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. Author manuscript; available in PMC: 2022 Nov 21.
Published in final edited form as: Int J Soc Psychiatry. 2020 Dec 3;68(1):118–128. doi: 10.1177/0020764020978274

Perceived health, adversity, and posttraumatic stress disorder in Syrian and Iraqi refugees

Arash Javanbakht 1, Lana Ruvolo Grasser 1, Soyeong Kim 2, Cynthia L Arfken 1, Nicole Nugent 2
PMCID: PMC9678010  NIHMSID: NIHMS1850515  PMID: 33269642

Abstract

Background:

Exposure to armed conflict and fleeing country of origin for refugees has been associated with poorer psychological health.

Methods:

Within the first month following their arrival in the United States, 152 Syrian and Iraqi refugees were screened in a primary care setting for posttraumatic stress disorder (PTSD), anxiety, and depression and rated their perceived health, and perceived level of adversity of violence, armed conflict/flight. The moderating effects of psychiatric symptoms on the relation between perceived adversity and perceived health were assessed.

Results:

Three models based on diagnosis (PTSD, anxiety, and depression) were tested. While significant effects were found on perceived adversity negatively influencing perceived health across diagnoses, slightly different patterns emerged based on diagnosis.

Discussion:

Findings suggest that refugees’ perception regarding adversity of violence, armed conflict, and flight may contribute to perceived health, with a moderating role of clinically significant symptoms of PTSD, anxiety, and depression.

Keywords: PTSD, perceived health, perceived adversity, Syrian and Iraqi refugees

Introduction

In recent years, the numbers of refugees fleeing violence, armed conflict, and trauma has increased exponentially, and often refugees flee violence, armed conflict, and trauma only to face significant ongoing stress and sometimes even new trauma as they await resettlement. Once refugees are out of the immediate conflict, ongoing displacement related stressors at entry and integration cause significant psychological strain (Juarez et al., 2019; Miller & Rasmussen, 2017). As refugees do not migrate, but rather flee their homelands, we will use the term flight to refer to refugees’ displacement from their homeland to their new country of residence. In many Western countries, newly arriving refugees are required to undergo a physical health screening. A recent review study reports that when screening is provided, it rarely includes assessment of refugees’ trauma history or mental health (Hvass & Wejse, 2017). The lack of screening that could connect refugees to appropriate psychological care is alarming given evidence that posttraumatic stress disorder (PTSD) is increased relative to host populations at the time of resettlement (as high as war veterans) and that anxiety and depression are elevated a few years after resettlement (Giacco et al., 2018; Giacco & Priebe, 2018; Javanbakht et al., 2019). Research has shown that refugees with PTSD are more likely to report somatic concerns including chronic pain (Rometsch-Ogioun El Sount et al., 2019) and therefore use primary care settings more than mental health resources (Abu Suhaiban et al., 2019). As such, there is a significant need for easily administered and clinically relevant screening measures to can help connect refugees to mental health resources through primary care settings.

Clinical evidence suggests that cognitive appraisal of stress, trauma, and adversity can modulate the impact of trauma on an individual (Iversen et al., 2008; James et al., 2013; Lancaster et al., 2016; Nissen et al., 2015; Oflaz et al., 2014; Pinto et al., 2015). Cognitive appraisal of the traumatic event may impact stress reactivity both during and following exposure through modulation of the medial prefrontal cortex, amygdala, and hippocampus on the hypothalamus, in turn affecting reactivity of the hypothalamic pituitary adrenal axis (HPA). While acute HPA axis responses have a protective role, chronic activation can lead to negative consequences for mental and physical health (Kamin & Kertes, 2017). Indeed, abnormal levels of glucocorticoids, the downstream product of the HPA axis, can interfere with activity in both the frontal cortex and the hippocampus (Pitman et al., 2012). These are both key brain regions involved in regulating amygdala reactivity in PTSD [16] and may link trauma and physical health. Patients with PTSD have higher prevalence of a diverse group of chronic medical conditions, from cardiovascular disease to metabolic syndromes (Boscarino, 2006, 2008; Hotopf et al., 2006), and these are associated with more severe PTSD (Brailey et al., 2018), even after controlling for other risk factors (Cohen et al., 2009). Those exposed to trauma may also have physical sequelae of traumatic injuries in cases of violence and armed conflict related trauma, or torture.

