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
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
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
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
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
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-
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. The next question was what psychology can contribute to an alleviation of the suffering of traumatized individuals in this region. We aimed to develop a specific treatment approach.
For the development of a treatment method, it is essential to understand the current knowledge of the psychological and neurobiological mechanisms behind the disorder (chapter 5) and previous treatment approaches (chapter 6). We applied this knowledge to the political background of organized violence and developed Narrative Exposure Therapy
(NET), the principles of which are explained in chapter 7. To examine the efficacy of NET, we carried out a randomized controlled trial with Sudanese refugees living in Uganda, and compared the efficacy of NET with other methods that have been used to treat trauma- tized refugees.
After a general conclusion, I present one example of the testimonies of refugees who participated in the treatment study (appendix). These testimonies can illustrate the meaning of traumatic war experiences within the life context of individual persons. Thus, they pro- vide information that is usually hidden behind statistics.
2 Organized violence
2.1 Definition
Despite the destructive power of violence it remains a universal and enduring phe- nomenon. Human history can be structured along the series of wars between nations and bloody conflicts in states. Different religions and social movements have always tried to condemn violence and proposed a peaceful coexistence of people. Nevertheless, still today violence dominates many parts of the world and the danger of war and terror remains a continuous threat for most people.
Violence appears in different forms. Prominent classifications of violence distin- guish between different forms with regard to the context (Derriennic, 1971). A major di- mension to qualify types of violence is their degree of organization. Examples of unorgan- ized types of violence are assaults, domestic violence, sexual abuse and other crimes that happen at an individual level. On the other hand, wars and political persecution provide the context for more organized forms of violence including torture, combat situations and bombardments.
The term organized violence is widely used in the political (Derriennic, 1971) as well as in the medical and psychological literature (Basoglu, 1993; Jensen, Schaumburg, Leroy, Larsen, & Thorup, 1989; Van Velsen, Gorst-Unsworth, & Turner, 1996). Notwith- standing the recent popularity of this concept, there is no consistent definition. It is mainly used in the study of the characteristics and consequences of torture, wars and forced migra- tion. Other authors use terms like “state-sponsored violence” (S. M. Weine & Laub, 1995) and “severe human rights violations” (Silove, 1999) to describe related occurrences. Based on the usage of the term in literature and the classifications of violence offered by Derriennic (1971) and Galtung (1969) the following definition might describe the current understanding of organized violence:
Organized violence is violence that is directly and actually applied with a systematic strategy by members of a group with at least a minimum of centrally guided structure (police units, rebel organizations, terror organiza- tions, paramilitary and military formations). It is applied with a certain con- tinuity against individuals and groups with a different political attitude, na-
tionality as well as racial, cultural or ethnical background. It is characterized by the violation of central human rights or other basic rights of people.
Organized violence encompasses three types of violence. The first type is the per- manent state-sponsored persecution that is present in all dictatorships, and even in some countries that are considered democracies. This harassment includes different forms of vio- lence like torture, extralegal executions, disappearances etc. The second type is the massive violence committed against people in an interstate war or a civil war. The third type of or- ganized violence is characterized by violence committed by terror organizations. Whereas there is much literature on the consequence of torture and wars, terrorism did not attract much research until recently, so I will concentrate on the description of the characteristics and consequences of wars and torture.
2.2 Wars
2.2.1 Number and Locations
A war is a mass conflict that involves fighting between two or more armed parties.
Probably most people could accept this definition, but it is not sufficient. In current wars it is increasingly difficult to distinguish wars from other conflicts. Consequently, different political scientists have developed various definitions of war. These definitions differ with respect to the questions of whether regular government forces have to be involved and the degree of organization in the forces that is required to classify for an army. In addition, most definitions have a cut off value for the number of battle-related casualties per year that are required to classify for a war (see Gleditsch, Wallensteen, Eriksson, Sollenberg, &
Strand, 2002 for the discussion of the differences of the definitions).
