Skip to main content
SpringerLink
Log in

Baksbat (Broken Courage): The Development and Validation of the Inventory to Measure Baksbat, a Cambodian Trauma-based Cultural Syndrome of Distress

  • Original Paper
  • Published:
Culture, Medicine, and Psychiatry Aims and scope Submit manuscript

Abstract

This article outlines the development and validation of an inventory measuring a Cambodian cultural syndrome of distress called ‘baksbat’ (broken courage). The inventory development phase involved ethnographic interviews with a preliminary group of 53 experts having knowledge or experience of baksbat. The initial ethnographically derived inventory with 32 items was developed and administered to a second group of 390 consecutive patients to assess factor loadings. The validation phase used confirmatory factor analysis (CFA) to test goodness-of-fit of four hypothesized factor models of the newly developed inventory in a third group of 159 participants. CFA confirms three-factor models that have the best goodness-of-fit, thus a 24-item baksbat inventory clustering of three-symptom categories was developed. Multiple regression, which assesses the relationship between the dependent variable (PTSD) and a subcluster of baksbat inventory (predictors), shows baksbat inventory accounts for 47 % of the total variance of symptoms in PTSD (R 2 = .47). Of the three-symptom clusters, ‘psychological distress’ shows significant contribution to the total variance of symptoms in PTSD (β = .63, p < .001). Of significance, some symptoms of baksbat were independent from symptoms of PTSD with isolated symptoms that are culturally specific. These preliminary findings suggest that baksbat could be a potential Cambodian trauma-based syndrome with its own culturally validated inventory.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Notes

  1. In the Khmer Rouge time, people hid their identity to survive. They told each other to dam doeum kor (plant the kapok tree or Ceiba pentandra tree), which means to pretend to be mute and deaf. In Khmer language the word kor has different function. Kor as a noun means kapok tree (Ceiba pentandra) but kor as an adjective means ‘mute and deaf.’ So, people survive because they plant the mute tree or pretend to be mute, dumb and deaf.

  2. Pursat, Battambang, Banteay Meanchey, Siem Reap, Preah Vihear, Kampong Thom, Kampot and Takeo provinces.

References

  • Atkinson T.M., Barry D., Laura S., Tito R.M., Mike F., Dawn L., Mary S., Yuelin L., Jennifer H., Charles S.C., Howard I.S., William S.B., and Ethan B. 2011 Using Confirmatory Factor Analysis to Evaluate Construct Validity of the Brief Pain Inventory (BPI). Journal of Pain and Symptoms Management 41(3):558–565.

    Article  Google Scholar 

  • Bernsen, Markus 2005 Mental Health Workers Preparing for Khmer Rouge Trial Fallout. Phnom Penh Post, Cambodia.

  • Braken J.P., and Petty C.I., ed. 1998 Rethinking the Trauma of War. London: Free Association Books.

    Google Scholar 

  • Byrne, Barbara M. 2004 Structural Equation Modeling with AMOS: Basic Concepts, Apllications, and Programming. Mahwah, NJ: Erlbaum.

    Google Scholar 

  • Byrne, Barbara M. 2010 Structural Equation Modeling with AMOS: Basic Concepts, Applications and Programming. 2nd Edition. New York. Routledge.

    Google Scholar 

  • Chandler, David P. 2007 A history of Cambodia. Boulder, CO: Westview Press.

    Google Scholar 

  • Cheung, Peter 1994 Post Traumatic Stress Disorder among Cambodian refugees in New Zealand. Journal of Traumatic Stress 40(1):17–26.

    Google Scholar 

  • Chhim, Sotheara 2012 Baksbat (Broken Courage): A Trauma-Based Cultural Syndrome in Cambodia. Medical Anthropology. doi:10.1080/01459740.2012.674078.

  • Chourn, Nath 1967 Dictionnaire Cambodgien. Volume I & II. Phnom Penh: Étude de L’Institute Bouddhistique.