Trauma not only impacts physical health and puts one at greater risk for a host of medical conditions, but also influences one’s perception of health. A large study of more than 2,000 male and female veterans reported an association between PTSD symptoms and self-reported health problems as indicated by the Brief Symptom Inventory and Health Symptom Checklist (Wagner et al., 2000). In a sample of women with a history of trauma, PTSD symptoms were also found to be associated with worse self-reported health based on a single item asking individuals to rate overall physical health in the past year on a 5-point Likert-type scale ranging from 1 (poor) to 5 (excellent), a standard assessment of health perceptions (Kimerling et al., 2000). Additionally, PTSD mediated the relation between trauma and self-reported poor health (Kimerling et al., 2000).

Thus far, the majority of research on perception of trauma and related adversity has been focused on the relation with PTSD, and less is known about the association with depression and anxiety, which are often observed following trauma. Depression is one of the most common comorbid diagnoses with PTSD (Rytwinski et al., 2013), with an independently high burden on quality of life and health status (Elderon & Whooley, 2013). Furthermore, our knowledge of the impact of cumulative trauma on PTSD and other psychopathology is limited. Anxiety and depressive disorders often develop following exposure to trauma, and both are frequently comorbid with PTSD (Rytwinski et al., 2013). Despite this, there is little published research on self-assessment of health on comorbid anxiety and depression in traumatized populations. Given the growing population of individuals chronically exposed to trauma, including urban residents, first responders, and refugees, this area of research is becoming increasingly important.

In summary, an integrated model of perceived adversity of traumatic experiences and perceived health has not been studied before. In this work, we aimed to research these domains of perception of traumatic experiences and their impact on perceived health as moderated by trauma-related disorders PTSD, anxiety, and depression. We examined the relation between perceived cumulative adversity and perceived health, and whether this relation differed due to presence of PTSD, anxiety, or depression in a group of Syrian and Iraqi refugees who had been exposed to civilian war trauma (violence and armed conflict) and stress of fleeing their homeland. We hypothesized that greater perceived adversity would be associated with poorer perceived health. Furthermore, each diagnosis of PTSD, anxiety, and depression will have conditional effects on the hypothesized relation. Findings can have diagnostic, preventive, and therapeutic implications. A number of studies have used single-item questions to evaluate perceived trauma, adversity, and health (Berthold et al., 2014; Le et al., 2018; Whitsett & Sherman, 2017); these simple questions can be easily integrated into routine physical health screenings for first responders, resettling refugees, military personnel, etc. in order to determine who may be in need of psychological care. Therapeutically, if there is a consistent pattern of perception of adversity and physical health in a subgroup of traumatized patients, they may be more responsive to cognitive therapeutic methods addressing specific cognitive schemas.

Methods

Participants

This is a cross-sectional study from a convenience sample of Syrian and Iraqi refugees. This study was a collaboration between an academic institution and a non-profit social service agency conducting physical health screening mandated for recently arrived Syrian and Iraqi refugees. All screenings were scheduled within 1 month following arrival in the U.S.

Syrian and Iraqi refugees were recruited from two clinics serving the majority of individuals resettling in the area (Arfken et al., 2018; Javanbakht et al., 2018, 2019). Inclusion criteria were: age 18 to 65, able and willing to provide informed, written consent, and able to understand English or Arabic. Recruitment took place between June 2016 and May 2017. The study procedures were reviewed and approved by the Institutional Review Board.

