An Overview of in the Refugee Population Kara MacIntyre University of Virginia School of Medicine April 2021 Abstract Somatization, or the expression of medically unexplained symptoms that cause distress and impairment, is a common problem in the refugee population. Refugees are often subjected to traumatic experiences and repeated stressors, such as torture, abuse, and postmigration living difficulties, which can lead to the development of trauma-related disorders, such as anxiety, , and somatization. The pathogenesis of somatization in refugees can be explained by multiple mechanisms such as an undiagnosed physical illness, the result of past trauma, and cultural stigma. There is a well-documented co-occurrence of somatization with other psychological disorders, especially with PTSD. With the increasing numbers of refugees encountering the western health system, it is important that physicians and other healthcare providers are able to recognize and treat conditions that affect this population, especially somatization. Many patients require psychological treatment in addition to their medical treatment, and cognitive-behavioral therapy has been found to be the most effective psychological therapy for depression, anxiety, and somatization. General treatment tenets for somatization and related disorders include building a strong, positive relationship between the physician and the patient, scheduling frequent, supportive visits, and avoiding medication or testing when the interventions are not indicated. It is also important to keep in mind the barriers to treatment that refugees may face, such as language, health literacy, or cultural stigma. Introduction to live with debilitating pain, and she can see no end in sight. Mrs. S feels that her Mrs. S is a 55 year old woman who symptoms are being dismissed by the many presents to her primary care physician with physicians who have worked with her, and unrelenting pain in her abdomen, knees, her medical bills continue to pile up. This and lower back. Her symptoms have been situation is not only frustrating and worsening for five years. Seven years ago, disheartening for Mrs. S, but also for her she was forced to flee Afghanistan after physicians, whose goals are to find and witnessing several family members be treat the cause of Mrs. S’s pain. murdered by a terrorist group. After Somatization, or the expression of physical arriving to the United States as a refugee, symptoms causing distress and impairment she was at first overwhelmed with joy and that cannot be medically explained, is a gratitude to finally have a safe place to call term used to describe this situation. In this home for her children. However, when her paper, I will discuss somatization, what it is symptoms began, she underwent an and how it manifests, what factors make it extensive medical work-up, including a common problem for refugees, and how imaging studies, blood tests, and we can address it. gastroenterological procedures, only to reveal normal results. Today, she continues

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Background The diagnosis of somatic symptom disorder was introduced in the Diagnostic As of 2020, there are currently 26.3 and Statistical Manual of Mental disorders, million refugees, or persons who have been Fifth Edition (DSM-5), which was published forced to leave their country in order to in 2013. Somatic symptom disorder is escape war, persecution, or natural defined as persistent physical symptoms disaster, worldwide.1 Sadly, this number accompanied by excessive thoughts, continues to grow by about 1% each year.2 anxiety, and/or behaviors that cause Refugees often experience multiple and significant distress and are not necessarily prolonged traumatic events and post- explained by a recognized medical migratory distress, which can lead to the condition. This diagnosis was meant to development of conditions. combine and replace the older diagnoses of In fact, the prevalence of mental health , undifferentiated disorders are high in this population, with somatoform disorder, , and around 55% of refugees in European , which were included in the countries reporting at least one current prior edition of the DSM. These diagnoses mental health disorder. Commonly were collectively referred to as somatoform reported mental health conditions in this disorders.7 However, some researchers and population include posttraumatic physicians continue to recognize the more disorder (PTSD), depression, anxiety, and specific diagnoses under somatoform somatization.3 disorders, and these diagnoses are still It is estimated that 5-7 percent of retained by the World Health Organization’s patients in the general United States International Classification of – population suffer from somatization.4 For 10th Revision (ICD-10).8 Another term that is many reasons that will be discussed in this also commonly used is somatization, which paper, a high level of medically unexplained is a broad construct used to describe symptoms occur in refugees. Common patients with medically unexplained somatic symptoms in refugees include symptoms that cause distress and stomach aches, muscle, bone, and joint impairment, but is not a formal DSM-5 problems, weakness, and .5 These diagnosis.3,7 Somatization is the term used symptoms can cause important obstacles to in this paper unless otherwise noted. diagnosing and treating refugees, and can Epidemiology lead to disability and great suffering for the patients.3 It is important that physicians be It is estimated that somatization trained to recognize trauma symptoms, occurs in 5-7% of the general United States particularly somatization, in order to population.4 Patients with functional improve the mental health of refugees and disorders such as irritable bowel syndrome increase the utilization of mental health and have a higher prevalence services.6 of somatization.10 Risk factors for somatization include family history of What is somatization? chronic illness, health anxiety, childhood Terminology neglect, female sex, chaotic lifestyle, fewer years of education, lower socioeconomic status, history of alcohol and substance

