Which of the following symptom characteristics often accompanies posttraumatic stress disorder in refugees?
“Ms. A” is a 27-year-old mother of two from Northern Syria who currently resides in a large refugee camp in Turkey. She presented to a mental health clinic of a Syrian medical nongovernmental organization that operates near the camp and is staffed by psychologist, a medical doctor, and a visiting supervising psychiatrist. Ms. A was referred by her primary care physician for unexplained syncopal episodes. She had experienced these episodes intermittently over the past 3 months, often during the day when she would walk around the refugee camp. Her primary care physician had, over the course of several visits,ruled out possible medical causes for her symptoms and then referred Ms. A to the mental health clinic. She initially declined the referral, stating, “I am not majnoona [crazy],” but she reluctantly agreed to attend an appointment.
At her first appointment, Ms. A reported that she had been having these random fainting episodes with no clear triggers. She did not understand why she was referred to the mental health clinic, as this was clearly “a medical problem.” She reported fatigue, anhedonia, insomnia, and moderate anxiety symptoms without any panic attacks. She dismissed questions related to depressed mood, saying, “We are all depressed, wouldn’t you feel depressed if you lost everything?” She did not endorse psychotic symptoms, and she had no suicidal or homicidal ideation. She did not have any past history of mental health problems or treatment. She had never seen a mental health clinician in the past, and she remarked that she wasn’t sure why she should see one in the first place, as “this is only for rich people.” Her highest level of education had been middle school, after which she started working as a store attendant. At age 17, she met and married her husband (arranged through family members) and had two children with him. Her husband was currently in Germany, and she planned to join him there, but said she was unsure of when this would happen, as “I worry that he has forgotten about us.”
When asked about her exposure to war, she was evasive, saying that, like anyone else in the camp, she had seen dead bodies in the streets and had known many who had been murdered, tortured, or abducted. She said that she had an older brother who had joined the opposition armed forces, but she had not heard from him in 2 years. She also mentioned a cousin who was kidnapped by armed men and never returned. Ms. A flatly described fearing for her life and her children’s lives many times as she heard barrel bombs falling in their neighborhood. Finally, one day she witnessed a bomb hitting her neighbors’ house. She described watching the building collapse with the entire neighbor family inside. She matter-of-factly described watching this event unfold, but she expressed no affect in recounting the episode. She stated that this was the moment when she decided to leave. She commented that she did not see the point in discussing these stories, as “others have seen worse things, I should not complain.”
In talking about symptoms, Ms. A put her symptoms in context, saying, “You would be anxious too if you were in my place,” attributing it to her uncertain future and her financial situation. She remained largely focused on her fainting episodes and asked about several medical conditions that she thought might be causing them. The psychologist encouraged her to explore the triggers for the episodes, and after a long discussion, she said that they were related to times when she was “very upset.”
Given the prominence of her insomnia, depression, and anxiety symptoms, a diagnosis of major depressive disorder with anxiety symptoms was made by the consultant psychiatrist, and the patient was offered a trial of a serotonin reuptake inhibitor. Initially she was worried that she would get “addicted” to the medication. Psychoeducation was provided to distinguish antidepressant medication from benzodiazepines, which are commonly misused. She agreed to take the medication with the main goal of helping her sleep. She also reluctantly agreed to come for weekly psychotherapy with the psychologist, as “I am bored and there is nothing to do in the camp anyway.” She was started on sertraline, at 50 mg/day h.s.
After 1 month, Ms. A stated that the medication had helped her with her insomnia and the way she felt during the day. She had ceased having episodes where she felt overwhelmed, and she was experiencing fewer fainting episodes; she had gone from having four a week to one every 10 days. In therapy, she was able to report that her most recent episode occurred after hearing some particularly bad news about a disappeared friend whose body had been found. She was also able to connect many episodes temporally to having spoken to friends and family members back home and subsequently having sought out YouTube footage of bombings and other attacks that they had reported to her. She agreed to reduce the frequency of watching these videos, and she experienced fewer episodes as a result.
Despite the decrease in fainting episodes, however, she had begun to complain of increased diffuse body pain, headache, and numbness in her extremities. Over the course of the following month, these symptoms became the main focus of her psychotherapy sessions. Despite a lack of progress with the pain complaints, she kept coming to therapy, and she continued taking sertraline, the dosage of which had since been increased to 100 mg/day h.s. A month later, she was free of fainting episodes. She was still experiencing pain, but she had made progress in therapy and could identify triggers for her pain, such as when she felt overwhelmed by difficult emotions such as anger, sadness, or fear. After learning that one of her siblings had been killed in an air strike, her symptoms worsened and the fainting episodes returned. She also described nightmares and waking up at night with tachycardia and diaphoresis. At that time, the consulting psychiatrist recommended a trial of clonidine (0.1 mg/day h.s.) to deal with the nightmares, and she experienced a good response after the second dose. It was continued for 2 weeks but then discontinued because the patient started complaining of dry mouth (she remained free of nightmares afterward). After a week, the renewed fainting episodes stopped, and her focus returned to her complaint of chronic pain.
In therapy, Ms. A talked about feeling alone in the camp. Back home, she was always supported by her social network, and here she had nights when she cried all night and did not leave the tent. She described prayer as a way of coping, but occasionally she worried that “Allah may have forgotten about us.” She was feeling increasingly doubtful that she would ever make it to Germany and had been arguing with her husband about their financial situation, as they had spent most of their assets in the process of leaving Syria. She said that her hope for a better future for her children was keeping her going. Her psychologist noted that over the course of several months, the focus of their sessions began gradually to shift to her daily frustrations in the camp, anger at her kids for their “constant fighting with each other,” problems with her neighbors: “They gossip too much.” She had nearly ceased discussing her somatic pain. Her psychologist inquired about this, and Ms. A replied that she still had the pain, but she “forgot” to mention it. Her psychologist noted that she now appeared able to experience a full range of emotions in the session, including happiness, anger, and sadness, instead of the limited emotional range she had exhibited during the first month of treatment.