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01-12-2021 | Post-Traumatic Stress Disorder | Research article

Somatic distress among Syrian refugees with residence permission in Germany: analysis of a cross-sectional register-based study

Authors: Andrea Borho, Eva Morawa, Gregor Martin Schmitt, Yesim Erim

Published in: BMC Public Health | Issue 1/2021

Abstract

Background

Previous studies have already proven high rates of common mental disorders in Syrian refugees. Nevertheless, little is known about the patterns of somatic distress among this refugee population. For this reason, we aimed to examine the prevalence, co-occurrence, and risk factors of somatic distress among Syrian refugees in Germany.

Methods

This study analyzes the second measurement point (N = 116) of a prospective register-based survey among 200 adult Syrian refugees with residence permission in Germany. The survey consisted of information on sociodemographic and migration-specific characteristics, health care utilization, traumatic life events, acculturative stress (Barcelona Immigration Stress Scale (BISS); subscales: perceived discrimination, intercultural contact stress, homesickness, and general psychosocial stress), and self-reported outcomes of somatic distress (Patient Health Questionnaire (PHQ-15)), depression (PHQ-9), generalized anxiety disorder (GAD-7), and post-traumatic symptoms (Essen Trauma Inventory (ETI)).

Results

Almost half of the respondents (49.1%) were identified as being at risk of somatic distress (PHQ-15 score ≥ 6), and even 24.1% being bothered by moderate-to-severe levels of somatic distress (PHQ-15 score ≥ 10). The most robust associations with somatic distress were found for female gender, the amount of health care utilization, multiple trauma exposures, general psychosocial stress, and self-reported depression and anxiety symptoms. High comorbidities with somatic distress were shown for all of the common mental disorders studied.

Conclusions

The presented study reveals a significant risk of somatic distress among this displaced population and highlights implications for policy and health care providers.

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Flüchtlingshilfe UNO: [Biggest humanitarian crisis of our time]. https://www.uno-fluechtlingshilfe.de/hilfe-weltweit/syrien/ (2020). Accessed 02.01.2021.

BAMF. [The Federal Office in figures 2016 - Asylum, migration and integration]. https://www.bamf.de/SharedDocs/Anlagen/DE/Publikationen/Broschueren/bundesamt-in-zahlen-2016.pdf?__blob=publicationFile (2018). Accessed 02 Jan 2021.

Acarturk C, Cetinkaya M, Senay I, Gulen B, Aker T, Hinton D. Prevalence and predictors of posttraumatic stress and depression symptoms among Syrian refugees in a refugee camp. J Nerv Ment Dis. 2018;206(1):40–5. https://doi.org/10.1097/NMD.0000000000000693.CrossRefPubMed

Chung MC, Shakra M, AlQarni N, AlMazrouei M, Al Mazrouei S, Al HS. Posttraumatic stress among Syrian refugees: trauma exposure characteristics, trauma centrality, and emotional suppression. Psychiatry. 2018;81(1):54–70. https://doi.org/10.1080/00332747.2017.1354620.CrossRefPubMed

Kazour F, Zahreddine NR, Maragel MG, Almustafa MA, Soufia M, Haddad R, et al. Post-traumatic stress disorder in a sample of Syrian refugees in Lebanon. Compr Psychiatry. 2017;72:41–7. https://doi.org/10.1016/j.comppsych.2016.09.007.CrossRefPubMed

Hassan G, Ventevogel P, Jefee-Bahloul H, Barkil-Oteo A, Kirmayer LJ. Mental health and psychosocial wellbeing of Syrians affected by armed conflict. Epidemiol Psychiatr Sci. 2016;25(2):129–41. https://doi.org/10.1017/S2045796016000044.CrossRefPubMedPubMedCentral

Bogic M, Ajdukovic D, Bremner S, Franciskovic T, Galeazzi GM, Kucukalic A, et al. Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. Br J Psychiatry. 2012;200(3):216–23. https://doi.org/10.1192/bjp.bp.110.084764.CrossRefPubMed

Alpak G, Unal A, Bulbul F, Sagaltici E, Bez Y, Altindag A, et al. Post-traumatic stress disorder among Syrian refugees in Turkey: a cross-sectional study. Int J Psychiatry Clin Pract. 2015;19(1):45–50. https://doi.org/10.3109/13651501.2014.961930.CrossRefPubMed

Georgiadou E, Zbidat A, Schmitt GM, Erim Y. Prevalence of mental distress among Syrian refugees with residence permission in Germany: a registry-based study. Front Psychiatry. 2018;9:393. https://doi.org/10.3389/fpsyt.2018.00393.CrossRefPubMedPubMedCentral

10.

