Group differences in the structure of illness

The paper reports an attempt to study in a naturalistic and quantitative fashion the features of illness episodes. Such episodes, as perceived and reported by lay persons, constitute a basic datum in ethnomedicine. Yet, they have rarely been the object of systematic research for theoretical and methodological reasons. The paper discusses ways in which illness episodes have significance in ethnomedicine and in health services research generally, and describes a method which can be used in field situations to study them. The content, internal structure and organization which illness episodes have are given attention by analysing and measuring the components of illness in a panel of adult females who reside in the highland state of Chiapas in Southeastern Mexico. Comparisons are undertaken in the two most dissimilar subgroupings of the region. Some commonalities and group differences in the duration of symptoms and in the way symptoms interrelate are described. An interpretation of these differences is offered, with principal emphasis given to the social circumstances and to the (cultural) meanings of illness in the two groups. The procedure employed, which is consistent with the way in which vital signs are recorded in the hospital, lends itself to field studies of the way symptoms and signs of disease unfold in the individual across time. The idea of a language of illness, which is introduced and developed in the paper, is used to draw emphasis to the communicative and symbolic features of illness.     

Explanatory models of medically unexplained symptoms: a qualitative analysis of the literature

Background Medically unexplained symptoms (MUS) are common in primary health care. Both patients and doctors are burdened with the symptoms that negatively affect patients' quality of life. General practitioners (GPs) often face difficulties when giving patients legitimate and convincing explanations for their symptoms. This explanation is important for reassuring patients and for maintaining a good doctor-patient communication and relationship.Objective To provide an overview of explanatory models for MUS.Study design We performed a systematic search of reviews in PsycINFO and PubMed about explanatory models of MUS. We performed a qualitative analysis of the data according to the principles of constant comparative analysis to identify specific explanatory models.Results We distinguished nine specific explanatory models of MUS in the literature: somatosensory amplification, sensitisation, sensitivity, immune system sensitisation, endocrine dysregulation, signal filter model, illness behaviour model, autonomous nervous system dysfunction and abnormal proprioception. The nine different explanatory models focus on different domains, including somatic causes, perception, illness behaviour and predisposition. We also found one meta-model, which incorporates these four domains: the cognitive behavioural therapy model.Conclusion Although GPs often face difficulties when providing explanations to patients with MUS, there are multiple explanatory models in the scientific literature that may be of use in daily medical practice.     

Illness behavior and dysfunction: review of concepts and application to chronic pain

The purpose of this presentation is to review the elements that comprise the concept of illness behavior including elaboration of a more formal theoretical and operational model for illness behavior and then discuss the application of the illness behavior model to chronic pain, especially chronic orofacial pain. The model of illness behavior presented emphasizes four critical areas of conceptual interest, namely, (1) monitoring of somatic signals; (2) cognitive processes whereby bodily symptoms are interpreted; (3) attaching meaning to symptoms in the context of emotional state and concurrent environmental events; and (4) the ethnocultural influences that pervade meaning and shape coping responses. Our model of illness behavior was generalized from a closely related model developed to guide research when the specific illness behavior of interest was dysfunctional chronic pain behavior. We also include a time dimension in our chronic pain model. Dysfunctional chronic pain is understood to be the most important undesirable consequence associated with suffering a persistent pain condition. Dysfunctional chronic pain is a subset of illness behaviors inconsistent with medically documented findings, while the complaints of pain are prominent. Changes occur in emotional status, most typically reported as mood and behavioral changes associated with depression, such as demoralization, helplessness, and social isolation. Excesses in medical care, hospitalizations for surgery, and abuse of medications are further characteristics of dysfunctional chronic pain.     

Psychotic mania in glucose-6-phosphate-dehydrogenase-deficient subjects

BACKGROUND: Glucose-6-phosphate dehydrogenase (G6PD) deficiency has been associated with acute psychosis, catatonic schizophrenia, and bipolar disorders by previous inconclusive reports. A particularly disproportionate rate of enzyme deficiency was found in manic schizoaffective patients from 662 lithium patients surveyed in Sardinia. The purpose of this study was to describe clinical characteristics which may be potentially associated with G6PD deficiency. METHODS: Characteristics of episodes, course of illness, family pattern of illness, laboratory tests, and treatment response of 29 G6PD-deficient subjects with a Research Diagnostic Criteria diagnosis of manic schizoaffective disorder were abstracted from available records. RESULTS: The most peculiar pattern was that of acute recurrent psychotic manic episodes, mostly characterized by loosening of associations, agitation, catatonic symptoms, and/or transient confusion, concurrent hyperbilirubinemia, positive psychiatric family history, and partial response to long-term lithium treatment. CONCLUSIONS: A relationship between psychiatric disorder and G6PD deficiency is to be searched in the bipolar spectrum, particularly among patients with a history of acute episodes with psychotic and/or catatonic symptoms or with transient confusion.     

