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What is the role of culture in the mental health of help seekers who have experienced traumas? Given that trauma occurs in every culture, knowledge of how culture may impact symptom expression is of crucial importance in understanding the psychological difficulties and strengths of trauma survivors. This knowledge can also expand our appreciation of the range of ways all people may respond to trauma and provide insight into the nuances of traumatic symptoms.  

Cultural shapes the subjective meaning of trauma and pain and this in turn influences symptom expression (reviewed in Cohen et al., 1998; Frey, 2001; Kirmayer & Sartorius, 2007; Marsella & Christopher, 2004; Marsella, Friedman, Gerrity, & Scurfiled, 1996; Pole, Gone, & Kulkarni, 2008; Wilson, 2007). The rituals, values, and norms associated with culture guide perception and individual responses, including psychiatric symptoms (Hofstede, 1982; Schubert & Punamaki, 2011).  

Differences in individual and cluster-level PTSD symptoms and other comorbid symptoms could lead to differential relations between symptom clusters cross-culturally. For example, one study using a sample of Hispanic, non-Hispanic Caucasian, and African American survivors of sudden physical injury found that the Hispanic group reported higher levels of overall posttraumatic distress, and also different patterns of symptoms(Marshall, Schell, & Miles, 2009). The results of studies such as this lead to questions regarding whether certain cultures truly have higher levels of distress after experiencing a traumatic event, or whether cultural factors have an impact on the manifestation of mental health symptoms, particularly the type of symptoms actually being measured.  

Evident are cross-cultural differences in PTSD symptom clusters and factor structures (Marshall et al., 2009). However, specifically identifying these differences has proven difficult. For example, studies that look at racial/ethnic differences among PTSD symptoms and criteria have sometimes been contradictory in their findings (Smith, unpublished). These contradictory findings are reflective that the intersection of cultural identities influences symptomatology more than membership in any one cultural group. The inconsistencies also speak to the importance of considering culture(s) in symptom expression.

To begin, the avoidance/numbing cluster has been found to have cultural variability (reviewed in Hinton & Lewis-Fernández, 2010; Marsella, Friedman, & Spain, 1996), including lower prevalence rates in some cultures (reviewed in Hinton & Lewis-Fernández, 2010). This variability appears to be influenced by non-western differential expression of emotions, stoicism and differential views on individual responsibility (Gerrility & Solomon, 1996). Of importance is the difference between avoidance and numbing symptoms cross-culturally wherein there seems to be more commonality for avoidance symptoms and more variability for some numbing symptoms (e.g., social withdrawal depends on situational differences) (Drožđek, 2007).  

Some research has proposed more cultural differences in manifestation of avoidance symptoms (Marsella, Friedman, & Spain, 1996). The use of avoidance in traditional, collectivist cultures may actually be in service of an adaptive process following exposure to trauma (Elsass, 2001) and possibly explain the observed difference in symptom structure between those traumatized with PTSD and those without PTSD (Slobodin, Caspi, Klein, 2012).

With reference to re-experiencing symptoms, there is evidence for intrusive thoughts and memories being universal (reviewed in Hinton & Lewis-Fernández, 2010; Marsella, Friedman, & Spain, 1996), possibly attributed to their consistent biological basis (Marsella, Friedman, Gerrity, et al., 1996). However, universality and consistency does not mean that the symptoms are equally salient across cultures. Thus symptoms like flashbacks vary in their salience across cultural groups, and prevalence rates of distressing dreams are higher in certain cultural groups (reviewed in Hinton & Lewis-Fernández, 2010).

Lastly, with reference to the hyperarousal symptoms, even though there is suggestion of cultural differences in manifestation, there is also evidence to support a consistent biological basis for this cluster (Marsella, Friedman, Gerrity, et al., 1996). In fact, most individuals with PTSD experience hyperarousal symptoms, including poor sleep, poor concentration, and irritability (Drožđek, 2007).

Beyond the PTSD cluster of symptoms, cultural differences have been discussed in other common trauma symptoms, most notably dissociation and somatization.  Again, attempts to determine which cultural group, usually racial/ethnic groups, has more or less dissociation or somatization has proven problematic (Smith, unpublished).   

