The relationship of PTSD to key somatic complaints and cultural syndromes among Cambodian refugees attending a psychiatric clinic: The Cambodian Somatic Symptom and Syndrome Inventory (CSSI)

Abstract

This article describes a culturally sensitive questionnaire for the assessment of the effects of trauma in the Cambodian refugee population, the Cambodian Somatic Symptom and Syndrome Inventory (CSSI), and gives the results of a survey with the instrument. The survey examined the relationship of the CSSI, the two CSSI subscales, and the CSSI items to posttraumatic stress disorder (PTSD) severity and self-perceived functioning. A total of 226 traumatized Cambodian refugees were assessed at a psychiatric clinic in Lowell, MA, USA. There was a high correlation of the CSSI, the CSSI somatic and syndrome scales, and all the CSSI items to the PTSD Checklist (PCL), a measure of PTSD severity. All the CSSI items varied greatly across three levels of PTSD severity, and patients with higher levels of PTSD had very high scores on certain CSSI-assessed somatic items such as dizziness, orthostatic dizziness (upon standing), and headache, and on certain CSSI-assessed cultural syndromes such as khyâl attacks, “fear of fainting and dying upon standing up,” and “thinking a lot.” The CSSI was more highly correlated than the PCL to self-perceived disability assessed by the Short Form-12 Health Survey (SF-12). The study demonstrates that the somatic symptoms and cultural syndromes described by the CSSI form a central part of the Cambodian refugee trauma ontology. The survey indicates that locally salient somatic symptoms and cultural syndromes need be profiled to adequately assess the effects of trauma.

Keywords

assessment Cambodian Somatic Symptom and Syndrome Inventory cultural syndromes PTSD refugees somatization

Cross-cultural research indicates that many of the 17 posttraumatic stress disorder (PTSD) items listed in the Diagnostic and Statistical Manual-IV (DSM-IV; American Psychiatric Association, 2000) are a core part of the universal response to trauma, some examples being nightmares, startle, and vivid unwanted recall of trauma events; other DSM-IV PTSD items seem to be a much less salient aspect of the trauma response in non-Western cultures, for example, amnesia or numbing (for a review, see Hinton & Lewis-Fernández, 2011). But many key symptoms and syndromes that are a central part of the trauma response in particular cultural contexts are not assessed in the PTSD criteria (de Jong & Reis, 2010; Henry, 2006; Jenkins & Valiente, 1994; Kleinman & Kleinman, 1994; Kohrt & Hruschka, 2010; Pedersen, Kienzler, & Gamarra, 2010). The Cambodian Somatic Symptom and Syndrome Inventory (CSSI) assesses somatic symptoms and cultural syndromes that are a key part of the response to trauma among Cambodian refugees but that are not among the DSM-IV PTSD symptoms.

Development of the CSSI

The first author is fluent in Cambodian, lived in Southeast Asia for three years doing doctoral research, and has been the medical director of a Southeast Asian clinic in Lowell, MA, USA, for over twelve years where he has done over 20 hours of clinical work each week with traumatized Cambodian speakers, all the while conducting ethnography-focused and mixed-method studies. Building on this work, we developed a list of somatic symptoms and cultural syndromes that were found to be clinically important in this group. An initial instrument was piloted and revised according to clinical utility. We have used this instrument, the Cambodian Somatic Symptom and Syndrome Inventory (CSSI), as a standard assessment tool at the clinic to guide treatment for over three years and have found that the symptoms of the CSSI were crucially important to patients and much more salient than many of the PTSD symptoms. All the items were easily understood by patients and have clear face validity in the cultural context.

Other authors have argued for the clinical utility and theoretical importance of such locally validated scales, but few examples exist. The scales that have been created tend to be generated by lists obtained from community leaders and other informants, and the specific items have not been studied, so that information on their “emic” aspect is lacking (Ebigbo, 1986; Kinzie et al., 1982; Phan, Steel, & Silove, 2004).¹ Scale items should be examined to illustrate why they are culturally salient and important. Otherwise, one is left with a list of items and no understanding of how each of the items relates to the local experiencing of trauma, how the symptom came to be generated, what it means for a person in that culture to have the symptom or syndrome, and how the complaint varies across social and cultural contexts.

In this paper, we describe the CSSI and its application to an outpatient clinic sample. In the first section, we discuss somatic symptoms and syndromes that are prominent among Cambodian refugees and how they are generated (Hinton, Hinton, Loeum, & Pollack, 2008). We then present results from a survey that investigates the CSSI’s relationship to PTSD severity and self-perceived functioning.

Cambodian Somatic Symptom and Syndrome Inventory (Cambodian CSSI)

The CSSI consists of two scales (Table 1): culturally emphasized somatic complaints and key cultural syndromes. In the next two subsections, we discuss the cultural reasons for the salience of each of these in turn.
Table 1.
Contents of the Cambodian Symptom and Syndrome Inventory (CSSI)

Somatic symptoms Syndromes

1. Dizziness Somatic-focused syndromes

2. Standing up and feeling dizzy 1. Khyâl attacks

3. Blurry vision 2. Standing up and feeling poorly to the point you feared fainting, khyâl overload, or heart attack

4. Tinnitus

5. Headache 3. Neck soreness to the point you feared the neck vessels would burst

6. Neck soreness

7. Palpitations 4. “Heart weakness”

8. Shortness of breath 5. Sputum moving upward and causing you to feel you couldn’t breathe or might have a heart arrest

9. Chest tightness

10. Rising sputum 6. Khyâl hitting up from your stomach, making you fear you might die of asphyxia

11. Stomach bloating/discomfort

12. Cold hands and feet 7. Fear of “death of the hands, death of the arms” (slap day slap ceung)

13. Numbness in the arms and feet

14. Sore arms and legs 8. Excessive inner hotness (kdaw khnong)

15. Trembling of the arms and legs 9. Having a partial or full malaria attack

16. Weakness 10. Out of energy to the point you feared having a khyâl attack or dying from depletion

17. Poor appetite

18. Feeling of lightness in the body Agoraphobia/motion-sickness syndromes

11. “Poisoned by cars” (pul laan)

12. “Poisoned by people” (pul meunuh)

Emotion-focused syndromes

13. “Thinking too much”

14. Toxique

Cognitive-capacity syndrome

15. Forgetfulness/mental distraction (phluc phleang)

Spiritual-type syndromes

16. Light in the body as if your soul was not in your body

17. Fear that someone has sent an ampuu into your body

18. Fear of having low spiritual luck (rieusuy), high bad luck (krueh)

19. “Ghost pushing you down” (sleep paralysis)

Somatic complaints assessed in the CSSI

The CSSI assesses the 18 somatic symptoms listed in Table 1. We have given detailed ethnographic description of these symptoms and the reasons for their cultural salience among Cambodian trauma victims in previous publications (for a review, see Hinton & Good, 2009; Hinton & Lewis-Fernández, 2010, 2011). Each of these culturally salient symptoms can be thought of as being generated by one or more of four key processes: (a) the biology of trauma, (b) local ethnophysiology/cultural syndromes, (c) metaphoric associations, and (d) trauma associations (Hinton, Hinton, et al., 2008). People in different cultures may endorse the same somatic symptoms, but the symptom meaning—and manner of symptom generation—may differ according to these four dimensions, and this may cause certain symptoms found in all traumatized groups to be more prominent in specific cultural groups. Below we examine how these four processes or dimensions make the symptoms in the CSSI salient for Cambodian patients. Similar approaches to the multidimensional analysis of somatic symptoms can be found in Barsky (1992), Good (1977), Hinton and Good (2009), Hinton, Howes, and Kirmayer (2008), Jenkins and Valiente (1994), Kirmayer (1996), Kirmayer and Sartorious (2007), and Kleinman and Kleinman (1994).

The biology of trauma

Many Cambodians experienced extreme and prolonged stress and trauma during the Pol Pot period and afterwards (Becker, 1998; Chandler, 1991). Stress and trauma can result in changes in the nervous system that produce a constant state of anxiety. This high state of physiological arousal can cause all the culturally salient somatic symptoms in the CSSI (Hinton & Otto, 2006): palpitations and shortness of breath from activation of the autonomic nervous system (ANS), dizziness from ANS activation and anxiety effects on the balance system, neck soreness from muscle tension, and cold extremities from ANS-caused vasoconstriction.

