understanding psychopathology in migrants: a mixed categorical-dimensional approach

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http://isp.sagepub.com/ International Journal of Social Psychiatry http://isp.sagepub.com/content/early/2013/05/27/0020764013484237 The online version of this article can be found at: DOI: 10.1177/0020764013484237 published online 2 June 2013 Int J Soc Psychiatry Marco Menchetti and Ilaria Tarricone Mauro Braca, Domenico Berardi, Elisa Mencacci, Martino Belvederi Murri, Stefano Mimmi, Fabio Allegri, Fausto Mazzi, Understanding psychopathology in migrants: A mixed categorical-dimensional approach - Apr 7, 2014 version of this article was published on more recent A Published by: http://www.sagepublications.com can be found at: International Journal of Social Psychiatry Additional services and information for http://isp.sagepub.com/cgi/alerts Email Alerts: http://isp.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: What is This? - Jun 2, 2013 OnlineFirst Version of Record >> - Apr 7, 2014 Version of Record at Uppsala Universitetsbibliotek on November 16, 2014 isp.sagepub.com Downloaded from at Uppsala Universitetsbibliotek on November 16, 2014 isp.sagepub.com Downloaded from

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Page 1: Understanding psychopathology in migrants: A mixed categorical-dimensional approach

http://isp.sagepub.com/International Journal of Social Psychiatry

http://isp.sagepub.com/content/early/2013/05/27/0020764013484237The online version of this article can be found at:

 DOI: 10.1177/0020764013484237

published online 2 June 2013Int J Soc PsychiatryMarco Menchetti and Ilaria Tarricone

Mauro Braca, Domenico Berardi, Elisa Mencacci, Martino Belvederi Murri, Stefano Mimmi, Fabio Allegri, Fausto Mazzi,Understanding psychopathology in migrants: A mixed categorical-dimensional approach

  

- Apr 7, 2014version of this article was published on more recent A

Published by:

http://www.sagepublications.com

can be found at:International Journal of Social PsychiatryAdditional services and information for    

  http://isp.sagepub.com/cgi/alertsEmail Alerts:

 

http://isp.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

What is This? 

- Jun 2, 2013OnlineFirst Version of Record >>  

- Apr 7, 2014Version of Record

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International Journal of Social Psychiatry0(0) 1 –11© The Author(s) 2013Reprints and permissions: sagepub.co.uk/journalsPermissions.navDOI: 10.1177/0020764013484237isp.sagepub.com

E CAMDEN SCHIZOPH

Background

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 & Selten, 2005; de Wit et al., 2008; Fearon et al., 2006; Hutchinson & Haasen, 2004). Despite this, only a few studies have described migrants’ psychopathological features, mostly analysing some isolated symptoms (Familiar, Borges, Orozco & Medina-Mora, 2011; Lau, Cheng, Chow, Ungvari & Leung, 2009; Ritsner & Ponizovsky, 1998; Velthorst et al., 2011) or specific clinical populations, such as refugees and asylum seekers (Birman & Tran, 2008; Dobricki, Komproe, de Jong & Maercker,

2010; Laban, Gernaat, Komproe & DeJong, 2007; Montgomery, 2008; Nickerson, Bryant, Steel, Silove & Brooks, 2010; Norredam, Jensen & Ekstrøm, 2011; Porter & Haslam, 2005).

Understanding psychopathology in migrants: A mixed categorical- dimensional approach

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

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.

KeywordsMigration, psychopathology, transcultural psychiatry, categorical-dimensional approach, factor analysis

1 Bologna Transcultural Psychiatric Team (BoTPT), Department of Medical and Surgical Sciences, University of Bologna, Italy

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

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: [email protected]

484237 ISP0010.1177/0020764013484237International Journal of Social PsychiatryBraca et al.2013

Article

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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 & Mendlewicz, 1995; Haasen, Yagdiran, Mass & Krausz, 2000; Lin & Cheung, 1999), probably due to peculiar clini-cal presentation and/or expression of suffering across dif-ferent cultures (Kirmayer, 2001; Kirmayer & 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.

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, Möller, Strauss & Läge, 2009; Krueger & Bezdjian, 2009; Läge, Egli, Riedel, Strauss & Möller, 2011; Lecrubier, 2008; Möller, 2008; Möller 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).

