Culturally Sensitive Assessment of Anxious-Depressive Distress in Vietnam: Avoiding Category Truncation

Abstract

The present study investigated what complaints are prominent in psychologically distressed Vietnamese in Vietnam beyond standard symptoms assessed by Western diagnostic instruments for anxiety and depression. To form the initial Vietnamese Symptom and Cultural Syndrome Addendum (VN SSA), we reviewed the literature, consulted experts, and conducted focus groups. The preliminary VN SSA was then used in a general survey (N = 1004) of five provinces in Vietnam. We found that the VN SSA items were highly and significantly correlated with a measure of anxious-depressive psychopathology (a composite measure of the General Anxiety Disorder-7; Posttraumatic Diagnostic Scale; and Patient Health Questionnaire-9). The VN SSA item most highly correlated to anxious-depressive psychopathology was “thinking a lot” (r = .54), reported by 15.8% of the sample. Many other symptoms in the addendum also were prominent, such as orthostatic dizziness (i.e., dizziness upon standing up; r = .41), reported by 22.9% of the sample. By way of comparison, somatic complaints more typically assessed to profile Western anxious-depressive distress, such as palpitations, were less prominent, as evidenced by being less strongly correlated to Western psychiatric symptoms and being less frequent (e.g., palpitations: r = .31, 7.1% of the sample). Study results suggest that to avoid category truncation when profiling anxious-depressive distress among Vietnamese that items other than those in standard psychopathology measures should also be assessed.

Keywords

Vietnam anxiety depression idioms of distress cultural sensitive assessment

It is increasingly evident that measures of psychopathology, such as standard measures of trauma-related disorder, general anxiety, and depression, are just the tip of the iceberg in respect to those domains of distress. Patients often will report multiple other distress complaints if asked. In particular, it has been found that in many cultural groups somatic symptoms and “cultural syndromes” are a key part of the distress experience, a key aspect of the psychopathology ontology (Hinton & Lewis-Fernández, 2010). Not assessing these somatic symptoms and cultural syndromes results in category truncation, a lack of content validity, because assessing only Western-based anxious-depressive distress with standard measures of anxious-depressive psychopathology excludes such other key complaints (Hinton & Good, 2016a; Hinton & Lewis-Fernández, 2011; Murphy et al., 2015).

Looking beyond standard Western complaints to include key idioms of distress such as somatic symptoms and cultural syndromes when designing assessments, treatments, and public health interventions can help accomplish the following tasks, which might be called “dimensions of clinical utility of idioms of distress” (Hinton & Good, 2016a; Hinton & Lewis-Fernández, 2010):
Increase the number of persons seeking treatment for psychological disorders and willing to participate in treatment when it is stated that the treatment addresses the symptoms and syndromes that they experience (e.g., through public health campaigns);

Increase adherence to treatment by determining the symptoms and syndromes that most concern patients and making them part of assessment and treatment;

Increase the therapeutic alliance and empathic rapport;

Identify key treatment targets;

Increase treatment efficacy by determining culturally specific catastrophic cognitions about anxiety- and depression-related symptoms;

Identify the presence of key psychopathology networks, namely, the presence of causal networks of which the complaint is a key component (e.g., the idiom of distress as “causal network” indicator);

Serve as a key psychopathology and distress indicator (e.g., an indicator of having PTSD or other types of psychopathology);

Provide a non-stigmatizing framing of distress;

Allow the framing of the treatment in terms of the problems of concern to the patient;

Increase positive expectancy for successful outcome by framing the treatment in terms of the patient’s key concerns;

Increase therapist and intervention credibility; and

Measure treatment progress in a culturally sensitive way.

Our group has advocated for assessing key local idioms of distress through addendums—what we refer to as “Symptom and Syndrome Addendums,” or SSAs—to achieve these aims, and we have demonstrated aspects of clinical utility. For example, we created an SSA for persons of Cambodian origin, and we have shown how these idioms of distress improve over treatment (Hinton, Kredlow, Bui, Pollack, & Hofmann, 2012), are a key part of psychopathology such as trauma-related disorder (Hinton, Hinton, & Eng, 2015; Hinton, Kredlow, Pich, Bui, & Hofmann, 2013), form key hubs of causal networks (Hinton & Good, 2016a), and are important to address in Cognitive Behavioral Therapy (CBT) to modify catastrophic cognitions and to increase credibility and positive expectancy (Hinton, Rivera, Hofmann, Barlow, & Otto, 2012).

The goal of the current study was to develop a preliminary version of a Vietnamese SSA, and in particular to identify symptoms and syndromes not standardly assessed that have clinical importance in this population. An earlier study tried to identify items best suited to assess depression in a Vietnamese population, producing the Vietnamese Depression Scale, which consists of standard Western depression items but also includes certain somatic items such as headache (Dinh, Yamada, & Yee, 2009; Kinzie et al., 1982). A second, pioneering study tried to determine key symptoms among Vietnamese populations, creating the Phan Psychiatric Scale (Phan, Steel, & Silove, 2004). The purpose of that study was to assess anxiety, depression, and somatic symptoms in a culturally sensitive way, and to devise a scale for each. Although most of the Phan Scale symptoms are standard Western complaints, it included additional items such as several emphasizing “energy” (see below). The purpose of the present study is to further ascertain among a Vietnamese population those symptoms that should be assessed in addition to standard measures of psychopathology, a supplement approach, with an emphasis on somatic symptoms, given their prominence in non-Western populations during states of distress (Hinton & Lewis-Fernandez, 2011), and on cultural syndromes. For example, neither the Phan Psychiatric Scale nor the Vietnamese Depression Scale assess “thinking a lot,” which is a key idiom of distress among Vietnamese populations (Tran, 2017), nor do the scales assess “dizziness upon standing,” a key somatic complaint, nor “hit by a wind,” another important syndrome (Hinton et al., 2006, 2007; Hinton, Hinton, Pham, Chau, & Tran, 2003b; Hinton, Nguyen, & Pollack, 2007).

The first part of the current article describes how the symptom complaints for the preliminary Vietnamese Symptom and Syndrome Addendum (VN SSA) were identified (e.g., through literature review, clinical experience, and focus groups) and discusses the meaning of those complaints in the Vietnamese context. The second part describes the results of analyses with a large general population survey in Vietnam that utilized the addendum and standard measures of anxious-depressive distress in order to determine the correlation of the degree of being bothered by the preliminary SSA items to a composite measure of anxious-depressive distress. The survey also aimed to ascertain the rate of each VN SSA complaint in the sample.

