Trauma, ethnicity and posttraumatic stress disorder in outpatient psychiatry

Psychiatric services, more than most medical care services, are sensitive to cultural norms. How psychiatric distress is expressed varies culturally as do the expectations of help from professionals and relatives. This thesis focuses on the encounter between a multicultural population in a Stockholm suburb and the general psychiatric outpatient services.

The basis of the thesis is a register study. An entire year's cohort of patients (N= 839) was divided into eight ethnic groups according to country of birth. All ethnic groups had access to the psychiatric services. Diagnoses given at the clinic varied largely with ethnicity: patients of Greek origin were more likely to receive a diagnosis of somatoform disorder (OR= 8.8) and African patients more likely (OR= 5.6) to receive a diagnosis of psychosis (except schizophrenia) compared with the rest of the patient group. Swedes were about twice as likely as the rest to receive a personality disorder diagnosis (OR= 2.2).

Trauma and its consequences are underestimated in psychiatric services, illustrated by the fact that no patient had received a diagnosis of posttraumatic stress disorder (PTSD). With a focus on extreme trauma and its consequences, patients from four ethnic groups - Arabs from the Middle East, Iranians, Turks and Swedes - were selected for a follow-up questionnaire study 3-4 years after the index year. Of all patients, 89% had experienced any traumatic event and 77% multiple events. Probable PTSD was prevalent in all ethnic groups: 69% of Iranians, 59% of Arabs, 53% of Turks and 29% of Swedes fulfilled symptom criteria for the disorder. In logistic regression analyses, probable PTSD outcome was associated with multiplicity of relatives traumas (OR=3.1), multiplicity of own traumas (OR=2.6) and belonging to an ethnic minority (OR=2.4). Probable PTSD-patients had a significantly less favourable long-term outcome compared with other psychiatric patients regarding Self-rated health and participation in working life.

Patients, who perceived that their traumas had been sufficiently addressed in treatment, had significantly better outcome than other patients with traumas. This was demonstrated by high self-rated health (OR= 8.0) and low scores on the Self-Inventory for PTSD (OR= 7.7) and Depression scale (OR= 3.0). They also had high confidence in treatment staff (OR= 7.2). Reporting less than five different traumas (OR=4.6) and being an ethnic Swede (OR= 2.4) increased prospects of having trauma(s) sufficiently addressed.

Trauma experiences are highly prevalent among psychiatric outpatients and especially among those with a migrant background. Patients with unrecognised PTSD have on average poorer outcome than other psychiatric outpatients. To pay attention to trauma-also in the absence of sophisticated therapeutic skills-seems to improve long-term outcome and confidence in treatment staff considerably. To screen for traumas in general psychiatry would help treatment staff and patients together to evaluate the consequences of trauma(s) and assist in the process of working through. Special attention should be paid to patients with a migrant background.

List of scientific papers

I. Al-Saffar S, Borga P, Wicks S, Hallstrom T (2003). The influence of patients ethnicity, socio-demographic conditions and strain on psychiatric diagnoses given at an outpatient clinic. [Submitted]

II. Al-Saffar S, Borga P, Edman G, Hallstrom T (2003). The aetiology of posttraumatic stress disorder in four ethnic groups in outpatient psychiatry. Soc Psychiatry Psychiatr Epidemiol. 38(8): 456-62.
https://pubmed.ncbi.nlm.nih.gov/12910342

III. Al-Saffar S, Borga P, Hallstrom T (2002). Long-term consequences of unrecognised PTSD in general outpatient psychiatry. Soc Psychiatry Psychiatr Epidemiol. 37(12): 580-5.
https://pubmed.ncbi.nlm.nih.gov/12545235

IV. Al-Saffar S, Borga P, Lawoko S, Edman G, Hallstrom T (2003). The significance of addressing trauma in outpatient paychiatry. Nordic Journal of Psychiatry. [Accepted]