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Epidemiology and Treatment of Posttraumatic Stress Disorder in West-Nile Populations of Sudan and Uganda

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Epidemiology and Treatment of Posttraumatic Stress Disorder in West-Nile Populations of Sudan and Uganda 1 Epidemiology and Treatment of Posttraumatic Stress Disorder in West-Nile Populations of Sudan and Uganda Dissertation zur Erlangung des Doktorgrades Eingereicht an der mathematisch-naturwissenschaftlichen Sektion der Universität Konstanz von Dipl.-Psych. Frank Neuner im Juli 2003 2 Acknowledgements/Danksagung Schon seit einer Weile freue ich mich darauf, diese Danksagung zu schreiben. Nicht nur, weil das bedeutet, dass ich endlich die Arbeit drucken lassen kann. Vielmehr habe ich die Gelegenheit, mich nun einmal förmlich zu bedanken bei all den Personen, die zum Gelingen dieser Arbeit beigetragen haben. Ich bedanke mich bei Thomas Elbert für die wissenschaftliche Weitsicht sowie den unermüdlichen Enthusiasmus, mit dem er mich bei diesen Projekten unterstützt hat. Maggie Schauer war von Anfang an eine tragende Kraft bei allen unseren Traumaprojekten, mit ihr zusammen wurde die Narrative Expositionstherapie entwickelt. Ich danke ihr für das gegenseitige Vertrauen und die tragfähige Zusammenarbeit auch in schwierigsten Situa- tionen. Das unkomplizierte und höchst angenehme Klima der Arbeitsgruppe gab mir für die letzten Jahre ein anregendes Arbeitsumfeld. Bei Brigitte Rockstroh bedanke ich mich dafür, dass sie mich vom ersten Forschungsantrag bis jetzt zur Abgabe der Arbeit immer unterstützt hat und für all das, was sie mir im Studium und danach über klinische Psy- chologie und Forschungsmethoden beigebracht hat. Diese Doktorarbeit baut auf dem “Demography of Forced Migration” Projekt auf, das von Unni Karunakara von der John Hopkins Universität unter Betreuung von Prof. Burnham geleitet wurde. Unni war letztlich derjenige, der uns nach Uganda gebracht hat, ohne ihn hätten wir keine der Studien durchführen können, vielen Dank dafür. Als weitere Institutionen waren die Makarere Universität, Kampala und Ärzte ohne Grenzen (MSF) Holland beteiligt, die uns auch in einem medizinischen Notfall sehr professionell geholfen haben. Die Flüchtlingssiedlung Imvepi wird vom Deutschen Entwicklungsdienst unter Lei- tung von Adi Gerstl verwaltet. Für seine zuverlässige Unterstützung bin ich sehr dankbar, zumal wir zur Befriedigung unserer lebensnotwendigsten Grundbedürfnisse wie Essen, Schlafen und e-mail völlig abhängig waren vom DED. Bei der Therapiestudie waren außer Maggie, Thomas und mir noch Christine Klaschik und Elisabeth Kley als Untersucherinnen und Therapeutinnen und in der Nach- folgeuntersuchung auch Elisabeth Schauer beteiligt. Für all den unerschrockenen Einsatz 3 unter Kröten, Skorpionen und Rebellen bin ich sehr dankbar. Rebecca Horn und Barbara Meier können viel besser englisch als ich und haben diese Arbeit korrigiert. Ich danke für die endlosen formalen und inhaltlichen Anmerkungen (“strict but forgiving”). Eine solche Studie ist nicht möglich ohne ein gutes Team lokaler Mitarbeiter. Hier sind vor allem Mary A. Martin (“Tall Mary”) und Nicolas W. Krispo vorzuheben. Ihrer Überzeugungskraft, Begeisterung, Zuverlässigkeit sowie ihrem hohen Ansehen in der loka- len Bevölkerung ist zu verdanken, dass wir die sudanesischen Flüchtlinge von unserer Ar- beit überzeugen und für die Nachfolgeuntersuchungen wieder aufspüren konnten. Als ich diese Arbeit schrieb hatte immer wieder verschiedene ugandische Mitar- beiter des DED und sudanesische Flüchtlinge im Kopf, die ich in Imvepi kennengelernt hatte. Zu wenigen von ihnen habe ich noch sporadischen Kontakt, bei vielen frage ich mich, was wohl aus ihnen geworden ist. Ich bin ihnen sehr dankbar für all die bereichernden Begegnungen und die Erkenntnis, dass kulturelle Unterschiede im zwischenmenschlichen Kontakt völlig unerheblich sein können. Schließlich bedanke ich mich bei meinen Eltern für die langjährige Unterstützung meines Studiums. Ganz besonders bedanke ich mich bei meiner Frau Nicole, die meine Be- geisterung für Afrika teilt aber dennoch oft (bei nicht immer zuverlässigen Kommunika- tionsmittlen) auf meine Anwesenheit verzichten musste. Ich freue mich über das, was wir gemeinsam erreicht haben, und vor allem auch auf das, was uns gerade erwartet. Konstanz, im Juli 2003 Frank Neuner 4 Table of Contents 1 OVERVIEW 6 2 ORGANIZED VIOLENCE 9 2.1 Definition 9 2.2 Wars 10 2.3 Torture 16 2.4 Survivors of organized violence as refugees 19 3 PSYCHOLOGICAL CONSEQUENCES OF ORGANIZED VIOLENCE 21 3.1 The concept of posttraumatic stress disorder 21 3.2 PTSD in populations affected by organized violence 27 3.3 Criticism of PTSD concept 37 4 PTSD IN POPULATIONS AFFECTED BY THE SUDANESE WAR 45 4.1 The Sudanese Civil War 45 4.2 Sudanese refugees in Uganda’s West Nile region 53 4.3 Survey of West Nile populations 55 4.4 Dose-response effect for PTSD 68 4.5 Psychometric quality of the PTSD assessment 74 5 ETIOLOGICAL MODEL OF PSYCHOLOGICAL TRAUMA 84 5.1 Memory related features of PTSD 84 5.2 Traumatic event in memory 85 5.3 Sensory-perceptual representation 87 5.4 Autobiographic contextual memory 91 5.5 Neurobiological basis of memory and PTSD 95 5.6 Emotional Processing 97 5.7 The