Identifying Potential SSA Items and Their Meaning

Based on a review of the literature (Groleau & Kirmayer, 2004; Gustafsson, 2009; Hinton et al., 2001; Hinton, Hinton, Pham, Chau, & Tran, 2003a; Kinzie et al., 1982; Phan et al., 2004; Tran, 2017), the clinical experience of the authors in treating anxiety and depression symptoms in the Vietnamese population, and discussions with a Vietnamese psychiatrist on the research team, an initial list of potential symptoms and syndromes was generated. Next, two focus groups were held in Vietnam.

The focus groups were both led by a Vietnam-based U.S. clinical psychologist and a Vietnamese clinical psychologist fluent in English. The purpose of the focus groups was to gather information about how psycho-emotional distress impacts people in Vietnam, how people talk about their distress, the nature of typical distress complaints, and what meaning people give to their psycho-emotional complaints. In each focus group, participants engaged in an open, semi-structured discussion of these topics. Participants were then asked to evaluate items from the initial list of potential symptoms and syndromes for relevance in Vietnam, and to consider additional items for inclusion in the VN SSA. The first focus group was held in Hanoi, and had eight participants from a variety of fields including psychiatry, psychology, and education, many working with trauma (e.g., with veterans, victims of human trafficking, people impacted by natural disasters). The second focus group took place at the Da Nang Psychiatric Hospital in central Vietnam. This group included adult patients from the hospital who were experiencing a range of mental health problems, including depression, anxiety, and trauma-related difficulties, but excluding patients with psychosis and serious cognitive impairment.

Based on the suggestions derived from the focus groups, a draft version of the VN SSA was then piloted with community members in Da Nang. Following the pilot feedback, the VN SSA was again revised. The final VN SSA items are shown in Table 1, categorized into symptoms and syndromes. Below we first discuss the VN SSA symptoms, then the syndromes, detailing the meaning of the items and the reasons for their salience in the Vietnamese context. We also discuss related VDS and Phan scale items.
Table 1.
The preliminary Vietnamese Symptom and Syndrome Addendum (V SSA)

Symptoms

Cognitive complaint Forgetful, easily distracted

Somatic complaints Faintness or dizziness

Standing up and feeling dizzy

Headache

Blurry vision

Ringing in the ears

Neck or shoulder soreness

Shortness of breath

Heart palpitations

Pain in the heart or chest pain

Nausea or abdominal discomfort

Stomach pain

Poor appetite

Feeling weak in parts of the body

Tingling or stinging sensations in parts of the body

Arms and legs trembling

Numbness of the arms and feet

Cold hands and feet

Body shaking and feeling cold inside

Sudden coldness in the body and goosebumps on skin

Experience a sudden temperature change

Feel hot or cold

Excessive inner hotness like a fire inside

Sore arms and legs

Feeling of lightness in the body, like floating out of the body a little

Sleep-focused When going to sleep or waking up, suddenly unable to speak or move

Cultural Syndromes

Cognitive-focused “Thinking a lot”

Somatic-focused Standing up and feeling poorly, fearing fainting or heart attack

Experience “hit by the wind”

Heart weakness

Weak kidneys or need to urinate frequently

Supernatural-focused Fear having low spiritual luck, high bad luck

Light in the body, as if your soul was not in your body

Feel or act like possessed or controlled by a ghost

Fear that someone has sent a ghost into your body

Symptoms assessed by the initial VN SSA

The symptoms assessed by the initial VN SSA were categorized into three types: cognitive complaints, somatic complaints, and sleep-related complaints (for all of the items, see Table 1).¹

Cognitive complaints

One of the VN SSA questions combines two cognitive complaints, asking about the degree of being bothered by being “forgetful, easily distracted.” Distractibility and poor memory are closely related for several reasons, including that a poor ability to pay attention to ongoing events leads to poor memory of them (e.g., where one put one’s keys). This VN SSA item is similar to a complaint found among traumatized Cambodian populations (Hinton, Reis, & de Jong, 2016). (The Phan scale has two similar items, viz., “forgetful or absent minded” and “Did you feel absent-minded or were not able to remember what you have just done.”)

Somatic complaints

The VN SSA includes headache, ringing in the ears, and neck soreness, which are symptoms often generated by arousal. In addition to arousal, catastrophic cognitions play an important role in increasing the salience of these somatic complaints: Vietnamese fear that a headache indicates that cerebral nerve fibers are about to break, with headaches not uncommonly giving rise to panic attacks (Hinton et al., 2001). (The Phan scale has headache and tinnitus as items, and the Vietnamese Depression Scale has headache.)

Two VN SSA items assess dizziness. In Vietnamese populations, a prominent complaint is not only dizziness in a general sense but also more specifically dizziness upon standing up from a sitting or lying position (Hinton et al., 2004; Hinton, Hinton, et al., 2007). Among Vietnamese populations, orthostatic dizziness is seemingly generated both by catastrophic cognitions, for example, fear that a surge of blood pressure may occur on standing, and by the actual biology of orthostasis, namely, by anxiety and depression effects on the vagal system and hence on orthostatic adjustment, with certain Asian populations seemingly predisposed to orthostatic dysregulation (Hinton et al., 2010).

As “energy” is a key construct in the Vietnamese conceptualization of well-being (Groleau & Kirmayer, 2004; Hinton, Nguyen, Tran, & Quinn, 2005; Hinton, Sinclair, Chung, & Pollack, 2007; Phan & Silove, 1997; Tran, 2017), several symptoms related to energy are assessed in the preliminary SSA. The syndrome section also highlights several syndromes that focus on energy concerns (see below). Appetite is one such energy-related somatic item and a frequent source of concern, conceptualized by many Vietnamese as a key maintainer of energy by promoting intake (degree of appetite is also considered a key indicator of health in itself).² The item “feeling of weakness in parts of the body” is another example of the Vietnamese emphasis on the key role of bodily energy in health. (The Phan scale has multiple items that assess energy: “Do you feel slow or sluggish?”; “Did you feel fatigued after plenty of sleep?”; “Did you feel you had symptoms of a heart problem as if you were losing energy without any obvious reason?”; “Did you feel worn out or low in energy?”; “Did you feel low in energy?”; and “Did you feel increasingly tired day after day as if you had no energy to function?.” The Vietnamese Depression Scale also assesses several energy-related items such as “appetite,” “exhausted,” and “low-spirited.”)

Several somatic items in the preliminary VN SSA concern temperature regulation in the body. Of note, anxiety and anger often result in a shift of bodily temperature such as anxiety giving rise to cold extremities, and anger to heat in the face. In the Vietnamese case, temperature regulation is understood in terms of the flow of Chi in the body, of the balance of Yin and Yang (the traditional Chinese life energy forces) in the body, and of bodily energy, so that bodily temperature shifts may give rise to fears. Coldness in turn is understood as indicating a dangerous energy depletion or the deadly penetration of “wind” into the body (Hinton et al., 2003; Hinton, Nguyen, et al., 2005; Phan et al., 2004).

