Panic disorder among Vietnamese refugees attending a psychiatric clinic: prevalence and subtypes

Culturally Sensitive Assessment of Anxious-Depressive Distress in Vietnam: Avoiding Category Truncation

The present study investigated what complaints are prominent in psychologically distressed Vietnamese in Vietnam beyond standard symptoms assessed by Western diagnostic instruments for anxiety and depression. To form the initial Vietnamese Symptom and Cultural Syndrome Addendum (VN SSA), we reviewed the literature, consulted experts, and conducted focus groups. The preliminary VN SSA was then used in a general survey (N = 1004) of five provinces in Vietnam. We found that the VN SSA items were highly and significantly correlated with a measure of anxious-depressive psychopathology (a composite measure of the General Anxiety Disorder-7; Posttraumatic Diagnostic Scale; and Patient Health Questionnaire-9). The VN SSA item most highly correlated to anxious-depressive psychopathology was "thinking a lot" ( r = .54), reported by 15.8% of the sample. Many other symptoms in the addendum also were prominent, such as orthostatic dizziness (i.e., dizziness upon standing up; r = .41), reported by 22.9% of the sample. By way of comparison, somatic complaints more typically assessed to profile Western anxious-depressive distress, such as palpitations, were less prominent, as evidenced by being less strongly correlated to Western psychiatric symptoms and being less frequent (e.g., palpitations: r = .31, 7.1% of the sample). Study results suggest that to avoid category truncation when profiling anxious-depressive distress among Vietnamese that items other than those in standard psychopathology measures should also be assessed.

Pathways from conflict-related trauma and ongoing adversity to posttraumatic stress disorder symptoms amongst West Papuan refugees: The mediating role of anxiety and panic-like symptoms

BACKGROUND

Although the relationship involving exposure to traumatic events (TEs), conditions of adversity, and posttraumatic stress disorder (PTSD) is well established in the refugee field, the psychological factors mediating the relevant pathways are not as clearly delineated. In the present path analysis, we examined a model in which anxiety and panic-like symptoms mediated the path between conflict-related TEs, ongoing adversity, and PTS symptoms amongst 230 refugees from West Papua.

METHODS

Culturally adapted measures were applied to assess TE exposure, ongoing adversity, anxiety, panic-like, PTS, and depressive symptoms.

RESULTS

Our model identified two pathways leading from conflict-related exposure to PTS symptoms, one a direct path, the other mediated by a sequence of ongoing adversity, anxiety and panic-like symptoms. Older refugees from West Papua had higher levels of anxiety and panic-like symptoms than the younger adult generation born in PNG.

CONCLUSIONS

Our findings suggest that a focus on reducing anxiety and panic together with addressing social deprivations and threats may improve anxiety and panic amongst refugees, ultimately improving outcomes for PTS symptoms.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

The Clinical Ethnographic Interview: a user-friendly guide to the cultural formulation of distress and help seeking

Transcultural nursing, psychiatry, and medical anthropology have theorized that practitioners and researchers need more flexible instruments to gather culturally relevant illness experience, meaning, and help seeking. The state of the science is sufficiently developed to allow standardized yet ethnographically sound protocols for assessment. However, vigorous calls for culturally adapted assessment models have yielded little real change in routine practice. This paper describes the conversion of the Diagnostic and Statistical Manual IV, Appendix I Outline for Cultural Formulation into a user-friendly Clinical Ethnographic Interview (CEI), and provides clinical examples of its use in a sample of highly distressed Japanese women.

The Manifestation of Anxiety among Sesotho Speakers

Mental health research in black communities in South Africa has been neglected to an alarming degree. Consequently the health system is in a precarious situation owing to a lack of accurate data to facilitate proper planning. This study investigates the way in which anxiety is clinically manifested among Sesotho speakers. For this exploratory descriptive study, the participants consisted of 101 Sesotho speakers diagnosed with anxiety disorders. They were drawn from the population of patients visiting various health establishments in the Mangaung area, South Africa. A semi-structured interview based on the Psychiatric Interview Questionnaire was used to evaluate the participants. It consisted of two types of data collection: the open-ended interview and clinical observation. The results show that there were marked differences in the presentation of anxiety symptoms among Sesotho speakers in comparison with what has been reported in western literature. Anxiety among Sesotho speakers is characterized by the prevalence of hallucinations, and there are also overlapping symptoms of anxiety and depression.

