Providentia

The Children of War

A study focusing on the psychosocial effects chronic warfare among refugee children in Southern Darfur is presented in a recent issue of Omega. A sample of 331 children (aged 6-17) from three refugee camps were selected to be part of the study. Of those in the sample, 43 percent were girls and 57 per cent were boys with an average age of twelve years. All of the children in the study were interviewed and tested with measures of traumatic stress, depression, and grief.The study results indicate that there were no significant differences between genders in terms of exposure to traumatic experiences, including rape, but older children (13-17 years) experienced a larger number of traumatic exposures than younger children (6-12 years). Seventy-five percent of the children met the DSM-IV criteria for PTSD, and 38 per cent exhibited clinical symptoms of depression. Twenty per cent of the children sampled also reported significant levels of grief symptoms.

The authors found that increased exposure to war experiences led to higher levels of: (1) traumatic reactions; (2) depression; and (3) grief symptoms. Of the different war experiences examined, abduction, hiding to protect oneself, being raped, and being forced to kill or hurt family members were most predictive of traumatic reactions. Factors most likely to predict depressive symptoms included: being raped, seeing others raped, the death of a parent, being forced to fight, and having to hide to protect oneself. Similar findings were reported for grief reactions. While trauma, depression, and grief often occur together, the mechanisms and ways in which they interact are less understood. This is the first study examining the psychosocial effects of war experiences among refugee children currently living in Sudan's war-zone areas. The authors recognize the need for further research into war-related atrocities and their varying impact on the children's psychological well-being and overall adjustment. Implications for planning mental health interventions are also discussed.

Click here for the abstract.

Casualties of War

The Winter issue of Perspectives in Biology and Medicine presents a thoughtful overview on war and its casualties. Throughout America's first 145 years of war, far more of the country's military personnel died from infectious diseases than from combat injuries. This only began to change in World War II due to better methods of disease prevention and treatment. The authors suggested that soldier deaths throughout U.S. history can be divided into a Disease Era (1775-1918), during which infectious diseases were the major killer of America's armed forces, and a Trauma Era (1941-present), in which combat-related injuries were the major cause of fatalities. Using the 3,400 U.S. military fatalities in Iraq as a comparison, suicide deaths have become more prevalent than deaths from infectious disease.  Given the rising rate of suicides in U.S. soldiers posted overseas, this trend is not expected to change.

Click here for the abstract.

Seeking Refuge

The International Organization for Migration (IOM) has released a report indicating that Iraqi refugees in Lebanon are experiencing high levels of emotional distress and post-traumatic symptoms. The report outlines the results of a study carried out between November 2007 and January 2008 on 800 Iraqi refugees in Lebanon and Jordan. More than half of the refugees studied reported post-traumatic symptoms such as panic attacks, anger, fatigue, anxiety and sleep disorders. For the 34 per cent of study participants who reported experiencing direct violence, including attacks on themselves or family members, the emotional distress was particularly acute. In addition to the effects of recent trauma, factors relating to their uncertain existence as refugees are sources of added distress. Economic difficulties relating to lack of employment, poor living conditions and limited access to health and social resources and educational opportunities has led to physical expressions of anger and frustration. Domestic violence, behavioural and learning problems in children, and isolation are common experiences in refugee families.

"The level of instability is very high among the refugees. We see humanitarian agencies and governments responding to the basic needs of displaced Iraqis at home and abroad, and we need to see a similar response in dealing with their equally important psychological well-being," said Guglielmo Schinina, head of IOM's psychosocial office in the Middle East.

The study was carried out in partnership with international and non-governmental organizations such as the Iraqi Youth League and the Jordanian Women's Union, as well as UNICEF, which provided financial assistance.

