EJINME-03506; No of Pages 3

European Journal of Internal Medicine xxx (2017) xxx–xxx

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European Journal of Internal Medicine

journal homepage: www.elsevier.com/locate/ejim

Original Article

The “Ulysses syndrome”: An eponym identifies a psychosomatic disorder in

modern migrants
Raffaella Bianucci a,b,c,⁎, Philippe Charlier d,e, Antonio Perciaccante f, Donatella Lippi g, Otto Appenzeller h,i
a
Warwick Medical School, Microbiology and Infection Division, The University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom
b
Department of Public Health and Pediatric Sciences, Legal Medicine Section, University of Turin, Italy
c
UMR 7268, Laboratoire d'Anthropologie bio-culturelle, Droit, Etique & Santé (Adés), Faculté de Médecine de Marseille, France
d
Section of Medical and Forensic Anthropology (UVSQ & Paris-Descartes University EA 4569), Montigny-Le-Bretonneux, France
e
CASH & IPES, Nanterre, France
f
Department of Medicine, “San Giovanni di Dio” Hospital, Gorizia, Italy
g
Department of Experimental and Clinical Medicine, University of Florence, Italy
h
New Mexico Health Enhancement and Marathon Clinics Research Foundation, 361 Big Horn Ridge Dr, Albuquerque, NM, USA
i
New Mexico Museum of Natural History and Science, 1801 Mountain Road NW, Albuquerque, NM, USA

a r t i c l e i n f o a b s t r a c t

Article history: Due to civil wars, violence and persecutions, between 2015 and 2016, more than 1.4 million people, from the
Received 25 March 2017 Middle East and Africa, fled their counties and migrated to Europe. The vast majority of migrants, who have al-
Accepted 28 March 2017 ready experienced enormous level of stressors, are faced with dangerous, often lethal, migratory journeys.
Available online xxxx
Those who survive are exposed to adaptation stressors such as different languages, isolation, lack of work oppor-
tunities, diminished social status and a sense of failure in the new countries of residence. These are stressors that
Keywords:
Migrations patterns
go far beyond the usual adaptation stresses to new cultures and migrants experience permanent crises with an
Psychosomatic disorders imminent risk of developing the “Ulysses syndrome”. As a consequence, many individuals often develop symp-
Integration projects toms such as irritability, nervousness, migraine, tension headache, insomnia, tiredness, fear, loss of appetite
and generalized ill-defined discomfort. If left untreated these symptoms, originally described by Hofer in the
17th century, may degenerate into a severe psychosomatic disorder leading to reactive depression. Here we ex-
pand the concept of Ulysses' syndrome and illustrate new initiatives aimed at reducing the level of stressors in
migrants and at promoting their successful integration in their new countries.
© 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

1. Introduction postulated that nostalgia was a pathologic condition of imagination, a

't was now the hour that turneth back desireIn those who sail the sea,
and melts the heart,The day they've said to their sweet friends fare-
well…
[Dante, Purg. VIII, 1–3 (The Divine Comedy of Dante Alighieri trans-
lated by Henry Wadsworth Longfellow, London, G. Routledge 1867)]
The Swiss physician Johannes Hofer (1669–1752) coined the term
nostalgia (nostos = return home and algos = pain) in 1688 [1]. This
term remained unchanged for three centuries and was considered a
neurological disease. In his doctoral dissertation [1], basing his reason-
ing on the concept of imaginatio lesa (injured imagination), Hofer
⁎ Corresponding author at: Warwick Medical School, Microbiology and Infection
Division, The University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom.
E-mail address: r.bianucci@warwick.ac.uk (R. Bianucci).
cerebral disease of essentially demonic cause whose origin had to be iden-
tified into the quite continuous vibration of animal spirits through those fi-
bres of the middle brain in which impressed traces of ideas of the Fatherland
still cling [1,2]. Nostalgia affected the Swiss mercenaries who were fight-
ing in far-away lands and had lost the charms of the homeland, displaced
students and domestic help and servants working abroad [1,2]. These
individuals experienced an emotional lability ranging from despondency
to bouts of weeping, anorexia, fever, insomnia and suicide attempts [1,2].
Also named by the French, “Mal du Pays”, the terms nostalgia/home-
sickness, which was attributed to brain dysfunctions, persisted in the
18th and 19th centuries [2]. Between the end of the 19th and the begin-
ning of the 20th centuries, the clinical term “nostalgia” shifted from a
neurological disease to a psychosomatic disorder. The concepts of nos-
talgia and homesickness became separated in the latter part of the
20th century [2,3].
The continuing Middle Eastern war has produced a migrant crisis
not seen since the 1940ies with a resurgence of emotional problems
as originally described by Hofer [1].

