**3. Clinical features**

Four main features characterize post-traumatic stress disorder; namely: intrusive memories of the traumatic event, flashbacks, re-experience of the traumatic event and avoidant behaviour. Intrusive memories may take the form of bad dreams while re-experience of traumatic events and avoidant behavior may take the form of loss of interest in social contact; fear of visiting places where individuals experienced initial traumatic events such as farm fields; depersonalization or aggressive outbursts triggered by conversations; and or bad dreams. The Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychological Association (APA, 1992) gives the following clinical diagnostic criteria.


In addition the individual might report the following symptoms that might have been absent before the experience of the traumatic event.


Four main features characterize post-traumatic stress disorder; namely: intrusive memories of the traumatic event, flashbacks, re-experience of the traumatic event and avoidant behaviour. Intrusive memories may take the form of bad dreams while re-experience of traumatic events and avoidant behavior may take the form of loss of interest in social contact; fear of visiting places where individuals experienced initial traumatic events such as farm fields; depersonalization or aggressive outbursts triggered by conversations; and or bad dreams. The Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychological Association (APA, 1992) gives the following

 History of having experienced, witnessed or been confronted with events or an event that involved actual bodily harm or serious bodily injury or threatened death or threat

During the event the person responded with fear, sense of helplessness or horror in

 The affected person experiences recurrent painful recollections of the traumatic event including images, thoughts or perceptions among adults, or frightening dreams among

 Acting or feeling as though the traumatic event were reoccurring manifested by reliving the event, illusions, hallucinations and flash-backs among adults, or plays

Marked experience of emotional distress whenever the individual is exposed to

Experience of physical symptoms whenever the person is exposed to situations that

 Active efforts to avoid thoughts, feelings or conversations about the traumatic event; the client might actively attempt to avoid visiting places that might evoke memories of

Active efforts aimed to avoid activities, places or people that arouse recollections of the

Inability to remember important aspects of the traumatic event despite the individual's

Loss of hope in the future, e.g. feeling that one has no chance in marriage, raising

In addition the individual might report the following symptoms that might have been

Exaggerated response to stimuli in the surrounding such as sudden loud noise.

 Significant loss of interest or participation in pleasurable activities and daily chores. A feeling of emotional detachment or estrangement from friends and other social

**3. Clinical features** 

clinical diagnostic criteria.

children.

trauma.

groups.

of integrity to the person's body.

resemble the traumatic event.

his/her traumatic experience.

adults, or agitated disorganized behaviour in children.

involving actual traumatic events among children.

preoccupation with his/her traumatic experience.

Inability to experience loving warmth for others.

children or that one might die before long.

absent before the experience of the traumatic event. Difficulty falling asleep or staying asleep Being easily upset or getting angry

Being attentive and alert to spot signs of danger

Difficulty concentrating at tasks involving mental effort

situations that resemble an aspect of the traumatic event.

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 require any form of psychological intervention.

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 disorder symptoms among patients attending primary care.

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

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

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 191

A 72-years-old man who had been involved with religious work in northern Uganda was admitted to the psychiatric unit of a general hospital in northern Uganda with what seemed to be unclear to the junior mental health professionals in the hospital. The man had features of early dementia as well as major depressive disorder, and he complained that his memory was poor and that his mind kept going blank as he held conversations; indeed as he narrated his traumatic experiences, the man seemed hesitant, paused frequently to recollect his thoughts and repeatedly asked for questions or sentences to be repeated to him. The man had been exposed to repeated traumatic experiences both in Southern Sudan and northern Uganda for over four decades and he reported several episodes of witnessing torture, killings and human suffering; he himself reported at least three occasions of near escape from death, making him wonder as to why it was always him who had to go through the sort of traumatic experiences that he repeatedly encountered. While in hospital the man always ran out from his hospital room to spend the night outside the room in the open, claiming that attackers had come for him. Out of his several dreams related to traumatic situations, the man reported one example of him leading a group of five men who had attacked a refugee camp and killed many of the refugees before the authorities sent in reinforcement to rescue the refugees. When the reinforcement arrived they informed him and his men that since they were the ones that started the fighting, they would all be killed. Though he ordered his men to retreat, his men were all killed and he woke up from sleep