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Surviving the Holocaust

The January 2008 issue of the Journal of the American Geriatric Society presents that results of a longitudinal study examining the long-term effects of Holocaust exposure during young adulthood. A sample of four hundred fifty-eight subjects of European origin (aged 70 at baseline and 77 at follow-up) were assessed in the study. Information taken included biographical history of concentration camp internment, exposure to Nazi occupation during World War II, or lack thereof (the control subjects), and 7-year mortality data from the National Death Registry. The results indicated that the 93 survivors of the internment camps and the 129 survivors who experienced the occupation first-hand were more likely to differ from the 236 control subjects in terms of being male, being less educated, and having poorer social support. They were also found to report being less physically active, to experience greater difficulty in activities of daily living, to have poorer self-rated health, and to have greater usage of psychiatric medication. No other differences in health parameters or physical illnesses were found. Holocaust survivors and control subjects had similar rates of deterioration in health issues over the follow-up period, and 7-year mortality rates were identical. The authors conclude that while Holocaust survivors displayed significant psychosocial and functional impairment, there was no evidence found to support the hypothesis that the delayed effects of the trauma of the Holocaust influence physical health or mortality.

Click here for the abstract.

Mitigating Factors Citied in Restaurant Murder

An Australian judge cited mitigating factors raised in a psychological report to sentence restaurant owner Khanh Vo to seven years in prison for the manslaughter of 56-year old Anh Dung Nguyen. Vo stabbed Nguyen with a small kitchen knife after a fight broke out at the Bon Mua restaurant and karaoke bar in Richmond, Australia on the night of April 16, 2006. Justice Kevin Bell said in passing sentence that Vo, a father of two with no previous convictions, showed remorse by pleading guilty to the crime. In making his sentencing decision, Justice Bell took account of a psychologist's report that said Vo's violent childhood experiences as a refugee from Vietnam in the mid-1980s could have led him to overreact. He lived for a time in a refugee camp described in court as "violent and dangerous", especially for children. The report also suggested that Vo met many criteria depicting a major depressive episode and post-traumatic stress disorder.

Sources state that the fight began within half an hour of Mr Nguyen complaining about the length of time it took for Vo's wife and restaurant co-owner, Vy Huynh, to bring food to his table. After Ms Huynh complained to her husband, Vo recognised Mr Nguyen from a previous occasion in which Mr Nguyen allegedly said he would get a gun and shoot somebody if that person caused him trouble. Following the stabbing, Mr Nguyen was helped from the restaurant but died the next day, Justice Bell said.

Vo has served about 22 months in pre-sentence detention, making him eligible to seek release on parole in 2010.

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Police Estimate 17,000 Victims of Honour Violence in Great Britan Yearly

A spokesperson from the Association of Chief Police Officers (ACPO) reported that an estimated 17,000 cases of honour-related violence occur in Great Britain annually. The association also stated that figures relating to forced marriages are the "tip of the iceberg". The women and girls who are subjected to forced marriages, kidnappings, sexual assaults, beatings and even murder by relatives determined to uphold "family honour" may be up to 35 times higher than official figures suggest. Children as young as 11 have been sent abroad to be married, which has prompted the Foreign and Commonwealth Office to call on British consular staff in Bangladesh, India and Pakistan to take more action to identify and help British citizens believed to be the victims of forced marriages in recent years. The British Home Office is preparing action to address "honour" crimes by improving the response of police and other agencies and to encourage victims to come forward to receive needed support. New legislation is also being prepared to enable courts to tackle forced marriages.

Commander Steve Allen, head of ACPO's honour-based violence unit, is reported as saying that the actual number of honour victims is "massively unreported". He states that approximately 500 cases are dealt with each year and further adds that "If the generally accepted statistic is that a victim will suffer 35 experiences of domestic violence before they report, then I suspect if you multiplied our reporting by 35 times you may be somewhere near where people's experience is at." He made these comments to the House of Commons last week, following a series of gruesome murders and attacks on British women by their relatives.

The majority of victims of honour violence remain reluctant to come forward due to fear of retribution and perceived lack of community-based support. Young girls have gone missing from school registers and are said to be home-schooled while actually being taken out of the country to be married abroad. Support agencies report bring back at least three girls a week from Islamabad as victims of forced marriage. The British Government's Forced Marriage Unit (FMU) reported handling approximately 400 cases last year – 167 of them leading to young Britons being helped back to the UK to escape unwanted partners overseas. Home Office figures show that 15 per cent of cases involve men and boys.