http://dx.doi.org/10.1016/j.ejim.2017.03.020
0953-6205/© 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Please cite this article as: Bianucci R, et al, The “Ulysses syndrome”: An eponym identifies a psychosomatic disorder in modern migrants, Eur J
Intern Med (2017), http://dx.doi.org/10.1016/j.ejim.2017.03.020
2 R. Bianucci et al. / European Journal of Internal Medicine xxx (2017) xxx–xxx
2. The syndrome of the extreme migratory duel or “Ulysses
syndrome”
The existence of a severe psychosomatic disorder associated with
complex population migrations was recognized and named “Syndrome
of the Extreme Migratory Duel” in 1994. It was also named “Ulysses syn-
drome” by the Spanish psychiatrist Joséba Achotegui [4–8].
The eponym originates from the mythical Greek hero, Ulysses/Odys-
seus, the main character of the Homeric poem, the Odyssey. The rele-
vance of the story of Ulysses is so compelling that it is now used to
define an Odyssey that is “as a complex and treacherous journey in multi-
ple languages and in many cultures around the world” [4].
Over the past two centuries, human populations were often
displaced to improve their lives and each migration was characterized
by levels of stressors responsible for “simple migratory duel”. This
term describes a condition that encompasses both the fatigue of the
journey and the effort to adapt to the new country [4–8]. By the end
of the 19th century and during the 20th century, when working oppor-
tunities were available, most migrants overcame this psychological duel
and integrated successfully into the new societies [4–8].
Surveys on migrations in Spain in the nineteen eightieth (data col-
lector: Fundación Vidal i Barraquer and the present day (data collector:
Servicio de Atención Psicopatológica y Psicosocial a Inmigrantes y
Refugiados) have shown that migrants have progressively experienced
increased levels of stressor and the effects of the 21st century global
economic crisis together with the armed conflicts, persecution and pov-
erty have altered the migration patterns [4–8].
The vast majority of migrants have already experienced enormous
level of stressors, mainly linked to violence traumas and poverty in
their native countries. After forced separation from families and home-
land, they are faced with dangerous and, often lethal, migratory jour-
neys. Those who survive are exposed to adaptation stressors such as
different languages, isolation, lack of work opportunities, diminished
social status and diffuse sense of failure in the new countries of resi-
dence. These are stressors that go far beyond the usual adaptation
stresses when encountering new cultures. The fight for survival
(where will I sleep? where will I eat? what will I do with my life?),
the dreadful migration journeys and the constant anguish of being jailed
or repatriated (for those who have not applied for asylum) determine
the development of the so-called “extreme migration duel”.
When a person is forced to cope with exceptionally stressful living
condition, he/she becomes unfit to elaborate the “duel” and experiences
a permanent crisis. The concomitant presence of several pre- and post-
migration stressors increases the burden of each stressor exponentially.
If the stress factors persist over months or even years, then, the risk of
developing the “Ulysses syndrome” becomes imminent. Living in dread-
ful conditions leads alteration in people's personality and affects their
normal physiological processes, with activation of the hypothalamic-pi-
tuitary-adrenal (HPA) axis, altered secretion of hormones and of neuro-
transmitters, as originally postulated by Hans Seyle in 1936 [9]. As a
consequence, many individuals often develop symptoms such as irrita-
bility, nervousness, migraine, tension headache, insomnia, tiredness,
fear, loss of appetite and generalized ill-defined discomfort.
If left untreated these symptoms, originally described by Hofer in the
17th century [1], may degenerate into a severe psychosomatic disorder
leading to reactive depression. The effectiveness of antidepressants in
the treatment of reactive depression in migrants suggests that Hofer
was correct in attributing Ulysses' syndrome to midbrain dysfunction.