This is because culture needs to be thought of more dynamically than categorization.  For example, while dissociative and/or somatic type symptoms are described in stress- or trauma- related syndromes identified within various cultures (e.g. falling out, indisposition, attaques de various, khyˆal, and susto) similar presentations may not be found in those who may identify with these culture but now live in the United States.   

The existence of these syndromes suggest the already documented substantial physical morbidity and somatic syndromes associated with PTSD (MacFarlane, 2010; Gupta, 2013), demonstrates that the lack of separation between mental and physical functions typical of non-Western belief systems dictates a different approach to the somatic complaints and expressions of distress.  This is consistent with the idea that several non-Western and ethnic cultures use somatic symptomatology to express distress (Marsella, Friedman, Gerrity, et al., 1996; Marsella, Friedman, & Spain, 1996; Pole et al., 2008).  

In terms of the mechanisms, it is proposed that emotional distress (e.g., affective disorders), stressors and imbalances in the body may give rise to experiences of bodily distress, which is amplified if the symptoms are given certain cultural meanings or misattributions (Kirmayer & Sartorius, 2007).

In fact, cultural aspects influence the interpersonal responses that may reinforce certain somatic expressions, interpersonal responding to presence of bodily symptoms, interpretation of bodily symptoms, and concerns related to somatic symptoms. Hence some idioms of distress are somatic in nature (Kirmayer & Sartorius, 2007).

Additionally, a complex model is proposed for the way culture-specific syndromes and ethno-physiological processes join to generate anxiety symptoms, especially in response to traumatic triggers, that in turn result in the somatization of the stress response (Hinton, Kredlow, Pich, Bui, & Hofmann, 2013). Although a true understanding of these phenomena requires a profound knowledge of each specific culture, the model generates a conceptual approach.
An additional subject oftentimes not sufficiently addressed in relation to PTSD is shame. Suggested as a highly important factor in the effect of trauma on children and as predictive of the formation of PTSD (Herman, 2007; Budden, 2009), shame has enormous magnitude in traditional societies, and may be, in addition to the somatic path, another key to the observed complex trauma reactions in non-Western traumatized individuals(Caspi, Saroff, & Shorer, 2009).

Some of the aforementioned influences discussed in this article and the first two installments (see vol. 27(2) and vol. 27(5)) are considered in the DSM-5. To elaborate, the A3 category of indirect exposure (learning that a family member or friend experienced a violent traumatic event) may address cultural considerations related to trauma. Further, category B1 allows for assessment of memories that arise from culturally driven stressors.

Lastly, the category D criteria of cognitive and mood alterations in response to a traumatic event allows consideration of cultural variations in perception and response to traumatic events (Young & Johnson, 2010). However, some scholars have voiced the opinion that in the area of trauma and PTSD, the DSM-5 remains, for understandable reasons, a long way from cross-cultural adequacy (Phillips, 2010).


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About the Authors

Bita Ghafoori, PhD, is a clinical psychologist and a Professor of Counseling at California State University Long Beach. Her current research focuses on mental health disparities in traumatized populations, cultural considerations in the assessment and treatment of traumatic stress, and the dissemination of evidence-based, trauma focused therapies.

Yael Caspi, PhD, is a clinical psychologist and a researcher. She is the director of the veterans' psychiatric outpatient services at the Rambam Medical Health Center, in Haifa, Israel. Yael received her ScD degree from the Harvard School of Public Health in Boston, where she investigated the impact of refugee trauma in a community sample of Cambodian refugees. During the past few years she has been writing and advocating for increased awareness of war trauma and its impact on Bedouin servicemen in the Israel Defense Forces and their families.

Ateka Contractor, MA, is a fourth-year doctoral student (clinical psychology) at University of Toledo. She has obtained her masters degree in clinical psychology at Eastern Illinois University. Her main research and clinical interests are the interaction between PTSD and culture, and PTSD's comorbidity with depressive and impulse-based disorders using structural equation modeling techniques.

Stefanie F. Smith, PhD, is an Associate Professor at the California School of Professional Psychology at Alliant International University and maintains a private practice.  Her main research interests include neurophysiological and sensorimotor impacts of complex trauma and corresponding interventions, cultural impact on trauma symptomatology, and complex trauma's impact on health and risky health behaviors.


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