**2. Historical background of Post-Traumatic Stress Disorder**

Historically, the awareness of PTSD as a clinical syndrome followed wars such as the American Civil War, world wars I and II, and the Vietnam and Gulf Wars. Modern wars have become sophisticated and assume the form of guerrilla wars that take place in cities and directly affect civilians exposing adults and children alike to the senselessness of humans killing humans with little regard to the sacred value of human life. In Africa, active wars and organized violence have recently affected millions of civilians in Ivory Coast, Tunisia, Egypt and Somalia. Recent acts of ethnic violence, and organized violence following elections and religious fanaticism have affected hundreds of civilians in previously stable and peaceful communities in Rwanda, Democratic Republic of Congo, Kenya, Tanzania, and Uganda's capital city, Kampala on July 11, 2010.

in clinical settings and to journalists (Anonymous, 2007) leaves no doubt as to the clinical

Traumatic events are often sudden and overwhelming irrespective of their origin or nature though certain traumatic experiences last for a short time while others take a protracted or repeated course, particularly if they are politically motivated or occur in the hands of hostage takers or domestic abusers. With almost no exception, traumatic experience seems so unreal, horrible and unimaginable to most victims that its experience leaves victims helpless with a serious challenge to the human sense of omnipotence over the environment. Manmade traumatic events cause intense fear, a systematic weakening of the struggle for freedom, the break-up of victim's self-control fabric, and a total dependence on the perpetrator of the traumatic experience for survival. In most cases trauma victims may hold society as accomplices in their experience with the development of a sense of abandonment and loss of basic trust in the social order. Further more trauma victims develop selfblame, guilt feelings, loss of self-confidence and self-esteem. Emotional numbness that accompanies the traumatic experience causes severe loss of control over personal routines and dignity with a pervasive loss of sense of the future with the victim living by the day

The bulk of published research data on post-traumatic stress disorder concerns adults compared to children. However isolated published research data highlights the magnitude and psychological effects of traumatic stress, physical effects and long-term social consequences of conflict and war among child populations in conflict affected areas of Africa (Anonymous, 2007; Bardin, 2005; Betancourt et al, 2010; Betancourt et al, 2008a, b, c; Mock et al, 2004; Ovuga et al, 2008; and Pham et al, 2009). In an exception to current emphasis on providing care to adult clients, Onyut et al (2005) describe the potential value

Most available published data from war zones of Africa pay little attention to the clinical features of post-traumatic stress disorder, and most cases of probable post-traumatic stress disorder presenting at primary care units are misdiagnosed and mismanaged. In this chapter we describe the complex settings and clinical presentation of post-traumatic stress disorder in Northern Uganda. We supplement the chapter with material from our own assessment of mental health needs among children and adolescents in one district of northern Uganda that was the epicentre of Uganda's most protracted and brutal armed

Historically, the awareness of PTSD as a clinical syndrome followed wars such as the American Civil War, world wars I and II, and the Vietnam and Gulf Wars. Modern wars have become sophisticated and assume the form of guerrilla wars that take place in cities and directly affect civilians exposing adults and children alike to the senselessness of humans killing humans with little regard to the sacred value of human life. In Africa, active wars and organized violence have recently affected millions of civilians in Ivory Coast, Tunisia, Egypt and Somalia. Recent acts of ethnic violence, and organized violence following elections and religious fanaticism have affected hundreds of civilians in previously stable and peaceful communities in Rwanda, Democratic Republic of Congo,

of narrative exposure therapy for war-affected children in two camps in Uganda.

conflicts since the country attained independence from Britain in 1962.

**2. Historical background of Post-Traumatic Stress Disorder** 

Kenya, Tanzania, and Uganda's capital city, Kampala on July 11, 2010.

and public health significance of traumatic stress experience.

(Herman, 1997).

Uganda is a country in sub-Saharan Africa that suffered from the ravages of war, poverty and the consequences of the HIV/AIDS epidemic. Gulu in northern Uganda was hit especially hard by recent political upheaval and guerrilla warfare. While safety is no longer an issue in this region, grave social concerns remain arising from the deep wounds the war inflicted on the children in northern Uganda (Tonks, 2007). During the war thousands of children had been abducted: boys to serve as child soldiers; girls to be both killers and sometimes as officers' "wives". Many of the young girls became pregnant and bore children of their own. While the region may now be peaceful many of the young people are not at peace with themselves or their community. For those youngsters who were not abducted they grew up in a shadow of war and lived in extreme fear. Many lost their parents, siblings and friends to the war. Their lives and education were disrupted. In addition, in this developing country many children experience the stress of extreme poverty on a daily basis. They are often hungry and have experienced the loss of loved ones because of medical conditions such as malaria, tuberculosis and HIV/AIDS. In early 2000 Gulu district was hit with the deadly hemorrhagic fever, Ebola that killed many including 21 health care providers in St Mary's Hospital Lacor, the only mission hospital serving many parts of the country. In the year 2008 at least three districts in Northern Uganda were hit by hepatitis B epidemic that killed many pregnant women, adding to the troubles of the region.