Trauma not only results in a highly aroused state of the nervous system, with sympathetic nervous system activation and lowered vagal tone and control; it also increases arousability, that is, the tendency for anxiety and arousal to be rapidly induced by any of multiple causes ranging from sounds to emotions (Hinton, Nickerson, & Bryant, 2011). For example, when a trauma survivor worries about a problem such as the acting out behavior of a child or not having money to buy sufficient food, the easily activated ANS can cause a rapid increase of anxiety symptoms and the rapid induction of multiple somatic symptoms such as dizziness, palpitations, and neck soreness (Hinton et al., 2011). Trauma survivors tend to have reactivity to a variety of emotions other than just worry, including: anger, anxiety itself, stress, and even painful, nostalgic recall of the dead—in addition to the classic examples of noise-caused startle or trauma reminders, which are two types of reactivity listed among the DSM-IV PTSD symptoms.

By bringing about this combination of arousal and arousability, the psychobiology of trauma causes traumatized Cambodians to have extreme emotional states and multiple somatic symptoms such as those included in the CSSI. Cross-cultural differences in biology may also contribute to the salience of certain of the CSSI symptoms. Trauma causes biological effects that increase dizziness in general, dizziness on standing, and motion sickness² (Hinton, Hofmann, et al., 2010), and certain East and Southeast Asian populations such as Cambodian refugees may be particularly predisposed to these symptoms (Hinton & Good, 2009; Hinton, Hofmann, et al., 2010) or those of sleep paralysis (Hinton, Pich, Chhean, & Pollack, 2005).

Ethnophysiology-type cultural syndromes

Ethnophysiology concerns may cause Cambodians to be hypervigilant to the somatic symptoms listed in the CSSI; the somatic symptoms are thought to indicate an ethnophysiological disturbance or the occurrence of a cultural syndrome, and these concerns are particularly great when the person is in a self-perceived vulnerable state. To give one example of this culturally produced hypervigilance, all the CSSI somatic symptoms are thought by Cambodians to possibly indicate the onset of a “khyâl attack,” or “wind attack” (Hinton, Pich, Marques, Nickerson, & Pollack, 2010). In a khyâl attack, it is feared that blood and a wind-like substance called khyâl surge upward in the body to cause various somatic symptoms and potentially various bodily catastrophes: blood and khyâl can rush up into the neck to cause soreness from distension and possibly rupturing of the vessels there, or blood and khyâl can surge into the head to cause dizziness, tinnitus, and syncope. Table 2 lists the CSSI somatic symptoms that are thought to occur in a khyâl attack, the ethnophysiology that it is believed generates these symptoms, and the bodily disasters these symptoms foretell. Other cultural syndromes that can produce catastrophic cognitions about somatic symptoms assessed in the CSSI are discussed below in the cultural syndrome section.
Table 2.
The interpretation of somatic symptoms in terms of a khyâl attack: Correlated physiological state and feared consequence

Symptom Correlated physiological state Feared consequence

Dizziness A surge of khyâl and blood into the head Syncope, “khyâl attack,” and “khyâl overload" (khyâl koeu)

Tinnitus A pressure-like escape of khyâl from the ears, with tinnitus being called “khyâl exits from the ears” (khyâl ceuny taam treujieu) Deafness, khyâl attack, and syncope

Blurry vision A pressure-like escape of khyâl from the eyes Blindness, khyâl attack, and syncope

Headache A rush of khyâl and blood into the head and its vessels Syncope, blindness, and khyâl overload

Neck soreness A surge of khyâl and blood into the neck vessels Bursting of the neck vessels, the occurrence of khyâl attack or khyâl overload

Nausea Excessive khyâl in the stomach and abdomen and the khyâl threatens to rise upward in the body Khyâl rising upward from the abdomen into the body to cause asphyxia, cardiac arrest, and various cerebral catastrophes, to cause a khyâl attack and khyâl overload

Palpitations Khyâl has risen upward from the stomach or limbs to press on the heart and cause palpitations. The limbs have blocked vessels, and so the heart must work harder to pump blood and khyâl through the body, and this also results in palpitations. Cardiac arrest and all the disasters associated with a weakened heart, such as poor circulation in the limbs that results in the coagulation of blood in the limbs; this blockage of flow then causes a surge of khyâl and blood upward in the body

Shortness of breath Khyâl surges upward from the limbs or stomach to press on the lungs and cause shortness of breath Asphyxia, the occurrence of khyâl attack or khyâl overload

Soreness in the legs or arms Blockage of the flow of khyâl and blood at the joints, with sore joints being called “plugged vessels” (cok sosai) or “blocked khyâl” (sla khyâl) “Death” of the limbs from a lack of outward flow along the limbs, a surge of khyâl and blood upward in the body to cause the various disasters listed above: asphyxia, heart arrest, neck-vessel rupture, and syncope

Cold hands or feet Blockage of the flow of khyâl and blood in the limbs “Death” of the limbs from a lack of outward flow along the limbs, a surge of khyâl and blood upward in the body to cause the various disasters listed above: asphyxia, heart arrest, neck-vessel rupture, and syncope

Poor appetite A direct effect of excessive bodily khyâl Poor food intake may result in weakness, which in turn causes various physiological consequences: dizziness on standing, palpitations upon exposure to stimuli, and a predisposition to khyâl attacks.

Out of energy Serious depletion of the bodily energy supplies, which may result from poor appetite and sleep, excessive mental or physical exertion, or excessive bodily khyâl The body is depleted, which may cause a weakened heart, possibly resulting in heart arrest and in khyâl attacks: a weakened heart does not adequately pump and circulate the khyâl and blood, resulting in plugs in the limbs that then bring about an upward surge of khyâl and blood into the trunk.

Cultural syndrome- and ethnophysiology-caused hypervigilance towards somatic symptoms may increase awareness of these same somatic symptoms by attentional amplification, hence even a slight symptom like incipient dizziness may be perceived. The fear experienced upon noticing one of the feared symptoms, or even anticipating that it will occur in a certain situation (e.g., that standing up will cause dizziness, which is considered the key symptom of the onset of a dangerous “khyâl attack”) may induce a symptom as part of the physiology of fear. A vicious cycle of worsening then may ensue that leads to panic as fear worsens the symptom and the fear-worsened symptom causes yet more fear. Through this combination of attentional amplification and the physiology of fear, ethnophysiological concerns and cultural syndromes can lead to the worsening of symptoms associated with those ethnophysiologies and syndromes (on these sorts of escalating spirals, see also Kirmayer & Sartorius, 2007). Through these means, a Cambodian may experience escalating distress focused on a somatic symptom to the point of panic, such as a neck-focused or dizziness-focused panic attack centering on fears of the onset of a dangerous khyâl attack (Hinton, Um, & Ba, 2001b).

Metaphoric dimensions

Many of the CSSI somatic symptoms have important metaphoric dimensions in Khmer, the Cambodian language, that increase their cultural salience. In Khmer, multiple tropes describe distress in terms of spinning: “My son shakes me” (koun kreulôk khnyom), meaning “My son causes me great distress,” and “My brain is spinning” (wul khueu khabaal), meaning “I am overwhelmed.” Several Cambodian tropes involve neck soreness: “Arrived to my neck” (dâl gâ), meaning “I cannot take it any more,” and “Carrying a heavy load at the shoulder” (reek theunguen), meaning “I am overburdened with responsibility.” Owing to these metaphors, when a Cambodian thinks about a current problem it may bring about dizziness and neck soreness by a process that might be called metaphor-guided somatization. Symptoms may also activate the metaphor-network: if a Cambodian has dizziness or neck soreness for some reason, that symptom may evoke all the life issues encoded in memory by associated metaphors––in this way, such symptoms as dizziness on standing up or neck tension provoked by worry may bring to mind various problems such as conflicts with children or financial concerns. Metaphor-guided somatization and symptom-caused metaphor-network activation combine to cause certain somatic symptoms to be more prominent in the Cambodian cultural context (Hinton & Good, 2009; Hinton & Lewis-Fernández, 2010).