Following the physical health screening provided by primary care givers, refugees were informed of a paid, voluntary research study. They were told that participation in the study would not affect their participation with the primary care center, nor anything related to their resettlement or screening. Those who were interested were provided with more information by bilingual graduate-level research assistants. Those who agreed to participate were invited to a private room for additional explanation, consent process, and questionnaire administration. Given the limitations in the field setting, time constraints prevented administration of more comprehensive clinician administered questionnaires, like the Structured Clinical Interview. Instead, we focused our assessments on direct and common consequences of trauma (PTSD, anxiety, depression). All measures were self-administered and research assistants were available for answering inquiries and orally administering measures if preferred by the participant.

Measures

A demographic questionnaire was used to obtain sample characteristics including age, sex, country of origin, marital status, education, and medical condition. The PTSD Checklist Civilian version (PCL-C) DSM-IV version was used to screen for probable PTSD. The PCL-C has been extensively used and validated in multiple populations with differential trauma exposures (Terhakopian et al., 2008). A symptom severity score was generated from the sum of all 17 items. Determination of probable PTSD was based on the DSM-IV criteria. Total symptom severity score ranged from 37 to 85 for those with probable diagnosis of PTSD. The internal reliability of the PCL-C in this sample was excellent (α = .92).

As a screening tool for anxiety and depression, the Hopkins Symptom Checklist 25 items (HSCL-25) was used. The questionnaire assesses anxiety and depression in the last week (Hesbacher et al., 1980). It includes 10 questions on anxiety, and 15 questions on depression, and has been validated across multiple cultures and context, including refugees (Carlson & Rosser-Hogan, 1994; Cepeda-Benito & Gleaves, 2000; Hollifield et al., 2002). For anxiety, the mean score for the first 10 items on the HSCL was calculated. For depression, the mean score for the last 15 items on the HSCL was calculated. For both anxiety and depression, scores of 1.75 or higher were considered provisional diagnosis (Derogatis et al., 1974). The internal reliabilities for anxiety and depression were excellent (for anxiety α = .88 and for depression α = .92). It is noted that since no formal diagnostic clinical interviews were conducted, all diagnoses are provisional.

A single item was used to assess perceived (violence and armed conflict/flight related) adversity. Participants were asked to self-rate experience during ongoing violence and armed conflict in their homeland and flight (On a scale from 1 to 7, 7 being the worse thing happened to you, how would you score your experience with the war and migration?) with Likert-type responses ranging from 1 = ‘mildly traumatic’ to 7 = ‘worst thing in my life’. Continuous scaling was maintained for regression models as well as moderation models. Consistent with previous public health studies and epidemiological research (i.e. Jylhä et al., 1998; Nielsen & Krasnik, 2010), perceived health was measured using a single item. Participants were asked to self-rate their health (How do you rate your health today?) with possible responses of excellent, very good, good, fair, and poor. Continuous scaling was maintained for regression models as well as moderation models. We followed the Centers for Disease Control approach (Shaw et al., 2016) with Excellent, Very Good, or Good indicating better health and fair or poor responses indicating worse health.

Analytic approach

Descriptive statistics were generated for all variables to check data distributions and adherence to model assumptions. No significant skew or kurtosis was identified, and there were no outliers in the sample. Given the low incidence (<5%) of missing data, no further strategies were implemented. Pairwise plots did not indicate violations of linearity nor homoscedasticity. Pairwise correlations were reviewed to investigate multicollinearity and singularity, of which there was no evidence for (all r’s <.9), and all assumptions for moderation analysis were met. First, we used multiple regression to test the influence of moderator variables on perceived health while controlling for age and gender. We then investigated the moderation effects of psychiatric diagnosis (i.e. PTSD, anxiety, and depression) on perceived health using SPSS PROCESS macro (Hayes, 2013). The predictors were mean-centered (Cohen et al., 2003) and each diagnosis variable (PTSD, anxiety, depression) was dichotomized into ‘0’ (diagnostic criteria met) and ‘1’ (no diagnosis). Three separate models based on three diagnoses (PTSD, anxiety, and depression) were tested, expressed as:

