Understanding psychopathology in migrants: A mixed categorical-dimensional approach

Abstract

Background:

Literature on mental disorders in migrants is constantly increasing. Only a few studies describe psychopathological dimensions in migrants over their nosographic diagnoses; however, there is a growing literature about the greater utility of a categorical-dimensional approach, rather than a solely categorical approach, in the understanding of mental disorders. The aim of this paper is to describe the phenomenology of mental disorders in migrants referred to the Transcultural Psychiatric Team of Bologna (BoTPT), by analysing the psychopathological dimensions that underlie their clinical diagnoses.

Methods:

We recruited all migrants who attended the BoTPT between May 1999 and July 2009. The psychopathological assessment was conducted with the Association for Methodology and Documentation in Psychiatry (AMDP) and clinical diagnoses were formulated according to ICD-10. We proceeded through a two-step analysis: (1) comparing the prevalence rates of psychopathological symptoms across diagnoses; then (2) conducting a factor analysis to assess how those symptoms configure psychopathological dimensions and how these dimensions underlie clinical diagnoses.

Results:

As expected, we found significant associations between diagnoses and the prevalence of their core psychopathological symptoms. Factor analysis revealed a strong polymorphism of the psychopathological presentation of mental disorders and unexpectedly showed that in each diagnostic cluster, the first extracted factor was not composed of core symptoms.

Conclusions:

A mixed categorical-dimensional approach seems to improve the description of the psychopathology among migrants, as it adds relevant information regarding psychopathological dimensions useful to the understanding of the peculiar clinical expressivity of our patients.

Keywords

Migration psychopathology transcultural psychiatry categorical-dimensional approach factor analysis

Background

The relationship between migration and mental health has been the subject of various investigations in the last few decades. These were mainly prompted by the finding of a higher prevalence of mental disorders among migrants or ethnic minorities compared to natives or fellow countrymen without migratory experiences (Bhugra, 2003; Cantor-Graae & Selten, 2005; de Wit et al., 2008; Fearon et al., 2006; Hutchinson & Haasen, 2004). Despite this, only a few studies have described migrants’ psychopathological features, mostly analysing some isolated symptoms (Familiar, Borges, Orozco & Medina-Mora, 2011; Lau, Cheng, Chow, Ungvari & Leung, 2009; Ritsner & Ponizovsky, 1998; Velthorst et al., 2011) or specific clinical populations, such as refugees and asylum seekers (Birman & Tran, 2008; Dobricki, Komproe, de Jong & Maercker, 2010; Laban, Gernaat, Komproe & DeJong, 2007; Montgomery, 2008; Nickerson, Bryant, Steel, Silove & Brooks, 2010; Norredam, Jensen & Ekstrøm, 2011; Porter & Haslam, 2005).

The scarcity of studies describing psychopathology in migrants may represent an important limit to the comprehension of their mental diseases. Actually, several studies show possible misdiagnoses of mental disorders in migrant patients (Charalabaki, Bauwens, Stefos, Madianos & Mendlewicz, 1995; Haasen, Yagdiran, Mass & Krausz, 2000; Lin & Cheung, 1999), probably due to peculiar clinical presentation and/or expression of suffering across different cultures (Kirmayer, 2001; Kirmayer & Looper, 2006). Psychopathological exploration is important for the understanding of mental disorders in people with different cultural backgrounds as they may challenge the borders of Western nosography through a peculiar codification of suffering. In the last decades, the concept of culture-bound syndromes (CBS) was introduced in clinical psychiatry as an attempt to better account for the clinical peculiarity of some mental disorders found in specific geographical regions or populations: CBS is ‘a broad rubric that encompasses certain behavioral, affective and cognitive manifestations seen in specific cultures’, and would allow a proper labelling and management of clinical pictures that may not be linked to a particular diagnostic category (Balhara, 2011, p. 210). However, CBS still represents a further categorization of migrants’ psychic disease.

Few studies adopt a dimensional approach, while there is wide evidence about the greater utility of a categorical-dimensional approach, rather than a solely categorical approach, in the understanding of mental disorders in psychiatric patients (Demjaha et al., 2009; Egli, Riedel, Möller, Strauss & Läge, 2009; Krueger & Bezdjian, 2009; Läge, Egli, Riedel, Strauss & Möller, 2011; Lecrubier, 2008; Möller, 2008; Möller et al., 2011). These evidences recall the well-known debate about whether the categorical nosography sacrifices validity ‘on the altar of reliability’ (Mullen, 2007, p. 113), and how the diagnostic paradigm, with its ‘dehumanizing impact’ and its ‘dryly empirical approach’ (Andreasen, 2007), would neither address the basic mandate of medicine (Kirmayer, 2005) nor be useful for research (Andreasen, 2007).

The aim of our study is to describe the phenomenology of mental disorders of migrants referred to the Bologna Transcultural Psychiatric Team (BoTPT) by analysing the psychopathological configurations of their clinical diagnoses. In particular, we aim to assess: (1) the prevalence of psychopathological symptoms in patients’ clinical diagnoses; and (2) how those symptoms configure psychopathological dimensions that underlie clinical diagnoses.

Methods

Study setting

The Bologna West Community Mental Health Centre (CMHC) has developed one of the first projects in Italy which prioritises cultural competence at primary and secondary levels of care: the BoTPT (Tarricone et al., 2011). The BoTPT is composed of Bologna West CMHC mental health operators who dedicate part of their work to migrant psychiatric consultation. In the most difficult cases, the BoTPT team directly delivers psychiatric and psychosocial treatment to migrants; in other cases, the BoTPT team provides consultation geared towards identifying the mental and psychosocial needs of migrants, and then redirects patients within the CMHC and other services. Core personnel includes psychiatrists as well as social workers, psychiatric nurses, residents in psychiatry and medical anthropologists. If needed, a cultural mediator joins the multi-professional team. All migrants, with or without papers, and regardless of gender, age, country of origin and legal status (regular or irregular), can have access to the service.