Traumatic Amputation: A Case of Laotian Indignation and Injustice

Culture is an essential variable of diagnosis and treatment. A cultural perspective draws attention to the social context within which symptoms arise, are given meaning, and are managed. Ethno-cultural work on illness narratives suggests that most people can provide culturally-based explanations for their symptoms. While these explanations are inconsistent with biomedical theory, they relieve patient distress by allowing the patient to create meaning for symptoms. Exploring the characteristics, context, and antecedents of the symptoms enables the patient to convey them to the clinician who may have a divergent explanation of sickness. This case study uses the Outline for Cultural Formulation of the DSM-IV created for clinicians to elicit a narrative account of the illness experience from the patient. Our study examines how the patient, a Laotian used social indignation (“Kwam khem keuang”) as an explanatory model for his ailment. He was diagnosed with post-traumatic stress disorder after having undergone a traumatic amputation. In the process of explaining his illness through a cultural idiom, the patient was able to reveal both personal and collective meaning of repressed anger and frustration, expressing them in a context that was acceptable to him. This cultural idiom allowed the patient to reflect upon the structure of the health care system and the specific context in which symptoms and their possible origins are recounted and explored. It also clarified to the treating clinicians some categories of experience and causal explanations that did not fit easily with western biomedical and psychiatric understanding. The case study illustrates how a cultural approach to illness from the patient’s perspective offers a reflexive stance on the clinician–patient interaction that allows for better patient care.     

Nonlinear time-series approaches in characterizing mood stability and mood instability in bipolar disorder

Bipolar disorder is a psychiatric condition characterized by episodes of elevated mood interspersed with episodes of depression. While treatment developments and understanding the disruptive nature of this illness have focused on these episodes, it is also evident that some patients may have chronic week-to-week mood instability. This is also a major morbidity. The longitudinal pattern of this mood instability is poorly understood as it has, until recently, been difficult to quantify. We propose that understanding this mood variability is critical for the development of cognitive neuroscience-based treatments. In this study, we develop a time-series approach to capture mood variability in two groups of patients with bipolar disorder who appear on the basis of clinical judgement to show relatively stable or unstable illness courses. Using weekly mood scores based on a self-rated scale (quick inventory of depressive symptomatology-self-rated; QIDS-SR) from 23 patients over a 220-week period, we show that the observed mood variability is nonlinear and that the stable and unstable patient groups are described by different nonlinear time-series processes. We emphasize the necessity in combining both appropriate measures of the underlying deterministic processes (the QIDS-SR score) and noise (uncharacterized temporal variation) in understanding dynamical patterns of mood variability associated with bipolar disorder.     

Winter illness and vitamin C: the effect of relatively low doses.

After their random -llocation to one of three treatment aroups, 622 volunteers received either vitamin C or placebo in a maintenance dose of 500 mg once weekly and a therapeutic dose of 1500 mg daily on the 1st day and 1000 mg on the next 4 days of any illness. Two forms of vitamin C were employed: a sustained-release capsule containing ascorbic acid and a regular tabet containing a mixture of sodium and calcium ascorbate. In the 448 subjects who completed an average of 15 weeks in the study of total of 635 episodes of illness were recroded. Respiratory symptoms were recorded on at least 1 day in 92 per cent of these episodes. There were no consistent or significant differences in the sickness experience of the subjects receiving the sustained-release vitamin capsules compared to those receiving the vitamin tablets, but subjects in both vitamin groups experienced less severe illness than subjects in the placebo group, with approximately 25 per cent fewer days spent indoors because of the illness (P smaller than 0.05). These results are compatible with the belief that supplementary vitamin C can reduce the burden of winter illness, but the intake need not be as high as has sometimes been claimed.     