  • Model 1: Y = i1 + θX→Y(Perceived Adversity) + b2(PTSD diagnosis) + b4(Age) + b5(Gender) + eY, where θX→Y = b1 + b3(PTSD diagnosis)

  • Model 2: Y = i1 + θX→Y(Perceived Adversity) + b2(Anxiety diagnosis) + b4(Age) + b5(Gender) + eY, where θX→Y = b1 + b3(Anxiety diagnosis)

  • Model 3: Y = i1 + θX→Y(Perceived Adversity) + b2(Depression diagnosis) + b4(Age) + b5(Gender) + eY, where θX→Y = b1 + b3(Depression diagnosis)

Results

Descriptive statistics and bivariate correlations

Sample characteristics are summarized in Table 1 and study variables in Table 2. Participants were relatively young (Mage = 36.3 years, SD = 11.54), both genders equally represented (49.3% female), and about half had at least a high school education (46.0%). More than half (63.2%) were from Syria and 52 (33.6%) were from Iraq; five (3.2%) did not indicate their country of origin. A substantial proportion of participants (>70%) described their health to be good or better on the day of assessment and about 40% of respondents reported their experience of violence, armed conflict, and fleeing their homeland to be extremely traumatic based on the perceived adversity item.

Table 1.

Demographics.

Characteristics Total (N = 152)
Mean age (SD) 36.33 (11.54)
Females, % 49.3%
Education, %
 Illiterate 2.6
 Elementary/middle school 31.6
 High school 45.4
 College 18.4
 Post graduate 0.7
 Not reported 1.3
Marital status, %
 Married 71.0
 Single 21.0
 Divorced/widowed 7.3
 Not reported 0.7
Country of origin, %
 Syrian 63.1
 Iraq 33.6
 Reported 3.3
Any medical condition, % 37.0
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Table 2.

Means, standard deviations, bivariate correlations among study variables.

Variables 1 2 3 4 5 6 7 8
1. Age – .01 −.22** .39** −.01 .03 .06 −.03
2. Gender .01 – .12 .11 −.06 −.08 −.01 −.07
3. Education −.22** .122 – −.19* −.19* .04 −.06 −.16
4. Health .39** .11 −.19* – 0.22* .02 .10 .04
5. Perceived Adversity −.01 −.06 0.19* .22* – −.14 −.09 .00
6. PTSS Diagnosis .03 −.08 .04 .02 −.14 – .58** .47**
7. Anxiety Diagnosis .06 −.01 −.06 1.0 −.09 .58* – .64**
8. Depression Diagnosis −.03 −.07 −.16 .04 .00 .47** .64** –
 M 36.33 1.5 2.83 2.88 5.05 .31 .43 .51
 SD 11.54 .50 .78 1.20 2.02 .46 .50 .50
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*

p < .05.

**

p < .01.

Subsequently, a standard multiple regression was employed to test the relation between perceived health and perceived adversity, psychiatric diagnoses, gender, and age. The first regression model included perceived adversity, PTSD diagnosis, gender, and age and was found to be significantly associated with perceived health (F(4,141) = 9.48, p < .001). Composite model summary indicated explaining over 20% of the variance in perceived health (see Table 3). Age and perceived adversity were observed to be significantly associated with perceived health. The second regression model replacing PTSD with anxiety diagnosis, was statistically significant (F(4,139) = 9.97, p < .001) and predictor variables explained in total 22% of the variance in perceived health. Both age and perceived adversity were significant associated with perceived health. For the third regression model, which included perceived adversity, depression diagnosis, age, and gender as predictors of perceived health, was statistically significant (F(4,139) = 9.54, p < .001) and the model explained 22% of the variance in perceived health. Similar to previous regression models, and perceived adversity were significantly associated with perceived health.

Table 3.

Results of the multiple regression analyses.