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.

Methods

Study setting

The Bologna West Community Mental Health Centre (CMHC) has developed one of the first projects in Italy which prioritises cultural competence at primary and

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.

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).

Instruments

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).

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 & Mormont, 1983; Stieglitz, Fähndrich & 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 & Heim, 1994). The AMDP cov-ers the whole range of present psychopathological and somatic states through 100 psychopathological items (plus 15

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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, Dell’Osso & 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 & Peralta, 2001) and in first-episode psychoses (Cuesta, Peralta, Gil & Artamendi, 2003); depressive syndrome, along with negative syndrome, is very pertinent in the assessment of depressive disorders (Pietzcker & Gebhardt, 1983), and it has been used in several studies on depressive and other common mental disorders (Barnow, Linden, Lucht & Freyberger, 2002; Diefenbacher & Heim, 1994; Möller-Leimkühler, Bottlender, Strauss & Rutz, 2004), as well as somatic syndrome (Diefenbacher & Heim, 1994; Reischies, von Spiess, & 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).

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.

Statistical analysis

First, we compared the prevalence rates of symptoms across the diagnostic groups, using the χ2 test. Second we

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 scree test (Cattell, 1966) in respect of Kaiser’s criterion (eigenvalue greater than unity). Item loading with absolute values > 0.40 was used in the descrip-tion of the factors. When the same items loaded in different factors, we kept those with the higher saturation. Varimax rotation was chosen for the study of the variance. SPSS 18.0 software was used for all analyses.

Ethics

The study procedure was explained in detail and informed consent was obtained from patients, in compliance with the Helsinki Declaration.

Results

Sample and diagnoses

We recruited and evaluated 235 patients. Nearly all fitted three specific diagnostic clusters: 110 patients (47%) were diagnosed with neurotic disorders (ICD F40-F48: ‘neu-rotic, stress-related and somatoform disorders’); 60 (25%) were diagnosed with affective disorders (ICD F30-F39: ‘affective disorders’); 37 (16%) were diagnosed with psy-chotic disorders (ICD F20-F29: ‘schizophrenia, schizotypal and delusional disorders’). Twenty-eight patients (12%) were diagnosed with other disorders: eight alcohol-related disorders (F10), four personality disorders (F60); two sex-ual dysfunctions (F52); two moderate mental retardations (F71); two expressive language disorders (F80.1); one eat-ing disorder (F50); one post-encephalitic syndrome (F07.1); eight non-psychiatric diagnoses. Such subgroups were too small to be studied separately and we decided not to group them into a fourth cluster because of the excessive hetero-geneity among these diagnoses. Thus, these twenty-eight patients were excluded from our analyses.

Table 1 shows the socio-demographic characteristics of the 207 cases included. Fifty-three per cent (103 cases) were temporary labour migrants; 20% (38 cases) family reunification migrants; 17% (33 cases) forced migrants – refugees or asylum seekers; and 10% (20 cases) had migrated for other reasons. Some of them already had con-tacts with psychiatric services (21%) and received (or were still receiving) psychopharmacological treatment (51%), while others were drug-naive and/or at their first contact with a psychiatric service. Migrants with affective disor-ders were the oldest group, more frequently women and with a high level of education. Migrants with neurotic dis-orders were the youngest group and more frequently men, especially those diagnosed with post-traumatic stress disor-der (PTSD), which was the most frequent diagnosis in refu-gees and asylum seekers, while psychotic disorders were

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more frequently diagnosed in labour migrants. More details about our study population have been reported in our previ-ous paper (Tarricone et al., 2012b).

Psychopathological analysis and diagnoses

Table 2 shows the prevalence of psychopathological symp-toms in each diagnostic cluster. Positive symptoms and for-mal thought disorders were significantly more frequent in psychotic disorders. Most of the depressive symptoms were significantly more frequent in affective disorders; only rumination and feelings of loss of feeling were more

frequent in psychotic disorders than in affective disorders. The prevalence of negative affective symptoms and somatic symptoms did not show significant differences across the diagnostic groups, except for headache, which was more frequent in affective and neurotic disorders compared to psychotic disorders.

Factor analysis

We performed a factor analysis to assess how symptoms from the four AMDP syndromes segregated into psychopathological dimensions for each of the three diagnostic clusters (Table 3).