2 abuse, concurrent medical or psychiatric Pathogenesis of somatization in refugees disorders, and history of abuse or trauma.4,7 There are many plausible Patients with somatic symptom and related explanations of somatization in refugee disorders typically present to primary care populations, and many of these and general medicine clinicians rather than explanations are also valid for non-refugee psychiatrists, which emphasizes the patients. First, it’s important to emphasize importance of training all physicians, that somatization or somatic complaints especially generalists, to diagnose and may be caused by an undiagnosed physical manage these conditions.9 illness. Therefore, clinicians must first Health care utilization provide patients with a thorough somatic examination. It’s imperative to keep this in By definition, patients with mind since barriers such as poor language somatization and related disorders have and poor knowledge of the Western health physical symptoms that cause emotional system make the refugee population and behavioral distress. These patients are especially vulnerable to misdiagnosis and therefore more likely to use the healthcare dismissal. Additionally, in some cases, a system than other patients. This can lead to patient may warrant a re-examination, as an excess of healthcare dollars spent, which some illnesses have a latency period and emphases the need for identification and are undetectable until a later phase.5 treatment of this condition.5,7 Another possible cause of Clinical symptoms somatization in refugees is trauma. Somatization symptoms range from Research indicates that refugees are mild to severe, and encompass all organ approximately 10 times more likely to systems. Common symptoms include: pain experience psychological trauma than the symptoms; nonspecific symptoms such as general population, and many refugees fatigue, , and dizziness; have also suffered physical trauma.6 It has cardiopulmonary symptoms; long been documented that patients who gastrointestinal symptoms; neurological have experienced psychological and symptoms; and reproductive organ physical trauma can present with somatic symptoms. The most common burdensome symptoms that lack a medical explanation. symptom reported in patients with For instance, patients who have been somatization is pain.11 tortured often have chronic pain in the parts of their body that were physically Prognosis tortured, without any objective signs of Symptoms of somatic symptom pathology or injury. This same phenomenon disorders generally wax and wane, and are is also encountered in war veterans who chronic. Patients can recover. It is estimated have been previously wounded. For that 50-75% of patients with somatization example, the Gulf War syndrome is a improve, whereas 10-30% deteriorate. chronic disorder linked to a wide range of Presenting with fewer physical symptoms somatic symptoms such as pain, fatigue, and better baseline functioning are and diarrhea affecting returning veterans of considered better prognostic indicators.4 the Gulf War. This syndrome is thought to be caused by a combination of physical and