Another VN SSA item assesses feeling of lightness in the body. Bodily lightness may result in fear of soul loss (cf. to such feelings of bodily strangeness giving rise to a sense of dissociation in Western populations; Hinton & Good, 2009). In addition, “lightness” may be attributed to low energy because it is thought that low energy makes the soul easily displaced from the body: low energy → easily displaced soul → displaced soul.³

Sleep-focused complaint

The VN SSA also assesses one sleep-related complaint, namely, sleep paralysis. Sleep paralysis consists in the person being unable to move or speak either upon falling asleep or upon awakening, and there is usually a feeling of chest tightness and of shortness of breath. During sleep paralysis, the person not unusually sees a shadowy form approach the body, which may be considered to be a particular being. Sleep paralysis has been shown to be highly associated with psychopathology and to be especially common in certain groups (Hinton, Pich, Chhean, & Pollack, 2005; Hinton, Pich, Chhean, Pollack, & McNally, 2005).

Syndromes assessed by the Initial VN SSA

Below we discuss the syndromes assessed by the Initial VN SSI, divided into three types: cognitive-focused, somatic-focused, and supernatural-focused (for all the items, see Table 1).

Cognitive-focused cultural syndrome

The VN SSA assesses “thinking a lot.” “Thinking a lot” is a key complaint found in many cultural groups, which typically refers to ruminating in the broad sense, ranging from worry, to repetitively thinking about a depressive topic (e.g., self-blame, past failures, lost hopes), to recalling trauma memories (Hinton et al., 2016; Kaiser et al., 2015). Particular episodes of “thinking a lot” may focus on one or more of these types of thoughts: “Thinking a lot” often induces symptoms like headache and anxiety, and gives rise to catastrophic cognitions—for example, among Vietnamese, that “thinking too much” will “rupture brain fibers” and permanently disturb memory (Hinton et al., 2001)—and may trigger trauma recall. “Thinking a lot” is often a key part of a worry-initiated cyclical causal sequence as is shown in Figure 1.⁴ Thus “thinking a lot” indicates the presence of a causal sequence that centers on the presence of repeated dysphoric thinking about an upsetting topic such as finances, a missed loved one, a trauma, or self-blame.
Figure 1.
The “thinking a lot” causal sequence: The example of worry

Somatic-focused cultural syndromes

Several somatic-focused syndromes are profiled, one of which is an orthostatic syndrome, assessing for fear that standing up will provoke syncope or heart attack (of note, the somatic section of the preliminary VN SSA assesses “dizziness on standing”). Several other items in the section assess energy-related syndromes. For example, Vietnamese are concerned that weakness of the heart may lead to orthostatic dizziness, startle, and heart arrest, and that weakness of the kidneys may lead to loss of vital substance in the urine that will profoundly and dangerously deplete the bodily energy supplies (Hinton, Nguyen, et al., 2005). (The Phan scale also has a weak kidney item.) Another “energy” syndrome is “hit by the wind.” Vietnamese are concerned that when weak, the pores of the body may open and thus allow certain exterior winds to enter the body, thereby causing disorder. It is not uncommon for this fear of being “hit by the wind” to cause panic (Hinton et al., 2003).

Supernatural-focused syndrome

Several VN SSA items assess supernatural fears. Vietnamese sometimes attribute symptoms to spirit attack or other spiritual matters (Gustafsson, 2009; Kwon, 2008), as do many groups (Hinton & Good, 2016b). One item in the preliminary Vietnamese SSA is the fear of low spiritual luck. Vietnamese worry that low spiritual energy may result in multiple problems––being quick to anger, conflict with others, attack by spirits, and a general failure in all domains of life (low spiritual luck overlaps with the Buddhist idea of bad karma; Phan and Silove, 1999)––and Vietnamese use various means to determine their luck level and to redress it if necessary. Another syndrome is “feeling light as if the soul has left the body” (Hinton & Good, 2009). Two other items of the VN SSA are fear of possession and fear that someone has sent a ghost into one’s body (Gustafsson, 2009; Kwon, 2008).

Survey of Anxious-Depressive Psychopathology and the Preliminary Vietnamese SSA

As part of a major survey in Vietnam (N = 1004), the VN SSA was added as a culturally sensitive measure of distress. Below we summarize the setting, study populations, and procedures. For the results of the general study, see Pollack, Weiss, and Trung (2016).

Methods

Setting and study populations

The study focused on coastal central Vietnam, a largely rural region with a history of typhoons, floods, landsides, and other related natural disasters. From 2003 to 2012, eight typhoons, seven tropical storms, and seven tropical depressions impacted this broad area. People living in coastal central Vietnam are generally poor with low education levels. The median annual family income (which typically represents income from several adults) in this region is $1244 (compared to the national per capita GNI of $1550), and less than 40% of adults complete high school (Weiss et al., 2014). The purpose of the sampling frame was to obtain a representative sample of adults (individuals 18 years or older, excluding those with psychosis or serious cognitive impairment) living in areas of central coastal Vietnam under conditions of high stress due to frequent exposure to typhoons, tropical storms, and flooding. Five provinces covering the middle approximate 210 kilometers of coastline of central Vietnam were chosen. Within each province, two coastal village districts (an administrative unit of approximately 10,000 people) were selected from geographically separate areas, for a total of 10 data collection sites; and within each village district, adults were randomly selected for participation from public population lists. Participants ranged from 18 to 85 years of age with a median age of 42 years. Fifty-six percent were women, and 23% of those surveyed met caseness criteria for one or more psychiatric disorders based on the three measures of psychopathology.

Procedure

The project was conducted through the Da Nang Psychiatric Hospital (DNPH), the leading psychiatric hospital in central Vietnam, with the support of the provincial psychiatric hospitals in the four other provinces. Data collection for analyses reported here occurred in 2013–2014. Human subjects approval was obtained from the Da Nang Psychiatric Hospital U.S. FWA IRB (#00011251). Provincial psychiatric hospitals obtained support from the local Community Health Stations (CHS) in participating communities. CHS staff accompanied the data collector to participants’ homes, briefly introduced the project to potential participants, and left. The project data collector described the project in more detail, obtained informed consent from those interested in participating, and scheduled a time for the interview. Interviews lasted 1.5–2 hours and participants were given the option of breaking the assessment into two shorter periods. Participants were paid the equivalent of about U.S. $7.10 for the interview.

Measures

The culturally sensitive measure of distress was the preliminary VN SSA, consisting of 35 items, divided into symptoms and syndromes, which was developed as described above. For the items, see Table 1. The degree of being bothered in the last two weeks by each item was assessed on a 0–4 Likert-type scale, ranging from not bothered at all (0) to extremely bothered (4).