THE NEW PARADIGM OF RECOVERY FROM SCHIZOPHRENIA: CULTURAL CONUNDRUMS OF IMPROVEMENT WITHOUT CURE

This article is a qualitative investigation of the subjective experience of recovery from the perspective of persons living with schizophrenia-related disorders. An NIMH-sponsored ethnographic study of community outpatient clinics was completed for 90 persons taking second-generation antipsychotic medications. Research diagnostic criteria and clinical ratings were obtained in tandem with an anthropologically developed Subjective Experience of Medication Interview (SEMI) that elicits narrative data on everyday life and activities, medication and treatment, management of symptoms, expectations concerning recovery, and stigma. Ethnographic observations from diverse settings (clinics, public transportation, restaurants, homes) were also obtained. The primary findings are that recovery was experienced in relation to low levels of symptoms, the need to take medications to avoid hospitalization or psychotic episodes, and personal agency to struggle against the effects of illness. The majority of participants articulated their sense of illness recovery and expectation that their lives would improve. Improvement and recovery is an incremental, yet definitively discernable subjective process. Several problems were identified as part of this process surrounding cultural conflicts that generate the experience of ambivalence analyzed here as the “paradox of recovery without cure,” irreconcilable “catch-22” dilemmas involving sacrifice (e.g., one must be “fat” or be “crazy”), and substantial stigma despite improvement in illness and everyday life experience.     

Use of traditional and modern health services by Laotian refugees.

Although refugee health care emerged as a special interest in the United States following the influx of almost a million Southeast Asians since 1975, few studies have been done of the influence of refugee traditions on the use of Western medical services. The illness patterns, medical beliefs, and health care behavior of a Southeast Asian refugee group, the Mien from Laos are described in this study. A cohort of 119 Mien refugees living in Richmond, California, was observed for a 6-month period. In-home interviews were undertaken about all episodes of ill health, including treatment and health care decisions. This study shows that the Mien integrate traditional healing beliefs and practices with the use of American health services. Such findings are important because the increasing cultural diversity in the United States, particularly in Western states, necessitates that health care professionals understand the importance of cultural factors for access to and the use of health care by all patients including refugees and other immigrant groups.     

Physical and Emotional Health Problems Experienced by Youth Engaged in Physical Fighting and Weapon Carrying

Then aims of the current study were 1) to provide cross-national estimates of the prevalence of physical fighting and weapon carrying among adolescents aged 11–15 years; (2) To examine the possible effects of physical fighting and weapon carrying on the occurrence of physical (medically treated injuries) and emotional health outcomes (multiple health complaints) among adolescents within the theoretical framework of Problem Behaviour Theory. 20,125 adolescents aged 11–15 in five countries (Belgium, Israel, USA, Canada, FYR Macedonia) were surveyed via the 2006 Health Behaviour in School Aged Children survey. Prevalence was calculated for physical fighting and weapon carrying along with physical and emotional measures that potentially result from violence. Regression analyses were used to quantify associations between violence/weapon carrying and the potential health consequences within each country. Large variations in fighting and weapon carrying were observed across countries. Boys reported more frequent episodes of fighting/weapon carrying and medically attended injuries in every country, while girls reported more emotional symptoms. Although there were some notable variations in findings between different participating countries, increased weapon carrying and physical fighting were both independently and consistently associated with more frequent reports of the potential health outcomes. Adolescents engaging in fighting and weapon carrying are also at risk for physical and emotional health outcomes. Involvement in fighting and weapon carrying can be seen as part of a constellation of risk behaviours with obvious health implications. Our findings also highlight the importance of the cultural context when examining the nature of violent behaviour for adolescents.     