More than an estimated three hundred thousand refugees fleeing the civil war in Southern Sudan lived in various districts of the West Nile Region of Uganda. Kanarukana et al (2004) and Neuner et al (2004) reported high levels of mental health problems among the refugees and nationals including post-traumatic stress disorder, alcohol abuse and suicide. Following the fall of dictator Idi Amin of Uganda in 1979 wanton acts of violence against civilians in the West Nile region exposed nearly every family to horrible events of traumatic stress. The Northern Uganda war between government forces and the Lord's Resistance Army of Joseph Kony displaced more than two million civilians from their homes to internally displaced persons' camps in the entire Acholi, Lango and Teso sub-regions of Northern Uganda. Recent surveys have demonstrated significantly high rates of PTSD in the camps (Roberts et al 2008). Published data among various population groups from Northern Uganda suggest high levels of mental health problems including depression, alcohol abuse, anxiety and suicide (Ovuga, 2005; Ovuga et al, 2005a; Ovuga et al, 2005b; Roberts et al, 2008; and Ovuga et al, 2008; Roberts et al, 2009).

While poverty, personal loss and war trauma can produce devastating effects on children, not all children in a community will be impacted to the same degree or in the same manner. In fact, some very resilient children flourish in spite of severe adverse experiences (Betancourt and Khan, 2008). While some studies have been done on the emotional well being of specific groups in war affected areas, information about children is scarce, especially information about children less than 12 years of age. Most of the work that has been published was carried out at a time when there remained significant insecurity in the region of Gulu and many individuals feared for their wellbeing. Studies to date that have examined the emotional well being of individuals in northern Uganda have focused on two primary groups: 1) Internally displaced adults living in camps because of the war and 2) former child abductees of the Lord's Resistance Army (LRA). Research in these populations revealed a very high prevalence of PTSD and depression.

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 187

component of rehabilitation and reintegration of these children into their homes and community. Their research was prompted by the emergency psychiatric admission of 12 former child soldiers of the LRA in 2006 because of mass psychotic symptoms. Ovuga and colleagues studied a total of 102 children aged 6 to 18 years. This included the 12 children who were hospitalized and 90 schoolmates of those children. The 58 girls and 44 boys in the study were attending a rehabilitative boarding school for former abductees in northern Uganda. Data on posttraumatic stress disorder, depression, physical disabilities, socialdemographic variables and children's war experiences were collected by using the Harvard Trauma Questionnaire, a modified Hopkins Symptom Checklist and a 15- item War Experience Checklist. Results indicated a very high percentage of children had serious emotional symptoms. This group of youngsters had been severely traumatized with 87.3% reporting that they experienced 10 or more war related events. The data indicated that 55.9% of the children reported symptoms of posttraumatic stress disorder; 88.2% depressed mood and 21.6% had various forms of physical disability. A high percentage of the children (42.2%) reported a family history of severe mental illness. It was the clinical opinion of the authors of this study that the school environment may have contributed to the exacerbation of emotional symptoms. The "ultra-modern" school had limited resources and teachers; yet, the children's learning curriculum was significantly accelerated to enable them to "catch up" for educational time lost while in the bush placing significant pressure on these youngsters. Those older than 16 were limited to vocational training which in reality promised a future of hard work and poverty and left the children with little hope. In addition, the children were in a confined, structured environment away from home and family which may have recreated for them their days in rebel captivity. Finally, the school

viewed some of the youngsters as being possessed by demons (Ovuga et al 2008).

further trauma, as war has major impacts on children's development (Bardin, 2005).