A four-year-old male child was admitted to a large mental hospital in a former homeland in South Africa with scanty history of his psychiatric problem. By the time one of the authors (EO) saw him, the child's parents had returned to their remote rural village. The available information indicated that the child had been attended to at the rural district hospital and at a traditional healer's shrine without benefit. Each of the child's hands was firmly and securely crepe-bandaged into a fist. He had a combination of recent and old healing wounds and scratches in both temporo-frontal areas of the head. The child was otherwise of good nutritional status and there was no immediate evidence of child neglect. The reason for bandaging the child's hands became immediately obvious when the child suddenly began to hit himself with both hands in the injured areas of the head. The blows were so strong and fierce that an onlooker would feel sympathy and pity for the child. Efforts to prevent the child from his self-injurious behavior only led to resistance and even stronger blows to the child's head. Whenever the child got tired from hitting himself he would sometimes hold the hand of the nearest adult and beckon the adult to hit him. Routine laboratory test results were normal. Report of an electroencephalography indicated non-specific occasional spikes and waves in the temporal lobes, particularly in the right temporal lobe. The child was treated with an initial low dose of haloperidol, followed by ethosuximide but with no

Nursing report indicated, however, that the child was attracted to two female nurses both of who responded appropriately as surrogate mothers. The reports further indicated that each time the primary surrogate mother lifted the child into her arms he would reach out for and pull out her breasts though he did not attempt to breast-feed. While in the company of the surrogate mothers, the frequency and severity of the child's blows to his head decreased. This observation led us to believe that there was a problem with loss of attachment and to

**Vignette 3** 

**Vignette 4** 

clinical benefit.

just in time before he was himself killed.

depressive disorder or post-traumatic stress disorder; it is not uncommon for post-traumatic stress disorder and depression to co-exist in the same patient. Such individuals are usually intolerant to conversations that might remind them of their traumatic experiences, and may exhibit considerable levels of irritability and may therefore not wish to participate in conversations with family and friends. Individuals who prefer to be alone following exposure to traumatic events also exhibit episodes of depersonalization with aggressive outbursts. The triad of social isolation, depersonalization and aggressive outbursts is so characteristic of former rebel soldiers in northern Uganda that some communities readily recognize the psychological instability in affected individuals and often arrange a quiet room for the victims to rest before they can rejoin their peers in social activities.

#### **Vignette 1**

The following vignette about a 19-year old former child soldier in northern Uganda perhaps illustrates the complex manner in which post-traumatic stress disorder presents sometimes. The patient was referred to the psychiatric unit in a general hospital in northern Uganda by a humanitarian agency. The patient presented with severe cognitive impairment suggesting severe brain damage; he was disoriented to time, place and person and he had poor attention span and poor concentration with poor short-term and recent memories. The young man had no idea as to where his home was claiming that he came from a location in Okokoro county in northern Uganda; however his name suggested that he came from the West Nile region of Uganda. He claimed he had graduated from a university in central Uganda (non-existent) and that he came from the Congo-Somali-Ethiopia border. Clinical examination, and laboratory and radiological investigations revealed no physical abnormality. This case illustrates the psychological consequences of brainwashing and indoctrination that the rebel captors used to keep control of the young children they abducted and trained as members of their forces. However the cognitive impairment in this case may also be explained on the basis of memory impairment that accompanies the clinical features of post-traumatic stress disorder.

