-nitrosoguanidine (MNNG), benzo(a)pyrene (BP), dimethylbenzanthracene (DMBA), 1,1,-bis(p-chlorophenyl)-2,2,2-trichloroethane (DDT), safrole, diethylstilbestrol (DES), aflatoxin B1 (AFB1), and dieldrin and the noncarcinogens; dimethylformamide (DMF), fluorene, and pyrene. Mouse hepatocyte cultures were simultaneously treated with three concentrations of each compound and 3H-thymidine. After 24 hrs, cells were fixed and processed for autoradiography. 3H-thymidine incorporation in both experimental and control cell nuclei, as evidenced by autoradiographic grains, was quantitated microscopically. DMNA, DENA, 2-AAF, MNNG, BP, AFB1 and DMBA significantly increased UDS over untreated cells at all concentrations studied. DDT, DMF, fluorene, pyrene, safrole, DES, and dieldrin were negative for UDS in all concentrations examined. DMNA, 2-AAF and MNNG were also studied for UDS induction in 2 hr old, 1 day old and 4 day old cultures. A progressive decrease in UDS with increased time after plating was found in DMNA and 2-AAF treated cultures. After 4 days DMNA and 2-AAF induced UDS only at the highest concentrations examined (10(-3) M and 10(-4) M respectively). MNNG induced UDS at all time periods and concentrations sampled. An attempt to enhance the sensitivity of the UDS assay by inducing the mixed function oxidative enzyme activity in the hepatocytes with phenobarbital administered in vivo resulted in no statistically significant increase in UDS with DMNA, 2-AAF, MNNG, DDT, and dieldrin when compared with cells from non-induced animals.

Increasing uptake and bioactivation with development positively modulate diazinon toxicity in early life stage medaka (Oryzias latipes)

Diazinon, an organophosphate pesticide, becomes biotransformed to a more potent oxon metabolite that inhibits acetylcholinesterase (AChE). Early life stages (els) of medaka, Oryzias latipes, were used to determine how development of this teleost affects sensitivity to diazinon. With developmental progression, from day of fertilization to 7-day-old larvae, we found that the 96-h LC50 and AChE IC50 values decreased, indicating greater host sensitivity to diazinon upon continued development. We then examined changes in AChE activity, its inhibition by the active metabolite diazoxon, and uptake and bioactivation of the compound. AChE activity remained low during much of development but increased rapidly just prior to hatch. In addition, in vitro incubation of tissue homogenates from embryos or larvae showed no differences in the sensitivity of AChE to diazoxon. Uptake studies with 14C-diazinon revealed greater body burdens of 14C as medaka developed. In addition, AChE IC50 values determined by in vivo exposure to diazoxon were greater in larvae than in embryos. Because diazinon is bioactivated by the P450 enzyme system, two P450 inhibitors were used in vivo to explore the role of metabolism in sensitivity. When exposure to diazinon occurred in the presence of increasing amounts of piperonyl butoxide (PBO), AChE inhibition decreased in a dose-response fashion and 2.0 x 10(-5) M PBO alleviated any difference in inhibition between larvae and embryos. However, PBO did not alter total 14C uptake when exposed simultaneously with 14C-diazinon, nor did it affect AChE inhibition using diazoxon. Controls ruled out differential effects of PBO on uptake and inhibition. In addition, a second general P450 inhibitor, 1-aminobenzotriazole, also decreased AChE inhibition. Finally, using exogenous acetylcholinesterase as a trap for the oxon metabolite, larval microsomes displayed greater bioactivation of diazinon than did a microsomal preparation from embryos. Taken together, results suggest that uptake and bioactivation are working to enhance diazinon sensitivity in this developmental model of a teleost fish.