Gender differences in psychotic bipolar mania

Objective: This study examined gender differences in the prevalence and types of psychotic symptoms in bipolar mania.Methods: Participants were drawn from consecutive admissions to the psychiatric clinic in Chemnitz, Germany, in 2005. The diagnosis of bipolar disorder, manic episode was made within 24 hours of admission, and the severity of mania was assessed using the Young Mania Rating Scale (YMRS) and the German version of the Altman Self-Rating Mania Scale. Data collected for each patient included age at the onset of bipolar illness, number of previous episodes, social functioning between episodes, and duration of hospitalization for the index episode. Based on the Task Force for Methods and Documentation in Psychiatry system, psychotic symptoms were classified as hallucinations (visual, auditory, olfactory, tactile, acousma, somatic); delusions (paranoid, reference, guilt, grandeur, religious, erotomania, hypochondriac, poverty, jealousy); and ego disorder (thought control, thought broadcasting).Results: One hundred thirty-seven women and 109 men met the criteria for an acute manic episode, of whom 93 women and 62 men had psychotic symptoms. Compared with psychotic men, psychotic women had more delusions and hallucinations, both overall and per patient, and more delusions of reference and paranoid delusions. Psychotic women had more mixed states compared with psychotic men. Psychotic women differed from both psychotic men and nonpsychotic women on a number of clinical and social variables: they had higher YMRS scores and more previous episodes of depression despite an earlier onset of illness.Conclusion: Women with bipolar mania exhibited a specific pattern of psychotic symptoms that appeared to be associated with greater severity of the acute episode, more mixed states, and a more severe course of illness.     

Individual health and the visibility of village economic inequality: Longitudinal evidence from native Amazonians in Bolivia

Mounting evidence suggests that income inequality is associated with worse individual health. But does the visibility of inequality matter? Using data from a horticultural-foraging society of native Amazonians in Bolivia (Tsimane’), we examined whether village inequality in resources and behaviors with greater cultural visibility is more likely to bear a negative association with health than village inequality in less conspicuous resources. We draw on a nine-year annual panel (2002–2010) from 13 Tsimane’ villages for our main analysis, and an additional survey to gauge the cultural visibility of resources. We measured inequality using the Gini coefficient. We tested the robustness of our results using a shorter two-year annual panel (2008–2009) in another 40 Tsimane’ villages and an additional measure of inequality (coefficient of variation, CV). Behaviors with low cultural visibility (e.g., household farm area planted with staples) were less likely to be associated with individual health, compared to more conspicuous behaviors (e.g., expenditures in durable goods, consumption of domesticated animals). We find some evidence that property rights and access to resources matter, with inequality of privately-owned resources showing a larger effect on health. More inequality was associated with improved perceived health – maybe due to improved health prospects from increasing wealth – and worse anthropometric indicators. For example, a unit increase in the Gini coefficient of expenditures in durable goods was associated with 0.24 fewer episodes of stress and a six percentage-point lower probability of reporting illness. A one-point increase in the CV of village inequality in meat consumption was associated with a 4 and 3 percentage-point lower probability of reporting illness and being in bed due to illness, and a 0.05 SD decrease in age-sex standardized arm-muscle area. In small-scale, rural societies at the periphery of market economies, nominal economic inequality in resources bore an association with individual health, but did not necessarily harm perceived health. Economic inequalities in small-scale societies apparently matter, but a thick cultural tapestry of reciprocity norms and kinship ties makes their effects less predictable than in industrial societies.     

Continuum of depressive and manic mixed states in patients with bipolar disorder: quantitative measurement and clinical features

Bipolar mixed states combine depressive and manic features, presenting diagnostic and treatment challenges and reflecting a severe form of the illness. DSM-IV criteria for a mixed state require combined depressive and manic syndromes, but a range of mixed states has been described clinically. A unified definition of mixed states would be valuable in understanding their diagnosis, mechanism and treatment implications. We investigated the manner in which depressive and manic features combine to produce a continuum of mixed states. In 88 subjects with bipolar disorder (DSM-IV), we evaluated symptoms and clinical characteristics, and compared depression-based, mania-based, and other published definitions of mixed states. We developed an index of the extent to which symptoms were mixed (Mixed State Index, MSI) and characterized its relationship to clinical state. Predominately manic and depressive mixed states using criteria from recent literature, as well as Kraepelinian mixed states, had similar symptoms and MSI scores. Anxiety correlated significantly with depression scores in manic subjects and with mania scores in depressed subjects. Discriminant function analysis associated mixed states with symptoms of hyperactivity and negative cognitions, but not subjective depressive or elevated mood. High MSI scores were associated with severe course of illness. For depressive or manic episodes, characteristics of mixed states emerged with two symptoms of the opposite polarity. This was a cross-sectional study. Mixed states appear to be a continuum. An index of the degree to which depressive and manic symptoms combine appears useful in identifying and characterizing mixed states. We propose a depressive or manic episode with three or more symptoms of the opposite polarity as a parsimonious definition of a mixed state.     