M'Zah S, Lopes Cardozo B, Evans DP. Mental health status and service assessment for adult Syrian refugees resettled in metropolitan Atlanta: a cross-sectional survey. J Immigr Minor Health. 2019;21(5):1019–25. https://doi.org/10.1007/s10903-018-0806-6.CrossRefPubMedPubMedCentral

11.

Maldari T, Elsley N, Rahim RA. The health status of newly arrived Syrian refugees at the refugee health service, South Australia, 2016. Aust J Gen Pract. 2019;48(7):480–6. https://doi.org/10.31128/AJGP-09-18-4696.CrossRefPubMed

12.

Javanbakht A, Amirsadri A, Abu Suhaiban H, Alsaud MI, Alobaidi Z, Rawi Z, et al. Prevalence of possible mental disorders in Syrian refugees resettling in the United States screened at primary care. J Immigr Minor Health. 2019;21(3):664–7. https://doi.org/10.1007/s10903-018-0797-3.CrossRefPubMed

13.

Woltin KA, Sassenberg K, Albayrak N. Regulatory focus, coping strategies and symptoms of anxiety and depression: a comparison between Syrian refugees in Turkey and Germany. PLoS One. 2018;13(10):e0206522. https://doi.org/10.1371/journal.pone.0206522.CrossRefPubMedPubMedCentral

14.

Poole DN, Hedt-Gauthier B, Liao S, Raymond NA, Barnighausen T. Major depressive disorder prevalence and risk factors among Syrian asylum seekers in Greece. BMC Public Health. 2018;18(1):908. https://doi.org/10.1186/s12889-018-5822-x.CrossRefPubMedPubMedCentral

15.

Rohlof HG, Knipscheer JW, Kleber RJ. Somatization in refugees: a review. Soc Psychiatry Psychiatr Epidemiol. 2014;49(11):1793–804. https://doi.org/10.1007/s00127-014-0877-1.CrossRefPubMed

16.

Nesterko Y, Jäckle D, Friedrich M, Holzapfel L, Glaesmer H. Prevalence of post-traumatic stress disorder, depression and somatisation in recently arrived refugees in Germany: an epidemiological study. Epidemiol Psychiatr Sci. 2019;29:e40. https://doi.org/10.1017/S2045796019000325.

17.

Schweitzer R, Brough M, Vromans L, Asic-Kobe M. Mental health of newly arrived Burmese refugees in Australia: contributions of pre-migration and post-migration experience. Aust N Z J Psychiatry. 2011;45(4):299–307. https://doi.org/10.3109/00048674.2010.543412.

18.

McGrath M, Acarturk C, Roberts B, Ilkkursun Z, Sondorp E, Sijbrandij M, et al. Somatic distress among Syrian refugees in Istanbul, Turkey: A cross-sectional study. J Psychosom Res. 2020;132:109993. https://doi.org/10.1016/j.jpsychores.2020.109993.

19.

Aragona M, Rovetta E, Pucci D, Spoto J, Villa AM. Somatization in a primary care service for immigrants. Ethn Health. 2012;17(5):477–91. https://doi.org/10.1080/13557858.2012.661406.CrossRefPubMed

20.

Al Busaidi ZQ. The concept of somatisation: a cross-cultural perspective. Sultan Qaboos Univ Med J. 2010;10(2):180–6.PubMedPubMedCentral

21.

Klein J. Chronic pain, psychopathology, and DSM-5 somatic symptom disorder. Can J Psychiatr. 2015;60(11):528. https://doi.org/10.1177/070674371506001109.CrossRef

22.

Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry. 2005;62(8):903–10. https://doi.org/10.1001/archpsyc.62.8.903.CrossRefPubMed

23.

