Issues of Clinical Relevance

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Like other Hispanic groups in the United States, Nicaraguans come from a culture that adheres to traditional values, as described. Spanish is the predominant language of the immigrant generation, and Catholicism is the main religion. Family remains the most important institution of the group.

Nicaraguans, like other immigrant groups, have experienced residual psychological effects from the events that brought them to the United States and from the loss of their homeland. However, epidemiologic data indicate that although suicide and drug addiction have risen in the Nicaraguan society, they are less prevalent in the exile community, possibly confirming the principle of organic solidarity of migrant people when faced with hardship and challenge (Organization of American States 1995).

The most prevalent diagnoses among Nicaraguans in the United States are depression, anxiety, and posttraumatic stress disorder (PTSD). The following case vignettes have been selected to illustrate psychiatric issues that are pertinent to the Nicaraguan community.

The following case example illustrates low self-esteem in a woman who experienced previous abuse and a loss of professional status after immigrating to the United States and who had to become the head of the household.

Ms. H, a divorced woman in her 40s, sought psychiatric treatment because she was experiencing poor sleep, anxiety, weight loss, and tearfulness. She was the sole supporter of her two children but was employed in a low-paying position, even though she had had a professional career in Nicaragua. This greatly affected her self-esteem, and she was distressed that she could not do better. Her alcoholic ex-husband had verbally and physically abused her.

Treatment was started with an antidepressant, and weekly supportive therapy was successfully provided. The issues of low self-esteem in a woman who had come from a society of intricate machismo (the ideal of the strong, powerful, active man) and who had been abused were addressed in brief, focused psychotherapy. Eventually, Ms. H was able to obtain a better job, and she started dating a man who treated her with dignity and appreciation. At the monthly follow-up, her condition remained improved.

This case illustrates several issues that are relevant in working with Nic-araguan patients. First, this patient experienced a loss of professional status in immigrating to the United States. This has been the situation for many people who were professionals in their countries but in the United States are underemployed, not only in low-paying jobs but also in positions in which they are not able to use their skills. It is not atypical to see a former teacher cleaning houses or a former doctor working as a janitor in a hospital.

Second, this patient was the head of a household and was previously in an abusive relationship. Again, the experience of immigration has forced women to take on responsibilities they might not have had to assume in their homeland, such as working outside the home and being the primary breadwinner. However, it also has allowed them the opportunity to change circumstances that they might have been expected to tolerate in a more traditional setting, with a lingering abusive relationship.

The following case examples illustrate the importance of having a through understanding of patients' life circumstances in a patient with paranoia, a social marker of distress, and a patient with PTSD.

Mr. I, a college graduate in his 30s, went to Nicaragua to visit some friends and to reclaim some property that had been confiscated. While in Nicaragua, he developed intense fear, hid in his room, and refused to leave it. He began to think that the authorities were after him and that arrest warrants had been issued. When he returned to the United States, the intense paranoid delusion remained, along with elements of dysphoria and agitation. A brief psychotic disorder was diagnosed. He was treated with antipsychotic medications and weekly supportive psychotherapy. He responded successfully to treatment, and the medication was tapered. A year later, he remained symptom free.

Mr. J, a Nicaraguan man in his 40s, developed severe insomnia, flashbacks, and extreme apprehension several months after he arrived in the United States. His history revealed that while in Nicaragua, he had been imprisoned and subjected to subhuman, crowded conditions while incarcerated. He also developed intrusive, obsessional thinking and symptomatology of depression. He was given a diagnosis of PTSD. After brief psychotherapeutic intervention and temporary treatment with a sedative-hypnotic, Mr. J's symptoms remitted, and he was able to resume his normal life as a bank clerk.

In the above case examples, an understanding of Nicaragua's past and current political situation helped the clinician to understand the etiology of the symptoms and to commence the appropriate treatment. Traumatic experiences are often at the core of refugees' and immigrants' experiences, but they often remain undisclosed because of either the patient's inability to spontaneously bring them up or the clinician's reluctance to ask. People who have been tortured may feel shame, guilt, and helplessness or that it is useless to talk about their experiences because others simply will not understand. Similarly, therapists may inadvertently avoid opening up the discussion because of the difficulty in listening to stories of purposeful, horrifying brutality (Carrillo 1991; Lopez et al. 1988).

The following case example of a man with Alzheimer's disease illustrates several values that are important in Nicaraguan families and how these are affected by immigration.

Mr. L, an 85-year-old man, was brought to the doctor's office by his daughter because his memory was declining, he was wandering during the night, and he was making persistent claims that he was living on his farm in Nicaragua. After a thorough workup, he was given a diagnosis of advanced Alzheimer's disease. His daughter was very insistent on taking care of her father. She refused to place him in a nursing home because she was afraid "he would die there." She continued to take care of him, even though she lacked the financial resources, and eventually her stress became so prominent that she required antidepressant treatment.

The above case shows several values that are important in Nicaraguan families, including family loyalty and obligation and respect for and caregiv-ing of the elderly. In Nicaragua, the daughter might have been able to help care for her father with the support of an extended family in a society accustomed to taking care of the elderly at home. But in the United States, her energy was focused on everyday survival, and being a caregiver of her father felt like an other burden. Furthermore, the worsening of the father's condition may have been exacerbated by his own displacement (i.e., not knowing the language in the United States and lacking the familiarity of his homeland, neighborhood, and acquaintances to help orient him).

The following case illustrates some of the intergenerational conflicts that occur between immigrant parents and their children because they undergo different rates of acculturation (Bernal and Flores-Ortiz 1982).

John, a 16-year-old boy, was brought to treatment by his mother, who was concerned about her son's "habits." She reported that he was reclusive and spent long hours in his room listening to heavy metal music and not participating in family life. She also reported that he wore torn and loose pants. The mother had been born and raised in Nicaragua, was Catholic, and did not agree with all these "fads," as she expressed it. On interview, it was clear that John was experiencing a mild depression. He had also begun to smoke marijuana but quit after experiencing two panic attacks. After several weeks of treatment with an antidepressant and psychotherapy, his depressive symptoms remitted, he completely quit smoking marijuana, and his relationship with his parents improved. John reported that even his mother had made changes, becoming more tolerant of his musical choices. He was euthymic at 1-year follow-up.

Parents often feel as if their authority is weakened when their children do not defer to them in a way that is culturally expected, and, similarly, children may feel that their parents' expectations are too restrictive. The therapist must become a communication broker between the parent and the child and must help them see the world through each other's lenses. Also, as in the above case, it is important not to overlook substance use as self-medication for depression.

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