Cross-Cultural aspects of bereavement. II: Ethnic and cultural variations in the development of bereavement practices

Despite a growing interest in bereavement in cross-cultural perspective, few reports have described a comparative analysis of bereavement. By examining the social contexts in the transformations of Western bereavement practices, structures common to bereavement in a range of cultures can be identified. The paper compares the contemporary bereavement practices of several ethnic and cultural groups in North America: Blacks; ethnic Chinese; Southeast Asian refugees; Haitians; Italians; Greeks; and Spanish-speaking groups. Consideration is given to the state of widowhood in different cultural systems. The impact of modernization among traditional societies demonstrates that even though Western technologies are incorporated into the procedures followed by these modernizing societies, the deep cultural code remains intact. Five questions require further clarification: is bereavement an illness, or a rite de passage and a normal life event? How widespread and useful are protective factors, such as group support, that facilitate successful resolution of grief? How effective are mourning practices of various ethnic groups in preventing “bad grief”, and might some of these practices be beneficial if taken up by other ethnic groups? How can the Western health practitioner know that a bereaved person from an unfamiliar cultural group is suffering “bad grief”? How acceptable is Western grief counseling to non-Western clients?     

Association between the 2008–09 Seasonal Influenza Vaccine and Pandemic H1N1 Illness during Spring–Summer 2009: Four Observational Studies from Canada

Background

In late spring 2009, concern was raised in Canada that prior vaccination with the 2008–09 trivalent inactivated influenza vaccine (TIV) was associated with increased risk of pandemic influenza A (H1N1) (pH1N1) illness. Several epidemiologic investigations were conducted through the summer to assess this putative association.

Methods and Findings

Studies included: (1) test-negative case-control design based on Canada''s sentinel vaccine effectiveness monitoring system in British Columbia, Alberta, Ontario, and Quebec; (2) conventional case-control design using population controls in Quebec; (3) test-negative case-control design in Ontario; and (4) prospective household transmission (cohort) study in Quebec. Logistic regression was used to estimate odds ratios for TIV effect on community- or hospital-based laboratory-confirmed seasonal or pH1N1 influenza cases compared to controls with restriction, stratification, and adjustment for covariates including combinations of age, sex, comorbidity, timeliness of medical visit, prior physician visits, and/or health care worker (HCW) status. For the prospective study risk ratios were computed. Based on the sentinel study of 672 cases and 857 controls, 2008–09 TIV was associated with statistically significant protection against seasonal influenza (odds ratio 0.44, 95% CI 0.33–0.59). In contrast, estimates from the sentinel and three other observational studies, involving a total of 1,226 laboratory-confirmed pH1N1 cases and 1,505 controls, indicated that prior receipt of 2008–09 TIV was associated with increased risk of medically attended pH1N1 illness during the spring–summer 2009, with estimated risk or odds ratios ranging from 1.4 to 2.5. Risk of pH1N1 hospitalization was not further increased among vaccinated people when comparing hospitalized to community cases.

Conclusions

Prior receipt of 2008–09 TIV was associated with increased risk of medically attended pH1N1 illness during the spring–summer 2009 in Canada. The occurrence of bias (selection, information) or confounding cannot be ruled out. Further experimental and epidemiological assessment is warranted. Possible biological mechanisms and immunoepidemiologic implications are considered. Please see later in the article for the Editors'' Summary     

Persistently low natural killer cell activity, age, and environmental stress as predictors of infectious morbidity.

In recent studies of 'low natural killer (NK) cell syndrome', low NK activity was measured in individuals who were symptomatic, and therefore a causal relationship between low NK activity and infectious or other disease manifestations could not be concluded. However, preliminary work by members of our collaborative team (S.L. and R.H.) provided some indications for chronic low NK activity preceding and predicting subsequent infectious morbidity. This present study was designed to address this causal question in a larger sample, using a longitudinal design. Subjects were 106 healthy normal volunteers from the community. They were examined medically and psychosocially at baseline, and were then followed over a 6-month interval, with serial monthly assessments over the study period. The results supported our hypothesis that individuals who were currently healthy, but who exhibited a pattern of natural immunity characterized by persistently low NK cytotoxicity would be at risk for development of infectious sequelae over a 6-month follow-up period. The results also showed that younger age and the perception of more severe 'hassles' or stressors also predicted more infectious morbidity during the 6-month study period. Chronological age appeared to have both a direct, as well as indirect (via NK activity) association with illness outcome. Contrary to our expectation, the report of environmental stressors was directly associated with illness outcome, but not indirectly associated with outcome via natural immunity.     