Cross-cultural variations in the prevalence and presentation of anxiety disorders

Considerable cross-cultural variation exists in the prevalence and presentation of the anxiety disorders as defined by the fourth edition of the Diagnostic and Statistical Manual. Researchers debate whether this variation represents cultural differences in the phenomenology of universal disorders or the existence of unique culturally constructed disorders. This article reviews recent literature on the prevalence and presentation of five anxiety disorders: generalized anxiety disorder, social anxiety disorder, panic disorder, specific phobia and post-traumatic stress disorder, both across countries and within the USA. This article indicates that certain anxiety disorders (e.g., generalized anxiety disorder and panic disorder) may vary greatly in rate across cultural groups. It indicates that the clinical presentation of anxiety disorders, with respect to symptom presentation and the interpretation of symptoms, varies across cultures. A difference in catastrophic cognitions about anxiety symptoms across cultures is hypothesized to be a key aspect of cross-cultural variation in the anxiety disorders. Future research directions are suggested.

A critical review of psychological treatments of posttraumatic stress disorder in refugees

Despite much research evidence that refugees suffer from elevated rates of posttraumatic stress disorder (PTSD), relatively few studies have examined the effectiveness of psychological treatments for PTSD in refugees. The field of refugee mental health intervention is dominated by two contrasting approaches, namely trauma-focused therapy and multimodal interventions. This article firstly defines these two approaches, then provides a critical review of 19 research studies that have been undertaken to investigate the efficacy of these treatments. Preliminary research evidence suggests that trauma-focused approaches may have some efficacy in treating PTSD in refugees, but limitations in the methodologies of studies caution against drawing definitive inferences. It is clear that research assessing the treatment of PTSD in refugees is lagging behind that available for other traumatized populations. The review examines important considerations in the treatment of refugees. A theoretical framework is offered that outlines contextual issues, maintaining factors, change mechanisms and the distinctive challenges to traditional trauma-focused treatments posed by the needs of refugees with PTSD.

Anxiety disorder presentations in Asian populations: a review

This article reviews typical anxiety presentations in Asia, and among Asian refugees. In Asia, there are multiple functional somatic syndromes that are common anxiety presentations. These distress syndromes often produce catastrophic cognitions about anxiety-type somatic and psychological symptoms. These functional somatic syndromes should be understood, and specifically assessed and addressed, in order to optimize the evaluation and treatment of anxiety disorders among Asian individuals.

Fear of cultural extinction and psychopathology among Mandaean refugees: an exploratory path analysis

The Mandaeans are a small religious community originating from Iraq and Iran who are facing the possibility of cultural extinction within the next few generations. This study aimed to examine the relationships between life experiences, psychopathology and fear of cultural extinction in Mandaean refugees. A survey was conducted of 315 adult Iraqi Mandaean refugees living in Australia. Past traumatic experiences and current resettlement difficulties were assessed. Mental health outcomes were also examined, including measures of posttraumatic stress disorder (PTSD) and depression. Fear of cultural extinction was measured by items developed in consultation with the Mandaean community. A path analysis was employed to investigate the relationship between trauma, living difficulties, PTSD, depression, and fear of cultural extinction. Results indicated that trauma and living difficulties impacted indirectly on fear of cultural extinction, while PTSD (and not depression) directly predicted levels of anxiety about the Mandaean culture ceasing to exist. The current findings indicate that past trauma and symptoms of posttraumatic stress contribute to fear of cultural extinction. Exposure to human rights violations enacted on the basis of religion has significant mental health consequences that extend beyond PTSD. The relationship between perception of threat, PTSD, and fear of cultural extinction is considered in the context of cognitive models of traumatic stress. Government immigration policy must prioritize the reunification of small, endangered groups to sustain cultural traditions. Treatment interventions implemented with cultural groups facing extinction should take into consideration anxiety about loss of culture.