Table 1. Description of the sample.

AFF NEU PSY Total p

Gender Male 23 (38%) 68 (62%) 21 (57%) 112 (54%) .013Age Mean 36.7±11.2 31.9±8.9 34.8±10.6 33.8±10.1 .033Marital statusa Married 25 (43%) 42 (39%) 14 (39%) 81 (40%) .293Single 20 (34%) 50 (46%) 14 (39%) 84 (42%) Divorced/separated 13 (22%) 13 (12%) 8 (22%) 34 (17%) Widow – 3 (3%) – 3 (1%) Educationb >8 years 38 (68%) 58 (57%) 7 (21%) 103 (54%) <.001Occupation Employed 25 (42%) 48 (44%) 16 (43%) 89 (43%) .688Unemployed 21 (35%) 46 (42%) 15 (40%) 82 (40%) Other (student, retired, 14 (23%) 16 (14%) 6 (16%) 36 (17%) housewife) Residence permit 45 (80%) 72 (69%) 22 (67%) 139 (72%) .225Area of origin Maghreb 13 (22%) 35 (32%) 12 (32%) 60 (29%) .908Sub-Saharan Africa 13 (22%) 25 (23%) 9 (24%) 47 (23%) Asia 17 (28%) 25 (23%) 8 (22%) 50 (24%) Central-Southern America 4 (7%) 4 (4%) 2 (5%) 10 (5%) Eastern Europe 13 (22%) 21 (19%) 6 (16%) 40 (19%) Reason for migration3 Work 24 (45%) 55 (52%) 24 (69%) 103 (53%) .037Family reunion 16 (30%) 16 (15%) 6 (17%) 38 (20%) Political 6 (11%) 25 (24%) 2 (6%) 33 (17%) Other (study, health, tourism) 7 (13%) 10 (9%) 3 (9%) 20 (10%) Refugees/Asylum seekers 6 (10%) 19 (17%) 2 (6%) 27 (13%) .135Length of stay Mean (years) 7.4±6.1 5.9±5.1 7.8±7.6 6.6±5.9 .256Poor knowledge of Italian language

13 (22%) 25 (23%) 9 (24%) 47 (23%) .954

Previous contacts with psychiatric services

22 (37%) 14 (13%) 8 (22%) 44 (21%) .001

Already receiving pharmacological treatment

29 (48%) 47 (43%) 29 (81%) 105 (51%) <.001

Total n (%) 60 (29%) 110 (53%) 37 (18%)

AFF = affective disorders, NEU = neurotic, stress-related and somatoform disorders; PSY = schizophrenia, schizotypal and delusional disorders.a5 missing; b16 missing; c13 missing.

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Table 2. Symptomatological prevalence per diagnostic cluster.

AFF NEU PSY p Exploratory analyses

Depressive syndrome Rumination 3 (5%) 9 (8%) 6 (16%) .157 PSY>AFFt

Feelings of loss of feeling 3 (5%) 8 (7%) 6 (16%) .129 PSY>AFFt

Loss of vitality 34 (57%) 50 (45%) 12 (32%) .064 AFF>PSY*Depression 49 (82%) 75 (68%) 18 (49%) .003 AFF>PSY*

AFF>NEU*Hopelessness 27 (45%) 36 (33%) 10 (27%) .142 AFF>PSYt

Feelings of inadequacy 19 (32%) 27 (24%) 8 (22%) .475 Feelings of guilt 22 (37%) 24 (22%) 6 (16%) .04 AFF>PSY*

AFF>NEU*Inhibition of drive 26 (43%) 33 (30%) 11 (30%) .181 Worse in morning 6 (10%) 8 (7%) 3 (8%) .808 Interrupted sleep 16 (27%) 30 (27%) 5 (13%) .216 AFF>PSYt

NEU>PSYt

Shortened sleep 37 (63%) 48 (44%) 10 (27%) .002 AFF>PSY*AFF>NEU*NEU>PSYt

Early wakening 10 (17%) 19 (17%) 3 (8%) .387 Decreased appetite 17 (29%) 27 (25%) 7 (19%) .551 Positive syndrome Delusional mood 2 (3%) 2 (2%) 7 (19%) <.001 PSY>AFF*

