Understanding psychopathology in migrants: A mixed categorical-dimensional approach

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<ul><li><p> http://isp.sagepub.com/International Journal of Social Psychiatry</p><p> http://isp.sagepub.com/content/early/2013/05/27/0020764013484237The online version of this article can be found at:</p><p> DOI: 10.1177/0020764013484237</p><p> published online 2 June 2013Int J Soc PsychiatryMarco Menchetti and Ilaria Tarricone</p><p>Mauro Braca, Domenico Berardi, Elisa Mencacci, Martino Belvederi Murri, Stefano Mimmi, Fabio Allegri, Fausto Mazzi,Understanding psychopathology in migrants: A mixed categorical-dimensional approach</p><p>- Apr 7, 2014version of this article was published on more recent A </p><p>Published by:</p><p> http://www.sagepublications.com</p><p> can be found at:International Journal of Social PsychiatryAdditional services and information for </p><p> http://isp.sagepub.com/cgi/alertsEmail Alerts: </p><p> http://isp.sagepub.com/subscriptionsSubscriptions: </p><p> http://www.sagepub.com/journalsReprints.navReprints: </p><p> http://www.sagepub.com/journalsPermissions.navPermissions: </p><p> What is This? </p><p>- Jun 2, 2013OnlineFirst Version of Record &gt;&gt; </p><p>- Apr 7, 2014Version of Record </p><p> at Uppsala Universitetsbibliotek on November 16, 2014isp.sagepub.comDownloaded from at Uppsala Universitetsbibliotek on November 16, 2014isp.sagepub.comDownloaded from </p><p>http://isp.sagepub.com/http://isp.sagepub.com/content/early/2013/05/27/0020764013484237http://isp.sagepub.com/content/60/3/243http://www.sagepublications.comhttp://isp.sagepub.com/cgi/alertshttp://isp.sagepub.com/subscriptionshttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsPermissions.navhttp://isp.sagepub.com/content/60/3/243.full.pdfhttp://isp.sagepub.com/content/early/2013/05/27/0020764013484237.full.pdfhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://isp.sagepub.com/http://isp.sagepub.com/</p></li><li><p>International Journal of Social Psychiatry0(0) 1 11 The Author(s) 2013Reprints and permissions: sagepub.co.uk/journalsPermissions.navDOI: 10.1177/0020764013484237isp.sagepub.com</p><p>E CAMDEN SCHIZOPH</p><p>Background</p><p>The relationship between migration and mental health has been the subject of various investigations in the last few decades. These were mainly prompted by the finding of a higher prevalence of mental disorders among migrants or ethnic minorities compared to natives or fellow country-men without migratory experiences (Bhugra, 2003; Cantor-Graae &amp; Selten, 2005; de Wit et al., 2008; Fearon et al., 2006; Hutchinson &amp; Haasen, 2004). Despite this, only a few studies have described migrants psychopathological features, mostly analysing some isolated symptoms (Familiar, Borges, Orozco &amp; Medina-Mora, 2011; Lau, Cheng, Chow, Ungvari &amp; Leung, 2009; Ritsner &amp; Ponizovsky, 1998; Velthorst et al., 2011) or specific clinical populations, such as refugees and asylum seekers (Birman &amp; Tran, 2008; Dobricki, Komproe, de Jong &amp; Maercker, </p><p>2010; Laban, Gernaat, Komproe &amp; DeJong, 2007; Montgomery, 2008; Nickerson, Bryant, Steel, Silove &amp; Brooks, 2010; Norredam, Jensen &amp; Ekstrm, 2011; Porter &amp; Haslam, 2005).</p><p>Understanding psychopathology in migrants: A mixed categorical- dimensional approach</p><p>Mauro Braca,1 Domenico Berardi,1,2 Elisa Mencacci,1,3 Martino Belvederi Murri,1 Stefano Mimmi,4 Fabio Allegri,1 Fausto Mazzi,5 Marco Menchetti1,2 and Ilaria Tarricone1,2 </p><p>AbstractBackground: Literature on mental disorders in migrants is constantly increasing. Only a few studies describe psychopathological dimensions in migrants over their nosographic diagnoses; however, there is a growing literature about the greater utility of a categorical-dimensional approach, rather than a solely categorical approach, in the understanding of mental disorders. The aim of this paper is to describe the phenomenology of mental disorders in migrants referred to the Transcultural Psychiatric Team of Bologna (BoTPT), by analysing the psychopathological dimensions that underlie their clinical diagnoses.Methods: We recruited all migrants who attended the BoTPT between May 1999 and July 2009. The psychopathological assessment was conducted with the Association for Methodology and Documentation in Psychiatry (AMDP) and clinical diagnoses were formulated according to ICD-10. We proceeded through a two-step analysis: (1) comparing the prevalence rates of psychopathological symptoms across diagnoses; then (2) conducting a factor analysis to assess how those symptoms configure psychopathological dimensions and how these dimensions underlie clinical diagnoses.Results: As expected, we found significant associations between diagnoses and the prevalence of their core psychopathological symptoms. Factor analysis revealed a strong polymorphism of the psychopathological presentation of mental disorders and unexpectedly showed that in each diagnostic cluster, the first extracted factor was not composed of core symptoms.Conclusions: A mixed categorical-dimensional approach seems to improve the description of the psychopathology among migrants, as it adds relevant information regarding psychopathological dimensions useful to the understanding of the peculiar clinical expressivity of our patients.