Lanzara R, Scipioni M, Conti C. A clinical-psychological perspective on somatization among immigrants: a systematic review. Front Psychol. 2018;9:2792.CrossRefPubMed

24.

Hartz AJ, Noyes R, Bentler SE, Damiano PC, Willard JC, Momany ET. Unexplained symptoms in primary care: perspectives of doctors and patients. Gen Hosp Psychiatry. 2000;22(3):144–52. https://doi.org/10.1016/S0163-8343(00)00060-8.CrossRefPubMed

25.

Lolk M, Byberg S, Carlsson J, Norredam M. Somatic comorbidity among migrants with posttraumatic stress disorder and depression—a prospective cohort study. BMC Psychiatry. 2016;16(1):447. https://doi.org/10.1186/s12888-016-1149-2.CrossRefPubMedPubMedCentral

26.

Gupta MA. Review of somatic symptoms in post-traumatic stress disorder. Int Rev Psychiatry. 2013;25(1):86–99. https://doi.org/10.3109/09540261.2012.736367.CrossRefPubMed

27.

Aragona M, Catino E, Pucci D, Carrer S, Colosimo F, Lafuente M, et al. The relationship between somatization and posttraumatic symptoms among immigrants receiving primary care services. J Trauma Stress. 2010;23(5):615–22. https://doi.org/10.1002/jts.20571.CrossRefPubMed

28.

Teodorescu DS, Heir T, Siqveland J, Hauff E, Wentzel-Larsen T, Lien L. Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study. BMC Psychol. 2015;3(1):7. https://doi.org/10.1186/s40359-015-0064-5.CrossRefPubMedPubMedCentral

29.

Kounou KB, Brodard F, Gnassingbe A, Foli AAD, Sager JC, Schmitt L, et al. Posttraumatic stress, somatization, and quality of life among Ivorian refugees. J Trauma Stress. 2017;30(6):682–9. https://doi.org/10.1002/jts.22244.CrossRefPubMed

30.

Jongedijk RA, Eising DD, van der Aa N, Kleber RJ, Boelen PA. Severity profiles of posttraumatic stress, depression, anxiety, and somatization symptoms in treatment seeking traumatized refugees. J Affect Disord. 2020;266:71–81. https://doi.org/10.1016/j.jad.2020.01.077.CrossRefPubMed

31.

Mölsä M, Punamäki RL, Saarni SI, Tiilikainen M, Kuittinen S, Honkasalo ML. Mental and somatic health and pre- and post-migration factors among older Somali refugees in Finland. Transcult Psychiatry. 2014;51(4):499–525. https://doi.org/10.1177/1363461514526630.CrossRefPubMed

32.

Cheung A, Makhashvili N, Javakhishvili J, Karachevsky A, Kharchenko N, Shpiker M, et al. Patterns of somatic distress among internally displaced persons in Ukraine: analysis of a cross-sectional survey. Soc Psychiatry Psychiatr Epidemiol. 2019;54(10):1265–74. https://doi.org/10.1007/s00127-019-01652-7.CrossRefPubMed

33.

Morina N, Kuenburg A, Schnyder U, Bryant RA, Nickerson A, Schick M. The Association of Post-traumatic and Postmigration Stress with pain and other somatic symptoms: an explorative analysis in traumatized refugees and asylum seekers. Pain Med. 2018;19(1):50–9. https://doi.org/10.1093/pm/pnx005.CrossRefPubMed

34.

Laban CJ, Gernaat HB, Komproe IH, Schreuders BA, De Jong JT. Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in the Netherlands. J Nerv Ment Dis. 2004;192(12):843–51. https://doi.org/10.1097/01.nmd.0000146739.26187.15.CrossRefPubMed

35.

Spiller TR, Schick M, Schnyder U, Bryant RA, Nickerson A, Morina N. Somatisation and anger are associated with symptom severity of posttraumatic stress disorder in severely traumatised refugees and asylum seekers. Swiss Med Wkly. 2016;146:w14311.PubMed

36.

BAMF. [Current figures 2020]. https://www.bamf.de/SharedDocs/Anlagen/DE/Statistik/AsylinZahlen/aktuelle-zahlen-mai-2020.pdf?__blob=publicationFile&v=4 (2020). Accessed 02 Jan 2021.

37.