PSY>NEU*Delusional perception 1 (2%) 1 (1%) 12 (32%) <.001 PSY>AFF*

PSY>NEU*Delusional irruption 2 (3%) 1 (1%) 9 (24%) <.001 PSY>AFF*

PSY>NEU*Delusional ideas 1 (2%) 1 (1%) 18 (49%) <.001 PSY>AFF*

PSY>NEU*Systematized delusions 2 (3%) 4 (4%) 9 (24%) <.001 PSY>AFF*

PSY>NEU*Delusional dynamics 1 (2%) – 15 (40%) <.001 PSY>AFF*

PSY>NEU*Delusions of reference 3 (5%) 2 (2%) 16 (43%) <.001 PSY>AFF*

PSY>NEU*Delusions of persecution 3 (5%) 4 (4%) 23 (62%) <.001 PSY>AFF*

PSY>NEU*Verbal hallucinations 1 (2%) 3 (3%) 18 (49%) <.001 PSY>AFF*

PSY>NEU*Bodily hallucinations 1 (2%) 1 (1%) 4 (11%) .006 PSY>AFFt

PSY>NEU*Depersonalization 2 (3%) 2 (2%) 10 (27%) <.001 PSY>AFF*

PSY>NEU*Thought withdrawal – – 4 (11%) <.001 PSY>AFF*

PSY>NEU*Other feelings of alien influence – 2 (2%) 8 (22%) <.001 PSY>AFF*

PSY>NEU*Negative syndrome Inhibition of thinking – 4 (4%) 4 (11%) .027 PSY>AFF*Retardation of thinking 3 (5%) 6 (5%) 4 (11%) .453 Circumstantiality of thinking 1 (2%) 3 (3%) 10 (27%) <.001 PSY>AFF*

PSY>NEU*Restriction of thinking 1 (2%) 3 (3%) 9 (24%) <.001 PSY>AFF*

PSY>NEU*Blunted affect 6 (10%) 11 (10%) 6 (16%) .552 Emotional rigidity 4 (7%) 7 (6%) 3 (8%) .935 Lack of drive 26 (43%) 33 (30%) 11 (30%) .181 AFF>NEUt

(Continued)

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In the affective group (AFF) we extracted three factors, altogether explanatory of 37.2% of the variance. The first factor was exclusively composed of positive symptoms (delusional mood, delusional perception, delusional irrup-tion, delusional ideas, delusional dynamics, delusions of reference, delusions of persecution, depersonalization), while the second was mostly constituted by negative symp-toms (circumstantiality of thinking, restriction of thinking, blunted affect, emotional rigidity, social withdrawal, hypo-chondriasis); only in the third and last factor did we find variables derived from the depressive syndrome, along with other positive and negative symptoms (loss of vitality, hopelessness, inhibition of drive, systematized delusions, retardation of thinking, lack of drive). Among patients in the psychotic group (PSY), we extracted four factors that accounted for 39.9% of the variance: the first factor was mostly composed of somatic symptoms (nausea, dizziness, palpitations, cardiac pain, rumination, interrupted sleep), the second mostly of negative symptoms (inhibition of thinking, retardation of thinking, restriction of thinking, blunted affect, emotional rigidity, feelings of loss of feel-ing, breathing difficulties), the third nearly only of depres-sive symptoms (loss of vitality, depression, hopelessness, inhibition of drive, lack of drive) and the fourth nearly only of positive symptoms (delusional irruption, verbal halluci-nations, thought withdrawal, other feelings of alien influ-ence, circumstantiality of thinking). In the neurotic group (NEU) we extracted five factors, accounting for 37.5% of variance explanation. The first factor was almost exclu-sively composed of negative symptoms (inhibition of thinking, retardation of thinking, circumstantiality of think-ing, restriction of thinking, emotional rigidity, rumination), the second almost only of depressive symptoms (feelings of inadequacy, inhibition of drive, worse in morning, short-ened sleep, early wakening, lack of drive) and the third mostly by positive symptoms (systematized delusions, ver-bal hallucinations, bodily hallucinations, hypochondriasis,

nausea). The fourth factor comprised only somatic symp-toms (breathing difficulties, increased sweating, hot flashes), while the fifth only positive symptoms (delusional ideas, delusions of reference, delusions of persecution).