The standard Western symptom measures of anxiety-related symptoms used in the study were the Generalized Anxiety Disorder-7 (GAD-7, internal consistency in current survey, α = .90), which assesses general anxiety symptoms in the last two weeks, rated on a 0–3 Likert-type scale (“not at all” to “nearly every day”) (Lowe et al., 2008), and the Post-Traumatic Diagnostic Scale (PDS, α = .88), which assesses PTSD symptoms in the last month on a 0–4 Likert-type scale (“not at all” to “extremely”) (Powers, Gillihan, Rosenfield, Jerud, & Foa, 2012). The standard measure of depression was the Patient Health Questionnaire (PHQ-9, α = .87), which assesses depression symptoms in the last two weeks, rated on a 0–3 Likert-type scale (“not at all” to “nearly every day”) (Kroenke, Spitzer, & Williams, 2001). To form a general measure of anxious-depressive psychopathology, the three psychopathology measures (GAD, PDS, PHQ) were standardized and summed.

A U.S. clinical psychologist fluent in Vietnamese as well as a Vietnamese psychiatrist and a Vietnamese clinical psychologist both fluent in English translated the measures, and the translation was checked through independent back-translations and comparison to the original. Measures were then reviewed by teams from the five participating provincial psychiatric hospitals for appropriateness for Vietnamese participants, with translations adjusted based on their feedback.

Results

Table 2 shows the correlation of the items of the VN SSA to the joint measure of psychopathology, percentage of participants endorsing the item, and the mean degree of being bothered by those having the item.⁵
Table 2.
Correlation of the Vietnamese SSA items to anxious-depressive psychopathology, SSA item frequency in the entire sample (N = 1004), and mean score of those with the complaint

Complaint Correlation to anxious-depressive psychopathology % in the entire sample with that complaint Mean score (SD) of those with the complaint (0–4 Likert Scale)

1 Thinking a lot .54* 15.9% 1.4 (.8)

2 Faintness or dizziness .45* 24.8% 1.5 (.7)

3 Poor appetite .45* 15.8% 1.2 (.7)

4 Headache .44* 40.9% 1.5 (.8)

5 Feeling weak in parts of the body .44* 20.9% 1.6 (.8)

6 Standing up and feeling poorly, fearing faint- ing or heart attack .43* 11.3% 1.4 (.7)

7 Forgetful, easily distracted .42* 7.5% 1.3 (.8)

8 Standing up and feeling dizzy .41* 22.9% 1.5 (.7)

9 Shortness of breath .38* 12.4% 1.5 (.8)

10 Fear of having low spiritual luck, high bad luck .37* 7.3% 1.3 (.8)

11 Sore arms and legs .33* 14.2% 1.6 (.8)

12 Numbness of the arms and feet .31* 23.2% 1.5 (.8)

13. Heart palpitations .31* 7.1% 1.4 (.7)

14 Tingling or stinging sensations in parts of the body .31* 16.4% 1.6 (.8)

15 Body shaking and feeling cold inside .31* 3.7% 1.3 (.8)

16 Sudden coldness in the body and goosebumps on skin .30* 3.6% 1.2 (.8)

17 Feeling of lightness in the body, like floating out of the body a little .29* 2.8% 1.3 (.8)

18 Weak kidneys or need to urinate frequently .29* 4.4% 1.5 (.9)

19 When going to sleep or waking up, suddenly unable to speak or move .29* 6.0% 1.3 (1.0)

20 Blurry vision .29* 13.4% 1.6 (.9)

21 Nausea or abdominal discomfort .29* 9.5% 1.5 (.8)

22 Cold hands and feet .29* 2.4% 1.3 (.4)

23 Pain in the heart or chest pain .28* 11.9% 1.6 (.8)

24 Experience “hit by the wind” .26* 3.4% 1.4 (.9)

25 Heart weakness .26* 5.5% 1.6 (.9)

26 Stomach pain .26* 19.5% 1.5 (.8)

27 Arms and legs trembling .26* 4.4% 1.5 (.7)

28 Ringing in the ears .25* 5.7% 1.3 (.7)

29 Light in the body, as if your soul was not in your body .25* 6.2% 1.3 (.8)

30 Neck or shoulder soreness .24* 11.7% 1.3 (.7)

31 Experience a sudden temperature change .24* 3.0% 1.2 (.9)

32 Feel hot or cold .21* 6.8% 1.3 (.7)

33 Excessive inner hotness like a fire inside .21* 2.9% 1.4 (.9)

34 Feel or act like possessed or controlled by a ghost .15* 0.8% 1.8 (1.1)

35 Fear that someone has sent a ghost into your body .15* 1.6% 1.2 (1.1)

p < .001

All VN SSA items were significantly correlated to the measure of anxious-depressive psychopathology at p < .001. “Thinking a lot” was the most highly correlated item (r = .54), and it was significantly more correlated to psychopathology than the next item, “faintness or dizziness” (r = .45), with a z score of 2.67 (p < .01). Items with a correlation to anxious-depressive distress similar to “faintness or dizziness” included “poor appetite,” “headache,” “feeling weak in parts of the body,” “standing up and feeling poorly, fearing fainting or heart attack,” “forgetful, easily distracted,” and “standing up and feeling dizzy.” The items least correlated to psychopathology were the ghost attack items.

The most frequently occurring symptom was headache, which was experienced in the last two weeks by 40.9% of those surveyed, followed by faintness or dizziness (24.8%), numbness (23.2%), and “standing up and feeling dizzy” (22.9%). The least frequent symptoms were two supernatural items: having a ghost sent into one (1.6%) or being possessed by a ghost (0.8%).

Of note, somatic symptoms often considered key indicators of distress among Western populations, such as heart palpitations, had lower correlations with the general psychopathology variable, and were less frequent. For instance, standing up and feeling dizziness had statistically larger correlations to psychopathology than did palpitations (r = .41 vs. r = .31, z = 2.57, p < .05) and was far more frequent (22.9% versus 7.1%).

Discussion

The current study illustrated that anxious-depressive psychopathological distress in a Vietnamese population is accompanied by multiple symptoms (often somatic) and syndromes not typically assessed, and that these symptoms and syndromes form a key part of that distress ontology. We found that such items as “thinking too much” and orthostatic dizziness were core areas of distress, as much or more so than such typically assessed somatic complaints as palpitations. Not assessing these key complaints is to commit the error of category truncation when profiling anxious-depressive distress in a Vietnamese context.