3 psychological factors. It can also be difficult psychological distress in refugees, it is to distinguish physical from unsurprising that refugees experience high psychological distress, as one can be rates of trauma-related mental health responsible for or exacerbate the other, and conditions, such as PTSD, anxiety, vice versa. should be added depression, and somatization.12,13 In fact, to the somatic treatment in these cases, as research has shown that refugees are 10 it has been stated that sometimes times more likely to have PTSD than age- psychological distress can prevent somatic matched individuals in the general symptoms from being cured.5 population.5 Another possible explanation is the There is a frequent and well- stigma that patients fear they may documented co-occurrence of PTSD and encounter for expressing mental health unexplained somatic symptoms. issues. This can lead patients to present Furthermore, there is a particularly high physical problems rather than psychological comorbidity rate of PTSD and somatization problems, sometimes unconsciously. in refugee populations.12 There are several Additionally, the health system is biased possible mechanism through which towards physical illnesses. There are more somatization may be associated with PTSD. resources, training, and diagnostic tests These mechanisms include: traumatic available for somatic issues than for injuries sustained in the traumatic event; psychological issues. Furthermore, many autonomic, immunologic, and patients feel that a physical disease neuroendocrine dysregulation resulting legitimizes their illness. For example, in from PTSD; somatoform disorders many non-Western countries, people see associated with elevated stress levels; or as a service specifically for genetic predispositions. These mechanisms patients diagnosed with , and result from psychological, behavioral, and they are fearful of stigmatization if they biological factors, in addition to the were to seek psychiatric treatment. 5 complex interactions between these Therefore, stigma plays a role in all patients factors.12 with somatization, but refugees are more Several studies have focused on vulnerable due to their cultural background. elucidating the interaction between PTSD Somatization and PTSD and somatization in refugees. A study by Morina et al. found that different patterns By definition, refugees have of somatic symptoms are associated with experienced persecution, and are therefore different clusters of PTSD symptoms. For often subjected to traumatic situations, example, DSM-5 PTSD Criteria D including torture, bereavement, and life- “alterations in cognitions and mood” and E threatening experiences. In addition, “alterations in arousal and reactivity” were refugees often experience postmigration primarily related the somatic symptom of stressors, including unemployment, weakness.12 In another study, Spiller et al. discrimination, insecure visa status, and demonstrated that that somatization, family separation.12 Considering the well- explosive anger, and postmigration living documented dose-response relationship difficulties were positively correlated with between trauma exposure and PTSD severity.13 These findings have a

4 number of implications. One is that PTSD pharmacological and psychological should be routinely screened for in refugees treatment, were found to have significant with nonspecific or medically unexplained effects on depression, anxiety, and somatic complaints and pain, and vice somatization. Based on qualitative versa. In addition, when treating refugee observations, the probability of significant patients with somatization and/or PTSD, a pre-post treatment effects in trials with close and interdisciplinary collaboration is outcomes of depression, anxiety, and advisable in order to distinguish between somatization were 56%, 44%, and 42%, complaints in need of somatic treatment respectively. Cognitive behavioral therapy and those accessible for psychological was found to be the most effective interventions.12,13 treatment. The paper noted that the studies on dynamic therapies used observational Somatization treatments for refugees designs, and therefore need further With the increasing number of investigation due the lack of randomized refugee patients encountering western control trials (RCT). Of the three outcomes, medical services, it is especially important somatization had the fewest number of that clinicians be trained in identifying and studies on treatment for migrants, which treating the health problems commonly suggests the need to conduct more studies affecting this population, including focused on testing the efficacy of somatization and other trauma-associated psychological treatments for somatization disorders. General treatment tenets for in refugees.2 somatization and related disorders include As previously noted, since many of building a strong, positive relationship the psychological disorders affecting between the physician and the patient, and refugee patients are associated with past scheduling frequent, supportive visits. It is physical or psychological trauma, it is also important to avoid medication or imperative that their treatment focus on testing when the interventions are not any trauma they may have experienced. indicated.4 The best practice interventions for In the last 20 years, research into psychological trauma is considered to be psychological and pharmacological holistic, community-oriented, and culturally treatments for migrants afflicted with appropriate, with a view to building on mental health conditions has increased, and strengths within individuals and many of these treatments have been shown communities rather than focusing on to be effective. A meta-analysis by deficits. In addition, testimonial based and Sambucini et al. was recently conducted emotion focused therapies are considered that included 52 studies over a 24 year an important part of any trauma informed period on the effectiveness of psychological intervention.6 Therefore, treatments for treatments on three psychiatric disorders in refugees suffering from somatization or migrants, including refugees. This study other trauma-associated conditions could found that all treatments used in the result in better outcomes by combining studies, which included cognitive behavioral medical and psychiatric assessments and therapy (CBT), narrative exposure therapy, treatments.5 psychodynamic therapy, and combined