Discussion

In this study, we examined the prevalence of symptoms and the psychopathological structure of mental disorders in a wide group of migrants: we found that, despite the fact that clinical symptoms were more prevalent in the ascribed diagnoses as expected (depressive symptoms in affective disorders, positive and negative symptoms in psychotic dis-orders), the factor structure of mental disorders was mainly constituted by symptoms that are not usually considered as ‘core symptoms’ in the main diagnostic criteria.

We found peculiar and polymorphic psychopathological configurations of the diagnostic clusters studied in our migrant population. However, only 37–40% of the variance was explained by the extracted factors: this implies that there is a strong polymorphism of the psychopathological presentation of the three diagnostic clusters studied and a weak psychopathological validity of the clinical diagnoses.

The psychopathological polymorphism found could be due to the different cultural backgrounds of migrants and to their complex ways of signifying psychic disease through meanings acquired in different, specific social contexts. Moreover, such a polymorphism could also be due to the diversity of diagnoses included in each diagnostic cluster, even if from a categorical point of view we found expected correlations between diagnostic clusters and core symp-toms’ prevalence. Surprisingly, we found that in each of the diagnostic clusters the first extracted factor was predomi-nantly composed of elements not belonging to the tradition-ally ascribed psychopathological dimensions.

Among psychotic disorders, the first factor was almost exclusively composed of somatic symptoms. Somatic

AFF NEU PSY p Exploratory analyses

Social withdrawal 13 (22%) 36 (33%) 8 (22%) .205 NEU>AFFt

Somatic syndrome Hypochondriasis 5 (8%) 15 (14%) 7 (19%) .311 Nausea 4 (7%) 5 (5%) 3 (8%) .693 Breathing difficulties 3 (5%) 3 (3%) 1 (3%) .713 Dizziness 3 (5%) 9 (8%) 2 (5%) .686 Palpitations 4 (7%) 8 (7%) 3 (8%) .965 Cardiac pain 5 (8%) 2 (2%) 3 (8%) .098 AFF>NEUt

Increased sweating 1 (2%) 2 (2%) 1 (3%) .930 Headache 20 (33%) 30 (27%) 4 (11%) .045 AFF>PSY*

NEU>PSY*

Hot flashes – 3 (3%) 1 (3%) .435

AFF = affective disorders; NEU = neurotic, stress-related and somatoform disorders; PSY = schizophrenia, schizotypal and delusional disorders.*= significant; t = trend.

Table 2. (Continued)

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symptoms are common not only among patients with major depression and anxiety diagnoses, but also among those with schizophrenia and other psychoses, both among migrants

and natives (Simon & VonKorff, 1991). Somatization is a complex psychopathological construct, probably encom-passing both psychosocial and biological factors: it has been

Table 3. Factor analysis.

AFFECTIVE NEUROTIC PSYCHOTIC

I II III I II III IV V I II III IV

Dep

ress

ive

synd

rom

e

Rumination 0.519 0.437 Feelings of loss of feeling 0.483 Loss of vitality 0.445 0.816 Depression 0.816 Hopelessness 0.624 0.799 Feelings of inadequacy 0.700 Feelings of guilt Inhibition of drive 0.517 0.907 0.635 Worse in morning 0.450 Interrupted sleep 0.670 Shortened sleep 0.445 Early wakening 0.464 Decreased appetite

Po

siti

ve s

yndr

om

e

Delusional mood 0.991 Delusional perception 0.936 Delusional irruption 0.903 0.545Delusional ideas 0.936 0.668 Systematized delusions 0.843 0.508 Delusional dynamics 0.936 Delusions of reference 0.747 0.924 Delusions of persecution 0.858 0.759 Verbal hallucinations 0.859 0.423Bodily hallucinations 0.931 Depersonalization 0.903 Thought withdrawal 0.840Other feelings of alien influence 0.786

Neg

ativ

e sy

ndro

me Inhibition of thinking 0.926 0.675

Retardation of thinking 0.808 0.846 0.851 Circumstantiality of thinking 0.953 0.832 0.552Restriction of thinking 0.953 0.890 0.486 Blunted affect 0.735 0.570 Emotional rigidity 0.839 0.508 0.892 Lack of drive 0.531 0.907 0.635 Social withdrawal 0.445

So

mat

ic s

yndr

om

e Hypochondriasis 0.732 0.412 Nausea 0.630 0.940 Breathing difficulties 0.858 0.690 Dizziness 0.939 Palpitations 0.940 Cardiac pain 0.940 Increased sweating 0.932 Headache Hot flashes 0.924

Eigenvalue 6.701 4.452 3.358 3.926 3.497 2.823 2.811 2.340 5.445 4.260 3.814 2.848 % of variance 17.2 11.4 8.6 9.6 8.5 6.9 6.8 5.7 13.3 10.4 9.3 6.9

Note: Only item loadings with absolute values > 0.40 are shown.