Trauma associations to somatic sensations

The symptoms on the CSSI are also salient among Cambodian refugees owing to trauma associations. Many Cambodian refugees experienced severe traumas in the past––e.g., during the Pol Pot period, observing a killing, being beaten, being threatened with death––that brought about somatic symptoms such as dizziness as a result of fear and activation of the ANS (Hinton, Hinton, et al., 2008). Some of these trauma events by their very nature tended to strongly induce certain somatic symptoms. Dizziness was induced by many traumas: performing slave labor while starving, which not uncommonly caused syncope, particularly when doing jobs like rice transplanting that involved repeatedly bending over; being struck in the head by the Khmer Rouge as a punishment; encountering corpses, which brought about nausea and dizziness; and having daily bouts of malaria attacks for months (endured by almost every Cambodian), during which extreme dizziness and other symptoms were experienced. The most common form of slave labor was carrying heavy loads of dirt balanced at the neck on a pole during dam building that produced severe neck soreness and discomfort; and the daily malarial episodes almost always induced strong neck soreness and headache (Hinton, Hsia, Park, Rasmussen, & Pollack, 2009).

If a Cambodian now experiences one of these trauma-linked somatic symptoms for any reason––e.g., dizziness that results from standing up or becoming anxious––the somatic symptom may bring to mind the trauma event that featured that somatic symptom, such as feeling dizzy upon witnessing an execution or doing slave labor, in what might be called somatic-symptom activation of the trauma memory network, and that somatic symptom may well worsen because trauma recall increases arousal which, in turn, increases the somatic symptom by physiological means or because recall of the trauma event that featured the somatic sensation causes a somatic flashback. The somatic symptom may begin with trauma recall: thinking about a trauma event (“I recall seeing someone killed” or “I remember being forced to do slave labor while starving”) may increase arousal and induce many somatic symptoms through the physiology of arousal, and thinking about a trauma event may result in somatic flashbacks and so induce somatic symptoms linked to the memory such as dizziness, that is, may cause the original trauma to be recalled with all its sensorial aspects (Hinton, Hinton, et al., 2008).

Cultural syndromes assessed in the CSSI

The CSSI also assesses cultural syndromes that are prominent aspects of the Cambodian response to trauma (see Table 1): somatic-focused syndromes (10 items): agoraphobia/motion-sickness-type syndromes (two items); emotion-focused syndrome (one item); a cognitive-deficit syndrome (one item); and spiritual-type syndromes (four items). We have given detailed ethnographic description of all of these syndromes in previous publications (for a review, see Hinton & Good, 2009; Hinton & Lewis-Fernández, 2010, 2011).

Somatic-focused syndromes (10 items)

One item assesses fear of khyâl attacks, which were described above. Khyâl, a wind-like substance, is thought to flow throughout the body alongside blood, but sometimes the normal flow of khyâl and blood suddenly becomes disturbed and khyâl and blood surge upward in the body toward the head, an event called a khyâl attack that may cause the somatic symptoms and disasters described in Table 2 (Hinton, Pich, et al., 2010). A particularly severe khyâl attack may be triggered by standing up that is referred to as “khyâl overload” (khyâl koeu) and is a greatly feared physiological disturbance (Hinton, Um, & Ba, 2001a). Other common causes of khyâl attacks are worry or any kind of anxiety or fright, for example, that brought about by a nightmare. The CSSI asks how much the person was bothered in the last month by khyâl attacks and by ethnophysiological concerns associated with khyâl attacks: having khyâl moving up from the stomach to the point of fearing death by asphyxia; neck soreness to the point of fearing the neck vessels would burst; fear of the death of the arms or legs; and standing up and feeling poorly to the point of fearing fainting and khyâl overload. Because each of these somatic complaints (e.g., neck soreness) not only involves culturally specific catastrophic cognitions but also particular trauma associations and metaphoric associations (e.g., trauma associations and metaphoric associations to neck sensations), we consider each of these a syndrome (e.g., the sore neck syndrome; Hinton et al., 2001b).

Another CSSI syndrome item is heart weakness. Cambodians worry that heart weakness will cause strong reactivity to various stimuli, for example, to sounds and to smells; that heart weakness predisposes to certain negative emotional states that include being easily frightened, becoming angry, and engaging in worry; and that heart weakness may cause heart arrest (Hinton, Hinton, Um, Chea, & Sak, 2002). Heart weakness is also thought to cause dizziness upon standing up, palpitations, and shortness of breath (the heart is considered to drive breathing by a piston-like action), and a weak heart is thought to pump blood and khyâl poorly, predisposing to having cold extremities and khyâl attacks. Cambodians attribute heart weakness to many causes, including poor sleep, poor appetite, and excessive worry.

The following are four other somatic-focused syndromes assessed by the CSSI. Cambodians worry that a thick saliva (viz., sleih, which we will translate as “sputum”) may rise up from the stomach and cause blocking of the breathing apparatus and the workings of the heart.³ Cambodians also worry about having bouts of “inner hotness,” or kdaw khnong, a condition characterized by excessive bodily heat that results in thirst and a sense of heat rising in the chest. “Inner hotness” predisposes to anger, and may cause the blood to boil and so send a steam upward in the body to cause most of the symptoms and disasters described for a khyâl attack (Table 2). The CSSI also assesses whether the patient considered him- or herself to have been bothered by malaria-like attacks in the last month. As a unique form of anxiety, Cambodians frequently experience a malaria-like attack: rigors (i.e., a sense of great coldness in the body that provokes a dramatic shaking that may last 30 minutes or more), then a great heat in the body, and finally sweating that brings about relief. These attacks feature prominent panic symptoms like palpitations, dizziness, and neck pain. The CSSI also assesses “fear of being out of energy to the point that it may cause a khyâl attack or death.” Patients worry that the body will start to malfunction if depleted of energy and that this may cause death.

Agoraphobia/motion-sickness syndromes (two items)

“Car poisoning” (pul laan) is a khyâl attack caused by traveling in a car. Riding in a car is thought by Cambodian refugees to cause dizziness and khyâl attacks owing to the sudden starts and stops, the bumps, and the complex, shifting visual stimulation. “People poisoning” (pul meunuh) is a khyâl attack caused by going out into a public space such as into a mall or a crowded Buddhist temple. If a person is considered to be weak, these localities are thought to cause him or her to be dizzy owing to the experiencing of multiple sensory stimuli––auditory, olfactory, and visual (viz., the constant movement of people and an ever-changing visual array)––that come from several directions, that pull the attention to various localities, and that provoke a constant turning of the head as the person notices each stimulus, with that turning of the head further increasing dizziness.⁴

Emotion-focused syndrome (two items)

An emotion-focused syndrome assessed in the CSSI is “toxique.” This indicates a state in which the person has engaged in worry and other anxious thoughts to the point of being irritable and potentially violent. The syndrome’s name is adopted from French colonial medicine and is related to that time period’s ideas about the biology of neurasthenia. The other emotion-focused syndrome in the CSSI is “thinking a lot” (kut caraeun), which describes an anxious mental state that has the following characteristics: one thinks of upsetting topics such as current problems (e.g., money problems and problems with children), past trauma events (e.g., those that occurred in the Pol Pot period), or separation from loved ones owing to their death or their living at a distance (e.g., often the parents and siblings of patients live in Cambodia); one has a hard time not thinking about these things; and one thinks about these things to the point that it is considered damaging, that is, the ruminations are depleting one’s mind and body, predisposing to heart weakness and khyâl attacks, and they are overheating the brain to the point that there may be permanent memory loss and a state of forgetfulness, even insanity. (Worry and “thinking a lot” episodes, along with standing up, are three of the most common causes of khyâl attacks.)

Cognitive-deficit syndrome (one item)

Phluc pheang literally means “forgetfulness/mental distraction” and refers to a mental state in which the person often forgets things, like having left a pot with boiling water on the stove to make rice. It is a mental state in which the person often floats off in thought to contemplate other things such as past traumas and current worries and so becomes oblivious to his or her current surroundings. This may happen at any time: when talking to someone or driving a car. It is feared that this mental state may progress to a permanent state of forgetfulness, even insanity. Cambodian Buddhism emphasizes focused attention, for example, attending to the breath in meditation, and this syndrome’s state of mental distraction is the opposite of that cultural ideal. Buddhism sensitizes Cambodians to the concept of the “wandering mind.”