Variables B SE t p
Model 1 (constant) 0.78 0.70 .48
Age 0.39 0.01 5.24 <.0001
Gender 0.10 0.18 1.32 .19
Perceived adversity 0.23 0.05 3.05 <.05
PTSD −0.01 0.18 −0.13 .90
F(1, 141) = 9.48, R2 = .21, p < .001
Model 2 (constant) 0.48 0.45 .66
Age 0.38 0.01 5.10 <.0001
Gender 0.10 0.18 1.31 .19
Perceived adversity 0.24 0.05 3.19 <.005
Anxiety 0.11 0.18 1.51 .13
F(4, 139) = 9.97, R2 = .22, p < .001
Model 3 (constant) 0.49 0.47 <.05
Age 0.39 0.01 5.21 <.0001
Gender 0.10 0.18 1.33 .21
Perceived adversity 0.23 0.05 3.05 .07
Depression 0.07 0.18 0.92 .36
F(4,139) = 9.54, R2 = .22, p < .001
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Perceived adversity, PTSD, and perceived health

Moderation analysis was conducted to examine the effect of psychiatric diagnosis on the link between perceived adversity and perceived health using the PROCESS macro (Model 1). The predictor variable of perceived adversity, the covariates of age and gender, and the moderator – PTSD diagnosis, were regressed on the dependent variable of perceived health, producing model summary of F(5,140) = 8.25, p < .001, R = .46, R2 = .21. As shown by Table 4, the interaction effect of perceived adversity and PTSD diagnosis was not significant, indicating the difference between the two slopes based on PTSD diagnosis was not significantly different than zero. However, perceived adversity was significantly associated with perceived health for individuals with PTSD diagnosis (b = .16 SE = .08, t = 2.05, p < .05, LLCI = .0054, ULCI = .3070) as well as for those without PTSD diagnosis (b = .13, SE = .06, t = 2.17, p < .05, LLCI = .0118, ULCI = .2555). Specifically, as perceived adversity increases by one unit, their perceived health decreases by .156 units for individuals with PTSD diagnosis. Similarly, as perceived adversity increases by one unit, their perceived health decreases by .134 units for individuals without PTSD diagnosis.

Table 4.

Moderation of perceived adversity on perceived health by diagnosis.

Variables b SE t p LLCI ULCI
Model 1 Intercept 0.91 0.37 2.61 <.01 0.231 1.681
Age 0.04 0.01 4.91 <.0001 0.024 0.057
Gender 0.26 0.19 1.38 .17 −0.111 0.621
Perceived adversity (PA) 0.13 0.06 2.17 <.05 0.012 0.256
PTSD 0.14 0.19 0.74 .46 −0.232 0.509
PA × PTSD 0.02 0.10 0.23 .82 −0.170 0.215
F(5, 140) = 8.26, R2 = .46, p < .001
Model 2 Intercept 0.91 0.37 2.46 <.05 0.179 1.635
Age 0.04 0.01 4.77 <.0001 0.024 0.057
Gender 0.25 0.19 1.32 .19 −0.122 0.615
PA 0.10 0.07 1.46 .15 −0.036 0.235
Anxiety 0.28 0.19 1.53 .13 −0.083 0.648
PA × anxiety 0.10 0.10 1.04 .30 −0.090 0.289
F(5, 138) = 8.55, R2 = .48, p < .001
Model 3 Intercept 0.92 0.40 2.29 <.05 0.124 1.708
Age 0.04 0.01 4.95 <.0001 0.025 0.057
Gender 0.24 0.19 1.27 .21 −0.135 0.619
PA 0.14 0.07 1.86 .07 −0.008 0.278
Depression 0.17 0.19 0.92 .36 −0.199 0.547
F(5,138) = 7.71, R2 = .46, p < .001 PA × depression 0.00 0.10 0.04 .97 −0.184 0.191
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Perceived adversity, anxiety, and perceived health