#### **Vignette 2**

A 40-years-old married man and father of four children was admitted with severe psychotic symptoms and features of alcohol dependence to the psychiatric unit of a general hospital in northern Uganda. The man had been violent toward his wife for her failure to respond to his sexual advances, as he seemed to her not stable psychologically. Additionally the man's admission was prompted by his unusual behavior of watching a line of ants as they moved into and out of an anthill. The man interpreted the line of ants as government soldiers tracking rebel forces in northern Uganda. In a systematic order he crushed and killed some of the ants that he believed were government soldiers while sparing the ones that he thought were rebel soldiers. In therapy the man lamented the extent to which people in northern Uganda had suffered from the effects of the northern Uganda war and he wished that he were able to prevent a return of war in the region. The man reported repeated dreams of him hiding up in very tall trees to avoid being spotted by helicopter gunships, or looking down on government soldiers who would stare up helplessly at him from down below after escaping from them. Despite the location of his residence in northern Uganda, and the symptoms of post-traumatic stress disorder, the man denied any history of traumatic experience or links with either rebel forces or government troops.

#### **Vignette 3**

190 Post Traumatic Stress Disorders in a Global Context

depressive disorder or post-traumatic stress disorder; it is not uncommon for post-traumatic stress disorder and depression to co-exist in the same patient. Such individuals are usually intolerant to conversations that might remind them of their traumatic experiences, and may exhibit considerable levels of irritability and may therefore not wish to participate in conversations with family and friends. Individuals who prefer to be alone following exposure to traumatic events also exhibit episodes of depersonalization with aggressive outbursts. The triad of social isolation, depersonalization and aggressive outbursts is so characteristic of former rebel soldiers in northern Uganda that some communities readily recognize the psychological instability in affected individuals and often arrange a quiet

The following vignette about a 19-year old former child soldier in northern Uganda perhaps illustrates the complex manner in which post-traumatic stress disorder presents sometimes. The patient was referred to the psychiatric unit in a general hospital in northern Uganda by a humanitarian agency. The patient presented with severe cognitive impairment suggesting severe brain damage; he was disoriented to time, place and person and he had poor attention span and poor concentration with poor short-term and recent memories. The young man had no idea as to where his home was claiming that he came from a location in Okokoro county in northern Uganda; however his name suggested that he came from the West Nile region of Uganda. He claimed he had graduated from a university in central Uganda (non-existent) and that he came from the Congo-Somali-Ethiopia border. Clinical examination, and laboratory and radiological investigations revealed no physical abnormality. This case illustrates the psychological consequences of brainwashing and indoctrination that the rebel captors used to keep control of the young children they abducted and trained as members of their forces. However the cognitive impairment in this case may also be explained on the basis of memory impairment that accompanies the clinical

A 40-years-old married man and father of four children was admitted with severe psychotic symptoms and features of alcohol dependence to the psychiatric unit of a general hospital in northern Uganda. The man had been violent toward his wife for her failure to respond to his sexual advances, as he seemed to her not stable psychologically. Additionally the man's admission was prompted by his unusual behavior of watching a line of ants as they moved into and out of an anthill. The man interpreted the line of ants as government soldiers tracking rebel forces in northern Uganda. In a systematic order he crushed and killed some of the ants that he believed were government soldiers while sparing the ones that he thought were rebel soldiers. In therapy the man lamented the extent to which people in northern Uganda had suffered from the effects of the northern Uganda war and he wished that he were able to prevent a return of war in the region. The man reported repeated dreams of him hiding up in very tall trees to avoid being spotted by helicopter gunships, or looking down on government soldiers who would stare up helplessly at him from down below after escaping from them. Despite the location of his residence in northern Uganda, and the symptoms of post-traumatic stress disorder, the man denied any history of

traumatic experience or links with either rebel forces or government troops.

room for the victims to rest before they can rejoin their peers in social activities.

**Vignette 1** 

**Vignette 2** 

features of post-traumatic stress disorder.