Spiritual-type syndromes (four items)

One CSSI syndrome item assesses fear of having had the soul displaced from the body. Cambodians worry that the soul may be displaced by fear. Soul dislocation may cause prolonged illness, a feeling of bodily lightness, hyperreactivity to all stimuli (e.g., noises), and possibly death. The person who is prone to such dislocation uses the expression, “soul at the end of the hair” (prolung niw jong so), a condition having symptoms similar to soul loss itself. Various rituals may then be used to call the soul back to the body and secure it there. The CSSI also assesses fears that a spiritual object called an ampuu has been sent into the body. This will cause periodic acute bouts of stomach discomfort as well as anger, anxiety, and multiple somatic symptoms. A former lover is often suspected to have hired a practitioner of black magic to send the ampuu into the body. Another CSSI syndrome item assesses concerns of having low spiritual energy (rieusuy). While in a low-luck state, the person fails in all ventures, is predisposed to anger and other negative emotions such as fear, and is vulnerable to various types of spiritual attacks. Such spiritual attacks include nightmares, because nightmares are often interpreted as being the result of an assault by malevolent spirits as the sleeper’s soul wanders outside the body during sleep, with that attack only possible due to the person being in a weakened spiritual state (Hinton, Hinton, et al., 2009).

The CSSI also assesses one spiritual-type cultural syndrome that is the local interpretation of sleep paralysis, a syndrome that is common in the Cambodian population, particularly among those with PTSD (Hinton et al., 2005). In sleep paralysis, the person suddenly cannot move or speak and may see a shape come towards the body. Cambodian patients almost always see a shape during sleep paralysis, usually a black shadow, and they feel chest tightness when the shape reaches the body. And this shape is usually thought to be a malevolent spirit pushing down on the body and for this reason Cambodians refer to sleep paralysis as “a spirit pushes you down” (khmaoch sangot). Cambodians usually consider this shape to be a dangerous malevolent being, often the ghost of a dead person such as that of someone they saw killed during the Pol Pot period or of someone who died in the house in which they are now living. A bad death is believed to produce a malicious and vengeful spirit.

The clinic survey

The purpose of the survey was to assess traumatized Cambodian refugees attending a psychiatric clinic in a culturally sensitive manner by using the CSSI. We examined the relationship of the CSSI (CSSI total score, CSSI somatic and syndrome subscales, and CSSI items) to PTSD severity, and we investigated whether the CSSI total score or PTSD severity was more strongly correlated with self-perceived functioning.

Method

The survey occurred at a clinic that provides psychiatric services in Lowell, MA, USA, a city that is home to over 30,000 Cambodian refugees, the second largest community in the United States. Lowell is an urban center with high rates of crime and unemployment that is about an hour’s drive from Boston, MA. Patients are referred to the clinic by community primary care clinicians or by other patients. The survey only included patients who had initially presented to the clinic with PTSD, which was the case for 95% of patients. Most patients had been at the clinic for several years. Consecutive qualifying patients were given the PTSD Checklist (a measure of PTSD severity), the CSSI (a measure of culturally specific complaints and syndromes), and the SF-12 (a measure of self-perceived functioning). The project was approved by the clinic’s institutional review board, and informed consent was obtained. Of the 226 patients surveyed, 66% were women, with the average age being 52.6 (SD = 9.5). All participants had lived through the Pol Pot genocide. Only 5% of the patients were working, and the majority spent their time taking care of children or grandchildren. Almost all had a tenuous economic status, living at the poverty line.

Measures

PTSD Checklist (PCL)

The PCL assesses how much each of the 17 DSM–IV PTSD criteria has bothered the patient in the last month, each assessed on a 1–5 Likert-type scale (McDonald & Calhoun, 2010): 1 (not at all), 2 (a little bit), 3 (moderately), 4 (quite a bit), and 5 (extremely). The Cambodian version of the PCL has excellent test–retest (at 1 week) and interrater reliability (r = .91 and .95, respectively). Among the Cambodian population, the “44” cut-off score has excellent correspondence to the diagnosis made by a rater using the Structured Clinical Interview for PTSD (SCID) module for PTSD (k = .81; 30 patients) (Hinton, Rasmussen, Nou, Pollack, & Good, 2009).

Cambodian Somatic Symptom and Syndrome Inventory (CSSI)

The scale assesses somatic symptoms and cultural syndromes that are particularly salient among traumatized Cambodian population but are not assessed in the DSM-IV criteria. The CSSI items are divided into two subscales (see Table 1): a somatic scale (18 items) and a syndrome scale (19 items), with the syndrome scale having five subscales (see Table 1). The CSSI assesses how much the patient was bothered by certain somatic symptoms or syndromes in the last 4 weeks, each rated on a 0–4 Likert-type scale: 0 (not at all), 1 (a little bit), 2 (moderately), 3 (quite a bit), and 4 (extremely). We previously established the test–retest reliability with 30 patients for the somatic scale and syndrome scale (r = .91 and r = .89, respectively) and for the syndrome subscales (all rs > .85). The CSSI is not designed to indicate “disorder” at a certain average score of the scale or subscales. Rather the CSSI is intended to be used along with standardized assessment tools such as a PTSD measure to reveal the severity of certain culturally salient somatic complaints and cultural syndromes that are a key part of the presentation of trauma-related distress among Cambodian patients.

Short Form-12 Health Survey (SF-12)

The SF-12 is a measure of self-perceived health that has two subscales, one measuring emotional functioning and the other physical functioning (Ware, Kosinski, & Keller, 1996). The time frame is the last month. The score is standardized to the general population so that 50 represents the average level of functioning and each change of 10 points indicates 1 standard deviation from that mean, with lower scores indicating worse functioning. We have validated the scale for the Cambodian population in a previous study (Hinton, Sinclair, Chung, & Pollack, 2007).

Results

Reliability of the CSSI

In this study, the CSSI scales showed excellent internal consistency (see measures for previously obtained test–retest data). For the somatic scale, the alpha was .91, and for the syndrome scale, .88, with the all the multi-item syndrome subscales having excellent internal consistency as well (all alphas > .84).

PCL, CSSI, and SF-12 scores in the patient population

Gender did not have significant effects on the PCL, CSSI, or SF-12 scores (ps > .05), nor did age. Based on a PCL cut-off score of 44, 55% (124/226) of the patients had PTSD. On the PCL scale, the mean item score was 3.1 (SD = 0.8) in the PTSD group and 1.5 (SD = 0.5) in the non-PTSD group. On the CSSI scale, the mean score was 2.0 (SD = 0.8) in the PTSD group and 0.6 (SD = 0.5) in the non-PTSD group. Tables 3–5 show that the CSSI, the two CSSI scales, and all the CSSI items were highly correlated to PTSD severity (PCL score). As assessed by the SF-12, we found the group with PTSD had much worse self-perceived functioning than the non-PTSD group, 30.8 (SD = 10.3) versus 43.0 (SD = 11.1), t(2, 224), p < .001. This indicates a serious impairment in self-perceived functioning in the PTSD group.
Table 3.
Relationship of the CSSI total score and subscales to PTSD severity on PCL

Comparison of scale scores for three levels of PTSD severity

CSSI scale Correlation with PTSD score No PTSD (n = 102) M (SD) Moderate PTSD (n = 56) M (SD) Severe PTSD (n = 68) M (SD) F(2, 23)†

CSSI total score .67* 0.6 (0.6) 1.5 (0.6) 2.4 (0.7) 163.5*

CSSI somatic scale .71* 0.8 (0.5) 1.6 (0.6) 2.5 (0.7) 133.5*

CSSI syndrome scale .63* 0.6 (0.5) 1.4 (0.6) 2.3 (0.8) 158.8*

Note. CSSI = Cambodian Symptom and Syndrome Inventory. Each CSSI is rated on a 0–4 Likert-type scale. Each PTSD item is rated on a 1–5 Likert-type scale. The three groups are determined by the PCL scores: no PTSD = PCL score of 0–2.5; moderate PTSD = a PCL score of 2.6–3.6; and severe PTSD = a PCL score of 3.7–5.