Molecular characterization of L-CPT I deficiency in six patients: insights into function of the native enzyme.

Carnitine palmitoyltransferase I (CPT I) catalyzes the formation of acylcarnitine, the first step in the oxidation of long-chain fatty acids in mitochondria. The enzyme exists as liver (L-CPT I) and muscle (M-CPT I) isoforms that are encoded by separate genes. Genetic deficiency of L-CPT I, which has been reported in 16 patients from 13 families, is characterized by episodes of hypoketotic hypoglycemia beginning in early childhood and is usually associated with fasting or illness. To date, only two mutations associated with L-CPT I deficiency have been reported. In the present study we have identified and characterized the mutations underlying L-CPT I deficiency in six patients: five with classic symptoms of L-CPT I deficiency and one with symptoms that have not previously been associated with this disorder (muscle cramps and pain). Transfection of the mutant L-CPT I cDNAs in COS cells resulted in L-CPT I mRNA levels that were comparable to those expressed from the wild-type construct. Western blotting revealed lower levels of each of the mutant proteins, indicating that the low enzyme activity associated with these mutations was due, at least in part, to protein instability. The patient with atypical symptoms had approximately 20% of normal L-CPT I activity and was homozygous for a mutation (c.1436C-->T) that substituted leucine for proline at codon 479. Assays performed with his cultured skin fibroblasts indicated that this mutation confers partial resistance to the inhibitory effects of malonyl-CoA. The demonstration of L-CPT I deficiency in this patient suggests that the spectrum of clinical sequelae associated with loss or alteration of L-CPT I function may be broader than was previously recognized.     

Prevalence,natural history,and relationship of wheezy bronchitis and asthma in children. An epidemiological study

Three randomly selected groups of 7-year-old schoolchildren in Melbourne with mild wheezy bronchitis, with moderate wheezy bronchitis, and with asthma were compared with a control group, and the patients followed up until 10 years of age. Comparison showed that if there was any significant difference between the study groups and the controls it was usually present in all these study groups. It was considered that children with wheezy bronchitis and asthma were from the same population with the same underlying basic disorder, and that there was a wide spectrum in various aspects of the natural history of the disorder.About 11% of all children aged 10 years had had some asthmatic episodes. Seventy per cent. of these children ceased having asthma before 10 years of age, while about 30% (3·7% of the whole community) continued to have episodes. There was a highly significant correlation between early age of onset, the frequency of episodes in the first year of symptoms, and the persistence of asthmatic episodes up to 10 years of age.Ten per cent. of all children with asthmatic episodes continued to have symptoms as severely at 10 years as at an earlier period. In this group the onset of symptoms was almost always before 3 years of age, there was a high frequency of episodes in the first year of symptoms, and boys and girls were affected in the ratio of 7:3.     

A Transcultural Model of the Centrality of “Thinking a Lot” in Psychopathologies Across the Globe and the Process of Localization: A Cambodian Refugee Example

We present a general model of why “thinking a lot” is a key presentation of distress in many cultures and examine how “thinking a lot” plays out in the Cambodian cultural context. We argue that the complaint of “thinking a lot” indicates the presence of a certain causal network of psychopathology that is found across cultures, but that this causal network is localized in profound ways. We show, using a Cambodian example, that examining “thinking a lot” in a cultural context is a key way of investigating the local bio-cultural ontology of psychopathology. Among Cambodian refugees, a typical episode of “thinking a lot” begins with ruminative-type negative cognitions, in particular worry and depressive thoughts. Next these negative cognitions may induce mental symptoms (e.g., poor concentration, forgetfulness, and “zoning out”) and somatic symptoms (e.g., migraine headache, migraine-like blurry vision such as scintillating scotomas, dizziness, palpitations). Subsequently the very fact of “thinking a lot” and the induced symptoms may give rise to multiple catastrophic cognitions. Soon, as distress escalates, in a kind of looping, other negative cognitions such as trauma memories may be triggered. All these processes are highly shaped by the Cambodian socio-cultural context. The article shows that Cambodian trauma survivors have a locally specific illness reality that centers on dynamic episodes of “thinking a lot,” or on what might be called the “thinking a lot” causal network.