In recent years, the living conditions of millions of immigrants, around the world, have become increasingly difficult. Everywhere have been erected walls, barriers, moats. The seas, as in the case of the Mediterranean Sea, which was for a long time a sea of ​​exchange of culture and civilization, have become a border, a barrier.¹ At the family level, forced separations have been experienced. Throughout the world, many children have been separated from their parents at stages of life in which they need protection and security to grow and mature.

Nowadays there is a lot of talk about migration at the demographic and economic level, very relevant aspects, without a doubt. But it is very important to bear in mind that the protagonist of migration is the immigrant. We are talking about people, human beings of flesh and blood, with feelings, with illusions. When referring to migration, we not only have to see the graphs and economic statistics, it is essential to see people, rehumanize migration.

In my experience as psychiatrist, since the 90s I have been directing a mental health care service for immigrants in the port of Barcelona (España). ​​I have been able to see first-hand how the great hardships and adversities that millions of immigrants suffer today generate very intense levels of stress

It must be taken into account that immigrants are, in general, a selection of strong, resilient people, but I have been able to see how the extreme stressors they suffer "exceed the adaptation capacity of the human being".²

The suffering that these immigrants transmitted to me in the consultations (loneliness, fear, helplessness, absence of opportunities) made me remember in July 2002 the experiences of Ulises, the hero of the Odyssey and thus I described and coined the term "The Syndrome of Immigrant of the immigrant with chronic and multiple stress or Ulysses Syndrome"

It is important to point out that humans have the ability to elaborate migratory mourning because migration has been a very relevant phenomenon in the history of humanity, "We descend from beings that have migrated successfully many times throughout the evolutionary process".³ That is why migration is not a cause of mental disorder.

Migration is a risk factor from the perspective of mental health. But, is a risk factor only if the following situations occur.

1. If there is vulnerability: the immigrant is unhealthy or has disabilities, or has had a traumatic history, has suffered violence, child abandonment
2. If the level of stressors, of difficulties to adapt to the new country is very high: the host environment is hostile
3. If both conditions are met.

It is important to explore the vulnerability of the migrant, and also if the environment in the new country is very hostile, or if both things occur at the same time. Then the situation will become very difficult for the immigrant.

1. The situation of forced loneliness, especially in the case of broken, divided, families. Many times, in the immigrant families there are long separations between parents and minor children. Loneliness is also accompanied by great anguish and concern for the situation of loved ones. This situation affects attachment⁴ a central element in the functioning of mental health.
2. Having to fight for survival, often lacking the basic needs of housing, health, work, social rights, etc.
3. The feeling of hopelessness at not seeing a way out of the situation and seeing that the barriers and walls that prevent integration into the host society are insurmountable.
4. And the fear that millions of immigrants live in today's world both on the migratory journey (crossing deserts, seas, the Daréin Jungle in Central America...) and because they find themselves without rights, whit helplessness. The situation is even worse in the case of women who may be victims of sexual violence.

Thus, the causes of the Ulysses syndrome are a combination of forced loneliness, the experience of extreme survival situations, and the absence of opportunities associated to live with terror and helplessness. However, these stressors, which are already very relevant, are increased by the following characteristics:

1. Multiplicity: stressors reinforce each other
2. Chronicity: we are not talking about to have a bad day, or a bad season, but about long years of living in extreme situations
3. The lack of control over stressors related to learned helplessness (Seligman
4. The great intensity of the stressors, linked to survival situations
5. All these stressful situations are experienced by immigrants with very little social support. Capital stock⁵ is very low.

Furthermore, to add even more difficulty to the situation of immigrants in extreme situations, assistance services are often not prepared, they do not know in depth the mental health problems of flashlight immigrants. And there is a great risk of victimization, hyper medicalization of the suffering of immigrants. It’ is very important to resalt that Ulysses syndrome is not a mental disorder, it belongs to the area of mental health, the area of stress and mourning

The Ulysses Syndrome is a problematic related to the area of mental health, it is a symptomatology reactive to stress in situations of extreme migratory mourning that cannot be elaborated. We believe that proposing the category of Ulysses Syndrome" helps prevent these immigrants from being treated as sick people, when in reality are people that live a very difficult situation of stress

I consider there are a risk in the intervention with these immigrants living extreme situations -on the one hand, the devaluation of their suffering, the banalization of extreme migratory mourning -and on the other hand, the danger of confusion between the situation of stress and the mental disorder (depression, adjustment disorder, posttraumatic stress disorder) and the risk of medicalization

From my perspective^1,2,6,7 there are seven griefs in migration, griefs related with the most relevant areas of life