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explained in terms of altered ‘symptom attribution’ and altered physiological mechanisms such as increased somatic sensitivity. In migrant populations, sociocultural factors, such as stigmatization towards mental illness, fear of dis-crimination, different expectations on the host country’s health care system and explanations related to the illness, might account for a higher prevalence of somatization (Kirmayer & Looper, 2006). In this regard, a recent study carried out in Italy showed that among migrants, distress due to post-migratory living difficulties amplified the tendency to somatize (Aragona et al., 2011). Furthermore, positive and negative symptomatology was preeminent only in the later factors of psychotic disorders. Similarly, in affective disor-ders, the first two explanatory factors of the variance were almost exclusively represented by positive and negative symptoms, while elements of depressive syndrome result to be preponderant only in the third factor. Likewise, in neu-rotic disorders, the first factor is constituted mostly by nega-tive items.

Our results entail several explanatory hypotheses. In our sample, patients with psychotic disorders show the phe-nomenological centrality of the bodily experience, which may often become the primary or only channel of commu-nication in a migratory context. This can be further dis-cussed through three different perspectives: anthropological, phenomenological and transcultural. According to an anthropological perspective, people live in the world through the body and it is always through the body that they live the experiences that shape their existence. In medical semiotics, the crises of the body and its languages of suffer-ing are almost always directly related to organ dysfunction: the biomedical perspective neglects the fact that the mani-festations of suffering of the body have to be thought of as historically grounded languages, which are the result of a dialectic process between perceptual, cognitive and inter-personal experiences. Such a process is shaped by cultur-ally based ways of thinking of and understanding the experience in relation to factors such as family, work and other social contexts (Kirmayer & Sartorius, 2007). According to the phenomenological perspective, corporal-ity is a particular form of human existence through which man speaks and expresses himself: such language becomes the out-and-out vehicle of communication when spoken language grows fainter as a result of a renunciation to com-municating towards the community and by cause of a with-drawal into one’s inner self. In this condition of isolation, corporality becomes the refuge of the being, the site of a drive now blind that pushes towards the existential void of one’s own private world (‘idios kosmos’) (Binswanger, 1947). This could be a significant process for migrants, for whom linguistic barriers can thwart the verbal transmission of emotional states and psychic disease. According to a transcultural perspective, corporality and somatic symp-toms could be classified as cultural idioms of distress, new meanings for a range of emotions ‘improvised through

fragmentary metaphors grounded in bodily experience’ (Kirmayer & Young, 1998, p. 427). Cultural idioms of dis-tress would not define discrete disorders as somatoform disorders, but rather they would just be ‘culturally pre-scribed modes of understanding and narrating health prob-lems and broader personal and social concerns’ (Kirmayer & Sartorius, 2007, p. 835); thus, rather than being reduced to any broader diagnostic entity, they would configure as disorders in their own right cutting across DSM categories (Kirmayer & Young, 1998). These forms of body language can be read as tools for the repositioning of the subject in the context of his/her family or in his/her role in the social context.

‘In a larger sense then, symptoms can be understood as having meanings as moves within a local system of power. [...] Certain symptoms have been interpreted as being forms of “resistance” or “weapons of the weak”, used to evade or attenuate injustices or to undermine otherwise unassailable power holders’. (Kirmayer & Young, 1998, p. 425)

Finally, several works have tried to emphasize how close the relation is between the symptomatic manifestation – and the sociocultural context into which it is shaped – and the process of signification (Jenkins & Barrett, 2004), thus suggesting the need to ‘move beyond the conventional view of culture as pathoplastic (merely shaping psychotic experiences and giving them content) to a view of culture as playing a role in the very structure of psychotic experi-ence itself’ (Barrett, 1998, p. 491).