*
p < .001; †for all scales, all follow-up paired independent samples t tests among the three groups were significant at p < .001

Table 5.
Relationship of syndromes of the CSSI to PTSD severity

Comparison of the item score for three levels of PTSD severity

Type of syndrome and syndrome item Correlation with PTSD score No PTSD (n = 102) M (SD) Moderate PTSD (n = 56) M (SD) Severe PTSD (n = 68) M (SD) F(2, 23)†

Somatic-focused syndromes

1. Khyâl attacks .59* 0.8 (1.0) 1.7 (1.1) 2.6 (1.4) 43.1*

2. Standing up and feeling poorly to the point you feared fainting, khyâl overload, or heart attack .76* 0.5 (0.8) 1.7 (1.3) 3.0 (1.1) 132.5*

3. Neck soreness to the point you feared the neck vessels would burst .65* 0.5 (0.9) 1.7 (1.3) 2.5 (1.5) 55.8*

4. “Heart weakness” .64* 0.6 (0.9) 1.7 (1.3) 2.5 (1.4) 54.8*

5. Sputum moving upward and causing you to feel you couldn’t breathe or might have heart arrest .48* 0.2 (0.6) 0.6 (1.0) 1.5 (1.6) 30.4*

6. Khyâl hitting up from your stomach, making you fear you might die of asphyxia .43* 0.5 (1.0) 0.9 (1.1) 1.7 (1.6) 20.5*

7. Fear of “death of the hands, death of the arms”(slap day slap ceung) .57* 0.7 (1.2) 1.9 (1.3) 2.5 (1.5) 41.5*

8. Excessive “inner hotness” (kdaw khnong) .44* 0.6 (0.9) 1.2 (1.2) 1.8 (1.4) 19.3*

9. Having a partial or full malaria attack .50* 0.2 (0.6) 0.7 (1.1) 1.6 (1.5) 32.1*

10. Out of energy to the point you feared having a khyâl attack or dying from depletion .63* 0.7 (1.0) 1.7 (1.2) 2.6 (1.3) 52.8*

Agoraphobia/motion-sickness syndromes

11. “Poisoned by cars” (pul laan) .39* 0.5 (1.0) 0.7 (1.2) 1.6 (1.5) 15.4*

12. “Poisoned by people” (pul meunuh) .49* 0.6 (1.1) 1.3 (1.2) 2.4 (1.6) 36.4*

Emotion-focused syndrome

13. “Thinking too much” .78* 0.5 (1.0) 2.6 (1.0) 3.6 (0.8) 125.3*

14. Toxique .34* 1.0 (1.1) 1.2 (1.3) 1.7 (1.8) 27.4*

Cognitive-capacity syndrome

15. Forgetfulness/mental distraction (phluc) phleang) .61* 1.0 (1.2) 2.1 (1.2) 2.9 (1.2) 50.7*

Spiritual-type syndromes

16. Light in the body as if your soul was not in your body .63* 0.6 (1.0) 1.3 (1.2) 2.6 (1.2) 65.4*

17. Fear that someone has sent an ampuu into your body .40* 0.5 (1.0) 0.9 (1.0) 1.6 (1.6) 8.6*

18. Fear of having low spiritual luck (rieusuy), high bad luck (krueh) .45* 0.7 (1.0) 1.5 (1.2) 2.3 (1.5) 22.6*

19. “Ghost pushing you down” (sleep paralysis) .55* 0.2 (0.4) 0.9 (1.0) 1.7 (1.6) 47.9*

*
p < .001; † for all scales, all follow-up paired independent samples t tests among the three groups were significant at p < .001, except the following for no PTSD versus moderate PTSD: Number 11, 14, 17.

CSSI scale and item scores at three levels of PTSD severity

We divided the patients into three groups based on level of severity of PTSD symptoms as indicated by PCL scores: (a) without PTSD (0–2.5), (b) mild/moderate PTSD (2.6–3.6), and (c) severe PTSD (3.7–5). We based these cut-offs on the desire to create groups of approximately equal numbers and on conventional cut-offs for PTSD severity (McDonald & Calhoun, 2010). The severity of the CSSI total score, the CSSI somatic and syndrome scales, and the individual CSSI items increased with level of PTSD severity (Tables 3–5). Several CSSI items had extremely high scores at the highest PTSD level: among the somatic items, dizziness, standing up and feeling dizzy,⁵ headache, blurry vision, and weakness; and among the syndrome items, “thinking a lot,” “standing up and feeling dizzy to the point of fainting, khyâl attack, or heart attack,” and “forgetfulness/mental distraction.” The items that were highly correlated to PTSD also differentiated well among the three groups (see Tables 4 and 5), the best differentiators being certain somatic items, namely, dizziness and dizziness on standing, and certain syndromes, namely, “thinking too much” and “fear of having a khyâl overload, heart attack, or fainting upon standing.”
Table 4.
Relationship of somatic symptoms of the CSSI to PTSD severity

Comparison of item scores for three levels of PTSD severity

Somatic symptom item Correlation with PTSD score No PTSD (n = 102) M (SD) Moderate PTSD (n = 56) M (SD) Severe PTSD (n = 68) M (SD) F(2, 23)†

1. Dizziness .67* 0.8 (1.0) 1.9 (1.2) 3.0 (1.3) 70.3*

2. Standing up and feeling dizzy .71* 0.7 (0.9) 1.7 (1.1) 2.9 (1.1) 91.2*

3. Blurry vision .63* 0.9 (1.1) 2.0 (1.2) 2.9 (1.2) 63.7*

4. Tinnitus .60* 0.6 (1.0) 1.6 (1.2) 2.5 (1.4) 52.9*

5. Headache .61* 1.0 (1.2) 2.1 (1.2) 2.9 (1.2) 50.7*

6. Neck soreness .62* 0.8 (1.0) 1.9 (1.1) 2.6 (1.4) 53.1*

7. Palpitations .55* 0.9 (1.2) 1.8 (1.3) 2.6 (1.3) 38.0*

8. Shortness of breath .61* 0.6 (0.8) 1.4 (1.3) 2.5 (1.4) 54.8*

9. Chest tightness .53* 0.5 (0.9) 1.0 (1.1) 2.0 (2.4) 34.2*

10. Rising sputum .40* 0.5 (1.0) 0.9 (1.0) 1.6 (1.6) 8.2*

11. Stomach bloating/discomfort .34* 1.0 (1.1) 1.2 (1.3) 1.8 (1.5) 28.5*

12. Cold hands and feet .45* 0.7 (1.0) 1.3 (1.2) 2.2 (1.5) 22.6*

13. Numbness in the arms and feet .43* 0.9 (1.2) 1.1 (1.3) 2.2 (1.4) 28.5*

14. Sore arms and legs .61* 1.1 (1.2) 2.2 (1.2) 2.9 (1.2) 46.7*

15. Trembling of the arms and legs .65* 0.5 (0.8) 1.2 (1.1) 2.3 (1.3) 60.5*

16. Weakness .62* 1.0 (1.2) 2.0 (1.1) 2.8 (1.2) 52.8*

17. Poor appetite .56* 0.5 (0.8) 1.5 (1.1) 2.2 (1.5) 44.2*

18. Feeling of lightness in the body .55* 0.5 (1.0) 1.1 (1.2) 2.0 (1.4) 35.1*

*
p < .001; † for all scales, all follow-up paired independent samples t tests among the three groups were significant at p < .001, except the following for no PTSD versus moderate PTSD: Number 11, 13.

Correlation of the CSSI and PCL to Self-Perceived Functioning (SF-12)

The CSSI was more strongly related to the SF-12 than the PCL (r = .7 vs. r = .5), which was a statistically significant difference, Fisher’s z test, z = 3.4, p < .001.

Discussion

The survey confirmed that the somatic symptoms and cultural syndromes of the CSSI are a prominent aspect of the experience of PTSD among traumatized Cambodian refugees. Across each of the three levels of PTSD severity, there was a significant increase in the CSSI total score, the CSSI somatic and syndrome scales, and all the CSSI items. This suggests that Cambodian patients with significant PTSD not only have PTSD symptoms but also multiple culture-specific somatic symptoms as well as several culture-specific syndromes. We also found that the CSSI was more strongly correlated than the PTSD scale to self-perceived functioning.