Study population

For the present study we examined data collected from all first-generation migrants who attended the BoTPT between May 1999 and July 2009. The formal inclusion criteria were: (1) patients having their first contact with our service in the indicated time frame; and (2) patients completing our full socio-demographic, migratory and psychopathological assessment. No formal exclusion criteria were applied. Data were collected within one month from their first access. We define as ‘migrants’ people who move from one area to another for varying periods of time and for any reason (WHO, 2003).

Instruments

In order to collect socio-demographic and migration history information we used the Bologna Migration History and Social Integration Questionnaire (Bo-MHQ): it explores migrants’ characteristics (socio-economic and legal conditions, cultural background, social support, quality of life) before, during and after the migration process. The Bo-MHQ was developed by our research team and is currently implemented by the research project ‘EUropean network of national schizophrenia networks studying Gene-Environment Interactions’ (HEALTH-F2-2010-241909; EU-GEI: http://www.eu-gei.eu). A pilot version of the schedule has been used in previous works from our research team (Tarricone et al., 2012a).

To assess psychopathological symptoms we used the Association for Methodology and Documentation in Psychiatry (AMDP, 1979): this is a standardized method of documentation widely spread and validated in Europe (Bobon, 1983; Bobon, von Frenckell & Mormont, 1983; Stieglitz, Fähndrich & Renfordt, 1988), based on traditional descriptive psychopathology (Jaspers, 1913; Schneider, 1950). To our knowledge, it was used only once to explore psychopathology in people with different ethno-cultural backgrounds (Diefenbacher & Heim, 1994). The AMDP covers the whole range of present psychopathological and somatic states through 100 psychopathological items (plus 15 reserve psychopathological items) and 40 somatic items (plus seven reserve somatic items), that are scored on a Likert scale ranging between 0 (absent) and 4 (very severe), according to the AMDP Italian version (Conti, Dell’Osso & Cassano, 1990). Psychopathological and somatic items can be grouped under eight psychopathological syndromes as in Pietzcker et al. (1983): of these, we have used those syndromes that in literature are more often used and significantly associated to clinical diagnoses, namely depressive, positive (paranoid-hallucinatory), negative (apathetic) and somatic (autonomic) syndromes. Positive and negative syndromes have already been shown to be structural psychopathological dimensions in non-affective psychoses (Cuesta & Peralta, 2001) and in first-episode psychoses (Cuesta, Peralta, Gil & Artamendi, 2003); depressive syndrome, along with negative syndrome, is very pertinent in the assessment of depressive disorders (Pietzcker & Gebhardt, 1983), and it has been used in several studies on depressive and other common mental disorders (Barnow, Linden, Lucht & Freyberger, 2002; Diefenbacher & Heim, 1994; Möller-Leimkühler, Bottlender, Strauss & Rutz, 2004), as well as somatic syndrome (Diefenbacher & Heim, 1994; Reischies, von Spiess, & Stieglitz, 1990). Thus, we examined all the 43 psychopathological and somatic items that are included in these four syndromes, testing their categorical correlation and their dimensional distribution in diagnostic clusters. Depressive syndrome is constituted by 13 items (rumination, feelings of loss of feeling, loss of vitality, depression, hopelessness, feelings of inadequacy, feelings of guilt, inhibition of drive, worse in morning, interrupted sleep, shortened sleep, early wakening, decreased appetite), as well as positive syndrome (delusional mood, delusional perception, delusional irruption, delusional ideas, systematized delusions, delusional dynamics, delusions of reference, delusions of persecution, verbal hallucinations, bodily hallucinations, depersonalization, thought withdrawal, other feelings of alien influence). Negative syndrome was composed of eight items (inhibition of thinking, retardation of thinking, circumstantiality of thinking, restriction of thinking, blunted affect, emotional rigidity, lack of drive, social withdrawal) and somatic syndrome had nine items (hypochondriasis, nausea, breathing difficulties, dizziness, palpitations, cardiac pain, increased sweating, headache, hot flashes).

Psychiatric diagnoses were formulated by clinical psychiatrists according to ICD-10 (WHO, 1992) criteria. Case notes were used to complete the Item Group Checklist (IGC) of the Schedule for Clinical Assessment of Neuropsychiatry, Version 2.1 (SCAN; WHO, 1998) and to collect data on symptoms at the time of presentation. Diagnoses were grouped under ICD-10 major categories, in order to perform our analyses on sufficiently numerous diagnostic subgroups.

Statistical analysis

First, we compared the prevalence rates of symptoms across the diagnostic groups, using the χ² test. Second we conducted separated factor analyses to examine the underlying psychopathological dimensions in each diagnostic subgroup. The number of the factors to extract was determined with the scree test (Cattell, 1966) in respect of Kaiser’s criterion (eigenvalue greater than unity). Item loading with absolute values > 0.40 was used in the description of the factors. When the same items loaded in different factors, we kept those with the higher saturation. Varimax rotation was chosen for the study of the variance. SPSS 18.0 software was used for all analyses.

Ethics

The study procedure was explained in detail and informed consent was obtained from patients, in compliance with the Helsinki Declaration.

Results

Sample and diagnoses

We recruited and evaluated 235 patients. Nearly all fitted three specific diagnostic clusters: 110 patients (47%) were diagnosed with neurotic disorders (ICD F40-F48: ‘neurotic, stress-related and somatoform disorders’); 60 (25%) were diagnosed with affective disorders (ICD F30-F39: ‘affective disorders’); 37 (16%) were diagnosed with psychotic disorders (ICD F20-F29: ‘schizophrenia, schizotypal and delusional disorders’). Twenty-eight patients (12%) were diagnosed with other disorders: eight alcohol-related disorders (F10), four personality disorders (F60); two sexual dysfunctions (F52); two moderate mental retardations (F71); two expressive language disorders (F80.1); one eating disorder (F50); one post-encephalitic syndrome (F07.1); eight non-psychiatric diagnoses. Such subgroups were too small to be studied separately and we decided not to group them into a fourth cluster because of the excessive heterogeneity among these diagnoses. Thus, these twenty-eight patients were excluded from our analyses.