“Thinking a lot” was the item most highly correlated to general psychopathology (r = .54) and the correlation was statistically higher than the next item. A recent survey indicated the central importance of this complaint in global perspective (Kaiser et al., 2015), and recent articles have described why it is such an important complaint to assess (Hinton et al., 2016; Hinton, Reis, & de Jong, 2015; Yarris, 2011, 2014). The prominence of “thinking a lot” suggests that it should be a key item to assess, and to target and track in treatment. Future studies among Vietnamese populations should identify what the exact content of “thinking a lot” is, what symptoms “thinking a lot” usually induces, whether “thinking a lot” often brings about catastrophic cognitions and trauma recall, and how the problem of “thinking a lot” is typically treated. For example, in the Cambodian group, this excessive cognizing syndrome is at the hub of a network of psychopathology (Hinton et al., 2016; Hinton, Reis, et al., 2015): “thinking a lot” is primarily about current life concerns; results in multiple somatic symptoms (e.g., headache [often migraine in type], blurry vision, and palpitations), insomnia, forgetfulness, and anger; gives rise to catastrophic cognitions; triggers negative memories; and is treated by various traditional healing techniques such as meditation, the seemingly opposite state to that of “thinking too much.”

“Dizziness and feeling faint” was a key complaint, with a high correlation (r = .45) to psychopathology and with a high frequency (24.8%). Multiple studies have noted the prominence of dizziness in certain Asian populations, and have hypothesized as to the reasons (Hinton, Hinton, et al., 2015; Kleinman & Kleinman, 1994): metaphoric resonance to dizziness, biological predisposition to dizziness induction (e.g., as tested in paradigms involving an optokinetic drum), and the prominence of local cultural syndromes involving dizziness that give rise to hypervigilance to dizziness. In the present study, one seemingly key reason for dizziness prominence was the frequency of dizziness triggered by standing up. We found that dizziness on standing up was an extremely common complaint, reported by 22.9% of those surveyed, and highly correlated to psychopathology (r = .41). The complaint of “standing up and feeling poorly, fearing fainting or heart attack” was also relatively common (11.3%), and was highly correlated to anxious-depressive psychopathology (r = .43). Multiple studies have also shown dizziness upon standing up, that is, orthostasis-caused dizziness, to be a key complaint in Cambodian populations as indicated by its being highly related to psychopathology and being part of key causal sequences (Hinton et al., 2010; Hinton, Hofmann, Pollack, & Otto, 2009). Those studies reveal how orthostasis-caused dizziness results from the complex interaction of the biology of orthostasis (with possible ethnic differences in the orthostatic response), catastrophic cognitions about dizziness, memory associations to dizziness, and metaphors of dizziness. Studies of orthostatic dizziness among Vietnamese populations have also suggested the link to psychopathology and the presence of these causal sequences (Hinton et al., 2004; Hinton, Hinton, et al., 2007).

Headache also was highly correlated to psychopathology (r = .44) and extremely common (40.9%). This finding highlights the need to investigate this complaint in more detail. (The item is also in the Phan and the Vietnamese Depression scale, as noted above.) Recent studies have found migraine headache to be common in certain cultural groups and that “thinking a lot” is a common cause of that headache (Hinton et al., 2016; Yarris, 2011, 2014), and one study found that the migraine headache commonly causes visual aura and blurry vision (Hinton et al., 2016). One Phan scale item assesses “seeing flashing lights,” which may well be endorsed in many cases owing to visual aura associated with migraine. (Of note, blurry vision was correlated to psychopathology in the current study.)

Several items related to energy level are in the preliminary Vietnamese SSA. Feeling of weakness in the body was found in 20.9% of those surveyed, and was highly correlated to psychopathology (r = .44), and what Vietnamese consider to be a key replenisher of energy, namely, appetite, was common and highly related to psychopathology (r = .45). Other weakness-related items that were relatively common and significantly correlated to psychopathology were fear of being “hit by the wind,” weak kidney, and weak heart as well as items that assess a sense of bodily cold and those that assess orthostatic dizziness, with degree of dizziness on standing locally conceived as a test of bodily energy. The clustering of these weakness items and how sufferers treat those symptoms need further investigation. The various weakness items seem to fall under the rubric of energy concerns, and form a local “energy causal network,” a local ethnophysiology of energy, a local ethnopsychology emphasizing energy (Hinton, Sinclair, et al., 2007; Phan & Silove, 1997; Tran, 2017).

The rate of sleep paralysis was relatively elevated, with 6% of those surveyed having experienced it in the last two weeks. In general populations in the West, the lifetime* prevalence is approximately 7.6%, and most often the event occurs once in a lifetime or only every few years (Sharpless, 2016; Sharpless & Barber, 2011). In the Vietnamese population, further study of sleep paralysis is needed, including the rate of hallucinations during the sleep paralysis, what is hallucinated, and the cultural meanings of these events. Associated fears need to be addressed in treatments for anxiety (Hinton, Pich, Chhean, Pollack, et al., 2005).

Of the three supernatural concerns items, only being bothered by “bad luck, low good luck” was highly correlated to psychopathology (r = .37), and it was relatively common, found in 7.3% of those surveyed. Those with this concern would most likely worry that physical weakness may indicate spiritual depletion, that nightmares may be a spiritual assault, that bodily pain may be a spirit attack stigmata, and that all action will result in failure. The help-seeking of those with this “bad luck” complaint needs to be investigated. Only 1.6% of those surveyed had been bothered in the last two weeks with concerns of a spirit being sent into the body, and only 0.8% of being possessed or controlled. Of note, this low rate likely contributed at least in part to lower levels of correlation to psychopathology, but the presence of these complaints indicates considerable psychopathology. Many authors have written on how Vietnamese may interpret nightmare and physical symptoms in terms of visitation and even possession by spirits (Gustafsson, 2009; Kwon, 2014). In assessment, screening questions about concerns regarding spirit attack and possession should be standard procedure.

Limitations and Directions for Future Research

It will be important for future studies to examine the local meanings of the complaints identified in the current study in more detail, including assessing semantic networks related to these complaints as well as help-seeking. As noted above, somatic symptoms may result from a combination of metaphoric associations, catastrophic cognitions, and memory associations that interact in a looping manner in causal sequences (Hinton & Good, 2016a; Hinton, Hinton, Eng, & Choung, 2012; Hinton, Hinton, Loeum, & Pollack, 2008; Hinton & Simons, 2015). The complaint of “thinking a lot” can be examined in terms of causal sequence and local treatments by using the “Thinking a Lot” questionnaire (Hinton et al., 2016; Hinton, Reis, et al., 2015). In these and other various ways, the causal networks related to the SSA complaints should be profiled, a key part of designing culturally sensitive and effective interventions (Hinton, Rivera, et al., 2012).