Culture and the anxiety disorders: recommendations for DSM-V

BACKGROUND

The anxiety disorders specified in the fourth edition, text revision, of The Diagnostic and Statistical Manual (DSM-IV-TR) are identified universally in human societies, and also show substantial cultural particularities in prevalence and symptomatology. Possible explanations for the observed epidemiological variability include lack of measurement equivalence, true differences in prevalence, and limited validity or precision of diagnostic criteria. One central question is whether, through inadvertent "over-specification" of disorders, the post-DSM-III nosology has missed related but somewhat different presentations of the same disorder because they do not exactly fit specified criteria sets. This review canvases the mental health literature for evidence of cross-cultural limitations in DSM-IV-TR anxiety disorder criteria.

METHODS

Searches were conducted of the mental health literature, particularly since 1994, regarding cultural or race/ethnicity-related factors that might limit the universal applicability of the diagnostic criteria for six anxiety disorders.

RESULTS

Possible mismatches between the DSM criteria and the local phenomenology of the disorder in specific cultural contexts were found for three anxiety disorders in particular. These involve the unexpectedness and 10-minute crescendo criteria in Panic Disorder; the definition of social anxiety and social reference group in Social Anxiety Disorder; and the priority given to psychological symptoms of worry in Generalized Anxiety Disorder. Limited evidence was found throughout, particularly in terms of neurobiological markers, genetic risk factors, treatment response, and other DSM-V validators that could help clarify the cross-cultural applicability of criteria.

CONCLUSIONS

On the basis of the available data, options and preliminary recommendations for DSM-V are put forth that should be further evaluated and tested.

Long-term mental health of Vietnamese refugees in the aftermath of trauma

BACKGROUND

There is no long-term prospective study (>20 years) of the mental health of any refugee group.

AIMS

To investigate the long-term course and predictors of psychological distress among Vietnamese refugees in Norway.

METHOD

Eighty Vietnamese refugees, 57% of the original cohort previously interviewed in 1982 (T(1)) and 1985 (T(2)), completed a self-report questionnaire prior to a semi-structured interview. Mental health was measured using the Symptom Checklist-90-Revised (SCL-90-R).

RESULTS

The SCL-90-R mean Global Severity Index (GSI) decreased significantly from T(1) to T(3) (2005-6), but there was no significant change in the percentage reaching threshold scores (GSI =1.00). Trauma-related mental disorder on arrival and the trajectory of symptoms over the first 3 years of resettlement predicted mental health after 23 years.

CONCLUSIONS

Although the self-reported psychological distress decreased significantly over time, a substantial higher proportion of the refugee group still remained reaching threshold scores after 23 years of resettlement compared with the Norwegian population. The data suggest that refugees reaching threshold scores on measures such as the SCL-90-R soon after arrival warrant comprehensive clinical assessment.

Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V

This review covers the literature since the publication of DSM-IV on the diagnostic criteria for panic attacks (PAs) and panic disorder (PD). Specific recommendations are made based on the evidence available. In particular, slight changes are proposed for the wording of the diagnostic criteria for PAs to ease the differentiation between panic and surrounding anxiety; simplification and clarification of the operationalization of types of PAs (expected vs. unexpected) is proposed; and consideration is given to the value of PAs as a specifier for all DSM diagnoses and to the cultural validity of certain symptom profiles. In addition, slight changes are proposed for the wording of the diagnostic criteria to increase clarity and parsimony of the criteria. Finally, based on the available evidence, no changes are proposed with regard to the developmental expression of PAs or PD. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

Prevalence and demographic correlates of intimate partner violence in Asian Americans

This study provides the first national estimates of the prevalence and correlates of intimate partner violence (IPV) among Asian Americans. Population estimates are based on data from 1470 Asian Americans interviewed for the National Latino and Asian American Study. Interviews were conducted in English, Chinese, Tagalog, or Vietnamese. Results suggest that rates of IPV among Asian Americans are low compared to the general U.S. population. Minor violence victimization by a current intimate partner was reported by 10.2% of women and 12.0% of Asian American men. Notably, a greater proportion of participants admitted having perpetrated IPV than having been a victim. Predictors of IPV included younger age, higher SES, alcohol- and substance-use disorders, depression, ethnicity, and being U.S.-born. Results suggest the need for additional research to examine the interactions between gender, ethnicity, and acculturation to develop group-specific models of IPV risk and resilience within diverse Asian American groups.