Table 1 shows the socio-demographic characteristics of the 207 cases included. Fifty-three per cent (103 cases) were temporary labour migrants; 20% (38 cases) family reunification migrants; 17% (33 cases) forced migrants – refugees or asylum seekers; and 10% (20 cases) had migrated for other reasons. Some of them already had contacts with psychiatric services (21%) and received (or were still receiving) psychopharmacological treatment (51%), while others were drug-naive and/or at their first contact with a psychiatric service. Migrants with affective disorders were the oldest group, more frequently women and with a high level of education. Migrants with neurotic disorders were the youngest group and more frequently men, especially those diagnosed with post-traumatic stress disorder (PTSD), which was the most frequent diagnosis in refugees and asylum seekers, while psychotic disorders were more frequently diagnosed in labour migrants. More details about our study population have been reported in our previous paper (Tarricone et al., 2012b).

Table 1.

Description of the sample.

	AFF	NEU	PSY	Total	p
Gender
Male	23 (38%)	68 (62%)	21 (57%)	112 (54%)	.013
Age
Mean	36.7±11.2	31.9±8.9	34.8±10.6	33.8±10.1	.033
Marital status^a
Married	25 (43%)	42 (39%)	14 (39%)	81 (40%)	.293
Single	20 (34%)	50 (46%)	14 (39%)	84 (42%)
Divorced/separated	13 (22%)	13 (12%)	8 (22%)	34 (17%)
Widow	–	3 (3%)	–	3 (1%)
Education^b
>8 years	38 (68%)	58 (57%)	7 (21%)	103 (54%)	<.001
Occupation
Employed	25 (42%)	48 (44%)	16 (43%)	89 (43%)	.688
Unemployed	21 (35%)	46 (42%)	15 (40%)	82 (40%)
Other (student, retired, housewife)	14 (23%)	16 (14%)	6 (16%)	36 (17%)
Residence permit	45 (80%)	72 (69%)	22 (67%)	139 (72%)	.225
Area of origin
Maghreb	13 (22%)	35 (32%)	12 (32%)	60 (29%)	.908
Sub-Saharan Africa	13 (22%)	25 (23%)	9 (24%)	47 (23%)
Asia	17 (28%)	25 (23%)	8 (22%)	50 (24%)
Central-Southern America	4 (7%)	4 (4%)	2 (5%)	10 (5%)
Eastern Europe	13 (22%)	21 (19%)	6 (16%)	40 (19%)
Reason for migration³
Work	24 (45%)	55 (52%)	24 (69%)	103 (53%)	.037
Family reunion	16 (30%)	16 (15%)	6 (17%)	38 (20%)
Political	6 (11%)	25 (24%)	2 (6%)	33 (17%)
Other (study, health, tourism)	7 (13%)	10 (9%)	3 (9%)	20 (10%)
Refugees/Asylum seekers	6 (10%)	19 (17%)	2 (6%)	27 (13%)	.135
Length of stay
Mean (years)	7.4±6.1	5.9±5.1	7.8±7.6	6.6±5.9	.256
Poor knowledge of Italian language	13 (22%)	25 (23%)	9 (24%)	47 (23%)	.954
Previous contacts with psychiatric services	22 (37%)	14 (13%)	8 (22%)	44 (21%)	.001
Already receiving pharmacological treatment	29 (48%)	47 (43%)	29 (81%)	105 (51%)	<.001
Total n (%)	60 (29%)	110 (53%)	37 (18%)

AFF = affective disorders, NEU = neurotic, stress-related and somatoform disorders; PSY = schizophrenia, schizotypal and delusional disorders.

5 missing; ^b16 missing; ^c13 missing.

Psychopathological analysis and diagnoses

Table 2 shows the prevalence of psychopathological symptoms in each diagnostic cluster. Positive symptoms and formal thought disorders were significantly more frequent in psychotic disorders. Most of the depressive symptoms were significantly more frequent in affective disorders; only rumination and feelings of loss of feeling were more frequent in psychotic disorders than in affective disorders. The prevalence of negative affective symptoms and somatic symptoms did not show significant differences across the diagnostic groups, except for headache, which was more frequent in affective and neurotic disorders compared to psychotic disorders.

Table 2.

Symptomatological prevalence per diagnostic cluster.