Some other limitations and future directions should be noted. We assessed the degree of being bothered in a two-week timeframe but a four-week window may be optimal in some cases, particularly to assess events that are highly distressing but less common, such as sleep paralysis. Furthermore, certain items might be added to a future SSA. In particular, an item assessing the syndrome called “neurasthenia” (suy nhuoc thân kinh; also called “nerve weakness,” or suy yêu thân kinh) might be important to include, given that it was recently demonstrated to be an important syndrome in the Vietnamese context (Tran, 2017). Although we did include items assessing weakness and certain weakness syndromes, we did not include this specific item. As another possible addition, although we asked about possession and concerns about spiritual weakness, a more general probe might also be used, such as asking how much the person was bothered by ghosts.

Future studies should examine the relationship of individual items of the Vietnamese SSA as well as the SSA scale scores to specific DSM-5 disorders. For example, the “thinking a lot” item might be expected to be particularly strongly related to generalized anxiety disorder. Such investigations are a key part of an approach that is both “emic” and “etic.” That diagnosis-focused approach supplements the transdiagnostic approach taken in the current article that emphasizes the overlap between constructs such as anxiety and depression and hence assesses the higher order dimension that is dysphoria (Brown & Barlow, 2009; Hankin et al., 2016; Kim & Eaton, 2015).

Conclusion

The current study identified certain key complaints of distress among Vietnamese with anxious-depressive psychopathology. Key items that should be routinely assessed among Vietnamese populations include “thinking a lot,” dizziness, headache, orthostatic dizziness, and energy-related concerns like bodily weakness, poor appetite, and “hit by the wind.” These items should be assessed in order to avoid a category truncation in respect to assessing anxious-depressive psychopathology in the Vietnamese case, in order to attain content validity. But to assess items without ethnography and investigation of the local meaning of the items is an error of decontextualization (Hinton & Good, 2016a), a neglect of the local semiotics of these complaints, a neglect of local key causal networks—an assessment of the complaint without a determination of the associated semiotic and causal networks.⁶ To determine the Vietnamese ontology of distress, these complaints need to be further investigated in these ways. Through such research the Vietnamese Symptom and Syndrome Addendum (SSA) can be further developed and contextualized to inform assessment and treatment.

	Complaint	Correlation to anxious-depressive psychopathology	% in the entire sample with that complaint	Mean score (SD) of those with the complaint (0–4 Likert Scale)
1	Thinking a lot	.54*	15.9%	1.4 (.8)
2	Faintness or dizziness	.45*	24.8%	1.5 (.7)
3	Poor appetite	.45*	15.8%	1.2 (.7)
4	Headache	.44*	40.9%	1.5 (.8)
5	Feeling weak in parts of the body	.44*	20.9%	1.6 (.8)
6	Standing up and feeling poorly, fearing faint- ing or heart attack	.43*	11.3%	1.4 (.7)
7	Forgetful, easily distracted	.42*	7.5%	1.3 (.8)
8	Standing up and feeling dizzy	.41*	22.9%	1.5 (.7)
9	Shortness of breath	.38*	12.4%	1.5 (.8)
10	Fear of having low spiritual luck, high bad luck	.37*	7.3%	1.3 (.8)
11	Sore arms and legs	.33*	14.2%	1.6 (.8)
12	Numbness of the arms and feet	.31*	23.2%	1.5 (.8)
13.	Heart palpitations	.31*	7.1%	1.4 (.7)
14	Tingling or stinging sensations in parts of the body	.31*	16.4%	1.6 (.8)
15	Body shaking and feeling cold inside	.31*	3.7%	1.3 (.8)
16	Sudden coldness in the body and goosebumps on skin	.30*	3.6%	1.2 (.8)
17	Feeling of lightness in the body, like floating out of the body a little	.29*	2.8%	1.3 (.8)
18	Weak kidneys or need to urinate frequently	.29*	4.4%	1.5 (.9)
19	When going to sleep or waking up, suddenly unable to speak or move	.29*	6.0%	1.3 (1.0)
20	Blurry vision	.29*	13.4%	1.6 (.9)
21	Nausea or abdominal discomfort	.29*	9.5%	1.5 (.8)
22	Cold hands and feet	.29*	2.4%	1.3 (.4)
23	Pain in the heart or chest pain	.28*	11.9%	1.6 (.8)
24	Experience “hit by the wind”	.26*	3.4%	1.4 (.9)
25	Heart weakness	.26*	5.5%	1.6 (.9)
26	Stomach pain	.26*	19.5%	1.5 (.8)
27	Arms and legs trembling	.26*	4.4%	1.5 (.7)
28	Ringing in the ears	.25*	5.7%	1.3 (.7)
29	Light in the body, as if your soul was not in your body	.25*	6.2%	1.3 (.8)
30	Neck or shoulder soreness	.24*	11.7%	1.3 (.7)
31	Experience a sudden temperature change	.24*	3.0%	1.2 (.9)
32	Feel hot or cold	.21*	6.8%	1.3 (.7)
33	Excessive inner hotness like a fire inside	.21*	2.9%	1.4 (.9)
34	Feel or act like possessed or controlled by a ghost	.15*	0.8%	1.8 (1.1)
35	Fear that someone has sent a ghost into your body	.15*	1.6%	1.2 (1.1)

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Devon E. Hinton, MD, PhD., is an anthropologist and psychiatrist, and an Associate Clinical Professor of Psychiatry at Massachusetts General Hospital, Harvard Medical School, and the Department of Global Health and Social Medicine. He has researched culturally specific presentations of somatic symptoms, panic attacks, panic disorder, and PTSD among Southeast Asian populations, particularly Cambodian and Vietnamese refugees, and among Latino populations. He and his team have written extensively on treatment adaptation for these cultural groups, particularly traumatized refugees.

Amie Alley Pollack, PhD, is a Senior Research Associate, Department of Psychology and Human Development at Vanderbilt University and a Visiting Professor at Vietnam National University. Dr. Pollack researches mental health development in Vietnam, risk and resiliency in communities affected by natural disasters in Vietnam, and barriers to global health development. She is currently Principle Investigator of the Healthy Communities Typhoon Recovery Project and she provides training and technical assistance to a variety of programs focused on mental health development in Vietnam and Cambodia.

Bahr Weiss, PhD is Director of Clinical Training and Associate Professor of Psychology in the Department of Psychology and Human Development, Vanderbilt University, and a Visiting Foreign Professor at Vietnam National University-Hanoi. His research focuses on global mental health, and cultural influences on development, expression, and treatment of psychopathology. His global health work includes development of the first graduate program in clinical psychology in Vietnam, and a large scale, long-term monitoring survey in coastal Vietnam to assess the effects of increased typhoons in this region (as part of global climate change) on mental health. His cross-cultural work focuses on the influence of socio-cultural factors on adolescent psychopathology in Vietnam, Cambodia, and the U.S.