In Model 2, the predictor variable of perceived adversity, the moderator of anxiety diagnosis, and covariates, age and gender were regressed on the dependent variable of perceived health and yield model summary of F(5,138) = 8.55, p < .001, R = .48, R2 = .23. The interaction effect of perceived adversity and anxiety diagnosis was not statistically significant. However, among those who screened positive for anxiety diagnosis, perceived adversity was significantly associated with perceived health (b = .20, SE = .07, t = 2.93, p < .05, LLCI = .0648, ULCI = .3339), indicating as perceived adversity increases by one unit, their perceived health decreases by .199 units. On the other hand, perceived adversity was not significantly associated with perceived health for refugees without a positive anxiety diagnosis (b = .10, SE = .07, t = 1.46, p = .148, LLCI = −.0358, ULCI = .2353).

Perceived adversity, depression, and perceived health

The final model was estimated entering perceived adversity as predictor, age and gender as covariates, depression diagnosis as moderator and perceived health as outcome variable. Model summary indicated the model was significant, F(5,138) = 7.71, p < .001, R = .47, R2 = .22. The interaction effect of perceived adversity and depression diagnosis was not significant. However, perceived adversity was significantly associated with perceived health for individuals with depression diagnosis (b = .14, SE = .06, t = 2.25, p < .05, LLCI = .0168, ULCI = .2608). Similar to Model 2, no significance was found among those without depression diagnosis (b = .14, SE = .073, t = 1.86, p = .065, LLCI = −.0083, ULCI = .2784). Findings indicate that as perceived adversity increases by one unit, their perceived health decreases by .139 units for individuals with depression diagnosis while holding the effects of age and gender constant. A visual represenation of the moderation effects can be seen in Figure 1.

Figure 1.

Figure 1.

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A visual representation of moderation effect.

Discussion

The present findings support consideration and assessment of perceived adversity among recently arrived Iraqi and Syrian refugees, given the relation to perceived health. To our knowledge, this is the first published study of the relation between perceived health, perceived adversity of flight and violence/armed conflict exposure, and psychiatric diagnosis (i.e. PTSD, anxiety, and depression) in a refugee population. Consistent with past literature, perceived adversity was significantly associated with perceived health for both refugees who did and did not screen positive for PTSD diagnosis; in other words, perception of violence, armed conflict, and flight adversity is significantly associated with perceived health irrespective of PTSD diagnosis. Analysis of influences on anxiety diagnosis showed a slightly different pattern. Specifically, findings supported our hypothesis in that perceived adversity was significantly associated with perceived health for refugees with clinically elevated anxiety symptoms. However, this relation was not statistically significant among refugees who did not meet the threshold for anxiety diagnosis. We also found that perceived adversity was significantly associated with perceived health for those who met criteria for depression, but not for refugees lacking diagnosis of depression. Overall, the findings suggest that refugees’ perceived adversity regarding violence, armed conflict, and flight may contribute to their perception of their health, and there may be a consistent pattern of perception of adversity with somatic distress.

Clinically significant symptoms of psychopathology were highly prevalent among this sample of refugees. As previously reported, approximately 30% of participants screened positive for provisional diagnosis of PTSD, 50% for depression, and 42% for anxiety (Javanbakht et al., 2019), and our findings were comparable to similar studies of Syrian and Iraqi refugees resettling outside of the United States (Abu Suhaiban et al., 2019; Acarturk et al., 2018; Ibrahim et al., 2019; Kazour et al., 2017).

Perceived flight and violence/armed conflict adversity and perceived health

Overall, refugees indicated moderate-to-severe levels of perceived adversity with regard to their exposure to violence and armed conflict. Specifically, on a scale of 1 to 7 (1 being mildly traumatic and 7 being the worst thing that can happened to someone), 39% of participants indicated their experiences to be ‘the worst thing that can happen to someone’ and only 10% reported their experience as ‘mildly traumatic’. Notably, the perceived heath ratings were more positive. Over 70% of participants reported their perceived health to be good or better. Our cohort is a relatively young (Mage = 36.33 years) and educated group, which signifies the ‘perceived’ aspect of physical health independent of objective diagnoses.