Physical injuries include fractures, brain damage, seizures, sexually transmitted diseases and unplanned pregnancies. Psychological impact of traumatic events as seen in Northern Uganda include post-traumatic stress disorder, panic disorder, alcohol abuse and psychosis. At social and community levels, the Northern Uganda war has contributed significantly to lack of education, poverty, early marriages especially among girl children, family breakup among older persons, fear among male youths about getting married and the disempowerment of men as heads of households. Trans-generational effects and conflicts between neighbouring communities (Volkan, 2004) remain serious threats to social security and stability as renewed cycles of violence, war, prejudice, revenge motifs and lack of social

Victims of PTSD may suffer a variety of complications that may take the form of physical injuries or the psychological impact of the traumatic event per se. In addition war and violence have destabilizing effects on the social and individual lives of members of affected communities. In northern Uganda former child soldiers are called stigmatizing and criminalizing names that makes it difficult for the affected individuals to be reintegrated into their communities. The children of former female child soldiers who returned from the bush war are often not accepted by the communities of the child mothers, thus essentially uprooting the former child mothers from their communities and social roots. Additionally communities in northern Uganda still face the prospects of ethnic conflicts with potential for

**2.2 Complications of traumatic experiences in Northern Uganda** 

development remain significant issues in the region.

Roberts et al. (2008) and Vinck et al. (2007) separately conducted studies on adult Ugandans living in camps for internally displaced persons (IDPs). Roberts and associates used the Harvard Trauma Questionnaire in 2006 to study traumatic exposures and PTSD symptoms in 1,210 participants while Vinck and his colleagues used the PTSD Checklist-Civilian Version in 2,585 adults. Both sets of investigators used the Hopkins Symptom Checklist-25 to assess for levels of depression in the study participants. The data of Roberts and Vinck each showed very high rates of PTSD (54% and 74.3% respectively) as well as high rates of depression (67% and 44.5% respectively). The prevalence of PTSD was high even compared with other groups with post conflict PTSD (de Jong 2001). The high rates of PTSD in the Ugandan IDPs may be explained by the long duration of exposure (almost 2 decades) of highly traumatizing events including mutilation, abduction, abductees forced to commit violent crimes and displacement of approximately 2 million people. Furthermore, the conditions in the camps contributed to ongoing trauma and deprivation.

Performing a cross-sectional study of 2,875 individuals, selected through a multi-stage stratified cluster design in 8 districts of northern Uganda, Pham and associates (2009) reported that one-third of subjects experienced abduction and more than half of the respondents and greater than two-thirds of abductees met criteria for PTSD. Factors that increased the risk for former abductees experiencing PTSD were: female gender, being a member of the Acholi ethnic group (not surprising as the war began in the Acholi subregion), witnessing or participating in a number of traumatic events and experiencing difficulty upon re-entry into their communities. Increased risk for depression was associated with an older age of males at time of abduction, lower score on a social relationship scale, high incidence of exposure to traumatic events, high incidence of forced acts of violence and difficulty with re-entry into their communities.

Ilse Derluyn and colleagues (2004) confined their research to 301 former child soldiers in Gulu and Lira towns. The researchers used a semi-structured interview format to learn of past experiences. Additionally, 71 of the children were randomly selected to complete the Impact of Events Scale Revised (IESR). The age span of participants was from 12 to 28 years. Close to one third of the children were orphans. On the average, each child experienced six traumatic events during abduction. The rate of PTSD in the group was extremely high at 97%. The age of the child, the length of abduction, and period of time between escape and research did not affect the rate of PTSD.

Interested in the psychological and social rehabilitation of former child soldiers Bayer et al (2008) performed a cross-sectional field study of 169 former child soldiers in rehabilitation centres in Uganda and the Democratic Republic of the Congo. At the time of this 2005 study the former soldiers ranged in age from 11 to 18 years (mean age 15.3 years). The purpose of this study was to investigate the association between PTSD symptoms and feelings of openness to reconciliation as well as revenge in the study subjects. The investigators used a sample specific events scale and the Child Posttraumatic Stress Disorder Reaction Index. To study openness to reconciliation and feelings of revenge structured questionnaires were utilized. Data indicated that the child soldiers were exposed to high levels of trauma. Over 90% witnessed a shooting and more than half reported having killed someone. Close to 35% of the youngsters scored significantly for PTSD symptoms. Those with more PTSD symptoms were significantly less open to reconciliation and had more feelings of revenge.