Renner A, Hoffmann R, Nagl M, Roehr S, Jung F, Grochtdreis T, et al. Syrian refugees in Germany: perspectives on mental health and coping strategies. J Psychosom Res. 2020;129:109906. https://doi.org/10.1016/j.jpsychores.2019.109906.CrossRefPubMed

38.

Zbidat A, Georgiadou E, Borho A, Erim Y, Morawa E. The perceptions of trauma, complaints, somatization, and coping strategies among Syrian refugees in Germany—a qualitative study of an at-risk population. Int J Environ Res Public Health. 2020;17(3):693. https://doi.org/10.3390/ijerph17030693.CrossRefPubMedCentral

39.

Borho A, Viazminsky A, Morawa E, Schmitt GM, Georgiadou E, Erim Y. The prevalence and risk factors for mental distress among Syrian refugees in Germany: a register-based follow-up study. BMC Psychiatry. 2020;20(1):362. https://doi.org/10.1186/s12888-020-02746-2.CrossRefPubMedPubMedCentral

40.

Sousa V, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract. 2011;17(2):268–74. https://doi.org/10.1111/j.1365-2753.2010.01434.x.CrossRefPubMed

41.

Tomás-Sábado J, Antonin M, Qureshi A, Collazos F. Construction and preliminary validation of the Barcelona Immigration Stress Scale. Psychol Rep. 2007;100(3):1013–23. https://doi.org/10.2466/pr0.100.3.1013-1023.

42.

Revollo H-W, Qureshi A, Collazos F, Valero S, Casas M. Acculturative stress as a risk factor of depression and anxiety in the Latin American immigrant population. Int Rev Psychiatry. 2011;23(1):84–92. https://doi.org/10.3109/09540261.2010.545988.CrossRefPubMed

43.

Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):258–66. https://doi.org/10.1097/00006842-200203000-00008.CrossRefPubMed

44.

Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med. 1990;150(8):1685–9. https://doi.org/10.1001/archinte.150.8.1685.CrossRefPubMed

45.

Kroenke K, Spitzer RL, Williams JBW, Löwe B. The Patient Health Questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345–59. https://doi.org/10.1016/j.genhosppsych.2010.03.006.

46.

Korber S, Frieser D, Steinbrecher N, Hiller W. Classification characteristics of the Patient Health Questionnaire-15 for screening somatoform disorders in a primary care setting. J Psychosom Res. 2011;71(3):142–7. https://doi.org/10.1016/j.jpsychores.2011.01.006.

47.

Comellas RM, Makhashvili N, Chikovani I, Patel V, McKee M, Bisson J, et al. Patterns of somatic distress among conflict-affected persons in the Republic of Georgia. J Psychosom Res. 2015;78(5):466–71. https://doi.org/10.1016/j.jpsychores.2015.01.015.

48.

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.CrossRefPubMedPubMedCentral

49.

Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. https://doi.org/10.1001/archinte.166.10.1092.CrossRefPubMed

50.

Tagay S, Schlottbohm E, Lindner M, Friederich HC, Duellmann S. The Essen Trauma-Inventory (ERI). Z Psychosom Med Psychother. 2015;61:109.

51.

Cohen J. Statistical power analysis. Curr Dir Psychol Sci. 1992;1(3):98–101. https://doi.org/10.1111/1467-8721.ep10768783.CrossRef

52.

OECD: Health at a Glance 2019. http://www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm (2019). Accessed 02.01.2021.

53.

Mershed M, Busse R, Van Ginneken E. Healthcare financing in Syria: satisfaction with the current system and the role of national health insurance-a qualitative study of householders' views. Int J Health Plann Manag. 2012;27(2):167–79. https://doi.org/10.1002/hpm.2102.CrossRef

54.

Laban CJ, Komproe IH, Gernaat HB, de Jong JT. The impact of a long asylum procedure on quality of life, disability and physical health in Iraqi asylum seekers in the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2008;43(7):507–15. https://doi.org/10.1007/s00127-008-0333-1.CrossRefPubMed

55.

Torun P, Mücaz Karaaslan M, Sandıklı B, Acar C, Shurtleff E, Dhrolia S, et al. Health and health care access for Syrian refugees living in İstanbul. Inte J Public Health. 2018;63(5):601–8. https://doi.org/10.1007/s00038-018-1096-4.CrossRef

56.