	AFF	NEU	PSY	p	Exploratory analyses
Depressive syndrome
Rumination	3 (5%)	9 (8%)	6 (16%)	.157	PSY>AFFt
Feelings of loss of feeling	3 (5%)	8 (7%)	6 (16%)	.129	PSY>AFFt
Loss of vitality	34 (57%)	50 (45%)	12 (32%)	.064	AFF>PSY*
Depression	49 (82%)	75 (68%)	18 (49%)	.003	AFF>PSY* AFF>NEU*
Hopelessness	27 (45%)	36 (33%)	10 (27%)	.142	AFF>PSYt
Feelings of inadequacy	19 (32%)	27 (24%)	8 (22%)	.475
Feelings of guilt	22 (37%)	24 (22%)	6 (16%)	.04	AFF>PSY* AFF>NEU*
Inhibition of drive	26 (43%)	33 (30%)	11 (30%)	.181
Worse in morning	6 (10%)	8 (7%)	3 (8%)	.808
Interrupted sleep	16 (27%)	30 (27%)	5 (13%)	.216	AFF>PSYt NEU>PSYt
Shortened sleep	37 (63%)	48 (44%)	10 (27%)	.002	AFF>PSY* AFF>NEU* NEU>PSYt
Early wakening	10 (17%)	19 (17%)	3 (8%)	.387
Decreased appetite	17 (29%)	27 (25%)	7 (19%)	.551
Positive syndrome
Delusional mood	2 (3%)	2 (2%)	7 (19%)	<.001	PSY>AFF* PSY>NEU*
Delusional perception	1 (2%)	1 (1%)	12 (32%)	<.001	PSY>AFF* PSY>NEU*
Delusional irruption	2 (3%)	1 (1%)	9 (24%)	<.001	PSY>AFF* PSY>NEU*
Delusional ideas	1 (2%)	1 (1%)	18 (49%)	<.001	PSY>AFF* PSY>NEU*
Systematized delusions	2 (3%)	4 (4%)	9 (24%)	<.001	PSY>AFF* PSY>NEU*
Delusional dynamics	1 (2%)	–	15 (40%)	<.001	PSY>AFF* PSY>NEU*
Delusions of reference	3 (5%)	2 (2%)	16 (43%)	<.001	PSY>AFF* PSY>NEU*
Delusions of persecution	3 (5%)	4 (4%)	23 (62%)	<.001	PSY>AFF* PSY>NEU*
Verbal hallucinations	1 (2%)	3 (3%)	18 (49%)	<.001	PSY>AFF* PSY>NEU*
Bodily hallucinations	1 (2%)	1 (1%)	4 (11%)	.006	PSY>AFFt PSY>NEU*
Depersonalization	2 (3%)	2 (2%)	10 (27%)	<.001	PSY>AFF* PSY>NEU*
Thought withdrawal	–	–	4 (11%)	<.001	PSY>AFF* PSY>NEU*
Other feelings of alien influence	–	2 (2%)	8 (22%)	<.001	PSY>AFF* PSY>NEU*
Negative syndrome
Inhibition of thinking	–	4 (4%)	4 (11%)	.027	PSY>AFF*
Retardation of thinking	3 (5%)	6 (5%)	4 (11%)	.453
Circumstantiality of thinking	1 (2%)	3 (3%)	10 (27%)	<.001	PSY>AFF* PSY>NEU*
Restriction of thinking	1 (2%)	3 (3%)	9 (24%)	<.001	PSY>AFF* PSY>NEU*
Blunted affect	6 (10%)	11 (10%)	6 (16%)	.552
Emotional rigidity	4 (7%)	7 (6%)	3 (8%)	.935
Lack of drive	26 (43%)	33 (30%)	11 (30%)	.181	AFF>NEUt
Social withdrawal	13 (22%)	36 (33%)	8 (22%)	.205	NEU>AFFt
Somatic syndrome
Hypochondriasis	5 (8%)	15 (14%)	7 (19%)	.311
Nausea	4 (7%)	5 (5%)	3 (8%)	.693
Breathing difficulties	3 (5%)	3 (3%)	1 (3%)	.713
Dizziness	3 (5%)	9 (8%)	2 (5%)	.686
Palpitations	4 (7%)	8 (7%)	3 (8%)	.965
Cardiac pain	5 (8%)	2 (2%)	3 (8%)	.098	AFF>NEUt
Increased sweating	1 (2%)	2 (2%)	1 (3%)	.930
Headache	20 (33%)	30 (27%)	4 (11%)	.045	AFF>PSY* NEU>PSY*
Hot flashes	–	3 (3%)	1 (3%)	.435

AFF = affective disorders; NEU = neurotic, stress-related and somatoform disorders; PSY = schizophrenia, schizotypal and delusional disorders.

*= significant; t = trend.

Factor analysis

We performed a factor analysis to assess how symptoms from the four AMDP syndromes segregated into psychopathological dimensions for each of the three diagnostic clusters (Table 3).

Table 3.

Factor analysis.

		AFFECTIVE			NEUROTIC					PSYCHOTIC
		I	II	III	I	II	III	IV	V	I	II	III	IV
Depressive syndrome	Rumination				0.519					0.437
	Feelings of loss of feeling										0.483
	Loss of vitality			0.445								0.816
	Depression											0.816
	Hopelessness			0.624								0.799
	Feelings of inadequacy					0.700
	Feelings of guilt
	Inhibition of drive			0.517		0.907						0.635
	Worse in morning					0.450
	Interrupted sleep									0.670
	Shortened sleep					0.445
	Early wakening					0.464
	Decreased appetite
Positive syndrome	Delusional mood	0.991
	Delusional perception	0.936
	Delusional irruption	0.903											0.545
	Delusional ideas	0.936							0.668
	Systematized delusions			0.843			0.508
	Delusional dynamics	0.936
	Delusions of reference	0.747							0.924
	Delusions of persecution	0.858							0.759
	Verbal hallucinations						0.859						0.423
	Bodily hallucinations						0.931
	Depersonalization	0.903
	Thought withdrawal												0.840
	Other feelings of alien influence												0.786
Negative syndrome	Inhibition of thinking				0.926						0.675
	Retardation of thinking			0.808	0.846						0.851
	Circumstantiality of thinking		0.953		0.832								0.552
	Restriction of thinking		0.953		0.890						0.486
	Blunted affect		0.735								0.570
	Emotional rigidity		0.839		0.508						0.892
	Lack of drive			0.531		0.907						0.635
	Social withdrawal		0.445
Somatic syndrome	Hypochondriasis		0.732				0.412
	Nausea						0.630			0.940
	Breathing difficulties							0.858			0.690
	Dizziness									0.939
	Palpitations									0.940
	Cardiac pain									0.940
	Increased sweating							0.932
	Headache
	Hot flashes							0.924
	Eigenvalue	6.701	4.452	3.358	3.926	3.497	2.823	2.811	2.340	5.445	4.260	3.814	2.848
	% of variance	17.2	11.4	8.6	9.6	8.5	6.9	6.8	5.7	13.3	10.4	9.3	6.9

Note: Only item loadings with absolute values > 0.40 are shown.

