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Trauma and posttraumatic
stress disorder in Africa
Dr Lukoye Atwoli
Senior Lecturer in Mental Health
Moi University School of Medicine
Outline
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Introduction
Trauma in Africa
Posttraumatic stress disorder
Other posttraumatic syndromes in Africa
Gaps in the knowledge: a research
agenda
• Conclusion
Introduction
• Traumatic events are a common occurrence
on the African continent
• Concomitant posttraumatic mental disorders
disproportionately afflict Africans as a result
• Africans experience suffering due to these
conditions just like people in other parts of
the world
• Research needs to begin moving towards
solutions to the problem of trauma and PTSD
Trauma in Africa
• Trauma rates in Africa are among the highest in the
world. According to the World Health Organization, each
year there are more than 200,000 road traffic deaths in
Africa and perhaps 20 to 30 times as many people
seriously injured. Injury rates are predicted to increase
by around 80% by 2020.
• Approximately 250,000 children are being abused as
child soldiers in the world today (2007). Many of them,
often influenced by ethnic tensions, are involved in
conflicts in Africa's Great Lakes Region
• In an Urban Xhosa Primary Care Population
in South Africa, 94% reported exposure to
traumatic events (mean, 3.8) (Carey et al.
2003)
• In the South African Stress and Health Study
(SASH), 73.8% of 4315 respondents reported
at least one potentially traumatic event
exposure. Unexpected death of a loved one,
physical violence and accidents were the
most commonly reported events (Atwoli et al,
under review)
• Over 80% of 2041 South African and
Kenyan school-children reported exposure
to severe trauma in a cross-national study
(Seedat et al, 2004)
• In the Nigerian Survey of Mental Health
and Well-Being, 63% of the respondents
reported exposure to at least one
potentially traumatic event
• In an ongoing study among orphans and
separated children in Western Kenya,
77.1% of boys and 73.7% of the girls
indicated that they had been bullied,
among other potentially traumatic events
(Atwoli et al, unpublished)
• Tables 1 and 2 illustrate this more
graphically
OSCAR study
Gender, n (%)
Traumatic
events
Male
Female
P-value
Sexual violence
140 (16.1)
92 (13.2)
0.11
Physical violence 297 (34.2)
155 (22.3)
<0.0001
Bullying
670 (77.1)
513 (73.7)
0.12
Parent died of
HIV
85 (9.8)
70 (10.1)
0.856
Type of Care Environment, n (%)
Traumatic
events
CCI, n=746
HH, n=746
SC, n=73
P-value
Sexual
violence
89 (11.9)
120 (16.1)
23 (31.5)
<0.0001
Physical
violence
231 (31.0)
178 (23.9)
43 (58.9)
<0.0001
Bullying
599 (80.3)
524 (70.2)
60 (82.2)
<0.0001
Parent died
of HIV
92 (12.3)
61 (8.2)
2 (2.7)
0.003
OSCAR study
Criticisms of the trauma
construct
• Wessels and colleagues have criticised the trauma
construct as “a medical model and its problematic
western assumptions and foci on pathology,
symptoms, and curative, therapeutic processes.”
(Bracken, 1998; Eisenbruch, 1991; Kleinman, 1987;
Pupavac, 2001; Summerfield, 1999, 2004; Wessells,
1999)
“The trauma paradigm decontextualizes human suffering
by reducing it to individual terms, when many of the
greatest sources of suffering are collective and are
grounded in a socio-historic context of human rights
violations.”
• A new focus on resilience and assets is
encouraged, away from the focus on deficits
• In Africa, especially, critics are arguing that “a
trauma focus is less useful than a more
holistic, community-based and culturally
grounded approach.”
• Culture is emphasised as having a bearing
on concepts of suffering and trauma,
precluding a universal trauma idiom
• However, this critique also opens itself up for
criticism, by minimising the potential of
Africans to experience suffering and trauma
just like their Western counterparts
• It is driven by the concept of limited
resources, emphasising the use of locally
available resources to deal with our
challenges
• It is the driving force behind arguments for
new models of health care delivery ‘in
resource-poor settings’
Who has ever heard of ‘National
Security in Resource-poor
settings’?
• The solution lies in designing instruments
that take into consideration individual
experiences as far as possible, and avoid
generalising even within ‘cultures’
• The trauma construct comes as close as
any other idea in mental health to defining
a personal narrative of suffering
In any case, what does the
opening phrase- “In my culture,
we (don’t)…” mean?