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It is also important to realize that 2020. Accessed April 18, 2021. engagement with the mental health care https://www.unhcr.org/refugee-statistics/ system is a critical part of obtaining 2. Sambucini D, Aceto P, Begotaraj E, Lai C. treatment for psychological trauma. Efficacy of psychological interventions on Unfortunately, there are numerous barriers depression anxiety and somatization in at both the system level and individual level migrants: a meta-analysis. J Immigr Minor preventing the refugee population from Health. 2020;22(6):1320-1346. obtaining care including language, cost, doi:10.1007/s10903-020-01055-w health literacy, transportation, stigma (especially for mental health), availability of 3. Jongedijk RA, Eising DD, van der Aa N, services, training for clinicians working with Kleber RJ, Boelen PA. Severity profiles of refugees, and the cultural appropriateness posttraumatic stress, depression, anxiety, of care. In fact, a systematic review by Due and somatization symptoms in treatment et al. found that for refugees with seeking traumatized refugees. J Affect psychological problems, access rates of Disord. 2020;266:71-81. mental health services were low, while doi:10.1016/j.jad.2020.01.077 general healthcare access was comparable or greater than the general population.6 4. Kurlansik SL, Maffei MS. Somatic symptom disorder. Am Fam Physician. Conclusion 2016;93(1):49-54. In conclusion, for reasons such as an 5. Rohlof HG, Knipscheer JW, Kleber RJ. undiagnosed physical illness, past trauma, Somatization in refugees: a review. Soc repeated stressors, and cultural stigma, Psychiatry Psychiatr Epidemiol. somatization is a common problem in the 2014;49(11):1793-1804. refugee population.5 With the number of doi:10.1007/s00127-014-0877-1 refugees increasing worldwide, it is especially important for physicians and 6. Due C, Green E, Ziersch A. Psychological other healthcare providers to be able to trauma and access to primary healthcare diagnose and treat conditions that for people from refugee and asylum-seeker commonly affect this population, including backgrounds: a mixed methods systematic somatization. To treat somatization, many review. Int J Ment Health Syst. 2020;14:71. patients require psychological treatment in Published 2020 Sep 11. addition to their medical treatment, and doi:10.1186/s13033-020-00404-4 cognitive-behavioral therapy has been 7. Ciccarelli SK, White JN. : DSM found to be the most effective.4 It is also 5. Boston: Pearson; 2014 important to keep in mind the many barriers to treatment that refugees may 8. Classification of Diseases (ICD). World face. Health Organization. https://www.who.int/standards/classificati References ons/classification-of-diseases. Accessed 1. The UN Refugee Agency (UNHCR). May 1, 2021 UNHCR’s Refugee Population Statistics 9. Kirmayer LJ, Robbins JM. Three forms of Database Website. Updated December 8, somatization in primary care: prevalence,

6 co-occurrence, and sociodemographic 12. Morina N, Kuenburg A, Schnyder U, characteristics. J Nerv Ment Dis. Bryant RA, Nickerson A, Schick M. The 1991;179(11):647-655. association of post-traumatic and doi:10.1097/00005053-199111000-00001 postmigration stress with pain and other somatic symptoms: an explorative analysis 10. Claassen-van Dessel N, van der Wouden in traumatized refugees and asylum JC, Dekker J, van der Horst HE. Clinical value seekers. Pain Med. 2018;19(1):50-59. of DSM IV and DSM 5 criteria for diagnosing doi:10.1093/pm/pnx005 the most prevalent somatoform disorders in patients with medically unexplained 13. Spiller TR, Schick M, Schnyder U, Bryant physical symptoms (MUPS). J Psychosom RA, Nickerson A, Morina N. Somatisation Res. 2016;82:4-10. and anger are associated with symptom doi:10.1016/j.jpsychores.2016.01.004 severity of posttraumatic stress disorder in severely traumatised refugees and asylum 11. Tomenson B, Essau C, Jacobi F, et al. seekers. Swiss Med Wkly. Total somatic symptom score as a predictor 2016;146:w14311. Published 2016 May 6. of health outcome in somatic symptom doi:10.4414/smw.2016.14311 disorders. Br J Psychiatry. 2013;203(5):373- 380. doi:10.1192/bjp.bp.112.114405

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