A 72-years-old man who had been involved with religious work in northern Uganda was admitted to the psychiatric unit of a general hospital in northern Uganda with what seemed to be unclear to the junior mental health professionals in the hospital. The man had features of early dementia as well as major depressive disorder, and he complained that his memory was poor and that his mind kept going blank as he held conversations; indeed as he narrated his traumatic experiences, the man seemed hesitant, paused frequently to recollect his thoughts and repeatedly asked for questions or sentences to be repeated to him. The man had been exposed to repeated traumatic experiences both in Southern Sudan and northern Uganda for over four decades and he reported several episodes of witnessing torture, killings and human suffering; he himself reported at least three occasions of near escape from death, making him wonder as to why it was always him who had to go through the sort of traumatic experiences that he repeatedly encountered. While in hospital the man always ran out from his hospital room to spend the night outside the room in the open, claiming that attackers had come for him. Out of his several dreams related to traumatic situations, the man reported one example of him leading a group of five men who had attacked a refugee camp and killed many of the refugees before the authorities sent in reinforcement to rescue the refugees. When the reinforcement arrived they informed him and his men that since they were the ones that started the fighting, they would all be killed. Though he ordered his men to retreat, his men were all killed and he woke up from sleep just in time before he was himself killed.

#### **Vignette 4**

A four-year-old male child was admitted to a large mental hospital in a former homeland in South Africa with scanty history of his psychiatric problem. By the time one of the authors (EO) saw him, the child's parents had returned to their remote rural village. The available information indicated that the child had been attended to at the rural district hospital and at a traditional healer's shrine without benefit. Each of the child's hands was firmly and securely crepe-bandaged into a fist. He had a combination of recent and old healing wounds and scratches in both temporo-frontal areas of the head. The child was otherwise of good nutritional status and there was no immediate evidence of child neglect. The reason for bandaging the child's hands became immediately obvious when the child suddenly began to hit himself with both hands in the injured areas of the head. The blows were so strong and fierce that an onlooker would feel sympathy and pity for the child. Efforts to prevent the child from his self-injurious behavior only led to resistance and even stronger blows to the child's head. Whenever the child got tired from hitting himself he would sometimes hold the hand of the nearest adult and beckon the adult to hit him. Routine laboratory test results were normal. Report of an electroencephalography indicated non-specific occasional spikes and waves in the temporal lobes, particularly in the right temporal lobe. The child was treated with an initial low dose of haloperidol, followed by ethosuximide but with no clinical benefit.

Nursing report indicated, however, that the child was attracted to two female nurses both of who responded appropriately as surrogate mothers. The reports further indicated that each time the primary surrogate mother lifted the child into her arms he would reach out for and pull out her breasts though he did not attempt to breast-feed. While in the company of the surrogate mothers, the frequency and severity of the child's blows to his head decreased. This observation led us to believe that there was a problem with loss of attachment and to

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 193

In this section we summarize the findings of our research on the patterns of mental health problems of children in northern Uganda. The findings highlight the diverse nature of traumatic experiences and their associated psychological distress symptoms the children aged 4-17 in the region experience. We conducted a cross-sectional survey of children in Gulu district using both qualitative and quantitative research methods. We used stratified cluster sampling strategy to select two urban and two rural villages in Gulu District. We randomly selected the participating villages from 2 sub-counties (one rural and one urban) in Gulu District. We estimated that 100-150 children would participate in the study. The parent or caretaker of each child or adolescent selected was also requested to participate in

Participant selection involved community leaders in each village who helped the research team to discuss the research in general terms with the identified children and their caregivers and gave them the opportunity to ask questions and to think about possible participation. We explained the research project; and gave the participating children and their caregivers the opportunity to ask questions. A simple consent/assent form was explained to each potential participating child and caregiver. If they still wished to participate we asked that they sign the consent/assent form or place a thumbprint in the case of those who could not write. (In some of the studies referred to above only verbal consent was obtained). Throughout the interviews participants were asked if they were okay in participating and given the opportunity to stop if they chose to. At the end of each interview participants were asked how they felt about having participated and if they had any questions about the project at the end. Each caregiver was given a phone number to call or a person they could contact (they may not have access to a phone) who could contact one of our team members (EO or CL) if any concerns or questions should arise in the future