Gastrointestinal-focused panic attacks among Cambodian refugees: associated psychopathology, flashbacks, and catastrophic cognitions

Among Cambodian refugees attending a psychiatric clinic, we assessed psychopathology associated with gastrointestinal panic (GIP), and investigated possible causal mechanisms, including "fear of fear" and GIP-associated flashbacks and catastrophic cognitions. GIP (n=46) patients had greater psychopathology (Clinician-Administered PTSD Scale [CAPS] and Symptom Checklist-90-R [SCL]) and "fear of fear" (Anxiety Sensitivity Index [ASI]) than did non-GIP patients (n=84). Logistic regression revealed that general psychopathology (SCL; odds ratio=4.1) and fear of anxiety-related sensations (ASI; odds ratio=2.4) predicted the presence of GIP. Among GIP patients, a hierarchical regression revealed that GIP-associated trauma recall and catastrophic cognitions explained variance in GIP severity beyond a measure of general psychopathology (SCL). A mediational analysis indicated that SCL's effect on GIP severity was mediated by GIP-associated flashbacks and catastrophic cognitions.

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.

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.

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.

Olfactory-triggered panic attacks among Khmer refugees: a contextual approach

One hundred Khmer refugees attending a psychiatric clinic were surveyed to determine the prevalence of olfactory-triggered panic attacks as well as certain characteristics of the episodes, including trigger (i.e. type of odor), frequency, length, somatic symptoms, and the rate of associated flashbacks and catastrophic cognitions. Forty-five of the 100 patients had experienced an olfactory-triggered panic attack in the last month. Trauma associations and catastrophic cognitions (e.g. fears of a 'wind attack', 'weakness', and 'weak heart') were common during events of olfactory panic. Several case examples are presented. A multifactorial model of the generation of olfactory panic is adduced. The therapeutic implications of this model for the treatment of olfactory panic are discussed.

'Hit by the wind' and temperature-shift panic among Vietnamese refugees

Surveying 60 Vietnamese patients with either current or past post-traumatic stress disorder, this article aims to phenomenologically characterize the syndrome of 'hit by the wind' in a multidimensional manner. This includes determining the patient conceptualization of the disorder, profiling 'hit by the wind' episodes suffered by patients in the previous month, and presenting case vignettes. Eighteen of the 60 patients (30%) suffered at least one episode of 'hit by the wind' in the last month; all 18 patients had at least one episode of 'hit by the wind' in the last month that met panic attack criteria. For the 18 patients, 33 episodes of'hit by the wind' that met panic attack criteria were experienced in the previous month. For these 33 episodes, the most frequently reported DSM-IV panic attack symptoms were chills (100%; 33/33) and dizziness (88%; 29/33). Flashbacks played a role in the 'hit by the wind' episodes for 5 of the 18 patients (28%). In the discussion, a model of how the syndrome of 'hit by the wind' generates panic is adduced; also, possible Chinese origins of the disorder are discussed.

Somatic panic-attack equivalents in a community sample of Rwandan widows who survived the 1994 genocide

The present study is the first to attempt to determine rates of panic attacks, especially 'somatically focused' panic attacks, panic disorder, symptoms of post-traumatic stress disorder (PTSD), and depression levels in a population of Rwandans traumatized by the 1994 genocide. The following measures were utilized: the Rwandan Panic-Disorder Survey (RPDS); the Beck Depression Inventory (BDI); the Harvard Trauma Questionnaire (HTQ); and the PTSD Checklist (PCL). Forty of 100 Rwandan widows suffered somatically focused panic attacks during the previous 4 weeks. Thirty-five (87%) of those having panic attacks suffered panic disorder, making the rate of panic disorder for the entire sample 35%. Rwandan widows with panic attacks had greater psychopathology on all measures. Somatically focused panic-attack subtypes seem to constitute a key response to trauma in the Rwandan population. Future studies of traumatized non-Western populations should carefully assess not only somatoform disorder but also somatically focused panic attacks.