  • De Jong, J., and van Ommeren, M. 2001 Toward a Cultural-Informed Epidemiology: Combining Quantitative and Qualitative Research in Transcultural Contexts. Transcultural Psychiatry 39(4):422–433.

    Article  Google Scholar 

  • De Jong, J., Komproe, I., and van Ommeren, M. 2003 Common Mental Disorders in Postconflict Settings. The Lancet 361:2128–2130.

    Article  Google Scholar 

  • De Jong, T.V.M. J., and R. Reis 2010 Kiyang-Yang, a West-African Post-War Idiom of Distress. Culture, Medicine and Psychiatry 34:301–321.

    Article  Google Scholar 

  • Dubois V., Tonglet R., Hoyois P., Ka S., Roussaux, J. P., and Hauff, E. 2004 Household Survey of Psychiatric Morbidity in Cambodia. International Journal of Social Psychiatry 50(2):174–185.

    Article  Google Scholar 

  • Eisenbruch, M. 1991 From Post-Traumatic Stress Disorder to Cultural Bereavement: Diagnosis of Southeast Asian refugees. Social Science Medicine 23(6):673–680.

    Article  Google Scholar 

  • Eisenbruch, M. 1992 Toward a Culturally Sensitive DSM Cultural Bereavement in Cambodian Refugees and the Traditional Healer as a Taxonomist. Journal of Nervous and Mental Disease 181(1):8–10.

    Article  Google Scholar 

  • Elsass, Peter 2001 Individual and Collective Traumatic Memories: A Qualitative Study of Post-Traumatic Stress Disorder Symptoms in Two Latin American Localities. Transcultural Psychiatry 38(3):306–316.

    Article  Google Scholar 

  • Field N.P., and Chhim S. 2007 Desire for Revenge and Attitudes to the Khmer Rouge Tribunal Among Cambodians. Journal of Loss and Trauma 13(4):352–372.

    Article  Google Scholar 

  • Firat M.F., O. Zen Kulakc, S. Oncel and A. Akcan 2009 Menstrual Attitude Questionnaire: confirmatory and exploratory factor analysis with Turkish sample. Journal of Advanced Nursing 65(3), 652–662.

    Article  Google Scholar 

  • Herman, JL 1992a Trauma and Recovery. New York: Basic Books.

    Google Scholar 

  • Herman, J. L. 1992b Complex PTSD: A Syndrome in Survivors of Pronlonged and Repeated Trauma. Journal of Traumatic Stress 5(3):377–391.

    Article  Google Scholar 

  • Hinton E.D., Pich V., Marques L., Nickerson A., and Pollack M.H. 2010 Khyal Attacks: A Key Idiom of Distress Among Traumatized Cambodia Refugees. Culture, Medicine and Psychiatry.

  • Hinton, E.D., Pich, V., Chhean, D., and Pollack, H.M. 2005 The Ghost Pushes You Down: Sleep Paralysis-Type Panic Attacks in a Khmer Refugee Population. Transcultural Psychiatry 42(1):46–-77.

    Article  Google Scholar 

  • Hinton, E.D., Un, K., and Ba, P. 2001 Kyaol Goeu (Wind Overload) Part I: A Cultural Syndrome of Orthostatic Panic among Khmer Refugees. Transcultural Psychiatry 38(4):403–432.

    Article  Google Scholar 

  • Hu L.T. and P.M. Bentler 1999 Evaluation Model Fit. In Structural Equation Modeling: Concepts, Issues and Application. R.H. Hoyle, ed., pp. 76–99. Thousand Oaks, CA. Sage Publication.

    Google Scholar 

  • Hubbard, Jon 2007 Using Brief Ethnographic Interviewing as a Method for Understanding an Issue, Problem or Idea from a Local Perspective. Minneapolis: Center for Victims of Tortures.

