**1. Introduction**

182 Post Traumatic Stress Disorders in a Global Context

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Post-Traumatic Stress Disorder (PTSD) is a psychiatric condition, which develops after a person experiences, witnesses, is confronted with or hears about emotionally stressful and painful experiences beyond what a human being can bear. The traumatic event may be life threatening; threatens body integrity and causes considerable fear, horror and a sense of helplessness in the affected individual (APA, 1992). Traumatic events are psychologically wounding to the individual and leave deep scars (Anonymous, 2009; and Tonks, 2007) on trauma victims; they are dehumanising, demoralising and humiliating, and may put an abrupt end to the hopes and plans of an otherwise enterprising individual, as the individual loses the sense of the future (Bardin, 2005) as one of the clinical features of post-traumatic stress disorder.

The experience of traumatic stress in the history of human kind is perhaps not new and was probably limited to the processes of survival in pre-historic times. However with civilization and modernization the nature scope and experience of traumatic stress has become more complex and sophisticated in terms of clinical significance, individual perception and interpretation of the traumatic experience, and public health importance. In Uganda the nature of traumatic stress ranges from natural events including road traffic accidents, industrial accidents, domestic accidents, floods, landslides and occasional earth tremors to manmade traumatic events such as orchestrated domestic violence, child abuse and neglect, and organized violence and war, the most recent of which took place from 1986 to 2009. In recent times there has been an upsurge of child abductions for human sacrifice in Uganda, and this has been extremely traumatizing to affected families and relatives.

War is of particular significance as it is manmade, is associated with significant mental health problems (Murthy & Lakshminarayana, 2006), causes more suffering, deaths and disability within the same time unit than an epidemic, and imposes considerable economic and social burden on communities (Murray et al, 2002). The psychological and psychiatric consequences of traumatic experience have been the subject of initial disagreement and debate in the international literature. However the personal accounts of victims of violence and war as detailed by Judith L. Herman (1997) in her book on trauma; and client accounts

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 185

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

**2.1 PTSD among refugees and in Internally Displaced Persons (IDP) camps in** 

epidemic that killed many pregnant women, adding to the troubles of the region.

and Ovuga et al, 2008; Roberts et al, 2009).

revealed a very high prevalence of PTSD and depression.

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;

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

**Northern Uganda** 

in clinical settings and to journalists (Anonymous, 2007) leaves no doubt as to the clinical and public health significance of traumatic stress experience.

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 (Herman, 1997).

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

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 conflicts since the country attained independence from Britain in 1962.