3. Current trends and future initiatives
Different surveys have been carried out throughout Europe in the
last decade to assess the risk of development of psychosomatic disor-
ders and other mental disorders in migrants and refugees [10–14].
Meta-analyses of studies performed in northern European countries
have shown that both first- and second-generation migrants were at
Please cite this article as: Bianucci R, et al, The “Ulysses syndrome”: An eponym identifies a psychosomatic disorder in modern migrants, Eur J
Intern Med (2017), http://dx.doi.org/10.1016/j.ejim.2017.03.020
greater risk of developing mental disorders such as schizophrenia than
non-migrants and that those from developing countries were more at
risk than those from developed ones [12]. The same study showed
that black migrants, in a prevalently white population, had an almost
fivefold increased risk of psychotic behaviour. And the risk is even
higher for migrants living in neighbourhoods with a low proportion of
residents from their own ethnic group compared with those
surrounded by many of their own ethnicity [12].
A large cohort study published in March 2016 examined l.3 million
people who had arrived in Sweden before 2011 [13]. Refugees had a
threefold higher incidence of schizophrenia and other psychotic disor-
ders than native-born Swedes, and a 66% higher incidence than mi-
grants who were not refugees. However, the overall risk for refugees
and migrants still remains comparatively low, at perhaps 2–3%. A
more recent analysis of UK migration data suggests that the level of in-
creased risk of psychotic disorders may depend on how old people were
when they migrated, with children potentially at greater risk [10].
Between the second half of 2015 and the first half of 2016, more than
1.4 million refugees (mainly from the Middle East and Africa) have fled
armed conflicts and poverty and have applied for asylum in Europe.
Germany (641,535), Sweden (142,560), Hungary (130,695), Italy
(103,430), Austria (83,080) and France (76,900) were the countries
that have received the highest number of migrants. Apparently there
is, at least, another half million of migrants, who reached the European
Community, and did not apply for asylum [10,11].
A local survey was performed in 2015 at Konstanz University on ref-
ugees who had applied for asylum in Germany; this showed that a quar-
ter of refugees had a post-traumatic stress syndrome, sleeplessness,
anxiety or depression and half of them showed severe signs of mental
disorder [10,11].
Similar surveys have been carried out in Italy. In 2015, 150,000 mi-
grants and refugees (especially from Somalia, Nigeria and Eritrea)
reached Sicily by sea following the Libyan route and over 3700 perished
during the journey [15].
The Italian Ministry of the Interior estimated that, in 2014, the per-
centage of disabled migrants including those suffering from mental dis-
orders was around 7,8%. However, it appears that the overall estimate of
individuals affected by psychosomatic disorders and admitted to health
assistance centres was, at least, double (15–16%) [16].
At the beginning of 2015, 5,014,000 non-Italian citizens were living
in Italy as determined by the Institute for the Study of the Multiethnicity
(ISMU) and, in March 2016, 80% of migrants entering Italy were illegal
and were living in extremely poor conditions [17].
A local survey was carried out at the STP Centre (Centre for the assis-
tance of foreigners temporary living in Italy) of the Galliera Hospital
(Genoa, Liguria) on one hundred and sixty individuals (legal and illegal
migrants). Fifty-nine percent of the interviewed reported a worsening
of their living conditions since their arrival in Italy and the causes of
their malaise was attributed by 32.3% to stress, anxiety and worries;
16,8% complained of osteo-muscular pathologies linked to emotional
unexpressed distress. [18].
A “Migrant First Aid Centre” for migrants was established at the
Galliera Hospital in 2015. All 3000 migrants who transited through
Genoa were identified and hosted in 1300 reception centres. A pilot pro-
ject, whose aim is to screen the physical and psychological conditions of
migrants, was initiated [17] and people affected by different kinds of in-