1. Grief for family and loved ones, related to the attachment, a fundamental instinct in human beings (and in all mammals). Today’ s world there are millions of children separated of his families, living forced separations
2. Grief due to language: specially when the migrant has dyslexia, dysgraphia, is illiterate, has no chance of learning the language of the host country.
3. The grief of culture: cosmovision, sense of time, religion, values
4. The grief of homeland: related to landscape, the intensity of light, the temperature, the colours, smells, humidity
5. The grief of social status: access to legal documents, to legal work, housing, etc.
6. The grief in relationship to the group of belonging: prejudices, discrimination, xenophobia, racism.
7. The grief due to risk regarding physical integrity: dangers in the migratory journey, risk of sexual violence against the women, risk of accident for work in extreme condition, substandard housing.

However, it is not the same to live these 7 griefs:

1. In good conditions, be able to integrate into the host country and be able to comply with the migration project (simple grief)
2. With many difficulties, but with effort being able to get ahead (complicated grief)
3. Or in extreme circumstances, without the possibility of the elaborating the migratory grief (extreme grief).

The symptoms of the Ulysses Syndrome are related to the immigrant's response to the situation they are experiencing and can be understood as an attempt to adapt to the extreme situation they are experiencing. The symptomatology is characterized by symptoms of different areas:

1. In the depressive area, there is basically sadness and crying, but are absent very important symptoms for the diagnosis of clinical depression, such as apathy, ideas of death, slowdown psychomotor
2. In the area of anxiety, there is nervousness, a tendency to recurring ideas, irritability, insomnia
3. In the somatic area, muscle pain related to tension, digestive discomfort and, above all, headaches are frequent. In our consultations we have found percentages of up to almost 80% of immigrants with headaches (the headaches are so frequent this symptom that I suggested the name of "in migraine: migraine of immigrant)²
4. In the area of confusion there are concentration difficulties, memory problems, temporal and spatial disorientation, depersonalization, etc.
5. It is very important to respect the worldview of the immigrant, take into account the cultural perspective, which is often symptomatology is expressed in relation to the evil eye, witchcraft, etc.

I consider that it is important to differentiate the area of mental disorders and the area of the reactions to the situations of intense stress and extreme mourning. If this differentiation is not done well, there is a risk of medicalizing many difficult situations in life, as migration in extreme situation.

The concept of Ulysses Syndrome includes all this very intense suffering of immigrants who are experiencing very hard situations, situations of extreme stress

Let's look at the differential diagnosis between The Ulysses Syndrome and various mental disorders:

1. Differential diagnosis with depression: As indicated before, immigrants with The Ulysses Syndrome do not have the principal symptoms for the diagnosis of depression as apathy, ideas of death, psychomotor slowdown.
2. Differential diagnosis with Adjustment disorder: to establish this diagnosis, it is necessary that the subject's response to the stress situations lived to be disproportionate. In the case of Ulysses Syndrome we see that the response of immigrants is fully proportional to extreme situation of stress.
3. Differential diagnosis with Post Traumatic Stress Disorder: because in Ulysses Syndrome there are no intrusive thoughts related to traumatic situations, no avoidance behaviors, no apathy, symptoms that are essential for the diagnosis of PTSD.

I consider that there is an overdiagnosis of mental disorders in immigrants. However, I must also say that the diagnosis of alcoholism addiction is relevant in immigrants and yet it is underdiagnosed. In my opinion, the greater risk of immigrants with Ulysses Syndrome, it not to developpe a psychotic o depressive disorder, the most relevant risk is to develop addictive disorders

MENTAL HEALTH   ULYSSES SYNDROME   MENTAL DISSORDER

Achotegui²

I consider it is important to take into account that the immigrant in general is a resilient person, especially the primary migrant, the first to emigrate, a person with the capacity to face risks. There are studies that have linked the ability to migrate successfully with the proper functioning of the dopaminergic system.

Forced loneliness, helplessness, despair ... the migrations of twenty one century evoke us of Homers' verses “ ... But the days found him sitting on the rocks or sands, torturing himself with tears, groans and heartache, and looking out with streaming eyes across the watery wilderness…." (Odyssey, Song V, 150,,)⁸ and the part of the text in which Ulysses tells Polyphem: “You ask me my name. I shall tell you. My name is nobody and nobody is what everyone calls me”. (Odyssey, Song IX, 360) “It is clear that if a man has to become a nobody in order to survive, if he has to remain permanently invisible, he will have no identity, will never become socially integrated, nor will he enjoy mental health.^2,9–15

None.

The author declares there is no conflict of interest.

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