Some of the CSSI somatic symptoms and syndromes were quite frequent or severe in the Cambodian group. One of these was “thinking a lot,” which had a mean score of 3.6 on the 0–4 Likert-type scale in the severe PTSD group. This complaint seems to result from several factors. As discussed earlier, traumatized populations appear to be predisposed to worry and to be hyperreactive to worry, with worry quickly escalating to a very anxious state (Hinton et al., 2011). Cambodians at the clinic almost all lived in a poor urban environment and were beset by financial, safety, and other concerns. They had many trauma memories from the Pol Pot period; they often nostalgically recalled relatives who died in the Pol Pot period; and had painful recollections of the many relatives who live in Cambodia and so were seldom seen. These factors led to the frequent experiencing of the syndrome of “thinking a lot.”

Three dizziness complaints (dizziness, dizziness upon standing, and “fear of fainting, khyâl overload, or heart attack upon standing up”) were extremely elevated and differentiated among the levels of severity of PTSD. Two other dizziness-type syndromes, (“poisoned by people” and “poisoned by cars”) also differentiated among levels of severity of PTSD. Other authors have noted the prominence of dizziness complaints among Cambodians, other Southeast Asian groups, and East Asians (Barrera, Wilson, & Norton, 2010; Hsu & Folstein, 1997). Kleinman and Kleinman (1994) argued that dizziness was one of the three paradigmatic distress complaints––along with exhaustion and pain––in China (see also Park, 2009). A recent survey of a student population in the United States found dizziness complaints to be particularly elevated in the panic attacks of Asian populations as compared to Caucasian and African American students (Barrera et al., 2010).

The four-dimension analysis described in the first part of this paper suggests why dizziness was such a prominent complaint among traumatized Cambodians at the clinic:
Dizziness is generated by the biology of trauma and anxiety, for example, through activation of the autonomic nervous system, through vagal effects, through impairment of the balance system (integration of visual, proprioceptive, and vestibular information), through PTSD effects on the orthostatic blood pressure response to standing up, and through anxiety and PTSD effects on motion sickness, with evidence that these orthostatic and motion sickness effects may be particularly marked in certain Asian populations;

dizziness is considered to be a key indicator of ethnophysiological disturbance (dizziness is thought to indicate that khyâl is rushing into the head during a khyâl attack to cause all the disasters outlined in Table 2) and a key symptom of several syndromes, and these dizziness-centered ethnophysiology concerns and cultural syndromes result in dizziness by producing hypervigilant seeking of dizziness and catastrophic cognitions about dizziness that bring about a vicious circle of escalating arousal (“looping effects”) centered on dizziness;

dizziness has extensive metaphoric resonances in the Cambodian language (e.g., spinning images in expressions used to convey distress) and this results in dizziness by metaphor-guided somatization and by dizziness-caused metaphor-network activation; and

dizziness is associated with specific trauma events (e.g., slave labor when starving, head blows, malaria events) and this results in dizziness having the power to activate trauma memory networks and by the frequent recall of dizziness-linked trauma events.

The results of the survey indicate that PTSD symptoms are just the “tip of the iceberg” among distressed, traumatized Cambodian refugees. If PTSD is present, so too are multiple other somatic symptoms and syndromes such as dizziness and dizziness-related syndromes. These somatic symptoms and syndromes are often of equal or greater concern to Cambodian refugee patients than the symptoms of PTSD symptoms, and they are strongly correlated to self-perceived functioning. Cambodian patients are unfamiliar with such concepts as “PTSD” but are keenly aware of and concerned about culturally salient trauma-related somatic symptoms and syndromes, like dizziness upon standing or neck soreness, khyâl attacks, weak heart, “thinking a lot,” or the “ghost pushes you down.” Some of the cultural syndromes have PTSD symptoms as key symptoms; for example, startle and rapidly becoming angry are key symptoms of “weak heart.”

The four-dimension analysis indicates how certain somatic symptoms and cultural syndromes become a central part of a group’s specific trauma ontology. The biology of trauma will result in a certain “symptom pool” (Shorter, 1992). This symptom pool may include PTSD symptoms (e.g., poor sleep, nightmares, unwanted recall of the trauma, and anger) as well as other symptoms potentially caused by trauma: arousal and arousability, various somatic symptoms, and certain adjustment deficits such as poor orthostatic adjustment and a predisposition to motion sickness (Hinton & Good, 2009; Mayer, 2007). All these trauma-caused symptoms will be interpreted in terms of the local ethnophysiology, ethnopsychology, and cultural syndromes, resulting in certain symptoms being highlighted and amplified; and depending on the ethnophysiology and cultural syndrome the particular symptom is attributed to, the person will have certain ideas about the cause, severity, and indicated manner of redress of the symptom. Somatic symptoms may also be amplified by trauma associations and metaphoric resonances, which are further key symptom dimensions.

The current study suggests that researchers and clinicians working in other cultural settings among traumatized populations should create somatic symptom and syndrome inventories (a locally specific SSI) to supplement PTSD scales and other standardized psychometric instruments. In this way, a more adequate depiction of the local response to trauma can be obtained and the symptoms and syndromes of concern in that locality can be addressed in clinical care, increasing empathy, understanding, and treatment efficacy (Hinton & Lewis-Fernández, 2010). The development of such scales needs to include a four-dimension analysis that addresses both the biology of trauma and the three meaning dimensions (ethnophysiology/cultural syndromes; metaphoric resonances; trauma associations) of each somatic symptom. Additionally, there should be a careful examination of the potential triggers of somatic symptoms and of particular cultural syndromes (Hinton et al., 2011). Only through a four-dimension analysis conjoined with an analysis of particular distress episodes can the meaning, manner of generation, and method of treatment of somatic symptoms and syndromes become clear.

Somatic symptoms	Syndromes
1. Dizziness	Somatic-focused syndromes
2. Standing up and feeling dizzy	1. Khyâl attacks
3. Blurry vision	2. Standing up and feeling poorly to the point you feared fainting, khyâl overload, or heart attack
4. Tinnitus
5. Headache	3. Neck soreness to the point you feared the neck vessels would burst
6. Neck soreness
7. Palpitations	4. “Heart weakness”
8. Shortness of breath	5. Sputum moving upward and causing you to feel you couldn’t breathe or might have a heart arrest
9. Chest tightness
10. Rising sputum	6. Khyâl hitting up from your stomach, making you fear you might die of asphyxia
11. Stomach bloating/discomfort
12. Cold hands and feet	7. Fear of “death of the hands, death of the arms” (slap day slap ceung)
13. Numbness in the arms and feet
14. Sore arms and legs	8. Excessive inner hotness (kdaw khnong)
15. Trembling of the arms and legs	9. Having a partial or full malaria attack
16. Weakness	10. Out of energy to the point you feared having a khyâl attack or dying from depletion
17. Poor appetite
18. Feeling of lightness in the body	Agoraphobia/motion-sickness syndromes
11. “Poisoned by cars” (pul laan)
12. “Poisoned by people” (pul meunuh)
Emotion-focused syndromes
13. “Thinking too much”
14. Toxique
Cognitive-capacity syndrome
15. Forgetfulness/mental distraction (phluc phleang)
Spiritual-type syndromes
16. Light in the body as if your soul was not in your body
17. Fear that someone has sent an ampuu into your body
18. Fear of having low spiritual luck (rieusuy), high bad luck (krueh)
19. “Ghost pushing you down” (sleep paralysis)