The work of Ovuga et al (2008) most clearly demonstrates the need to screen all former child soldiers for PTSD and depression and to provide psychological interventions as a

Roberts et al. (2008) and Vinck et al. (2007) separately conducted studies on adult Ugandans living in camps for internally displaced persons (IDPs). Roberts and associates used the Harvard Trauma Questionnaire in 2006 to study traumatic exposures and PTSD symptoms in 1,210 participants while Vinck and his colleagues used the PTSD Checklist-Civilian Version in 2,585 adults. Both sets of investigators used the Hopkins Symptom Checklist-25 to assess for levels of depression in the study participants. The data of Roberts and Vinck each showed very high rates of PTSD (54% and 74.3% respectively) as well as high rates of depression (67% and 44.5% respectively). The prevalence of PTSD was high even compared with other groups with post conflict PTSD (de Jong 2001). The high rates of PTSD in the Ugandan IDPs may be explained by the long duration of exposure (almost 2 decades) of highly traumatizing events including mutilation, abduction, abductees forced to commit violent crimes and displacement of approximately 2 million people. Furthermore, the

Performing a cross-sectional study of 2,875 individuals, selected through a multi-stage stratified cluster design in 8 districts of northern Uganda, Pham and associates (2009) reported that one-third of subjects experienced abduction and more than half of the respondents and greater than two-thirds of abductees met criteria for PTSD. Factors that increased the risk for former abductees experiencing PTSD were: female gender, being a member of the Acholi ethnic group (not surprising as the war began in the Acholi subregion), witnessing or participating in a number of traumatic events and experiencing difficulty upon re-entry into their communities. Increased risk for depression was associated with an older age of males at time of abduction, lower score on a social relationship scale, high incidence of exposure to traumatic events, high incidence of forced acts of violence and

Ilse Derluyn and colleagues (2004) confined their research to 301 former child soldiers in Gulu and Lira towns. The researchers used a semi-structured interview format to learn of past experiences. Additionally, 71 of the children were randomly selected to complete the Impact of Events Scale Revised (IESR). The age span of participants was from 12 to 28 years. Close to one third of the children were orphans. On the average, each child experienced six traumatic events during abduction. The rate of PTSD in the group was extremely high at 97%. The age of the child, the length of abduction, and period of time between escape and

Interested in the psychological and social rehabilitation of former child soldiers Bayer et al (2008) performed a cross-sectional field study of 169 former child soldiers in rehabilitation centres in Uganda and the Democratic Republic of the Congo. At the time of this 2005 study the former soldiers ranged in age from 11 to 18 years (mean age 15.3 years). The purpose of this study was to investigate the association between PTSD symptoms and feelings of openness to reconciliation as well as revenge in the study subjects. The investigators used a sample specific events scale and the Child Posttraumatic Stress Disorder Reaction Index. To study openness to reconciliation and feelings of revenge structured questionnaires were utilized. Data indicated that the child soldiers were exposed to high levels of trauma. Over 90% witnessed a shooting and more than half reported having killed someone. Close to 35% of the youngsters scored significantly for PTSD symptoms. Those with more PTSD symptoms were significantly less open to reconciliation and had more feelings of revenge. The work of Ovuga et al (2008) most clearly demonstrates the need to screen all former child soldiers for PTSD and depression and to provide psychological interventions as a

conditions in the camps contributed to ongoing trauma and deprivation.

difficulty with re-entry into their communities.

research did not affect the rate of PTSD.

component of rehabilitation and reintegration of these children into their homes and community. Their research was prompted by the emergency psychiatric admission of 12 former child soldiers of the LRA in 2006 because of mass psychotic symptoms. Ovuga and colleagues studied a total of 102 children aged 6 to 18 years. This included the 12 children who were hospitalized and 90 schoolmates of those children. The 58 girls and 44 boys in the study were attending a rehabilitative boarding school for former abductees in northern Uganda. Data on posttraumatic stress disorder, depression, physical disabilities, socialdemographic variables and children's war experiences were collected by using the Harvard Trauma Questionnaire, a modified Hopkins Symptom Checklist and a 15- item War Experience Checklist. Results indicated a very high percentage of children had serious emotional symptoms. This group of youngsters had been severely traumatized with 87.3% reporting that they experienced 10 or more war related events. The data indicated that 55.9% of the children reported symptoms of posttraumatic stress disorder; 88.2% depressed mood and 21.6% had various forms of physical disability. A high percentage of the children (42.2%) reported a family history of severe mental illness. It was the clinical opinion of the authors of this study that the school environment may have contributed to the exacerbation of emotional symptoms. The "ultra-modern" school had limited resources and teachers; yet, the children's learning curriculum was significantly accelerated to enable them to "catch up" for educational time lost while in the bush placing significant pressure on these youngsters. Those older than 16 were limited to vocational training which in reality promised a future of hard work and poverty and left the children with little hope. In addition, the children were in a confined, structured environment away from home and family which may have recreated for them their days in rebel captivity. Finally, the school viewed some of the youngsters as being possessed by demons (Ovuga et al 2008).