</p><p>KeywordsMigration, psychopathology, transcultural psychiatry, categorical-dimensional approach, factor analysis</p><p>1 Bologna Transcultural Psychiatric Team (BoTPT), Department of Medical and Surgical Sciences, University of Bologna, Italy</p><p>2Department of Mental Health, AUSL Bologna, Italy3University of Trento, Italy4Department of Medicine and Public Health, University of Bologna, Italy5Department of Mental Health, AUSL Modena, Italy</p><p>Corresponding author:Ilaria Tarricone, Bologna Transcultural Psychiatric Team (BoTPT), Department of Medical and Surgical Sciences, University of Bologna, Viale Pepoli 5, 40100, Bologna, Italy. Email: ilaria.tarricone@unibo.it</p><p>484237 ISP0010.1177/0020764013484237International Journal of Social PsychiatryBraca et al.2013</p><p>Article</p><p> at Uppsala Universitetsbibliotek on November 16, 2014isp.sagepub.comDownloaded from </p><p>http://isp.sagepub.com/</p></li><li><p>2 International Journal of Social Psychiatry 0(0)</p><p>The scarcity of studies describing psychopathology in migrants may represent an important limit to the compre-hension of their mental diseases. Actually, several studies show possible misdiagnoses of mental disorders in migrant patients (Charalabaki, Bauwens, Stefos, Madianos &amp; Mendlewicz, 1995; Haasen, Yagdiran, Mass &amp; Krausz, 2000; Lin &amp; Cheung, 1999), probably due to peculiar clini-cal presentation and/or expression of suffering across dif-ferent cultures (Kirmayer, 2001; Kirmayer &amp; Looper, 2006). Psychopathological exploration is important for the understanding of mental disorders in people with different cultural backgrounds as they may challenge the borders of Western nosography through a peculiar codification of suf-fering. In the last decades, the concept of culture-bound syndromes (CBS) was introduced in clinical psychiatry as an attempt to better account for the clinical peculiarity of some mental disorders found in specific geographical regions or populations: CBS is a broad rubric that encom-passes certain behavioral, affective and cognitive manifes-tations seen in specific cultures, and would allow a proper labelling and management of clinical pictures that may not be linked to a particular diagnostic category (Balhara, 2011, p. 210). However, CBS still represents a further categoriza-tion of migrants psychic disease.</p><p>Few studies adopt a dimensional approach, while there is wide evidence about the greater utility of a categorical-dimensional approach, rather than a solely categorical approach, in the understanding of mental disorders in psy-chiatric patients (Demjaha et al., 2009; Egli, Riedel, Mller, Strauss &amp; Lge, 2009; Krueger &amp; Bezdjian, 2009; Lge, Egli, Riedel, Strauss &amp; Mller, 2011; Lecrubier, 2008; Mller, 2008; Mller et al., 2011). These evidences recall the well-known debate about whether the categorical nosography sacrifices validity on the altar of reliability (Mullen, 2007, p. 113), and how the diagnostic paradigm, with its dehumanizing impact and its dryly empirical approach (Andreasen, 2007), would neither address the basic mandate of medicine (Kirmayer, 2005) nor be useful for research (Andreasen, 2007).</p><p>The aim of our study is to describe the phenomenology of mental disorders of migrants referred to the Bologna Transcultural Psychiatric Team (BoTPT) by analysing the psychopathological configurations of their clinical diagno-ses. In particular, we aim to assess: (1) the prevalence of psychopathological symptoms in patients clinical diagno-ses; and (2) how those symptoms configure psychopatho-logical dimensions that underlie clinical diagnoses.</p><p>Methods</p><p>Study setting</p><p>The Bologna West Community Mental Health Centre (CMHC) has developed one of the first projects in Italy which prioritises cultural competence at primary and </p><p>secondary levels of care: the BoTPT (Tarricone et al., 2011). The BoTPT is composed of Bologna West CMHC mental health operators who dedicate part of their work to migrant psychiatric consultation. In the most difficult cases, the BoTPT team directly delivers psychiatric and psychoso-cial treatment to migrants; in other cases, the BoTPT team provides consultation geared towards identifying the mental and psychosocial needs of migrants, and then redirects patients within the CMHC and other services. Core person-nel includes psychiatrists as well as social workers, psychiat-ric nurses, residents in psychiatry and medical anthropologists. If needed, a cultural mediator joins the multi-professional team. All migrants, with or without papers, and regardless of gender, age, country of origin and legal status (regular or irregular), can have access to the service.</p><p>Study population. For the present study we examined data collected from all first-generation migrants who attended the BoTPT between May 1999 and July 2009. The formal inclusion criteria were: (1) patients having their first con-tact with our service in the indicated time frame; and (2) patients completing our full socio-demographic, migratory and psychopathological assessment. No formal exclusion criteria were applied. Data were collected within one month from their first access. We define as migrants people who move from one area to another for varying periods of time and for any reason (WHO, 2003).