fectious and transmittable illnesses (HIV, hepatitis B, gonorrhoea, syph-
ilis, TB, pediculosis) received assistance. Help was also given to pregnant
women until the delivery and care to the newborn was provided. Specif-
ic psychological and psychiatric support was provided to those in need.
As a result, traumatized individuals felt that the quality of their lives had
improved and that they were experiencing a more positive attitude to-
wards the new environment. These data shows that the well-being of
each person, especially those who are frail and socially isolated, can
lead to improvements in their lives thus facilitating the process of adap-
tation [18].
 R. Bianucci et al. / European Journal of Internal Medicine xxx (2017) xxx–xxx
In 2016 an ecumenical collaboration between Catholics and Protes-
tants was established in Italy to join forces into a high-profile humani-
tarian project named “Humanitarian Corridors for Refugees”. A
Memorandum of Understanding was signed with the Italian Ministry
of Foreign Affairs and International Cooperation - General Directorate
for Italians Abroad and Migration Policies, the Ministry of Interior - De-
partment for Civil Liberties and Immigration [19].
The initiative is self-funded by the organizations that promote the
project and does not involve costs for the State. The aims of the pilot
project, which was the first of this kind in Europe, are multifold: 1- to
avoid dangerous journeys by sea through the Mediterranean thus re-
ducing the number of casualties; 2- to prevent the exploitation of refu-
gees by human traffickers; 3- to grant victims of persecution, torture
and violence as well as families with children, the elderly, the sick, per-
sons with disabilities, regardless of their religious or ethnic background,
to enter the Italian territory legally with humanitarian visas and to apply
for asylum in Italy [19].
The religious organizations send volunteers to make direct contact
with refugees in the country where the projects is active or work on re-
ports provided by local interests (local NGOs, associations, international
organizations, churches and ecumenical organizations etc.).
A list of potential beneficiaries will be sent to the Italian consular au-
thorities which forward the list to the Ministry of the Interior. The Min-
istry of Interior will examines each case and issues Visas with Limited
Territorial Validity (these visas are valid only for Italy and are pursuant
to art. 25 of the Visa Regulation (EC), which provides for a Member State
the possibility of issuing visas for humanitarian reasons or national in-
terest or because of international obligations).
The organizations provide refugees with legal assistance (for those
who wish to apply for international visas), provide economic support
for their travels to Italy, guarantee hospitality and accommodation in
different homes and shelters in Rome and Lazio, Emilia Romagna,
Trentino and Piemonte and support migrants during their integration
process in Italy.
These mechanisms allow refugees to enter Italy legally and safely.
Once in Italy, refugees are offered integration into the society (i.e. lan-
guage instructions, children are sent to school and adults are helped to
find jobs). Migrants are also provided with a copy of the Italian Consti-
tution translated in their own languages.
Between February 29, 2016 and March 2017, about 700 Syrian peo-
ple fleeing from war entered Italy using the “Humanitarian Corridors”. It
has been estimated that, thanks to the humanitarian corridors, a thou-
sand refugees from Lebanon (mostly Syrians who are fleeing war), Mo-
rocco (people from sub-Saharan countries affected by civil wars and
widespread violence) and Ethiopia, Eritrea, Somalia and Sudan, will ar-
rive in Italy over the next two years. Humanitarian corridors can be pro-
posed as replicable projects to all Members of the Schengen area and
not only by single associations.
On March 14, 2017, an agreement was signed at the Elysée Palace to
establish humanitarian corridors in France. Among the signatories, in
addition to the Ministers of the Interior and the French Foreign Affairs,
there were representatives of the promoting organizations: the Com-