Symptom	Correlated physiological state	Feared consequence
Dizziness	A surge of khyâl and blood into the head	Syncope, “khyâl attack,” and “khyâl overload" (khyâl koeu)
Tinnitus	A pressure-like escape of khyâl from the ears, with tinnitus being called “khyâl exits from the ears” (khyâl ceuny taam treujieu)	Deafness, khyâl attack, and syncope
Blurry vision	A pressure-like escape of khyâl from the eyes	Blindness, khyâl attack, and syncope
Headache	A rush of khyâl and blood into the head and its vessels	Syncope, blindness, and khyâl overload
Neck soreness	A surge of khyâl and blood into the neck vessels	Bursting of the neck vessels, the occurrence of khyâl attack or khyâl overload
Nausea	Excessive khyâl in the stomach and abdomen and the khyâl threatens to rise upward in the body	Khyâl rising upward from the abdomen into the body to cause asphyxia, cardiac arrest, and various cerebral catastrophes, to cause a khyâl attack and khyâl overload
Palpitations	Khyâl has risen upward from the stomach or limbs to press on the heart and cause palpitations. The limbs have blocked vessels, and so the heart must work harder to pump blood and khyâl through the body, and this also results in palpitations.	Cardiac arrest and all the disasters associated with a weakened heart, such as poor circulation in the limbs that results in the coagulation of blood in the limbs; this blockage of flow then causes a surge of khyâl and blood upward in the body
Shortness of breath	Khyâl surges upward from the limbs or stomach to press on the lungs and cause shortness of breath	Asphyxia, the occurrence of khyâl attack or khyâl overload
Soreness in the legs or arms	Blockage of the flow of khyâl and blood at the joints, with sore joints being called “plugged vessels” (cok sosai) or “blocked khyâl” (sla khyâl)	“Death” of the limbs from a lack of outward flow along the limbs, a surge of khyâl and blood upward in the body to cause the various disasters listed above: asphyxia, heart arrest, neck-vessel rupture, and syncope
Cold hands or feet	Blockage of the flow of khyâl and blood in the limbs	“Death” of the limbs from a lack of outward flow along the limbs, a surge of khyâl and blood upward in the body to cause the various disasters listed above: asphyxia, heart arrest, neck-vessel rupture, and syncope
Poor appetite	A direct effect of excessive bodily khyâl	Poor food intake may result in weakness, which in turn causes various physiological consequences: dizziness on standing, palpitations upon exposure to stimuli, and a predisposition to khyâl attacks.
Out of energy	Serious depletion of the bodily energy supplies, which may result from poor appetite and sleep, excessive mental or physical exertion, or excessive bodily khyâl	The body is depleted, which may cause a weakened heart, possibly resulting in heart arrest and in khyâl attacks: a weakened heart does not adequately pump and circulate the khyâl and blood, resulting in plugs in the limbs that then bring about an upward surge of khyâl and blood into the trunk.

Comparison of scale scores for three levels of PTSD severity
CSSI total score	.67*	0.6 (0.6)	1.5 (0.6)	2.4 (0.7)	163.5*
CSSI somatic scale	.71*	0.8 (0.5)	1.6 (0.6)	2.5 (0.7)	133.5*
CSSI syndrome scale	.63*	0.6 (0.5)	1.4 (0.6)	2.3 (0.8)	158.8*

Comparison of the item score for three levels of PTSD severity
Somatic-focused syndromes
1. Khyâl attacks	.59*	0.8 (1.0)	1.7 (1.1)	2.6 (1.4)	43.1*
2. Standing up and feeling poorly to the point you feared fainting, khyâl overload, or heart attack	.76*	0.5 (0.8)	1.7 (1.3)	3.0 (1.1)	132.5*
3. Neck soreness to the point you feared the neck vessels would burst	.65*	0.5 (0.9)	1.7 (1.3)	2.5 (1.5)	55.8*
4. “Heart weakness”	.64*	0.6 (0.9)	1.7 (1.3)	2.5 (1.4)	54.8*
5. Sputum moving upward and causing you to feel you couldn’t breathe or might have heart arrest	.48*	0.2 (0.6)	0.6 (1.0)	1.5 (1.6)	30.4*
6. Khyâl hitting up from your stomach, making you fear you might die of asphyxia	.43*	0.5 (1.0)	0.9 (1.1)	1.7 (1.6)	20.5*
7. Fear of “death of the hands, death of the arms”(slap day slap ceung)	.57*	0.7 (1.2)	1.9 (1.3)	2.5 (1.5)	41.5*
8. Excessive “inner hotness” (kdaw khnong)	.44*	0.6 (0.9)	1.2 (1.2)	1.8 (1.4)	19.3*
9. Having a partial or full malaria attack	.50*	0.2 (0.6)	0.7 (1.1)	1.6 (1.5)	32.1*
10. Out of energy to the point you feared having a khyâl attack or dying from depletion	.63*	0.7 (1.0)	1.7 (1.2)	2.6 (1.3)	52.8*
Agoraphobia/motion-sickness syndromes
11. “Poisoned by cars” (pul laan)	.39*	0.5 (1.0)	0.7 (1.2)	1.6 (1.5)	15.4*
12. “Poisoned by people” (pul meunuh)	.49*	0.6 (1.1)	1.3 (1.2)	2.4 (1.6)	36.4*
Emotion-focused syndrome
13. “Thinking too much”	.78*	0.5 (1.0)	2.6 (1.0)	3.6 (0.8)	125.3*
14. Toxique	.34*	1.0 (1.1)	1.2 (1.3)	1.7 (1.8)	27.4*
Cognitive-capacity syndrome
15. Forgetfulness/mental distraction (phluc) phleang)	.61*	1.0 (1.2)	2.1 (1.2)	2.9 (1.2)	50.7*
Spiritual-type syndromes
16. Light in the body as if your soul was not in your body	.63*	0.6 (1.0)	1.3 (1.2)	2.6 (1.2)	65.4*
17. Fear that someone has sent an ampuu into your body	.40*	0.5 (1.0)	0.9 (1.0)	1.6 (1.6)	8.6*
18. Fear of having low spiritual luck (rieusuy), high bad luck (krueh)	.45*	0.7 (1.0)	1.5 (1.2)	2.3 (1.5)	22.6*
19. “Ghost pushing you down” (sleep paralysis)	.55*	0.2 (0.4)	0.9 (1.0)	1.7 (1.6)	47.9*

Comparison of item scores for three levels of PTSD severity
1. Dizziness	.67*	0.8 (1.0)	1.9 (1.2)	3.0 (1.3)	70.3*
2. Standing up and feeling dizzy	.71*	0.7 (0.9)	1.7 (1.1)	2.9 (1.1)	91.2*
3. Blurry vision	.63*	0.9 (1.1)	2.0 (1.2)	2.9 (1.2)	63.7*
4. Tinnitus	.60*	0.6 (1.0)	1.6 (1.2)	2.5 (1.4)	52.9*
5. Headache	.61*	1.0 (1.2)	2.1 (1.2)	2.9 (1.2)	50.7*
6. Neck soreness	.62*	0.8 (1.0)	1.9 (1.1)	2.6 (1.4)	53.1*
7. Palpitations	.55*	0.9 (1.2)	1.8 (1.3)	2.6 (1.3)	38.0*
8. Shortness of breath	.61*	0.6 (0.8)	1.4 (1.3)	2.5 (1.4)	54.8*
9. Chest tightness	.53*	0.5 (0.9)	1.0 (1.1)	2.0 (2.4)	34.2*
10. Rising sputum	.40*	0.5 (1.0)	0.9 (1.0)	1.6 (1.6)	8.2*
11. Stomach bloating/discomfort	.34*	1.0 (1.1)	1.2 (1.3)	1.8 (1.5)	28.5*
12. Cold hands and feet	.45*	0.7 (1.0)	1.3 (1.2)	2.2 (1.5)	22.6*
13. Numbness in the arms and feet	.43*	0.9 (1.2)	1.1 (1.3)	2.2 (1.4)	28.5*
14. Sore arms and legs	.61*	1.1 (1.2)	2.2 (1.2)	2.9 (1.2)	46.7*
15. Trembling of the arms and legs	.65*	0.5 (0.8)	1.2 (1.1)	2.3 (1.3)	60.5*
16. Weakness	.62*	1.0 (1.2)	2.0 (1.1)	2.8 (1.2)	52.8*
17. Poor appetite	.56*	0.5 (0.8)	1.5 (1.1)	2.2 (1.5)	44.2*
18. Feeling of lightness in the body	.55*	0.5 (1.0)	1.1 (1.2)	2.0 (1.4)	35.1*

Footnotes

Funding

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

Notes

Devon E. Hinton, MD, PhD, is an anthropologist and psychiatrist, and is Associate Professor of Psychiatry at Harvard Medical School. His work has focused on culturally specific presentation of anxiety disorders and culturally sensitive treatment of PTSD. He is the coeditor, with Byron Good, of the volumes Culture and Panic Disorder (Stanford University Press, 2009) and Culture and PTSD (Cornell University Press, in press), as well as of a treatment manual for providing culturally sensitive CBT (Oxford University Press, in press). He is on the American Psychological Association panel to determine PTSD treatment guidelines. Address: Massachusetts General Hospital, Center for Anxiety and Traumatic Stress Disorders, One Bowdoin Square, 6th Floor, Boston, MA 02114, USA. Email: devon_hinton@hms.harvard.edu

M. Alexandra Kredlow, BA, is a doctoral student in Clinical Psychology at Boston University. She is currently a member of the Translational Research Program and is researching treatments for mood and anxiety disorders. She received her Bachelors of Arts degree from Stanford University in 2004. Subsequently, she completed a two-year position with the Center for Anxiety and Traumatic Stress Disorders and Complicated Grief Program at the Massachusetts General Hospital.