Lam T. Trung, MD, is the Director of the Da Nang Psychiatric Hospital, the third largest mental health facility in Vietnam, and an Adjunct Professor at the Da Nang Nursing College and the University of Da Nang. He is Vice-Director of the Vietnamese Psychiatric Association, and a member of the Vietnamese National Mental Health Committee. Dr. Trung’s research focuses on school-based and community mental health, and cultural adaptation of psychosocial mental health interventions for Vietnam. He has been the Vietnam PI on a number of major mental health research projects in Vietnam (e.g., D43 TW009089; R34 MH094648; R21 TW008435; R03 TW007923; D43 TW007769). He also is a practicing cognitive-behavioral psychotherapist, focusing on depression and other affect disorders.

References

Brown

T. A.

Barlow

D. H.

(2009) A proposal for a dimensional classification system based on the shared features of the DSM-IV anxiety and mood disorders: Implications for assessment and treatment. Psychological Assessment 21(3): 256–271.

Dinh

T. Q.

Yamada

A. M.

Yee

B. W.

(2009) A culturally relevant conceptualization of depression: An empirical examination of the factorial structure of the Vietnamese Depression Scale. International Journal of Social Psychiatry 55(6): 496–505.

Groleau

Kirmayer

L. J.

(2004) Sociosomatic theory in Vietnamese immigrants’ narratives of distress. Anthropology & Medicine 11: 117–133.

Gustafsson

M. L.

(2009) War and shadows: The haunting of Vietnam, Ithaca: Cornell University Press.

Hankin

B. L.

Snyder

H. R.

Gulley

L. D.

Schweizer

T. H.

Bijttebier

Nelis

et al. (2016) Understanding comorbidity among internalizing problems: Integrating latent structural models of psychopathology and risk mechanisms. Developmental Psychopathology 28: 987–1012.

Hinton

D. E.

Chau

Nguyen

Pham

Quinn

et al. (2001) Panic disorder among Vietnamese refugees attending a psychiatric clinic: Prevalence and subtypes. General Hospital Psychiatry 23: 337–344.

Hinton

D. E.

Good

B. J.

(2009) Culture and panic disorder, Palo Alto: Stanford University Press.

Hinton

D. E.

Good

B. J.

(2016a) The culturally sensitive assessment of trauma: Eleven analytic perspectives, a typology of errors, and the multiplex models of distress generation. In: Hinton

D. E.

Good

B. J.

(eds) Culture and PTSD: Trauma in historical and global perspective, Pennsylvania: University of Pennsylvania Press, pp. 50–113.

Hinton

D. E.

Good

B. J.

(2016b) Culture and PTSD: Trauma in historical and global perspective, Pennsylvania: University of Pennsylvania Press.

10.

Hinton

D. E.

Hinton

A. L.

Eng

K.-T.

Choung

(2012) PTSD and key somatic complaints and cultural syndromes among rural Cambodians: The results of a needs assessment survey. Medical Anthropology Quarterly 29: 147–154.

11.

Hinton

D. E.

Hinton

A. L.

Eng

K. T.

(2015) Key idioms of distress and PTSD among rural Cambodians: The results of a needs assessment survey. In: Hinton

D. E.

Hinton

A. L.

(eds) Genocide and mass violence: Memory, symptom, and recovery, Cambridge: Cambridge University Press, pp. 212–241.

12.

Hinton

D. E.

Hinton

Tran

Nguyen

Hsia

Pollack

M. H.

(2006) Orthostatically induced panic attacks among Vietnamese refugees: Associated psychopathology, flashbacks, and catastrophic cognitions. Depression and Anxiety 23(2): 113–115.

13.

Hinton

D. E.

Hinton

Tran

Nguyen

Hsia

et al. (2007) Orthostatic panic attacks among Vietnamese refugees. Transcultural Psychiatry 44: 515–545.

14.

Hinton

D. E.

Hinton

S. D.

Loeum

J. R.

Pollack

M. H.

(2008) The ‘multiplex model’ of somatic symptoms: Application to tinnitus among traumatized Cambodian refugees. Transcultural Psychiatry 45: 287–317.

15.

Hinton

D. E.

Hinton

S. D.

Pham

Chau

Tran

(2003) ‘Hit by the wind’ and temperature-shift panic among Vietnamese refugees. Transcultural Psychiatry 40(3): 342–376.

16.

Hinton

D. E.

Hofmann

S. G.

Orr

S. P.

Pitman

R. K.

Pollack

M. H.

Pole

(2010) A psychobiocultural model of orthostatic panic among Cambodian refugees: Flashbacks, catastrophic cognitions, and reduced orthostatic blood-pressure response. Psychological Trauma: Theory, Research, Practice, and Policy 2: 63–70.

17.

Hinton

D. E.

Hofmann

S. G.

Pollack

M. H.

Otto

M. W.

(2009) Mechanisms of efficacy of CBT for Cambodian refugees with PTSD: Improvement in emotion regulation and orthostatic blood pressure response. CNS Neuroscience and Therapeutics 15(3): 255–263.

18.

Hinton

D. E.

Kredlow

M. A.

Bui

Pollack

M. H.

Hofmann

S. G.

(2012) Treatment change of somatic symptoms and cultural syndromes among Cambodian refugees with PTSD. Depression and Anxiety 29: 148–155.

19.

Hinton

D. E.

Kredlow

M. A.

Pich

Bui

Hofmann

S. G.

(2013) 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 (SSI). Transcultural Psychiatry 50: 347–370.

20.

Hinton

D. E.

Lewis-Fernández

(2010) Idioms of distress among trauma survivors: Subtypes and clinical utility. Culture, Medicine, and Psychiatry 34: 209–218.

21.

Hinton

D. E.

Lewis-Fernández

(2011) The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression and Anxiety 28: 783–801.

22.

Hinton

D. E.

Nguyen

Pollack

M. H.

(2007) Orthostatic panic as a key Vietnamese reaction to traumatic events: The case of September 11th. Medical Anthropology Quarterly 21: 81–107.

23.

Hinton

D. E.

Nguyen

Tran

Quinn

(2005) Weak kidney and panic attacks in a traumatized Vietnamese male. Culture, Medicine, and Psychiatry 29: 125–135.

24.

Hinton

D. E.

Pham

Tran

Safren

S. A.

Otto

M. W.

Pollack

M. H.

(2004) CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: A pilot study. Journal of Traumatic Stress 17(5): 429–433.

25.

Hinton

D. E.

Pich

Chhean

Pollack

M. H.

(2005) “The ghost pushes you down”: Sleep paralysis-type panic attacks in a Khmer refugee population. Transcultural Psychiatry 42: 46–78.

26.

Hinton

D. E.

Pich

Chhean

Pollack

M. H.

McNally

R. J.

(2005) Sleep paralysis among Cambodian refugees: Association with PTSD diagnosis and severity. Depression and Anxiety 22(2): 47–51.

27.