In the affective group (AFF) we extracted three factors, altogether explanatory of 37.2% of the variance. The first factor was exclusively composed of positive symptoms (delusional mood, delusional perception, delusional irruption, delusional ideas, delusional dynamics, delusions of reference, delusions of persecution, depersonalization), while the second was mostly constituted by negative symptoms (circumstantiality of thinking, restriction of thinking, blunted affect, emotional rigidity, social withdrawal, hypochondriasis); only in the third and last factor did we find variables derived from the depressive syndrome, along with other positive and negative symptoms (loss of vitality, hopelessness, inhibition of drive, systematized delusions, retardation of thinking, lack of drive). Among patients in the psychotic group (PSY), we extracted four factors that accounted for 39.9% of the variance: the first factor was mostly composed of somatic symptoms (nausea, dizziness, palpitations, cardiac pain, rumination, interrupted sleep), the second mostly of negative symptoms (inhibition of thinking, retardation of thinking, restriction of thinking, blunted affect, emotional rigidity, feelings of loss of feeling, breathing difficulties), the third nearly only of depressive symptoms (loss of vitality, depression, hopelessness, inhibition of drive, lack of drive) and the fourth nearly only of positive symptoms (delusional irruption, verbal hallucinations, thought withdrawal, other feelings of alien influence, circumstantiality of thinking). In the neurotic group (NEU) we extracted five factors, accounting for 37.5% of variance explanation. The first factor was almost exclusively composed of negative symptoms (inhibition of thinking, retardation of thinking, circumstantiality of thinking, restriction of thinking, emotional rigidity, rumination), the second almost only of depressive symptoms (feelings of inadequacy, inhibition of drive, worse in morning, shortened sleep, early wakening, lack of drive) and the third mostly by positive symptoms (systematized delusions, verbal hallucinations, bodily hallucinations, hypochondriasis, nausea). The fourth factor comprised only somatic symptoms (breathing difficulties, increased sweating, hot flashes), while the fifth only positive symptoms (delusional ideas, delusions of reference, delusions of persecution).

Discussion

In this study, we examined the prevalence of symptoms and the psychopathological structure of mental disorders in a wide group of migrants: we found that, despite the fact that clinical symptoms were more prevalent in the ascribed diagnoses as expected (depressive symptoms in affective disorders, positive and negative symptoms in psychotic disorders), the factor structure of mental disorders was mainly constituted by symptoms that are not usually considered as ‘core symptoms’ in the main diagnostic criteria.

We found peculiar and polymorphic psychopathological configurations of the diagnostic clusters studied in our migrant population. However, only 37–40% of the variance was explained by the extracted factors: this implies that there is a strong polymorphism of the psychopathological presentation of the three diagnostic clusters studied and a weak psychopathological validity of the clinical diagnoses.

The psychopathological polymorphism found could be due to the different cultural backgrounds of migrants and to their complex ways of signifying psychic disease through meanings acquired in different, specific social contexts. Moreover, such a polymorphism could also be due to the diversity of diagnoses included in each diagnostic cluster, even if from a categorical point of view we found expected correlations between diagnostic clusters and core symptoms’ prevalence. Surprisingly, we found that in each of the diagnostic clusters the first extracted factor was predominantly composed of elements not belonging to the traditionally ascribed psychopathological dimensions.

Among psychotic disorders, the first factor was almost exclusively composed of somatic symptoms. Somatic symptoms are common not only among patients with major depression and anxiety diagnoses, but also among those with schizophrenia and other psychoses, both among migrants and natives (Simon & VonKorff, 1991). Somatization is a complex psychopathological construct, probably encompassing both psychosocial and biological factors: it has been explained in terms of altered ‘symptom attribution’ and altered physiological mechanisms such as increased somatic sensitivity. In migrant populations, sociocultural factors, such as stigmatization towards mental illness, fear of discrimination, different expectations on the host country’s health care system and explanations related to the illness, might account for a higher prevalence of somatization (Kirmayer & Looper, 2006). In this regard, a recent study carried out in Italy showed that among migrants, distress due to post-migratory living difficulties amplified the tendency to somatize (Aragona et al., 2011). Furthermore, positive and negative symptomatology was preeminent only in the later factors of psychotic disorders. Similarly, in affective disorders, the first two explanatory factors of the variance were almost exclusively represented by positive and negative symptoms, while elements of depressive syndrome result to be preponderant only in the third factor. Likewise, in neurotic disorders, the first factor is constituted mostly by negative items.

Our results entail several explanatory hypotheses. In our sample, patients with psychotic disorders show the phenomenological centrality of the bodily experience, which may often become the primary or only channel of communication in a migratory context. This can be further discussed through three different perspectives: anthropological, phenomenological and transcultural. According to an anthropological perspective, people live in the world through the body and it is always through the body that they live the experiences that shape their existence. In medical semiotics, the crises of the body and its languages of suffering are almost always directly related to organ dysfunction: the biomedical perspective neglects the fact that the manifestations of suffering of the body have to be thought of as historically grounded languages, which are the result of a dialectic process between perceptual, cognitive and interpersonal experiences. Such a process is shaped by culturally based ways of thinking of and understanding the experience in relation to factors such as family, work and other social contexts (Kirmayer & Sartorius, 2007). According to the phenomenological perspective, corporality is a particular form of human existence through which man speaks and expresses himself: such language becomes the out-and-out vehicle of communication when spoken language grows fainter as a result of a renunciation to communicating towards the community and by cause of a withdrawal into one’s inner self. In this condition of isolation, corporality becomes the refuge of the being, the site of a drive now blind that pushes towards the existential void of one’s own private world (‘idios kosmos’) (Binswanger, 1947). This could be a significant process for migrants, for whom linguistic barriers can thwart the verbal transmission of emotional states and psychic disease. According to a transcultural perspective, corporality and somatic symptoms could be classified as cultural idioms of distress, new meanings for a range of emotions ‘improvised through fragmentary metaphors grounded in bodily experience’ (Kirmayer & Young, 1998, p. 427). Cultural idioms of distress would not define discrete disorders as somatoform disorders, but rather they would just be ‘culturally prescribed modes of understanding and narrating health problems and broader personal and social concerns’ (Kirmayer & Sartorius, 2007, p. 835); thus, rather than being reduced to any broader diagnostic entity, they would configure as disorders in their own right cutting across DSM categories (Kirmayer & Young, 1998). These forms of body language can be read as tools for the repositioning of the subject in the context of his/her family or in his/her role in the social context.

‘In a larger sense then, symptoms can be understood as having meanings as moves within a local system of power. […] Certain symptoms have been interpreted as being forms of “resistance” or “weapons of the weak”, used to evade or attenuate injustices or to undermine otherwise unassailable power holders’. (Kirmayer & Young, 1998, p. 425)

Finally, several works have tried to emphasize how close the relation is between the symptomatic manifestation – and the sociocultural context into which it is shaped – and the process of signification (Jenkins & Barrett, 2004), thus suggesting the need to ‘move beyond the conventional view of culture as pathoplastic (merely shaping psychotic experiences and giving them content) to a view of culture as playing a role in the very structure of psychotic experience itself’ (Barrett, 1998, p. 491).