speechlessness of trauma: sociopolitical implications 101 5 6 PSYCHOTHERAPY OF PTSD 105 6.1 Overview 105 6.2 Acute Interventions/Debriefing 106 6.3 Psychodynamic Therapy 108 6.4 Anxiety management 109 6.5 Exposure oriented treatment 109 6.6 Cognitive Therapy 112 6.7 Combination of treatments 114 6.8 Treatment of survivors of organized violence 115 7 NARRATIVE EXPOSURE THERAPY (NET) 118 7.1 Basic principles of NET 118 7.2 Randomized controlled trial 120 7.3 Treatment 125 8 CONCLUSION 136 9 SUMMARY 141 10 ZUSAMMENFASSUNG 142 11 APPENDIX 144 12 REFERENCES 150 6 1 Overview The term “trauma” has achieved unequaled popularity in recent years. The word originates from the Greek “trau=ma”, meaning an injury or a wound. At first, it was adopted by medicine as a technical term referring to tissue damage that was caused by ex- ternal mechanisms. Later on, psychiatrists suggested that extremely stressful life events could be considered as traumas, as those events could contribute to the onset of mental dis- orders, even without any physical injury. In this context, trauma has become a metaphor to describe presumed wounds of the soul, caused by shocking events like combat experi- ences, sexual abuse and life-threatening accidents. In recent years, more disciplines have begun to use the term in a metaphorical sense, using it to indicate emotionally upsetting personal events as well as radical social, cultural and historical changes. Manifestations of traumas have been identified in literature, music, architecture and film. For example, in his analysis “Das Trauma der verfehlten Melodie bei Robert Schumann” Zizek (1999) has used both personal traumatic events in Robert Schu- mann’s life and a proposed cultural trauma caused by the change from the classicistic to the romantic epoch to explain the melody in Schumann’s compositions. Beyond different scientific disciplines, trauma has also found a place in every-day communications, referring to a wide variety of stressful personal and social events, like be- reavement, unemployment, and poverty. The widespread use of the term “trauma” for all kinds of stressful events has led to an increasing fuzziness in the definition, and the lack of conceptual clarity risks misunderstandings and a loss of meaning of the term. The expan- sion of the trauma definition was even reflected in scientific literature. For example, psy- chologists and psychiatrists recently discussed the traumatic consequences of sexual har- assment (Avina & O'Donohue, 2002) and even childbirth (Ayers & Pickering, 2001). This thesis deals with the traumatic consequences of organized violence on mental health. Organized violence includes wars, torture and other severe human rights violations. Whereas it is straightforward that war and torture can wound the psyche and thus be con- sidered as psychological traumas, organized violence is not first of all a psychological prob- lem. It is important to be aware of the political context of wars and torture to comprehend the meaning of organized violence for the individual and the societies. As the characteris- 7 tics of current warfare and torture are very different from the traditional view of these phenomena I will present information on the context of organized violence in chapter 2. As a response to the excessive generalization of the term “trauma”, a very specific and narrow “trauma” definition has evolved in recent years in psychological and psychiat- ric sciences. The psychiatric concept of posttraumatic stress disorder (PTSD) offers a framework for operational criteria of potential traumatic events and the characteristic symptoms of these events. I will explain these definitions in chapter 3.1. In this study I will refer to this understanding of “trauma”, as it applies to individuals. I will avoid the use of terms like “traumatized societies” and “collective trauma” as, contrary to the widespread use of these terms, there is no qualified definition of these concepts. The introduction of the PTSD concept has stimulated much empirical research. One interesting finding was that not all survivors of wars and torture are traumatized. Many epidemiological studies have investigated the rate of traumatized individuals in popu- lations affected by organized violence. Research in this field is confronted with many methodological challenges, I will discuss these problems and the current state of knowledge in chapter 3.2. Despite the vast research on PTSD, it has become popular to criticize the validity of the concept. This criticism is discussed in chapter 3.3. The Sudanese civil war is one of the world’s oldest civil wars and offers a perfect ex- ample for the illustration of the characteristics of modern warfare (chapter 4.1). We carried out an epidemiological study of PTSD in this context. We compared Sudanese nationals who remained in the West-Nile region of Sudan with refugees who had fled to West-Nile Uganda to analyze the effect of war and forced migration on the mental health of survivors of the war. The Ugandan hosts provided a control group as they are culturally similar to the Sudanese but had a quite peaceful existence in the past years (chapter 4.3). The epidemiological study offered an estimation of the size of the problem.
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