    Google Scholar 

  • Kinzie, D.J., Boehnlein, J.K., Leung P.K., Moore, L.J., Riley, C., and Smith, D. 1990 The Prevalence of PTSD and its Clinical Significance Among Southeast Asia Refugees. American Journal of Psychiatry 147(7):913–917.

    Google Scholar 

  • Kohrt, Brandon A, and Hruschka, Daniel J. 2010 Nepali Concepts of Psychological Trauma: The Role of Idioms of Distress Ethnopsychology and Ethnophysiology in Alleviating Suffering and Preventing Stigma. Culture, Medicine and Psychiatry 34:322–352.

    Article  Google Scholar 

  • Kumar, Rajendar 2008 Research Methodology. New Delhi, S. B. Naugia.

  • LeVine, Peg 2010 Love and Dread in Cambodia: Weddings, Births, and Ritual Harm under the Khmer Rouge. Singapore: NUS Press.

    Google Scholar 

  • Littlewood, R., and Cheng, A.T.A. 2001 Culture-Specific Psychiatric Illness? Author’s Reply. The British Journal of Psychiatry 179(5):460–461.

    Google Scholar 

  • Marsella, A.J., Friedman, M.T., Gerrity, T., and Schonfield, M., ed. 1996 Ethnocultural Aspects of PTSD. Washington: American Psychiatric Association.

    Google Scholar 

  • Marwa, S., Weinstein, H., and Mollica, R. 2007 The Harvard Trauma Questionnaire: Adapting A Cross-Cultural Instrument for Measuring Torture, Trauma and PTSD in Iraqi Refugees. International Journal of Social Psychiatry 53(5):447–463.

    Article  Google Scholar 

  • Meyers, L.S., G. Gamst, and A.J. Guarino, 2006 Applied Mulivariate Research, Design and Interpretation. Thousand Oaks, CA. Sage Publication.

    Google Scholar 

  • Mollica, F., McInnes, K., Poole, C., and Tor, S. 1998 Dose–Effect Relationships of Trauma to Symptoms of Depression and Post-Traumatic Stress Disorder Among Cambodian Survivors of Mass Violence. British Journal of Psychiatry 172(12):482–448.

    Google Scholar 

  • Mollica, Richard, F. 1991 Harvard Trauma Questionnaire: Cambodian Version. Boston: I.P. Clinic and H.S.o.P.H. Harvard Program in Refugee Trauma.

  • Pallant, Julie 2011 SPSS Survival Manual: A Step-by-Step Guide to Data Analysis Using SPSS Program. Crows Nest: Allen & Unwin.

  • Rechtman, Richard 2000 Stories of Trauma and Idioms of Distress: From Cultural Narratives to Clinical Assessment. Transcultural Psychiatry 37(3):403–415.

    Article  Google Scholar 

  • Sonis, J, GBIon J.L., de Jong, J.T., Field, N.P., Hean S., and Komproe I. 2009 Probable Posttraumatic Stress Disorder and Disability in Cambodia: Association with Perceived Justice, Desire for Revenge and Attitude Toward the Khmer Rouge Trials. JAMA 302(5):527–536.

    Article  Google Scholar 

  • Strauss, A., and Corbin, J. 1998 Basics of Qualitative Research. Thousands Oaks, CA: SAGE.

    Google Scholar 

  • Summerfield, D. 1999 A Critique of seven Assumptions Behind Psychological Trauma Programmes in War-Affected Areas. Social Science and Medicine 48:1449–1462.

    Article  Google Scholar 

  • Teddlie, Charles, and Yu, Fen 2007 Mixed Methods Sampling: A Typology With Examples. Journal of Mixed Methods Research 1:77–100.

    Article  Google Scholar 

  • Thompson, Ashley 2005 Calling the Souls: Cambodian Ritual Text. Phnom Penh: REYUM Publishing.

  • TPO 2011 Transcultural Psychosocial Organization: Annual Report 2011. Phnom Penh: TPO.