For what concerns affective disorders, instead, it is worth noticing the weight of positive and negative symptomatology in the psychopathological configurations shown by factor analysis. Such significance could have prognostic implications, as several studies have confirmed that negative symptoms predict a poorer outcome and deficit in social and cognitive functioning, not only among the schizophrenic spectrum but also in affective disorders (Bottlender, Strauss & Möller, 2010; Herbener & Harrow, 2004; Möller et al., 2010). Furthermore, Velthorst et al. (2011) focused attention on these two psychopathological dimensions in ethnic minorities, suggesting that the experience of attenuated positive symptoms, when accompanied by negative or depressive symptoms, can predict the transition to the first psychotic episode.

Neurotic disorders were characterized by different dimensions, each of them depicting a peculiar psychopathological shape of these mainly stress-related disorders: formal thought disorders, hallucinations, delusions, sleep and autonomic disorders. This variety of psychopathological expressivity may be due to the wide range of diagnoses included in this major category; although, it shows other different, polymorphic modalities of psychic effractions that migratory experience entails and their severity even in disorders that are not traditionally considered major disorders. It is noteworthy that this diagnostic cluster is mainly represented by young men, and in 13% of the cases by asylum seekers or refugees. This might explain in part the psychopathological variety of the five extracted dimensions, since these could reflect psychotic (formal thought disorders, hallucinations, delusions) and physiopathologic (sleep, autonomic) reactions to traumatic events.

Our study identified peculiar and unexpected psychopathological configurations in the clinical diagnoses of the patients assessed at our premises. If our results were to be replicated, this would remark the difficulty of collocating the psychic diseases of migrants inside the occidental nosography, and would highlight the difficulties of a categorical system describing the psychopathology of patients from other cultures. These results are in agreement with those of other studies suggesting that a categorical-dimensional approach would be more useful in the understanding of mental disorders (Demjaha et al., 2009; Egli et al., 2009; Krueger & Bezdjian, 2009; Läge et al., 2011; Lecrubier, 2008; Möller, 2008; Möller et al., 2011), with dimensions further enriching information contained within the traditional diagnostic systems (Allardyce, McCreadie, Morrison & van Os, 2007; Dikeos et al., 2006). To our knowledge, there is only one previous study that has explored migrants’ psychopathology through factor analysis (Hutchinson, Takei, Sham, Harvey & Murray, 1999).

This approach may have several clinical implications. The exploration of psychopathological dimensions may lead to an optimization of psychiatric intervention, by tailoring treatment to the individual. Furthermore, studies exploring associations of categorical and dimensional models have reported the superiority of dimensions over diagnostic categories at predicting clinical course, outcome and treatment response (Peralta, Cuesta, Giraldo, Cardenas & Gonzalez, 2002; Rosenman, Korten, Medway & Evans, 2003; van Os et al., 1996).

Limitations

These findings need to be considered in light of the study’s limitations, such as the lack of relevant information about medical and substance-related comorbidities, or the fact that some patients were already receiving treatment while others were not. Also, the sample size was relatively small, especially for the AFF and PSY cohorts: these findings can only be taken as tentative until replicated on a larger scale. Still, our study might add relevant evidence supporting the utility of a combined categorical-dimensional approach to understand psychopathology in migrants. Further studies should be carried out to confirm and extend our findings, possibly with a comparable native control group and follow-up assessment confirming the factors structure’s stability over time. Moreover, our study would need to be replicated in other settings to test the reproducibility of our observations. In the present study we did not analyse the correlation between migratory history’s features and psychopathology: this point deserves further studies, in order to elucidate if and how those features may impact on psychopathology.

Conclusions

We found that among migrants attending our services the factor structure of several mental disorders shows important differences when compared with the symptoms included in the ICD-10 diagnostic system. The analysis of psychopathological dimensions – particularly with a mixed categorical-dimensional approach – might allow a better understanding of mental disorders in migrants. In our experience, this approach is quite simple and feasible in the clinical setting. Thus, our results encourage future implementations of this methodology of psychopathological evaluation in the clinical transcultural context.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References

Allardyce

McCreadie

G. R.

Morrison

van Os

. (2007). Do symptom dimensions or categorical diagnoses best discriminate between known risk factors for psychosis? Social Psychiatry and Psychiatric Epidemiology, 42, 429–437.

AMDP (Arbeitsgemeinschaft fur Methodik und Dokumentation in der Psychiatrie). (1979). Das AMDP-System (3 Auflage): Manual zur Dokumentation psychiatrischer Befunde. Berlin: Springer-Verlag.

Andreasen

N. C.

(2007). DSM and the death of phenomenology in America: An example of unintended consequences. Schizophrenia Bulletin, 33, 108–112.

Aragona

Pucci

Carrer

Catino

Tomaselli

Colosimo

… Geraci

(2011). The role of post-migration living difficulties on somatization among first-generation immigrants visited in a primary care service. Annali dell’Istituto Superiore di Sanità, 47, 207–213.

Balhara

Y. P.

(2011). Culture-bound syndrome: Has it found its right niche? Indian Journal of Psychological Medicine, 33, 210–215.

Barnow

Linden

Lucht

Freyberger

H. J.

(2002). The importance of psychosocial factors, gender, and severity of depression in distinguishing between adjustment and depressive disorders. Journal of Affective Disorders, 72, 71–78.

Barrett

R. J.

(1998). The ‘schizophrenic’ and the liminal persona in modern society. Culture, Medicine and Psychiatry, 22, 465–494.

Bhugra

(2003). Migration and depression. Acta Psychiatrica Scandinavica, 108, 67–72.

Binswanger

(1947). Über Psychothérapie. In Binswanger

(ed.), Ausgewälte, Vorträge und Aufsätze (pp. 132–158). Bern: Francke.

10.

Birman

Tran

(2008). Psychological distress and adjustment of Vietnamese refugees in the United States: Association with pre- and postmigration factors. American Journal of Orthopsychiatry, 78, 109–120.

11.