Despite the high ratings of perceived health, perceived adversity and health were significantly correlated. There are several explanations for this finding. Perception may cover a spectrum of how a person understands mental and physical pain/discomfort (Leventhal et al., 2011). Previous work has shown that higher level of physical chronic pain (Asmundson & Katz, 2009; Moeller-Bertram et al., 2012) and increased pain perception (Tsur et al., 2017) link to reduced self-reported health (Cloitre et al., 2008; Kimerling et al., 2000) particularly for those diagnosed with PTSD. One potential mechanistic pathway is differences in interoceptive perception. For instance, neuroimaging studies frequently show anatomical and functional aberrations in the anterior insula in patients with PTSD, an area involved in interoceptive perception of bodily and emotional experiences (Chen et al., 2006; Duval et al., 2015; King et al., 2009). A common pathway to emotional distress and physical discomfort could be via abnormal activation of this region in highly traumatized samples. Furthermore, chronic HPA activation, hyperarousal and hypervigilance, and elevated inflammatory state may have a role in connecting mental distress and somatic symptoms. Inflammation in PTSD and depression is a current frontline in our understanding of negative impact of chronic exposure to stress on the brain and body. Proinflammatory factors CRP, IL1-beta, IL-6, and TNF-alpha that are frequently increased in PTSD and depression, are also involved in medical conditions with reduced sense of health, and fatigue (Byrne et al., 2016; Michopoulos et al., 2017).

Perceived adversity, psychopathology, and physical health

Our findings are consistent with previous evidence suggesting that self-reported rating of violence, armed conflict, and flight related adverse experience is significantly associated with perceived well-being among refugees. What we uniquely add to the existing literature is that self-reported rating of cumulative experience of trauma and flight is a good indicator of perceived health for highly symptomatic refugee populations.

Imaging research has shown that cognitive manipulation of an experience impacts the emotional reaction. For instance, when a person is asked to reappraise an experience (e.g. create a less painful narrative for a sad image), cognitive processes reduce amygdala activation and level of arousal via medial prefrontal limbic inhibitory pathways (Buhle et al., 2014). Similarly, the act of informing a person about a painful experience can create fear responses regardless of the experience happening or not (Olsson & Phelps, 2007). While defining the relation between remembrance of violence, armed conflict, and flight experience and development of PTSD is beyond the scope of the current study, the current findings still have clinical implication as it provides support for the significance of targeting the meaning and interpretation of flight experiences when working with refugee populations. Additional evidence suggests that cognitive preparation prior to processing traumatic experience and guidance to gain a sense of control towards their trauma exposure in treatment may facilitate diminishing effect of trauma (Essar et al., 2010; Pedersen et al., 2011). In a clinical setting, this can be implemented through modulation of cognitive perception of the traumatic experience and assistance to create a meaning that is less self-destructive.

A number of studies have examined use of self-reported measures of health in refugee populations (Dowling et al., 2017). Research with community samples has found that patients are comfortable with primary care visits that include screening questions about trauma and trauma-related symptoms (Goldstein et al., 2017). Refugees who screened positive for mental health concerns during a public health visit and who were referred for psychological services generally (79%) engaged in care and often (92%) continued with treatment for more than 3 months (Hollifield et al., 2013). Based on our findings, those who present with somatic/health complaints, if found to report a traumatizing perception of flight experiences, are likely to have mental health symptoms and may benefit from psychotherapy. Those individuals can be more confidently referred for psychiatric screening, especially when resources and time are limited (refugees, war zone, urban emergency departments). Furthermore, as some trauma-exposed patients are more comfortable discussing their physical symptoms of discomfort, approaching assessment of physical symptoms along with psychological symptoms as a single process may be especially effective in promoting both patient comfort and disclosure. This may be especially true in cultures where psychological/psychiatric care is generally only provided for severe mental illness (i.e. schizophrenia and other psychotic disorders). By incorporating assessment of psychological symptoms alongside physical symptoms, providers can facilitate a naturalistic process of acculturating immigrants to a new way of thinking about the kinds of support that can be availed through healthcare systems. Our findings support the critical importance of overcoming barriers to psychological care and facilitating engagement with mental health treatment as ‘principles of good practice’ in refugee populations (Giacco & Priebe, 2018).

