PTSD and Cultural Variance: Implications for Third Culture Kids

by | Mar 16, 2017 | Blog | 14 comments

Last year I was lucky enough to attend Katarina Holm-DiDio’s workshop on PTSD, at the Families in Global Transition conference in Amsterdam (I write about it more here). Katarina’s work is extensive and detailed, and you can find more about her and her current work here. She has since been generous enough to send me her thesis on the subject, in which she asks two questions

  1. How is post traumatic stress is manifested among people from different cultural backgrounds and regions?
  2. How can therapy and treatment for trauma related stress and PTSD be more culturally sensitive?

I have hesitated in writing this post – procrastinating might be more honest (!) Partly because this is a big topic that has touched many people’s lives, and partly because I would by no means count myself as an expert in it. However, I’m writing about PTSD and TCKs because I keep encountering TCK stories that feature pain and trauma, and I think that Katarina has touched on something that has wide-reaching implications for the TCK world. And this is the kind of something that needs to be heard.

Culture is defined by Katharina as:

“a shared system of meaning expressed through how we live and love, in our values and moral codes, and societal structures. How we define what is typical and healthy is cultural.”

And this is the critical point, that our experiences of trauma will be filtered through our own particular cultural lense. Our understanding of our selves, others and the world around us is influenced by our cultural world, and this in turn impacts on how we express emotional pain, and on how we heal. And this is where an understanding of culture bound syndromes can be helpful.

Culture Bound Syndromes are defined as, “recurrent, locally-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category” (American Psychiatric Association, p. 898). Bear in mind that these are considered ‘other’ simply by virtue of not being American or European. Please also bear in mind that these are not deterministic – just because you originate in these localities does not mean that you will inevitably experiences these syndromes. Katarina goes on to outline specific examples of culture bound syndromes in her work:


Kyol goeu: or othostatic panic, “sudden episode of fainting, when the individual often is unresponsive but conscious” (Boehnlein, 2001)

Mexico, Peurto Rico and other Latin American Cultures

Ataques de nervios: “episode of acute emotional upset”, “it is a cultural variation on a panic attack”

Malaysia, Laos, Philippines, Polynesia, Papua New Guinea and Puerto Rico

Amok: “a dissociative episode when the person initially broods and then explodes into aggressive or homicidal acts towards things and others”

Mexico, Central and South America, some Latinos in the UK

Susto: “soul loss”, “often preceded by a frightening event that results in sadness and being sick”, “low self-worth, dirtiness low motivation and sleep disturbances”, “traditionally healed by rituals where the soul is called back”


Hwa Byuang: “aches and pains, palpitations, anorexia, insomnia, fatigue, panic and fear of one’s death”

Malaysia, Thailand, Japan and the Philippines and some Siberian groups

Latah: “hypersensitive to sudden fright and is characterised by echolalia, being in a trance-like state and a tendency to follow commands”, “tends to be more common in middle-aged women”

Katarina concludes that a “principal question when discussing culture-bound illnesses or syndromes and how they are related to post traumatic stress is how health and illness are understood in different cultures.”

Sounds clear enough, right? Except this: TCKs grow up with multiple and at times conflicting cultural lenses. A British TCK may identify more closely with Mexican or Cambodian culture. A Cambodian may identify more closely with British culture. Will their symptoms of trauma and distress be recognised by their passport countries, when they are originate elsewhere?

When when identifying symptoms of trauma and distress in TCKs, it is not enough to be ‘culturally aware’. It is not enough to understand that a person’s cultural background impacts on experiences of both suffering and healing. Instead, the therapist needs to become fully aware of the hidden, as well as visible elements, of the TCK’s cultural history, moving beyond their current cultural identifications.

The implications of PTSD and its cultural variances are mind-blowing. Third Culture Kids are one group of many that migrate around this beautiful, and messy, globe of ours. And like others, their early cultural exposures and identifications may bear little resemblance to the cultures they move through and settle into in later life. As such, a clear and sensitive understanding of TCK life stories becomes crucial.

Therapists working with TCKs must understand ALL the “systems of meaning” and understandings about what is “typical and healthy” that play into TCKs world-views, so that we may be better positioned to better support their self-views as they move forward towards healing and wholeness.

** Holm-DiDio, K. Cultural Differences in Post Traumatic Stress Disorder Symptoms and Prevalence, Iona College

**Also at FIGT 2016, Amy Jung kindly shared some resources about complex PTSD, something that may be of interest to readers.