  • Vieira, L. Armando 2011 Interactive LISREL in Practice: Getting Started with a SIMPLE Approach. Heidelberg: Springer.

    Google Scholar 

  • Wartkins, W. Marley 2000 Monte Carlo PCA for Parallel Analysis. Real Basic.

Download references

Acknowledgments

I would like to sincerely thank the Australian Government and its people for awarding me the Australian Leadership Award (ALA) scholarship to undertake PhD degree at Monash University. This research project was kindly sponsored by USAID grant via the Center for Victims of Torture (CVT) in Minneapolis, USA. I would like to express my profound gratitude to the TPO Cambodia, friends and collaborators who have loyally supported me during this study.

Author information

Authors and Affiliations

  1. Transcultural Psychosocial Organization (TPO Cambodia), TPO Building, No 2&4, Oknha Vaing Road, Sangkat Phnom Penh Thmey, Khan Sen Sok, Phnom Penh, Cambodia

    Sotheara Chhim

  2. Monash Asia Institute, Monash University, 900 Dandenong Road, Caulfield East, VIC, 3145, Australia

    Sotheara Chhim

Authors
  1. Sotheara Chhim
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sotheara Chhim.

Appendix

Appendix

TPO Baksbat Inventory (TPO BI): An inventory measuring symptoms of trauma responses in Cambodia.

An individual who has baksbat should fulfil the following conditions: An individual must have experienced or witnessed traumatic events such as torture, physical or sexual abuse, been defeated in the war, been physically and psychologically oppressed, been held hostage, experienced a natural disaster, been frightened by ghosts, been chased by wild animals or other similarly frightening situations. When the traumatic event is over, the individual should experience problems in the following three areas: broken courage, erosion of self and psychological distress. Please indicate your problems' severity according to the following inventory.

 

Broken courage

0

1

2

3

4

TPO BI-1

Dares not make decisions or cannot make decisions

     

TPO BI-2

Dares not confront

     

TPO BI-3

Dares not want to take initiative

     

TPO BI-4

Submits to others or admitted defeat to others

     

TPO BI-5

Plants kapok tree (Dam doeum kor), remains mute

     

TPO BI-6

Feeling and acting cowardly compared to before or loss of courage

     

TPO BI-7

Marks the stone or pierce one’s ears as reminder (Kap-thmor-chamnam, chos-tracheak-chamnam)

     

TPO BI-8

Cannot be open as before

     

TPO BI-9

Cannot rely on oneself

     

Psychological distress

1

2

3

4

5

TPO BI-10

Sleeping problems

     

TPO BI-11

Trembling, shaking of extremities, cold extremities

     

TPO BI-12

Trouble thinking (difficulty concentrating)

     

TPO BI-13

Tightness in the chest, palpitations, difficulty breathing

     

TPO BI-14

Easily fearful (fears bad consequence may happen)

     

TPO BI-15

Feeling flat or low emotionally and physically

     

TPO BI-16

Extreme fear, fright

     

TPO BI-17

Irritable mood, easily getting angry

     

TPO BI-18

Feeling restless or trapped

     

TPO BI-19

Loss of self-confidence

     

TPO BI-20

Feeling lonely

     

Erosion of self

1

2

3

4

5

TPO BI-21

Avoids meeting others, reduced socialization

     

TPO BI-22

Loss of honesty

     

TPO BI-23

Selfishness

     

TPO BI-24

Reduced contact with former relationship, loss of relationship with others

     
  1. 0: Not at all, 1: A little, 2: Sometime, 3: Frequent, 4: Very frequent

Rights and permissions

Reprints and permissions

About this article

Cite this article

Chhim, S. Baksbat (Broken Courage): The Development and Validation of the Inventory to Measure Baksbat, a Cambodian Trauma-based Cultural Syndrome of Distress. Cult Med Psychiatry 36, 640–659 (2012). https://doi.org/10.1007/s11013-012-9279-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11013-012-9279-6

Keywords

Search

Navigation