#### **2.2 Complications of traumatic experiences in Northern Uganda**

Victims of PTSD may suffer a variety of complications that may take the form of physical injuries or the psychological impact of the traumatic event per se. In addition war and violence have destabilizing effects on the social and individual lives of members of affected communities. In northern Uganda former child soldiers are called stigmatizing and criminalizing names that makes it difficult for the affected individuals to be reintegrated into their communities. The children of former female child soldiers who returned from the bush war are often not accepted by the communities of the child mothers, thus essentially uprooting the former child mothers from their communities and social roots. Additionally communities in northern Uganda still face the prospects of ethnic conflicts with potential for further trauma, as war has major impacts on children's development (Bardin, 2005).

Physical injuries include fractures, brain damage, seizures, sexually transmitted diseases and unplanned pregnancies. Psychological impact of traumatic events as seen in Northern Uganda include post-traumatic stress disorder, panic disorder, alcohol abuse and psychosis. At social and community levels, the Northern Uganda war has contributed significantly to lack of education, poverty, early marriages especially among girl children, family breakup among older persons, fear among male youths about getting married and the disempowerment of men as heads of households. Trans-generational effects and conflicts between neighbouring communities (Volkan, 2004) remain serious threats to social security and stability as renewed cycles of violence, war, prejudice, revenge motifs and lack of social development remain significant issues in the region.

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 189

The recognition of post-traumatic disorder in northern Uganda is, however, not simple due to widespread beliefs in witchcraft and supernatural powers in rural areas, and many individuals with the disorder do not receive the intervention they need for a number of considerations. Children in rural areas and in schools receive severe corporal punishment almost routinely as a strategy by adults, teachers, and older children to instil discipline in them. Sometimes children are denied access to basic necessities of life including food in retribution for wrongs they might commit. Thus the nature and scope of traumatic stress in rural communities in northern Uganda is diverse and may pass as normal in the eyes of the ordinary individual. Rural communities in the region are more likely to somatise their ailments and to explain psychological distress in terms of witchcraft; spirit possession and or the non-performance of rituals to appease displeased ancestral spirits. As large communities were exposed to the traumatic events in the region, most people are inclined to underrate the psychological impact of their experiences in their lives, and to consider their psychological experiences as universally normal responses to their traumatic experiences. Informal social support exists at community level, which offers some degree of protection against psychological distress at least at superficial level (Betancourt and Khan, 2008), and most child soldiers (and adults) appear to adjust remarkably well to their traumatic experiences (Betancourt et al, 2010). As a result most investigators who are not accustomed to the social and cultural life of the communities mistakenly believe that post-traumatic stress disorder is rare in northern Uganda and that the communities in the region do not

Indeed some individuals may not in fact recover fully from their traumatic experiences due to the delayed onset of post-traumatic stress symptoms in some individuals (Jones, 1987), and the long-term effects of traumatic experiences such as rape (Shanks and Schull, 2000) despite appearing to function well in daily activities. Unpublished work from northern Uganda also indicates that poor parental mental health evidenced by previous history of traumatic stress, depression, suicidal behavior and alcohol abuse may predispose children to poor mental health either independently or arising secondary to children's own traumatic experience. Thus at least in the context of northern Uganda, despite the availability of ubiquitous social support networks children and adults alike may or may not be resilient to the effects of war experience in the region. This thus highlights the importance of routine screening for depression, suicidal behavior, anxiety disorders and post-traumatic stress

Post-traumatic stress disorder usually presents with vegetative symptoms of depressive and anxiety disorders or alcohol use disorder symptoms. Patients may complain about poor sleep due to dreams involving the dead beckoning them unto death. Direct inquiry about probable history of exposure to a traumatic event is required as dreams about the dead may be a significant sign of depressive disorder, anxiety disorder or PTSD representing intrusive thoughts. Sometimes patients may complain about having many thoughts or thinking too much. Too many thoughts may mean being worried, and signify depressive disorder or an anxiety disorder, particularly in association with frightening dreams in which the dreamer is visited by dead relatives, is chased by enemies/armed men, or is involved in battle. However too much thoughts may be an idiom for intrusive thoughts seen in post-traumatic stress disorder. Individuals may be described as preferring to be alone, and this description is the equivalent of loss of interest in social contact and pleasurable activities as in

require any form of psychological intervention.

disorder symptoms among patients attending primary care.

**3.1 Common symptom patterns of PTSD in northern Uganda** 