munity of Sant'Egidio, the Protestant Federation of France, the French
Bishops' Conference, Entraide Protestant and Secours Catholique. The
arrival of the first families from Lebanon is expected within the next
two months [20].
4. Conclusions
The political and social upheavals that characterize contemporane-
ous world condition have led to a resurgence of a psychosomatic
Please cite this article as: Bianucci R, et al, The “Ulysses syndrome”: An eponym identifies a psychosomatic disorder in modern migrants, Eur J
Intern Med (2017), http://dx.doi.org/10.1016/j.ejim.2017.03.020
3
disorder recognized since the 17th century. However, indifference and
intolerance can be fought and integration can protect more than walls.
By rediscovering the values of hospitality and solidarity, a successful in-
tegration can be reached with social-demographical and economical
benefits for both migrants and the hosting countries.
Funding
None.
Conflict of interest
None.
Acknowledgements
Raffaella Bianucci thanks the Wellcome Trust (202792/Z/16/Z) for
support of her research activity at Warwick Medical School, University
of Warwick (UK).
References
[1] Hofer J. Dissertation Medica de Nostalgia (Medical dissertation on nostalgia), trans.
Carolyn Kiser Anspach, Bulletin of the Institute of the History of Medicine. , vol. 2Bal-
timore: Johns Hopkins Press; 1934[381 pp].
[2] Sedikes C, Wildschut T, Baden D. Nostalgia - conceptual issues and existential func-
tions. In: Greenberg Jeff, editor. Handbook of experimental existential psychology.
New York: Guilford Publications; 2004. p. 200–14.
[3] Batcho KI. Personal nostalgia, worldview, memory, and emotionality. Percept Mot
Skills 1998;87:411–32.
[4] Achotegui J. Emigrar hoy en situaciones extremas. El síndrome de Ulises (Migrating
today in extreme conditions. The Ulysses Sindrome). Aloma, Revista de Psicologia,
Ciències de l'Educació i de l'Esport 2012;30(2):79–86.
[5] Omelianuk I, editor. Global perspectives on migration and development. GFMD
Puerto Vallarta and beyond. Global migration issues 1. Springer; 2012. p. 91–112.
[6] Achotegui J. Emigrar en el siglo XXI: estrés y duelo migratorio en el mundo de hoy. El
Síndrome del inmigrante con estrés crónico y múltiple-Síndrome de Ulises; 2009.
[7] Achotegui J. Cómo evaluar el estrés y el duelo migratorio. Escalas de evaluación de
factores de riesgo en la migración. Aplicación al estrés y el duelo migratorio. Escala
Ulises; 2009.
[8] La Crisis Achotegui J. Como Factor Agravante Del Síndrome De Ulises (Síndrome Del
Duelo Migratorio Extremo). Temas De Psicoanálisis, 3. ; 2012 [16 pp].
[9] Fink J. Eighty years of stress. Nature 2016;539:175–6.
[10] http://www.nature.com/news/the-mental-health-crisis-among-migrants-1.20767.
[11] http://www.nature.com/polopoly_fs/1.20770!/menu/main/topColumns/
topLeftColumn/pdf/538139a.pdf.
[12] Cantor-Graae E, Selten J-P. Schizophrenia and migration: a meta-analysis and re-
view. Am J Psychiatry 2005;162(1):2–24.
[13] Hollander AC, Dal H, Lewis G, Magnusson C, Kirkbride JB, Dalman C. Refugee migra-
tion and risk of schizophrenia and other non-affective psychoses: cohort study of 1.3
million people in Sweden. BMJ 2016;352:i1030.
[14] Pérez-Álvarez M, García-Montes JM, Vallina-Fernández O, Perona-Garcelán S. Re-
thinking schizophrenia in the context of the person and their circumstances:
seven reasons. Front Psychol 2016 https://doi.org/10.389/fpsyg.2016.01650.
[15] http://www.emergency.it/archivio/ml/report/EMERGENCY-REPORT-2015.pdf.
[Accessed on March 17 2017].
[16] http://ricerca.repubblica.it/repubblica/archivio/repubblica/2010/07/21/ansia-nostal-
gia-la-sindrome-di-ulisse.html. [Accessed on March13 2017].
[17] www.corriere.it/salute/neuroscienze/16_marzo_27/migranti-sotto-stress-
e7974b0e-f3f6-11e5-b407-9f5ad35fe288.shtml. [Accessed on March 13 2017].
[18] http://www.simmweb.it/images/XIVCongrSIMM2016/poster/70_Leone_SIMM2016.
pdf. [Accessed on March 22 2017].
[19] http://www.santegidio.org/pageID/1/langID/en/idLng/1064/HOME. [Accessed on
March 22 2017].
[20] http://www.santegidio.org/pageID/3/langID/en/itemID/20256/Humanitarian-corri-
dors-for-refugees-in-France-are-now-open-the-agreement-was-signed-at-the-
Elysee.html#3_20336,3_20292,3_20256,3_20172,3_20156. [Accessed on March 22
2017].