Centre for Population Mental Health Research, Liverpool Hospital and Psychiatry Research and Teaching Unit, School of Psychiatry, Cnr Forbes and Campbell Streets, University of New South Wales, Liverpool NSW 2170, Sydney, NSW, 2052, Australia.
Soc Psychiatry Psychiatr Epidemiol. 2019 Jun;54(6):771-780. doi: 10.1007/s00127-019-01666-1. Epub 2019 Feb 18.
Refugees may be at risk of experiencing a complicated form of bereavement. As yet, however, the nosological status of this putative category across cultures remains in question. We apply qualitative and quantitative methods to investigate the manifestations, prevalence, factorial structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua, a population with no past exposure to western concepts of grief or to formal mental health services.
Qualitative methods (focus groups and informant interviews) were used to identify cultural expressions of complicated bereavement derived from international classification systems, that is, DSM 5 persistent complex bereavement disorder (PCBD) and ICD-11 prolonged grief disorder (PGD) in developing a structured interview applied by trained field workers. Participants were adult West Papuan refugees and their offspring recruited from households (n = 486, response 85.8%) across nine villages in a remote town in Papua New Guinea.
The qualitative data obtained from focus groups (n = 20) and informant interviews (n = 4) with local psychiatrists supported the cultural validity of complicated bereavement. 16% (n = 78) of the sample met criteria for PCBD based on DSM-5 criteria and 103 (21%) met criteria for PGD based on ICD-11 criteria. Confirmatory factor analysis yielded a six-factor model of complicated bereavement with a moderately good fit to the data. The model included dimensions of anger/negative appraisal (AN), avoidance/giving up, estrangement from others, and confusion and diminished identity. In contrast, the DSM-5 three-factor model and the ICD-11 two-factor model each yielded a poor fit. Cumulative traumatic losses (β = 0.16, P = 0.03), duration since displacement [(β = 0.10, P = 0.02)] and postmigration living difficulties (β = 0.20, P = 0.01) were associated with an aggregated index of complicated bereavement, supporting the concurrent validity of the structure identified.
Culture and exposure to persecution and displacement may contribute to the content and configuration of the complicated bereavement reaction, an issue that requires recognition in international classification systems and clinical practice.
难民可能面临一种复杂形式的丧亲之痛。然而，目前这种假设的分类在跨文化背景下的疾病地位仍存在疑问。我们应用定性和定量方法来研究西巴布亚难民的复杂丧亲之痛的表现、流行率、因素结构和心理社会相关性，这些难民过去没有接触过西方的悲伤概念，也没有接触过正规的心理健康服务。
采用定性方法（焦点小组和知情者访谈）从国际分类系统中识别出与文化相关的复杂丧亲之痛的表现，即 DSM-5 持续性复杂丧亲障碍（PCBD）和 ICD-11 延长哀伤障碍（PGD），并开发了一种由受过训练的实地工作者应用的结构化访谈。参与者是来自巴布亚新几内亚一个偏远城镇的 9 个村庄的成年西巴布亚难民及其后代（486 名，回应率为 85.8%）。
从 20 次焦点小组（n=20）和 4 次与当地精神科医生的知情者访谈（n=4）中获得的定性数据支持了复杂丧亲之痛的文化有效性。根据 DSM-5 标准，16%（n=78）的样本符合 PCBD 标准，根据 ICD-11 标准，103 人（21%）符合 PGD 标准。验证性因素分析得出了一个具有中等拟合度的复杂丧亲之痛的六因素模型。该模型包括愤怒/负性评价（AN）、回避/放弃、与他人疏远、困惑和身份认同减弱等维度。相比之下，DSM-5 三因素模型和 ICD-11 两因素模型的拟合度都较差。累积创伤性损失（β=0.16，P=0.03）、流离失所以来的时间间隔[（β=0.10，P=0.02）]和后移民生活困难（β=0.20，P=0.01）与复杂丧亲之痛的综合指数相关，支持所确定结构的同时效度。
文化、接触迫害和流离失所可能会影响复杂丧亲之痛反应的内容和结构，这一问题需要在国际分类系统和临床实践中得到认可。