Complex PTSD – U.S. Department of Veterans Affairs

Complex post-traumatic stress disorder – Wikipedia

Other non-scholarly / unofficial sites are beginning to address this disorder. Examples:



  1. Dan Elyea

    Hello, Dr. Rachel,

    Interesting indeed to consider how being TCKs may put a different twist on PTSD and such.

    Not an illustration of PTSD, but of how cultural norms differ: I’ve observed very frequently with a death in the family that black women (including African-Americans and Haitians) carry on in what seems a crazy manner when expressing their grief. Extreme wailing and weeping, throwing themselves around, and even fainting seem to be very accepted and practiced. Occasionally, when a white family carries on a bit in a similar, though not as extreme a manner, I wonder whether they manage to “cleanse” their grief sooner and more thoroughly than some of us more restrained folks.

    Again, not necessarily PTSD, but still fallout from the MK experience would be night terrors, nightmares, and even daytime horrors. What I’m thinking of here are recurring dreams and frights, most awful, and occasioned by exposure to demonic activities in some foreign lands. I was troubled by this for many years, perhaps most of my life. And, not this topic, but somewhat related: the reality of the powers of darkness had one good effect on me . . . reassuring me of the actuality of God during a time of extreme doubt. It’s embarrassing to me that it took the powers of evil to strengthen my faith, but that’s how it happened for me. ~sigh~


    Dan Elyea

    • Dr. Rachel Cason

      Thank you so much for sharing your experiences, Dan. I’m sorry you had such a hard time with dreams and night terrors… but glad that you’ve found peace and strength over time. It’s useful as well as interesting to be aware of how different cultures respond to traumas; it introduces the idea that there is no one ‘right’ way of processing pain, or recieving healing.

    • Tabi

      I wanted to respond to Mr. Elyea’s comment. A culture-specific disorder for my part of the world isn’t listed here, but I likewise have had vivid nightmares, night terrors, and a feeling of being watched and followed especially when I am alone for most of my life. It has worsened at times of actual or potential transition, new role stress and strain, decision-making, geographical moves, and when I face or anticipate a separation from or am reunited with my parents or siblings (even though I’ve been “out of the nest for 10 years”). When I was a child I would wake my mother up because it only got better if she knew. I confess that sometimes I still do this to cope, or if it is too late at night I calm down by planning when I will call her.

      I’ve never thought of it as a cultural-experienced based form of PTSD, but maybe it is…

    • Daniel Hofer

      Mr Elyea,
      My interest was sparked by your testimony, as i have have nighttime fright and terror as well, after working in Africa and especially in Muslim cultural, religious, environments.
      How did you get help for this? I’m still not free from this, and thought it was just an element of spiritual warfare that was common. Please let me know all you can about this.

  2. Trisha Carter

    Hi Rachel,
    Thanks for your thought igniting post.

    I recently read ‘Tribe -On Homecoming and Belonging’ by Sebastian Junger. He is writing about PTSD in veterans and the impact of returning to a culture that seems ‘foreign’ to them where the values observed around them are not in line with the values they thought they were fighting for. He notes that the experience gained in the time in service isn’t really valued in terms of the most important currency – getting a new job. It struck me there were many comparisons and linkages to the TCK and expat / repat experiences. He implies that when that disconnect is greater then PTSD increases.
    It was a sobering read.

    • Dr. Rachel Cason

      Thank you so much for reading, Trisha, and for your input. I’ve added ‘Tribe’ to my Wish List! It is fascinating how many threads connect different experiences of cultural disconnection and ruptures in belonging… we have so much still to learn! Disconnection could be the best word to describe what many of my clients present with when we begin work together… disconnection with self, with others, with their own story.


    PTSD has also been criticized from the perspective of cross-cultural psychology and medical anthropology, especially with respect to refugees, asylum seekers, and political torture victims from non-Western regions.

    • Dr. Rachel Cason

      Yes… as with any ‘label’, it has it’s limits to explain the full variance of human experience. All tools should be used wisely…


    The argument for inclusion was that many sufferers of trauma and chronic trauma do not experience the standard symptoms of PTSD but rather symptoms of depression, anxiety, or dissociation, or of borderline personality disorder.

    • Dr. Rachel Cason

      Thank you for adding this insight!


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