For what concerns affective disorders, instead, it is worth noticing the weight of positive and negative symp-tomatology in the psychopathological configurations shown by factor analysis. Such significance could have prognostic implications, as several studies have confirmed that negative symptoms predict a poorer outcome and defi-cit in social and cognitive functioning, not only among the schizophrenic spectrum but also in affective disorders (Bottlender, Strauss & Möller, 2010; Herbener & Harrow, 2004; Möller et al., 2010). Furthermore, Velthorst et al. (2011) focused attention on these two psychopathological dimensions in ethnic minorities, suggesting that the experi-ence of attenuated positive symptoms, when accompanied by negative or depressive symptoms, can predict the transi-tion to the first psychotic episode.

Neurotic disorders were characterized by different dimensions, each of them depicting a peculiar psychopath-ological shape of these mainly stress-related disorders: for-mal thought disorders, hallucinations, delusions, sleep and autonomic disorders. This variety of psychopathological expressivity may be due to the wide range of diagnoses included in this major category; although, it shows other different, polymorphic modalities of psychic effractions that migratory experience entails and their severity even in disorders that are not traditionally considered major disor-ders. It is noteworthy that this diagnostic cluster is mainly represented by young men, and in 13% of the cases by

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asylum seekers or refugees. This might explain in part the psychopathological variety of the five extracted dimen-sions, since these could reflect psychotic (formal thought disorders, hallucinations, delusions) and physiopathologic (sleep, autonomic) reactions to traumatic events.

Our study identified peculiar and unexpected psycho-pathological configurations in the clinical diagnoses of the patients assessed at our premises. If our results were to be replicated, this would remark the difficulty of collocating the psychic diseases of migrants inside the occidental nosography, and would highlight the difficulties of a cate-gorical system describing the psychopathology of patients from other cultures. These results are in agreement with those of other studies suggesting that a categorical-dimen-sional approach would be more useful in the understanding of mental disorders (Demjaha et al., 2009; Egli et al., 2009; Krueger & Bezdjian, 2009; Läge et al., 2011; Lecrubier, 2008; Möller, 2008; Möller et al., 2011), with dimensions further enriching information contained within the tradi-tional diagnostic systems (Allardyce, McCreadie, Morrison & van Os, 2007; Dikeos et al., 2006). To our knowledge, there is only one previous study that has explored migrants’ psychopathology through factor analysis (Hutchinson, Takei, Sham, Harvey & Murray, 1999).

This approach may have several clinical implications. The exploration of psychopathological dimensions may lead to an optimization of psychiatric intervention, by tai-loring treatment to the individual. Furthermore, studies exploring associations of categorical and dimensional mod-els have reported the superiority of dimensions over diag-nostic categories at predicting clinical course, outcome and treatment response (Peralta, Cuesta, Giraldo, Cardenas & Gonzalez, 2002; Rosenman, Korten, Medway & Evans, 2003; van Os et al., 1996).

Limitations

These findings need to be considered in light of the study’s limitations, such as the lack of relevant information about medical and substance-related comorbidities, or the fact that some patients were already receiving treatment while others were not. Also, the sample size was relatively small, especially for the AFF and PSY cohorts: these find-ings can only be taken as tentative until replicated on a larger scale. Still, our study might add relevant evidence supporting the utility of a combined categorical-dimen-sional approach to understand psychopathology in migrants. Further studies should be carried out to confirm and extend our findings, possibly with a comparable native control group and follow-up assessment confirm-ing the factors structure’s stability over time. Moreover, our study would need to be replicated in other settings to test the reproducibility of our observations. In the present study we did not analyse the correlation between migra-tory history’s features and psychopathology: this point

deserves further studies, in order to elucidate if and how those features may impact on psychopathology.

Conclusions

We found that among migrants attending our services the factor structure of several mental disorders shows impor-tant differences when compared with the symptoms included in the ICD-10 diagnostic system. The analysis of psychopathological dimensions – particularly with a mixed categorical-dimensional approach – might allow a better understanding of mental disorders in migrants. In our expe-rience, this approach is quite simple and feasible in the clinical setting. Thus, our results encourage future imple-mentations of this methodology of psychopathological evaluation in the clinical transcultural context.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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