Hinton

D. E.

Reis

de Jong

J. T.

(2015) The “thinking a lot” idiom of distress and PTSD: An examination of their relationship among traumatized Cambodian refugees using the “Thinking a Lot” Questionnaire. Medical Anthropology Quarterly 29: 357–380.

28.

Hinton

D. E.

Reis

de Jong

J. T.

(2016) A transcultural model of the centrality of “thinking a lot” in psychopathologies across the globe and the process of localization: A Cambodian refugee example. Culture, Medicine, and Psychiatry 40: 570–619.

29.

Hinton

D. E.

Rivera

Hofmann

S. G.

Barlow

D. H.

Otto

M. W.

(2012) Adapting CBT for traumatized refugees and ethnic minority patients: Examples from culturally adapted CBT (CA-CBT). Transcultural Psychiatry 49: 340–365.

30.

Hinton

D. E.

Simons

(2015) Somatization, anxiety disorders (GAD, Panic Disorder, and PTSD), and the arousal complex in cultural context: The multiplex model and the cultural neuroscience of anxiety disorders. In: Kirmayer

L. J.

Lemelson

Cummings

(eds) Revisioning psychiatry: Cultural phenomenology, critical neuroscience, and global mental health, Cambridge: Cambridge University Press, pp. 343–374.

31.

Hinton

D. E.

Sinclair

Chung

R. C.

Pollack

M. H.

(2007) The SF-36 among Cambodian and Vietnamese refugees: An examination of psychometric properties. Journal of Psychopathology and Behavioral Assessment 29: 38–45.

32.

Kaiser

Haroz

Kohrt

Bolton

Bass

Hinton

D. E.

(2015) Thinking too much: A systematic review of a common idiom of distress. Social Science and Medicine 147: 170–183.

33.

Kim

Eaton

N. R.

(2015) The hierarchical structure of common mental disorders: Connecting multiple levels of comorbidity, bifactor models, and predictive validity. Journal of Abnormal Psychology 124(4): 1064–1078.

34.

Kinzie

J. D.

Manson

S. M.

Vinh

D. T.

Tolan

N. T.

Anh

Pho

T. N.

(1982) Development and validation of a Vietnamese-language depression rating scale. American Journal of Psychiatry 139(10): 1276–1281.

35.

Kleinman

(1994) How bodies remember: Social memory and bodily experience of criticism, resistance, and deligitimation following China’s cultural revolution. New Literary History 25: 707–723.

36.

Kroenke

Spitzer

R. L.

Williams

J. B.

(2001) The PHQ-9: Validity of a brief depression severity measure. Journal General Internal Medicine 16(9): 606–613.

37.

Kwon

(2008) Ghosts of war in Vietnam, Cambridge: Cambridge University Press.

38.

Kwon

(2014) The Vietnam War traumas. In: Hinton

D. E.

Hinton

A. L.

(eds) Genocide and mass violence: Memory, symptom, and recovery, Cambridge: Cambridge University Press.

39.

Lowe

Decker

Muller

Brahler

Schellberg

Herzog

et al. (2008) Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care 46(3): 266–274.

40.

Murphy

Goldner

E. M.

Goldsmith

C. H.

Oanh

P. T.

Zhu

Corbett

K. K.

et al. (2015) Selection of depression measures for use among Vietnamese populations in primary care settings: A scoping review. International Journal of Mental Health Systems 9: 31.

41.

Phan

Silove

(1997) The influence of culture on psychiatric assessment: The Vietnamese refugee. Psychiatric Services 48(1): 86–90.

42.

Phan

Steel

Silove

(2004) An ethnographically derived measure of anxiety, depression and somatization: The Phan Vietnamese Psychiatric Scale. Transcultural Psychiatry 41(2): 200–232.

43.

Pollack

A. A.

Weiss

Trung

L. T.

(2016) Mental health, life functioning and risk factors among people exposed to frequent natural disasters and chronic poverty in Vietnam. British Journal of Psychiatry 2(3): 221–232.

44.

Powers

M. B.

Gillihan

S. J.

Rosenfield

Jerud

A. B.

Foa

E. B.

(2012) Reliability and validity of the PDS and PSS-I among participants with PTSD and alcohol dependence. Journal of Anxiety Disorders 26(5): 617–623.

45.

Sharpless

B. A.

(2016) A clinician’s guide to recurrent isolated sleep paralysis. Neuropsychiatric Disease Treatment 12: 1761–1767.

46.

Sharpless

B. A.

Barber

J. P.

(2011) Lifetime prevalence rates of sleep paralysis: A systematic review. Sleep Medicine Review 15(5): 311–315.

47.

Tran

A. L.

(2017) Neurasthenia, Generalized Anxiety Disorder, and the medicalization of worry in a Vietnamese psychiatric hospital. Medical Anthropology Quarterly 31: 198–217.

48.

Weiss

Dang

Trung

Nguyen

M. C.

Thuy

N. T. H.

Pollack

(2014) A nationally-representative epidemiological and risk factor assessment of child mental health in Vietnam. International Perspectives in Psychology: Research, Practice, Consultation 3: 139–153.

49.

Yarris

K. E.

(2011) The pain of “thinking too much”: Dolor de cerebro and the embodiment of social hardship among Nicaraguan women. Ethos 39: 226–248.

50.

Yarris

K. E.

(2014) “Pensando mucho” (“thinking too much”): Embodied distress among grandmothers in Nicaraguan transnational families. Culture, Medicine, and Psychiatry 38(3): 473–498.

Symptoms
Cognitive complaint	Forgetful, easily distracted
Somatic complaints	Faintness or dizziness
	Standing up and feeling dizzy
	Headache
	Blurry vision
	Ringing in the ears
	Neck or shoulder soreness
	Shortness of breath
	Heart palpitations
	Pain in the heart or chest pain
	Nausea or abdominal discomfort
	Stomach pain
	Poor appetite
	Feeling weak in parts of the body
	Tingling or stinging sensations in parts of the body
	Arms and legs trembling
	Numbness of the arms and feet
	Cold hands and feet
	Body shaking and feeling cold inside
	Sudden coldness in the body and goosebumps on skin
	Experience a sudden temperature change
	Feel hot or cold
	Excessive inner hotness like a fire inside
	Sore arms and legs
	Feeling of lightness in the body, like floating out of the body a little
Sleep-focused	When going to sleep or waking up, suddenly unable to speak or move
Cultural Syndromes
Cognitive-focused	“Thinking a lot”
Somatic-focused	Standing up and feeling poorly, fearing fainting or heart attack
	Experience “hit by the wind”
	Heart weakness
	Weak kidneys or need to urinate frequently
Supernatural-focused	Fear having low spiritual luck, high bad luck
	Light in the body, as if your soul was not in your body
	Feel or act like possessed or controlled by a ghost
	Fear that someone has sent a ghost into your body