</p><p>Instruments</p><p>In order to collect socio-demographic and migration history information we used the Bologna Migration History and Social Integration Questionnaire (Bo-MHQ): it explores migrants characteristics (socio-economic and legal condi-tions, cultural background, social support, quality of life) before, during and after the migration process. The Bo-MHQ was developed by our research team and is currently imple-mented by the research project EUropean network of national schizophrenia networks studying Gene-Environment Interactions (HEALTH-F2-2010-241909; EU-GEI: http://www.eu-gei.eu). A pilot version of the schedule has been used in previous works from our research team (Tarricone et al., 2012a).</p><p>To assess psychopathological symptoms we used the Association for Methodology and Documentation in Psychiatry (AMDP, 1979): this is a standardized method of documentation widely spread and validated in Europe (Bobon, 1983; Bobon, von Frenckell &amp; Mormont, 1983; Stieglitz, Fhndrich &amp; Renfordt, 1988), based on traditional descriptive psychopathology (Jaspers, 1913; Schneider, 1950). To our knowledge, it was used only once to explore psychopathology in people with different ethno-cultural backgrounds (Diefenbacher &amp; Heim, 1994). The AMDP cov-ers the whole range of present psychopathological and somatic states through 100 psychopathological items (plus 15 </p><p> at Uppsala Universitetsbibliotek on November 16, 2014isp.sagepub.comDownloaded from </p><p>http://isp.sagepub.com/</p></li><li><p>Braca et al. 3</p><p>reserve psychopathological items) and 40 somatic items (plus seven reserve somatic items), that are scored on a Likert scale ranging between 0 (absent) and 4 (very severe), according to the AMDP Italian version (Conti, DellOsso &amp; Cassano, 1990). Psychopathological and somatic items can be grouped under eight psychopathological syndromes as in Pietzcker et al. (1983): of these, we have used those syndromes that in literature are more often used and significantly associated to clinical diagnoses, namely depressive, positive (paranoid-hallucinatory), negative (apathetic) and somatic (autonomic) syndromes. Positive and negative syndromes have already been shown to be structural psychopathological dimensions in non-affective psychoses (Cuesta &amp; Peralta, 2001) and in first-episode psychoses (Cuesta, Peralta, Gil &amp; Artamendi, 2003); depressive syndrome, along with negative syndrome, is very pertinent in the assessment of depressive disorders (Pietzcker &amp; Gebhardt, 1983), and it has been used in several studies on depressive and other common mental disorders (Barnow, Linden, Lucht &amp; Freyberger, 2002; Diefenbacher &amp; Heim, 1994; Mller-Leimkhler, Bottlender, Strauss &amp; Rutz, 2004), as well as somatic syndrome (Diefenbacher &amp; Heim, 1994; Reischies, von Spiess, &amp; Stieglitz, 1990). Thus, we examined all the 43 psychopathological and somatic items that are included in these four syndromes, testing their cate-gorical correlation and their dimensional distribution in diag-nostic clusters. Depressive syndrome is constituted by 13 items (rumination, feelings of loss of feeling, loss of vitality, depression, hopelessness, feelings of inadequacy, feelings of guilt, inhibition of drive, worse in morning, interrupted sleep, shortened sleep, early wakening, decreased appetite), as well as positive syndrome (delusional mood, delusional percep-tion, delusional irruption, delusional ideas, systematized delusions, delusional dynamics, delusions of reference, delu-sions of persecution, verbal hallucinations, bodily hallucina-tions, depersonalization, thought withdrawal, other feelings of alien influence). Negative syndrome was composed of eight items (inhibition of thinking, retardation of thinking, circumstantiality of thinking, restriction of thinking, blunted affect, emotional rigidity, lack of drive, social withdrawal) and somatic syndrome had nine items (hypochondriasis, nau-sea, breathing difficulties, dizziness, palpitations, cardiac pain, increased sweating, headache, hot flashes).</p><p>Psychiatric diagnoses were formulated by clinical psychi-atrists according to ICD-10 (WHO, 1992) criteria. Case notes were used to complete the Item Group Checklist (IGC) of the Schedule for Clinical Assessment of Neuropsychiatry, Version 2.1 (SCAN; WHO, 1998) and to collect data on symptoms at the time of presentation. Diagnoses were grouped under ICD-10 major categories, in order to perform our analyses on sufficiently numerous diagnostic subgroups.</p><p>Statistical analysis</p><p>First, we compared the prevalence rates of symptoms across the diagnostic groups, using the 2 test. Second we </p><p>conducted separated factor analyses to examine the under-lying psychopathological dimensions in each diagnostic subgroup. The number of the factors to extract was deter-mined with the scr...</p></li></ul>