Using a semi-structured interview we collected demographic information, descriptions given by the children of their personal experiences and their reactions to events in their lives. We covered areas of strengths as well as difficulties. A principal investigator (CL) or a trained assistant conducted the interviews. When indicated, an interpreter asked the questions in Luo (the primary language spoken in Gulu district) and translated the answers for the primary interviewer who spoke English. The primary interviewer clarified answers with the research subjects through the assistance of the interpreter. The primary interviewer wrote down answers to the questions on each questionnaire. We also used a semi-structured interview with parents/caregivers of the children to determine how well the children functioned emotionally and behaviorally. The investigators of this research project constructed the questions for the interview with the assistance of community members in order to be sure that the concept of how an individual functioned in daily life was consistent with cultural expectations. We examined the child's ability to function in 3 domains: 1) the home 2) in peer relationships and 3) at school, job (such as farming), or age appropriate

In order to gather the information required we developed three questionnaires to obtain information about the emotional well being of children in northern Uganda. In order to be culturally and linguistically accurate each questionnaire was developed with input from professionals and community members in the region. The questionnaires were first written

**4. Mental health problems of children in Northern Uganda** 

**Methods of data collection** 

about the research interview.

the study.

activity.

develop and break down a set of the child's self-injurious behavior pattern from the most complex to the smallest units for purposes of drawing up a behavior modification strategy based on appropriate rewards if the child refrained from self-injurious behavior and the withholding of attention or reward if the child engaged in any form of behavior considered by the surrogate mothers or other nurses as unacceptable. Each time the child's behavior was considered positive he was praised and occasionally presented with a personal toy, but each time his behavior was unacceptable this was indicated to him in a clear simple language promptly. The rules of the therapy were typed out and pinned on the notice boards on the children's ward for all nurses to follow in support of the two surrogate mothers. Though the author (EO) was from another culture, the behavior modification strategy was planned carefully with the nurses, written out in simple language and explained before its implementation. As part of the therapy, the bandages were removed from the child's hands as the initial reward for non-injurious behavior. All medications were also withdrawn and the child was left free to do whatever he wanted within the provisions of the behavior modification strategy. Using this strategy, the child's self-injurious behavior progressively and eventually resolved completely within two weeks. The child's clinging behavior on either of the surrogate mothers stopped; he became social and interacted freely with all nursing staffs on the ward and began to play with other children.

When the parents eventually came to take him home after six months, the mother narrated the history of the child's mental health problem as follows. The child was the first-born in the family and received the full attention of his mother. When he was two-and-half years old, a sibling came in between him and his mother. The child reacted with intense rivalry with his infant sibling who the child attempted repeatedly to push off from their mother's lap. When he failed in his efforts to push the infant from the mother's lap, he became more and more vicious in his attacks on the infant sibling. In a final effort to stop the child's hatred toward the infant sibling his mother confessed hitting the boy so hard that he stopped pushing the infant from her lap. In reaction the child turned his hatred toward himself and started to slap and scratch himself. As observed in the hospital whenever he got tired he would come to the mother and beckon her to slap him in the face as she had done. A full explanation was made to the mother as to the probable origin of his self-injurious behavior, which the parents accepted, and the mother believed the explanation would help in her future relations with the little boy, who we shall call Sipho in this chapter.

It is possible that this child suffered from two episodes of traumatic stress; first his loss of his first love object, the mother, and secondly the physical attack on his physical integrity by the mother. Though young, the child apparently drew the correct relationship between his hateful feelings toward his sibling and the punishment that he received from the mother. In order to protect himself and his infant sibling, the child took a middle option; selfpunishment that in adult term would have led him to suicidal behavior, which is a common occurrence in post-traumatic stress disorder. One might interpret his never-ending urge for punishment as an obsession, and the self-injurious behavior as a compulsive disorder. It is therefore not surprising that a program of response prevention that aimed to modify his behavior into a healthy lifestyle in the face of unavoidable challenge in life worked for him. The child's mental health problem that we might refer to basically as an obsessivecompulsive disorder probably qualifies to be intrusions and attempts to re-experience his traumatic experience in the hands of his mother. Further his behavior interfered significantly with his social functioning to the extent that it interrupted his normal relations with his parents and sibling resulting in hospitalization. Given the history this was a case of post-traumatic stress disorder co-morbid with obsessive-compulsive disorder.