Overall, perceived adversity seems to be important in trauma-related disorders, and perceived health may be influenced by trauma exposure and related symptomology. This is an important area of research, as it may shed light on the mechanisms involved in the interaction between trauma exposure, cognition, and physical health. From a therapeutic perspective, changing the cognitive understanding of trauma is a critical element of psychotherapy as it may improve not only mental health, but also perceived and objective physical health (Galovski et al., 2009). Cognitive preparedness and modification of meaning of the traumatic experience before, or immediately after it happens, may reduce psychopathology and potentially increase perceived health. Previous work, and clinical experience suggest that cognitive based methods of therapy can also improve perceived health (Galovski et al., 2009). Furthermore, for patients with consistent perception of cumulative adversity and physical health, and psychopathology, therapeutic approaches focusing on cognitive processing (mainly cognitive therapy), may be more helpful. Such patients may also respond better to body-based and present-focused approaches such as mindfulness, yoga, and movement therapies (Hopwood & Schutte, 2017).

This work has both strengths and limitations. The population in this study is unique in several aspects: it includes a relatively similar number of males and females, exposure to violence and armed conflict started and ended relatively at a similar time, and data for all participants were collected at the same stage of their journey as a refugee (first month following arrival in the US). We assessed not only PTSD, but also depression and anxiety. Finally, while previous work on perceived adversity is focused on the isolated experience of trauma, we examined the collective experience of trauma and flight. Our findings are limited by self-report nature of the questionnaires. Relatedly, due to the constraints of time and resources we did not use structured clinical interviews to assess diagnoses of PTSD, anxiety, or depression. The questionnaires used in the present study, however, have been empirically validated and widely used as a screening tool for provisional diagnoses for high-risk samples including refugees in clinical and research settings. In addition, we did not complete a comprehensive assessment of all past potentially traumatic experiences; however, this is reasonable given the goal of translation to a clinical healthcare setting where a comprehensive assessment may not be appropriate/reasonable during a primary care visit. Finally, our findings are limited to this population assessed at a unique time in their process of flight and resettlement and need to be replicated in other samples as well as in longitudinal designs.

Acknowledgements

We highly appreciate the great collaboration and support of the Arab American and Chaldean Council that led to success of this study. We also thank Israel Liberzon’s generous help and advice in design of this work, and Farah Alani, Zainab Rawi, Suzanne Manji, and Samantha Sonderman of Wayne State University for their critical participation in data collection and management. Arash Javanbakht’s effort is supported by 1R01HD099178. Nicole Nugent and Soyeong Kim’s effort are supported by R01MH108641 and R01MH105379. Lana Ruvolo Grasser’s effort is supported by F31MH120927.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from the State of Michigan (Lycaki/Young funds) in collaboration with Detroit Wayne Mental Health Authority and Behavioral Health Professionals, Inc. We highly appreciate the great collaboration and support of the Arab American and Chaldean Council that led to success of this study. We also thank Israel Liberzon’s generous help and advice in design of this work, and Farah Alani, Zainab Rawi, Suzanne Manji, and Samantha Sonderman of Wayne State University for their critical participation in data collection and management. Arash Javanbakht’s effort is supported by 1R01HD099178. Nicole Nugent and Soyeong Kim’s effort are supported by R01MH108641 and R01MH105379. Lana Ruvolo Grasser’s effort is supported by F31MH120927.

Footnotes

New contribution to the literature

Our findings suggest a consistent pattern of perception of adversity, and mental and physical distress, with clinical implications. It also underlines the importance of cognitive experience of trauma in development of psychopathology, and potentially physical health consequences.

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