Almost all victims of the most extreme crimes are women, killed in half of cases by their own husbands. Sometimes murders are carried out by other male relatives, or even assassins hired by family members. The psychological toll on women facing honour violence is considerable. Women aged 16 to 24 from Pakistani, Indian and Bangladeshi backgrounds are three times more likely to kill themselves than the national average for women of their age. A report published by the Centre for Social Cohesion found that many women felt unable to defy their families and therefore "suffer violence, abuse, depression, anxiety and other psychological problems that can lead to self-harm, schizophrenia and suicide". Advocates accuse the British government of not "taking honour crime seriously. Until this happens, the ideas of honour which perpetuate this violence will continue to be passed on through generations."

While most honour killings appear to occur in Muslim countries, cases have been reported in South Asian cultures including Hindu and Sikh communities in Canada, Denmark, Germany and the United States as well as in South America.

Click here for the link.

For the Amnesty International link.

Marrying Too Young

Those of you who have seen UNICEF's picture of the year will remember the expression of fear on 11-year old Ghulam's face as she gazes at her 40-year old fiance, Mohammad. The practice of child marriage continues unabated in various parts of the world including Afghanistan, Egypt, Ethiopia, Nigeria, Pakistan, India and the Middle East. The girls (often as young as 11 and sometimes even younger) are routinely married off as part of "arrangements" made by their family and usually without their consent. Unwanted girl children are often treated as second-class citizens and are denied access to basic education or even information concerning contraception. Despite being illegal in many countries, secret illegal weddings continue and have even been carried out in Western countries. In addition to issues of basic human rights such as forced sex, child brides face horrendous medical risks including increased risk of death from childbirth (early pregnancy is a leading cause of death for girls between the age of 15 to 19 in developing countries), anal and vaginal fistulas, domestic abuse, chronic anemia and obesity. The psychological trauma associated with these forced marriages can impact on their self-esteem and contribute to a pattern of lifelong poverty and early death.   

Despite ongoing education programs to warn of the dangers of child marriage, the practice is proving notoriously difficult to root out. For too many girls like Ghulam, it may already be too late.

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Sick Doris

Long before Sybil and the Three Faces of Eve, there was Doris Fischer and her case is still considered a classic (although little-known these days). It was in 1910 when she first came to the attention of Walter Franklin Prince, then-rector at an Episcopal church in Pittsburgh, Pennsylvania. Prince, who was born in 1863, received degrees in theology at Yale and Drew Theological Seminary. He would go on to become a prominent psychic researcher and psychotherapist but it was the Doris Fischer case for which he was best known. When he met the twenty-one year old "Doris Fischer" in his congregation, she appeared to be an extremely unhappy and lonely individual who was prone to odd mood and behaviour shifts. She also seemed to experience bouts of amnesia in which she would forget what she had previously said or done.

While Prince initially diagnosed her as suffering from hysteria (a common diagnosis for women patients of the time), he carefully studied her and concluded that she matched the clinical description of what was then known as "multiple personality". Over the years in which Prince followed the case, he came to identify at least five different personalities including "Margaret"- a child of about ten, "Sick Doris" who was a perpetual invalid, "Real Doris" whom Prince regarded as the core personality, "Sleeping Real Doris" and "Sleeping Margaret" who only seemed to emerge when Doris was in a hypnotic state. It was "Sleeping Margaret" who seemed to have the best insight into how Doris' different personalities worked together and often helped Prince as he attempted to get to know each personality individually.

Through sessions with "Sleeping Margaret", Prince was able to piece together some of Doris' background. She was born in 1889 of German parents and her father was an alcoholic who frequently abused her. The possibility of sexual abuse was never raised (it was a taboo topic at the time) although it was never ruled out either. It was apparently in her early childhood that "Margaret" first emerged as a defense against the abuse and alternated with "Real Doris". The third personality "Sick Doris" emerged after her mother's death when she was sixteen years old. She reported a total amnesia surrounding the five-year period between her mother's death and when she first began attending Prince's church. "Sleeping Margaret" only emerged once Prince began treating Doris.

Gaining access to Doris became much easier after Prince and his wife formally adopted her as their daughter (not the usual clinical approach, I'll admit). He published a massive 1300-page treatise on his prize patient in 1915 (he named her "Doris Fischer" in his publications although her real name after the adoption was Theodosia Prince). Prince would later publish another thousand-page treatise on the psychic experiments that he did with "Doris" (I mentioned that he was a psychic researcher) making this case the most well-documented example of multiple personality disorder on record. Over the years that he worked with Doris, Prince was able to reintegrate all of her personalities into "Real Doris" (although "Sleeping Margaret" still resurfaced at times whenever Doris/Theodosia was in hypnosis).