Bobon

(1983). Foreign adaptations of the AMDP-system. Modern Problems of Pharmacopsychiatry, 20, 19–34.

12.

Bobon

von Frenckell

Mormont

(1983). Interrater reliability of the French AMDP psychopathology scale: A new measurement in single cases. Modern Problems of Pharmacopsychiatry, 20, 161–173.

13.

Bottlender

Strauss

Möller

H. J.

(2010). Social disability in schizophrenic, schizoaffective and affective disorders 15 years after first admission. Schizophrenia Research, 116, 9–15.

14.

Cantor-Graae

Selten

J. P.

(2005). Schizophrenia and migration: A meta-analysis and review. American Journal of Psychiatry, 162, 12–24.

15.

Cattell

R. B.

(1966). The scree test for the number of factors. Multivariate Behavioral Research, 1, 245–276.

16.

Charalabaki

Bauwens

Stefos

Madianos

Mendlewicz

(1995). Immigration and psychopathology: A clinical study. European Psychiatry, 10, 237–244.

17.

Conti

Dell’Osso

Cassano

G .B.

(1990). Il sistema AMDP: Manuale per la valutazione e la documentazione della psicopatologia. Milano: Edizioni Grafiche Mazzucchelli.

18.

Cuesta

M. J.

Peralta

(2001). Integrating psychopathological dimensions in functional psychoses: A hierarchical approach. Schizophrenia Research, 52, 215–229.

19.

Cuesta

M. J.

Peralta

Gil

Artamendi

(2003). Psychopathological dimensions in first-episode psychoses: From the trunk to the branches and leaves. European Archives of Psychiatry and Clinical Neuroscience, 253, 73–79.

20.

Demjaha

Morgan

Landau

Dean

Reichenberg

… Dazzan

(2009). Combining dimensional and categorical representation of psychosis: The way forward for DSM-V and ICD-11? Psychological Medicine, 39, 1943–1955.

21.

de Wit

M. A.

Tuinebreijer

W. C.

Dekker

Beekman

A. J.

Gorissen

W. H.

Schrier

A. C

Verhoeff

A. P

. (2008). Depressive and anxiety disorders in different ethnic groups: A population based study among native Dutch, and Turkish, Moroccan and Surinamese migrants in Amsterdam. Social Psychiatry and Psychiatric Epidemiology, 43, 905–912.

22.

Diefenbacher

Heim

(1994). Somatic symptoms in Turkish and German depressed patients. Psychosomatic Medicine, 56, 551–556.

23.

Dikeos

D. G.

Wickham

McDonald

Walshe

Sigmundsson

T. H.

Bramon

… Sham

(2006). Distribution of symptom dimensions across Kraepelinian divisions. British Journal of Psychiatry, 189, 346–353.

24.

Dobricki

Komproe

I. H.

de Jong

J. T.

Maercker

(2010). Adjustment disorders after severe life-events in four postconflict settings. Social Psychiatry and Psychiatric Epidemiology, 45, 39–46.

25.

Egli

Riedel

Möller

H. J.

Strauss

Läge

(2009). Creating a map of psychiatric patients based on psychopathological symptom profiles. European Archives of Psychiatry and Clinical Neuroscience, 259, 164–171.

26.

Familiar

Borges

Orozco

Medina-Mora

M. E.

(2011). Mexican migration experiences to the US and risk for anxiety and depressive symptoms. Journal of Affective Disorders, 130, 83–91.

27.

Fearon

Kirkbride

J. B.

Morgan

Dazzan

Morgan

Lloyd

… Murray

R. M.

(2006). Incidence of schizophrenia and other psychoses in ethnic minority groups: Results from the MRC AESOP Study. Psychological Medicine, 36, 1541–1550.

28.

Haasen

Yagdiran

Mass

Krausz

(2000). Potential for misdiagnosis among Turkish migrants with psychotic disorders: A clinical controlled study in Germany. Acta Psychiatrica Scandinavica, 101, 125–129.

29.

Herbener

E. S.

Harrow

(2004). Are negative symptoms associated with functioning deficits in both schizophrenia and nonschizophrenia patients? A 10-year longitudinal analysis. Schizophrenia Bulletin, 30, 813–825.

30.

Hutchinson

Haasen

(2004). Migration and schizophrenia: The challenges for European psychiatry and implications for the future. Social Psychiatry and Psychiatric Epidemiology, 39, 350–357.

31.

Hutchinson

Takei

Sham

Harvey

Murray

R. M.

(1999). Factor analysis of symptoms in schizophrenia: Differences between white and Caribbean patients in Camberwell. Psychological Medicine, 29, 607–612.

32.

Jaspers

(1913). Allgemeine Psychopathologie. Berlin: Springer-Verlag.

33.

Jenkins

H. J.

Barrett

R. J.

(2004). Schizophrenia, Culture and Subjectivity. New York: Cambridge University Press.

34.

Kirmayer

L. J.

(2001). Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of Clinical Psychiatry, 13, 22–28.

35.

Kirmayer

L. J.

(2005). Culture, context and experience in psychiatric diagnosis. Psychopathology, 38, 192–196.

36.

Kirmayer

L. J.

Looper

K. J.

(2006). Abnormal illness behaviour: Physiological, psychological and social dimensions of coping with distress. Current Opinion in Psychiatry, 19, 54–60.

37.

Kirmayer

L. J.

Sartorius

(2007). Cultural models and somatic syndromes. Psychosomatic Medicine, 69, 832–840.

38.

Kirmayer

L. J.

Young

(1998). Culture and somatization: Clinical, epidemiological, and ethnographic perspectives. Psychosomatic Medicine, 60, 420–430.

39.

Krueger

R. F.

Bezdjian

(2009). Enhancing research and treatment of mental disorders with dimensional concepts: Toward DSM-V and ICD-11. World Psychiatry, 8, 3–6.

40.

Laban

C. J.

Gernaat

H. B.

Komproe

I. H.

DeJong

J. T.

(2007). Prevalence and predictors of health service use among Iraqi asylum seekers in the Netherlands. Social Psychiatry and Psychiatric Epidemiology, 82, 837–844.