It often means- “I would rather
(not)…”
Posttraumatic Stress Disorder
• PTSD exists in Africa!
• Since the 1940’s and 1950’s when the
scientific world believed that Africans do not
suffer from mental distress, we have moved
on to document all psychiatric pathology that
exists in mankind, on this continent
• Just like the trauma concept, however, there
are those who argue that the PTSD concept
cannot be mapped onto the African
experience
High PTSD rates
• In 2004, Derluyn et al evaluated clinically
significant symptoms of posttraumatic stress
disorder (PTSD) in former Ugandan child soldiers,
using the Impact of Event Scale–Revised. The
authors reported that nearly all children (97%)
showed posttraumatic stress reactions of clinical
importance.
• Peltzer (2000) investigated trauma symptoms as a
consequence of violent crime in an urban South
African community and found a rate of
posttraumatic stress disorder (PTSD) of 25.8% as
indicated by the PTSS-10 and of 42.2% by the
IES–R.
• In 2006, Atwoli et al reported a current PTSD
prevalence rate of 65.7% among Mau Mau
Concentration Camp survivors in Kenya,
about 50 years after their incarceration
• Pfeiffer (2011) found that 49% of former
abductees in N. Uganda suffered from PTSD,
while Klasen et al (2010) reported a rate of
36% among former Ugandan child soldiers
• In the urban Xhosa community in South
Africa, PTSD (current; 19.9%) was among
the most common diagnoses. (Seedat et al
2004)
• In the OSCAR study in Uasin Gishu County,
38.3% of the 1565 children have PTSD (boys
39.2%, girls 37.1%, p=0.380) (Atwoli et al,
unpublished)
• Olley et al (2007) reported a PTSD
prevalence rate of 14.8% among South
Africans living with HIV, and concluded:
• “In the South African context, PTSD is not
an uncommon disorder in patients with
HIV/AIDS. In some cases, PTSD is
secondary to the diagnosis of HIV/AIDS
but in most cases it is seen after other
traumas, with sexual violation and intimate
partner violence in women being
particularly important.” (Olley et al 2005)
Lower PTSD rates
• In the SASH study, the conditional
prevalence rate of lifetime PTSD was 2.3%,
with a 12-month prevalence of 0.7% in the
general sample
• The rate among those exposed to traumatic
events was 3.5%
• This study used a new method of estimating
community prevalence of PTSD using the
‘random event’ method (Atwoli et al, 2013,
under review)
• Similarly, Kamau et al in 2012 found a low
PTSD prevalence rate (1.3%) among
children with HIV in Kariobangi
• In Nigeria, Gureje et al reported ‘virtually
no generalised anxiety disorder or PTSD’
in the national study
• Obviously, then, PTSD rates widely differ across
the continent, and even within countries,
depending on a wide range of factors
• Instruments used to assess trauma and PTSD
have an impact on the prevalence rates, as does
the actual prevalence of potentially traumatic
events
• In Africa, most studies have not found the
traditional association between PTSD and gender,
perhaps due to the ubiquitous nature of violence
and victimisation across societies
Other posttraumatic syndromes
• Obviously, PTSD is not the only (or the most
important) outcome of exposure to potentially
traumatic events
• Studies have uncovered major depressive
disorder as a potentially more important
outcome, as well as substance use, other
anxiety disorders and somatoform disorders
• It has even been suggested that all these
disorders are part of the same continuum of
trauma-related psychiatric disorders, and
may perhaps even constitute one disorder!
Gaps in the knowledge: A
research agenda
• What is the actual population prevalence of trauma
and posttraumatic mental disorders?
• What role does culture play in the distribution of
trauma and posttraumatic morbidity?
• What are the successful methods of treating
posttraumatic mental disorders in Africans?
• Are there ‘African alternatives’ to proven treatments
such as CBT, Trauma-focussed CBT and EMDR?
• Do Africans experience trauma and distress differently
from other human beings?
• Are there successful African interventions for reducing
the burden of violence and why haven’t Africans
adopted them?
The answers, as they say, are
out there!
Conclusion
• Traumatic events are a common occurrence
on the African continent
• Concomitant posttraumatic mental disorders
disproportionately afflict Africans as a result
• Africans experience suffering due to these
conditions just like people in other parts of
the world
• Research needs to begin moving towards
solutions to the problem of trauma and
PTSD, and away from arguments on
construct validity