Vuth Pich, MSW, was born in Cambodia and survived the Khmer Rouge period. In the United States, he has worked to develop mental health services for the Cambodian population in Lowell, MA. He works at Arbour Counseling Services and also for the Massachusetts Department of Mental Health.

Eric Bui, MD, PhD, is a psychiatrist and a researcher. He received his MD from Toulouse University, France, and completed a PhD in Neurosciences at the Université Paul Sabatier, Toulouse, France. He is currently an Instructor at the Massachusetts General Hospital and Harvard Medical School and to date has published over 60 scientific papers or book chapters on trauma, anxiety, and related conditions.

Stefan G. Hofmann, PhD, is Professor of Psychology at the Department of Psychology at Boston University where he directs the Psychotherapy and Emotion Research Laboratory. His main research focuses on the mechanism of treatment change, translating discoveries from neuroscience into clinical applications, emotion regulation strategies, and cultural expressions of psychopathology, such as social anxiety disorder. He has more than 200 scientific publications and 15 books. He is the president of the Association of Behavioral and Cognitive Therapies, Editor of Cognitive Therapy and Research, and Associate Editor of Journal of Consulting and Clinical Psychology. He is the recipient of the 2012 Award for Excellence in Contributions to CBT, Aaron T. Beck Institute for Cognitive Studies at Assumption College.

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Comparison of scale scores for three levels of PTSD severity
CSSI scale	Correlation with PTSD score	No PTSD (n = 102) M (SD)	Moderate PTSD (n = 56) M (SD)	Severe PTSD (n = 68) M (SD)	F(2, 23)†
CSSI total score	.67*	0.6 (0.6)	1.5 (0.6)	2.4 (0.7)	163.5*
CSSI somatic scale	.71*	0.8 (0.5)	1.6 (0.6)	2.5 (0.7)	133.5*
CSSI syndrome scale	.63*	0.6 (0.5)	1.4 (0.6)	2.3 (0.8)	158.8*

Comparison of the item score for three levels of PTSD severity
Type of syndrome and syndrome item	Correlation with PTSD score	No PTSD (n = 102) M (SD)	Moderate PTSD (n = 56) M (SD)	Severe PTSD (n = 68) M (SD)	F(2, 23)†
Somatic-focused syndromes
1. Khyâl attacks	.59*	0.8 (1.0)	1.7 (1.1)	2.6 (1.4)	43.1*
2. Standing up and feeling poorly to the point you feared fainting, khyâl overload, or heart attack	.76*	0.5 (0.8)	1.7 (1.3)	3.0 (1.1)	132.5*
3. Neck soreness to the point you feared the neck vessels would burst	.65*	0.5 (0.9)	1.7 (1.3)	2.5 (1.5)	55.8*
4. “Heart weakness”	.64*	0.6 (0.9)	1.7 (1.3)	2.5 (1.4)	54.8*
5. Sputum moving upward and causing you to feel you couldn’t breathe or might have heart arrest	.48*	0.2 (0.6)	0.6 (1.0)	1.5 (1.6)	30.4*
6. Khyâl hitting up from your stomach, making you fear you might die of asphyxia	.43*	0.5 (1.0)	0.9 (1.1)	1.7 (1.6)	20.5*
7. Fear of “death of the hands, death of the arms”(slap day slap ceung)	.57*	0.7 (1.2)	1.9 (1.3)	2.5 (1.5)	41.5*
8. Excessive “inner hotness” (kdaw khnong)	.44*	0.6 (0.9)	1.2 (1.2)	1.8 (1.4)	19.3*
9. Having a partial or full malaria attack	.50*	0.2 (0.6)	0.7 (1.1)	1.6 (1.5)	32.1*
10. Out of energy to the point you feared having a khyâl attack or dying from depletion	.63*	0.7 (1.0)	1.7 (1.2)	2.6 (1.3)	52.8*
Agoraphobia/motion-sickness syndromes
11. “Poisoned by cars” (pul laan)	.39*	0.5 (1.0)	0.7 (1.2)	1.6 (1.5)	15.4*
12. “Poisoned by people” (pul meunuh)	.49*	0.6 (1.1)	1.3 (1.2)	2.4 (1.6)	36.4*
Emotion-focused syndrome
13. “Thinking too much”	.78*	0.5 (1.0)	2.6 (1.0)	3.6 (0.8)	125.3*
14. Toxique	.34*	1.0 (1.1)	1.2 (1.3)	1.7 (1.8)	27.4*
Cognitive-capacity syndrome
15. Forgetfulness/mental distraction (phluc) phleang)	.61*	1.0 (1.2)	2.1 (1.2)	2.9 (1.2)	50.7*
Spiritual-type syndromes
16. Light in the body as if your soul was not in your body	.63*	0.6 (1.0)	1.3 (1.2)	2.6 (1.2)	65.4*
17. Fear that someone has sent an ampuu into your body	.40*	0.5 (1.0)	0.9 (1.0)	1.6 (1.6)	8.6*
18. Fear of having low spiritual luck (rieusuy), high bad luck (krueh)	.45*	0.7 (1.0)	1.5 (1.2)	2.3 (1.5)	22.6*
19. “Ghost pushing you down” (sleep paralysis)	.55*	0.2 (0.4)	0.9 (1.0)	1.7 (1.6)	47.9*

Comparison of item scores for three levels of PTSD severity
Somatic symptom item	Correlation with PTSD score	No PTSD (n = 102) M (SD)	Moderate PTSD (n = 56) M (SD)	Severe PTSD (n = 68) M (SD)	F(2, 23)†
1. Dizziness	.67*	0.8 (1.0)	1.9 (1.2)	3.0 (1.3)	70.3*
2. Standing up and feeling dizzy	.71*	0.7 (0.9)	1.7 (1.1)	2.9 (1.1)	91.2*
3. Blurry vision	.63*	0.9 (1.1)	2.0 (1.2)	2.9 (1.2)	63.7*
4. Tinnitus	.60*	0.6 (1.0)	1.6 (1.2)	2.5 (1.4)	52.9*
5. Headache	.61*	1.0 (1.2)	2.1 (1.2)	2.9 (1.2)	50.7*
6. Neck soreness	.62*	0.8 (1.0)	1.9 (1.1)	2.6 (1.4)	53.1*
7. Palpitations	.55*	0.9 (1.2)	1.8 (1.3)	2.6 (1.3)	38.0*
8. Shortness of breath	.61*	0.6 (0.8)	1.4 (1.3)	2.5 (1.4)	54.8*
9. Chest tightness	.53*	0.5 (0.9)	1.0 (1.1)	2.0 (2.4)	34.2*
10. Rising sputum	.40*	0.5 (1.0)	0.9 (1.0)	1.6 (1.6)	8.2*
11. Stomach bloating/discomfort	.34*	1.0 (1.1)	1.2 (1.3)	1.8 (1.5)	28.5*
12. Cold hands and feet	.45*	0.7 (1.0)	1.3 (1.2)	2.2 (1.5)	22.6*
13. Numbness in the arms and feet	.43*	0.9 (1.2)	1.1 (1.3)	2.2 (1.4)	28.5*
14. Sore arms and legs	.61*	1.1 (1.2)	2.2 (1.2)	2.9 (1.2)	46.7*
15. Trembling of the arms and legs	.65*	0.5 (0.8)	1.2 (1.1)	2.3 (1.3)	60.5*
16. Weakness	.62*	1.0 (1.2)	2.0 (1.1)	2.8 (1.2)	52.8*
17. Poor appetite	.56*	0.5 (0.8)	1.5 (1.1)	2.2 (1.5)	44.2*
18. Feeling of lightness in the body	.55*	0.5 (1.0)	1.1 (1.2)	2.0 (1.4)	35.1*