41.

Läge

Egli

Riedel

Strauss

Möller

H. J.

(2011). Combining the categorical and the dimensional perspective in a diagnostic map of psychotic disorders. European Archives of Psychiatry and Clinical Neuroscience, 261, 3–10.

42.

Lau

P. W.

Cheng

J. G.

Chow

D. L.

Ungvari

G. S.

Leung

C. M.

(2009). Acute psychiatric disorders in foreign domestic workers in Hong Kong: A pilot study. International Journal of Social Psychiatry, 55, 569–576.

43.

Lecrubier

(2008). Refinement of diagnosis and disease classification in psychiatry. European Archives of Psychiatry and Clinical Neuroscience, 258(Suppl 1), 6–11.

44.

Lin

K. M.

Cheung

(1999). Mental health issues for Asian Americans. Psychiatric Services, 50, 774–780.

45.

Möller

H. J.

(2008). Systematic of psychiatric disorders between categorical and dimensional approaches: Kraepelin’s dichotomy and beyond. European Archives of Psychiatry and Clinical Neuroscience, 258(Suppl 2), 48–73.

46.

Möller

H. J.

Jäger

Riedel

Obermeier

Strauss

Bottlender

(2010). The Munich 15-year follow-up study (MUFUSSAD) on first-hospitalized patients with schizophrenic or affective disorders: Comparison of psychopathological and psychosocial course and outcome and prediction of chronicity. European Archives of Psychiatry and Clinical Neuroscience, 260, 367–384.

47.

Möller

H. J.

Jäger

Riedel

Obermeier

Strauss

Bottlender

(2011). The Munich 15-year follow-up study (MUFUSSAD) on first-hospitalized patients with schizophrenic or affective disorders: Assessing courses, types and time stability of diagnostic classification. European Psychiatry, 26, 231–243.

48.

Möller-Leimkühler

A. M.

Bottlender

Strauss

Rutz

(2004). Is there evidence for a male depressive syndrome in inpatients with major depression? Journal of Affective Disorders, 80, 87–93.

49.

Montgomery

(2008). Long-term effects of organized violence on young Middle Eastern refugees’ mental health. Social Science & Medicine, 67, 1596–1603.

50.

Mullen

P. E.

(2007). A modest proposal for another phenomenological approach to psychopathology. Schizophrenia Bulletin, 33, 113–121.

51.

Nickerson

Bryant

R. A.

Steel

Silove

Brooks

(2010). The impact of fear for family on mental health in a resettled Iraqi refugee community. Journal of Psychiatric Research, 44, 229–235.

52.

Norredam

Jensen

Ekstrøm

(2011). Psychotic symptoms in refugees diagnosed with PTSD: A series of case reports. Nordic Journal of Psychiatry, 65, 283–288.

53.

Peralta

Cuesta

M. J.

Giraldo

Cardenas

Gonzalez

(2002). Classifying psychotic disorders: Issues regarding categorical vs. dimensional approaches and time frame to assess symptoms. European Archives in Psychiatry and Clinical Neuroscience, 252, 12–18.

54.

Pietzcker

Gebhardt

(1983). Depressive syndromes and scales in the AMDP-system. Acta Psychiatrica Scandinavica, 310, 65–84.

55.

Pietzcker

Gebhardt

Strauss

Stockel

Langer

Freudenthal

(1983). The syndrome scales in the AMDP-system. Modern Problems of Pharmacopsychiatry, 20, 88–99.

56.

Porter

Haslam

(2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. Journal of the American Medical Association, 294, 602–612.

57.

Reischies

F. M.

von Spiess

Stieglitz

R. D.

(1990). The symptom pattern variations of unipolar depression during life span: A cross-sectional study. Comprehensive Psychiatry, 31, 457–464.

58.

Ritsner

Ponizovsky

(1998). Psychological symptoms among an immigrant population: A prevalence study. Comprehensive Psychiatry, 39, 21–27.

59.

Rosenman

Korten

Medway

Evans

(2003). Dimensional vs. categorical diagnosis in psychosis. Acta Psychiatrica Scandinavica, 107, 378–384.

60.

Schneider

(1950). Klinische Psychopathologie. Stuttgart: Thieme.

61.

Simon

G. E.

VonKorff

(1991). Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study. American Journal of Psychiatry, 148, 1494–1500.

62.

Stieglitz

R. D.

Fähndrich

Renfordt

(1988). Interrater study for the AMDP system. Pharmacopsychiatry, 2, 1451–1452.

63.

Tarricone

Atti

A. R.

Braca

Pompei

Morri

Poggi

… Berardi

(2011). Migrants referring to the Bologna Transcultural Psychiatric Team: Reasons for drop-out. International Journal of Social Psychiatry, 57, 627–630.

64.

Tarricone

Mimmi

Paparelli

Rossi

Mori

Panigada

Berardi

(2012a). First-episode psychosis at the West Bologna Community Mental Health Centre: Results of an 8-year prospective study. Psychological Medicine, 7, 1–10. doi: 10.1017/S0033291712000335.

65.

Tarricone

Stivanello

Ferrari

Colombini

Bolla

Braca

Berardi

(2012b). Migrant pathways to community mental health centres in Italy. International Journal of Social Psychiatry, 58, 505–511.

66.

van Os

Fahy

T. A.

Jones

Harvey

Sham

Lewis

… Murray

(1996). Psychopathological syndromes in the functional psychoses: Associations with course and outcome. Psychological Medicine, 26, 161–176.

67.

Velthorst

Nieman

D. H.

Veling

Klaassen

R. M.

Dragt

Rietdijk

van der Gaag

(2011). Ethnicity and baseline symptomatology in patients with an At Risk Mental State for psychosis. Psychological Medicine, 11. doi: 10.1017/S0033291711001486.

68.

WHO (World Health Organization). (1992). The ICD-10 Classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines. Geneva: WHO.

69.

WHO (World Health Organization). (1998). SCAN schedule for clinical assessment of neuropsychiatry (Version 2.1). Geneva: WHO.

70.

WHO (World Health Organization). (2003). International migration, health and human rights. Geneva: WHO.