Kocalevent RD, Hinz A, Brähler E. Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population. BMC Psychiatry. 2013;13(1):91. https://doi.org/10.1186/1471-244X-13-91.

57.

Ma-Kellams C. Cross-cultural differences in somatic awareness and interoceptive accuracy: a review of the literature and directions for future research. Front Psychol. 2014;5(1379).

58.

Rometsch C, Denkinger JK, Engelhardt M, Windthorst P, Graf J, Gibbons N, et al. Pain, somatic complaints, and subjective concepts of illness in traumatized female refugees who experienced extreme violence by the "Islamic state" (IS). J Psychosom Res. 2020;130:109931. https://doi.org/10.1016/j.jpsychores.2020.109931.CrossRefPubMed

59.

Morina N, Ford JD, Risch AK, Morina B, Stangier U. Somatic distress among Kosovar civilian war survivors: relationship to trauma exposure and the mediating role of experiential avoidance. Soc Psychiatry Psychiatr Epidemiol. 2010;45(12):1167–77. https://doi.org/10.1007/s00127-009-0160-z.CrossRefPubMed

60.

Cheung P. Somatisation as a presentation in depression and post-traumatic stress disorder among Cambodian refugees. Aust N Z J Psychiatry. 1993;27(3):422–8. https://doi.org/10.3109/00048679309075798.CrossRefPubMed

61.

Wu S, Renzaho A, Hall B, Shi L, Ling L, Chen W. Time-varying associations of pre-migration and post-migration stressors in refugees' mental health during resettlement: a longitudinal study in Australia. Lancet Psychiatry. 2021;8(1):36–47. https://doi.org/10.1016/S2215-0366(20)30422-3.CrossRefPubMed

62.

Erim Y, Schellong J. Special issue flight and migration. J Psychosom Res. 2020;138:110260. https://doi.org/10.1016/j.jpsychores.2020.110260.CrossRefPubMedPubMedCentral

63.

BAMF. [The Federal Office in figures 2014 - Asylum, migration and integration 2015]. https://www.bamf.de/SharedDocs/Anlagen/DE/Publikationen/Broschueren/bundesamt-in-zahlen-2014.pdf?__blob=publicationFile (2015). Accessed on 02 Jan 2021.

64.

BAMF. [The Federal Office in figures 2015 - Asylum, migration and integration 2016]. https://www.bamf.de/SharedDocs/Anlagen/DE/Publikationen/Broschueren/bundesamt-in-zahlen-2015.pdf?__blob=publicationFile (2016). Accessed on 02 Jan 2021.

65.

de Vroege L, Hoedeman R, Nuyen J, Sijtsma K, van der Feltz-Cornelis CM. Validation of the PHQ-15 for somatoform disorder in the occupational health care setting. J Occup Rehabil. 2012;22(1):51–8. https://doi.org/10.1007/s10926-011-9320-6.CrossRefPubMed

66.

Bozorgmehr K, Mohsenpour A, Saure D, Stock C, Loerbroks A, Joos S, et al. Systematic overview and mapping of empirical studies on the health status and medical care of refugees and asylum seekers in Germany (1990–2014). Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz. 2016;59(5):599–620. https://doi.org/10.1007/s00103-016-2336-5.CrossRef

67.

Hinton DE, Pich V, Chhean D, Safren SA, Pollack MH. Somatic-focused therapy for traumatized refugees: Treating posttraumatic stress disorder and comorbid neck-focused panic attacks among cambodian refugees. Psychotherapy (Chicago, Ill). 2006;43(4):491–505.CrossRef

Title: Somatic distress among Syrian refugees with residence permission in Germany: analysis of a cross-sectional register-based study
Authors: Andrea Borho
Eva Morawa
Gregor Martin Schmitt
Yesim Erim
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Post-Traumatic Stress Disorder
Care
Published in: BMC Public Health / Issue 1/2021
Electronic ISSN: 1471-2458
DOI: https://doi.org/10.1186/s12889-021-10731-x

At a glance: The STEP trials

Springer Medicine

Somatic distress among Syrian refugees with residence permission in Germany: analysis of a cross-sectional register-based study

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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