The Khmer 'Weak Heart' Syndrome: Fear of Death from Palpitations

According to the Khmer conception, a person suffering 'weak heart' (khsaoy beh daung) has episodes of palpitations on slight provocation (e.g. triggered by orthostasis, anger, a noise, worry, an odor or exercise) and runs the risk of dying of heart arrest during these periods of palpitations; too, the sufferer typically has other symptoms attributed to the purported cardiac dysfunction: fatigue, shortness of breath, and orthostatic dizziness. Many Khmer refugees suffer this cultural syndrome, an anxious-dysphoria ontology, most probably of French colonial provenance. The syndrome demonstrates considerable overlap with those Western illness categories that feature panic attacks, in particular post-traumatic stress disorder (PTSD) and panic disorder. In a psychiatric clinic survey, 60 percent (60/100) of those assessed believed themselves to currently suffer 'weak heart'; 90 percent (54/60) of those considering themselves to suffer from 'weak heart' thought that palpitations (e.g., those resulting from a loud noise or orthostasis) might result in death. The article illustrates the profoundly culturally constructed nature of 'cardiac sensations,' located in a specific historical trajectory and episteme; too, the article suggests that trauma may result more in panic disorder than 'PTSD' when autonomic arousal symptoms (in the present case, palpitations) are considered potentially life-threatening.

Dizziness and panic in China: associated sensations of zang fu organ disequilibrium

In China, distress is commonly experienced as dizziness that can develop into acute episodes resembling Western panic attacks. These distressing sensations occur in a unique cultural context with a distinctive set of associated symptoms, beliefs and purported etiologies. The experience of illness is informed by traditional Chinese medicine (TCM), an indigenous theory that elaborates a system of organ functioning called zang fi. Depending on the implicated zang fi organ disequilibrium, dizziness and panic present with a specific constellation of associated physical and mental symptoms. This paper presents a clinical survey of psychiatric disorders that demonstrates dizziness to be characteristic of Chinese anxiety states, most particularly panic. Three specific cases of dizziness-focused panic ascribed to different states of zangfu disequilibrium are described. In a typical pattern, initial dizziness and associated symptoms intensify until they generalize into panic attacks. The degree of dizziness and panic corresponds to the state of disequilibrium of the zang fu organ system as well as instability of the social, interpersonal and environmental context of the patient. This paper elucidates the dynamic interpretants of dizziness in the Chinese context to contribute to a medical anthropology of this sensation.

Panic probes and the identification of panic: a historical and cross-cultural perspective

This article reviews the historical development of the category of panic disorder in the United States, particularly the shifting perspectives on both what causes panic and how the presence of panic should be determined. The notion that panic attacks of a panic-disorder type must be "out of the blue" and "unexpected," except in the case of triggering by a particular place (i.e., agoraphobia), is critiqued. The authors illustrate that a meaningful epidemiological determination of panic rates in other cultural groups must be preceded by a detailed ethnography that ascertains the catastrophic cognitions, core symptoms, and typical cues of panic attacks in that particular context.

Panic disorder, somatization, and the new cross-cultural psychiatry: the seven bodies of a medical anthropology of panic

This article aims to adduce a framework that will allow for the cross-cultural study of panic disorder. The authors take sensation as the key unit of analysis, aiming to contribute to a medical anthropology of sensation. The seven analytic perspectives that are suggested in the article are the following: the full spectrum of panic attack sensations (the sensation body), the biological generation of panic sensations (the biological body), sensation as invoking an ethnophysiology (the ethnophysiological body), sensation as metaphor (the metaphoric body), sensation as invoking the landscape (the landscape body), sensation as invoking catastrophic cognitions (the catastrophic cognitions body), and sensation as invoking memory (the memory-associational body).

Kyol Goeu ('Wind Overload') Part I: A Cultural Syndrome of Orthostatic Panic among Khmer Refugees

Certain cultural syndromes seem to increase the risk of panic attacks by generating catastrophic cognitions about symptoms of autonomic arousal. These schemas create a constant anxious scanning of the body, hence facilitating, maintaining, and producing panic. As a case in point, a Khmer fainting syndrome,'wind overload' (kyol goeu), results in dire expectations concerning the autonomic symptoms experienced upon standing, thus contributing to the high rate of orthostatically induced panic observed in this population.