Multiple personality disorder (now known as Dissociative Identity Disorder) remains a controversial diagnosis, not to mention fairly rare these days. In my twenty years as a clinical psychologist dealing with trauma in various forms, I have never run across a case of it and there some researchers who are of the opinion that many reported cases are iatrogenic in nature. In the Doris Fischer case, there was a considerable blurring of the relationship between Doris and her therapist. Not only did she become Prince's adoptive daughter but she was also his prize patient (he often introduced visiting clinicians to "Sleeping Margaret") and test subject in different psychic experiments. A later clinician would report that "Doris' love for her adopted father was no ordinary love. She loved him not merely as a devoted daughter, she adored him almost as her God, in that he had saved her from hell and had, one might almost say, given her a soul". Did Prince's expectations impose demand characteristics that shaped his adopted daughter's reported symptoms? Given the current controversy over recovered memory and the potential impact of directed psychotherapy on suggestible subjects, the possibility seems all too real. Information concerning Doris/Theodosia's later life tends to be scarce although she experienced a relapse following Prince's death in 1934. Aside from the clinical report of the treatment that she received at that time, there seems to be nothing else available (if anyone has more information please let me know).

After Chernobyl

In the November issue of Psychological Medicine a study is presented examining the psychological aftermath of the 1986 Chernobyl accident . This study describes the long-term psychological effects of Chernobyl in 295 male clean-up workers sent to Chernobyl between 1986 and 1990. The workers were interviewed 18 years after the accident (71% participation rate) along with 397 geographically matched controls interviewed as part of the Ukraine World Mental Health (WMS) Survey 16 years after the accident. The authors examined group differences in common psychiatric disorders, suicide ideation and severe headaches, differential effects of disorder on days lost from work, and in the clean-up workers, the relationship of exposure severity to disorder and current trauma and somatic symptoms. The results indicated that relatively more clean-up workers than controls experienced depression (18.0% v. 13.1%) and suicide ideation (9.2% v. 4.1%) after the accident. In the twelve months before the interview, the rates of depression (14.9% v. 7.1%), post-traumatic stress disorder (PTSD) (4.1% v. 1.0%) and headaches (69.2% v. 12.4%) were elevated. Affected workers lost more work days than affected controls with exposure level was associated with current somatic and PTSD symptom severity. The authors concluded that workers tasked with cleaning up after major disasters can face long-term mental health consequences that need to be recognized and treated accordingly.

Click here for the abstract.

Victims Behind Bars

The August 2007 issue of Psychiatric Services presents the results of a study examining rates of sexual victimization among prison inmates with and without a mental disorder. Using inmates aged 18 or older in 13 prisons within a single mid-Atlantic state prison system (12 facilities for men and one for women), a total of 7,528 inmates completed the survey which was administered by audio-computer-assisted technology. Of the 6,964 male respondents, 58.5% were African American, 16.2% were non-Hispanic white, 19.8% were Hispanic, and 5.5% were of another race or ethnicity. Of the 564 female respondents, 48.4% were African American, 30.9% were non-Hispanic white, 14.4% were Hispanic, and 7.3% were of another race or ethnicity. Determination of history of mental disorder was based on self-reported previous treatment for particular mental disorders. Sexual victimization was measured by using questions adapted from the National Violence Against Women and Men surveys. The result indicated that approximately one in 12 male inmates with a mental disorder reported at least one incident of sexual victimization by another inmate over a six-month period, compared with one in 33 male inmates without a mental disorder. Among those with a mental disorder, sexual victimization was three times as high among female inmates (23.4%) as among male inmates (8.3%). African-American and Hispanic inmates with a mental disorder, independent of gender, reported higher rates of sexual victimization than their non-Hispanic white counterparts. The authors conclude by recognzing the hazards of prison life and call for the need to protect vulnerable inmates from predators inside prison. Screening for posttraumatic stress disorder and providing trauma-related treatment are vital.

Click here for the abstract.