The Hamburg working group for research into the causes of war (Arbeitsgemein- schaft Kriegsursachenforschung; AKUF) counted 31 wars in 2001 (Schreiber, 2002). Since the end of World War Two, the number of wars in the world was increasing more or less steadily until 1995, since when there was a small decrease (Gleditsch et al., 2002).
The public view of wars is dominated by knowledge about World Wars One and Two as well as subsequent wars with American or European participation, especially the Vietnam War. Despite the dominance of these inter-state wars in media reports, research
on current wars shows that wars that are characterized by two or more countries fighting each other are rather the exception than the rule. In 2001 more than nine out of ten wars (91%) were inner-state (or civil) wars (Schreiber, 2002). Whereas foreign armies may par- ticipate in the fights, these wars do not originate from conflicts between nations but within a country. There are two different reasons for civil wars. Currently, in about half of the inner-state wars a rebel army fights for the autonomy or secession of a region. In the other half of the wars, rebels aim at the overthrow of the ruling regime.
The wars in the world are not evenly distributed over the earth. There are certain major conflict zones that have generated most of the recent wars. The great majority of the 2001 wars (91%) were located in Africa, Asia and in the Near/Middle East. Figure 2.1 pre- sents the location of wars in the period between 1989 and 1999. It shows that one major conflict zone included Central America and the northern part of South America with some single conflicts in Central South America. A global line of conflicts spanned from Eastern Europe through the Balkans and the Middle East and India to Indonesia. The third zone of conflicts was Africa, where almost the whole continent has a history of wars in the last decade.
Figure 2.1. Armed conflicts 1989-99 by location, the circles indicate interstate wars and the crosses inner-state wars. From Gleditsch, Wallensteen, Eriksson, Sollenberg, & Strand (2001).
2.2.2 “New Wars”
The traditional view of wars is well described by Clausewitz famous statement that war is the continuation of politics with different means. This view of wars dominates the accounts of the major European wars since Napoleon. It describes different countries and alliances that wage wars with professional armies, whereby the majority of casualties are soldiers who die in the battlefields. Wars start with a declaration and are terminated by the capitulation of one party or a peace agreement. The war parties aim for victory in these wars by concentrating their forces in major battles.
It was not until the Balkan War that an inner-state war raised questions about the validity of this traditional view. Kaldor (1999) introduced the term “New War” to describe this and other similar current conflicts. She suggested that the general characteristics of warfare underwent major changes in recent years in the Balkan as well as in most other war regions. Several characteristics of “New Wars” have been suggested, and other researchers (e. g. Münkler, 2002) adopted this term in their analyses. As there is little research in war areas, most of the following conclusions were drawn from the observations of war journal- ists. For an illustration of the typical characteristics of current warfare in the Sudanese civil war, see chapter 4.1.
Irregular forces
Contrary to the traditional view on wars, current conflicts involve more than regu- lar armies. Instead, the fighting is dominated by irregular forces, including paramilitary units, rebel forces, mercenary troops and foreign armies that intervene in civil wars on one side. The majority of fighters on all sides of the conflicts have limited military training. As many characteristics of regular armies, like uniforms and regular salary, are not applicable to the majority of fighters, the clear separation between civilians and soldiers disappears.
Most current wars lack clear declarations of war, and the fighting parties seem to hesitate to provoke decisions through major battles. This results in long-lasting conflicts, that have also been called “low-intensity conflicts. The clear difference between peace and war time dissipates in these conflicts.
A major indicator of development towards irregular forces is the fact that most cur- rent wars involve children as fighters. Whereas in traditional wars children were only re- cruited by weakened parties, forcibly recruited child soldiers belong to the usual repertoire
of many modern forces. The advantage of the usage of children as fighters is that they are considered to be easily controlled and manipulated to be unscrupulous fighters as they lack norms and values and cannot judge risks and dangers in the same way adults can (Schreiber, 2002).
Justification on identity
Competing ideologies played a major role in traditional wars. In contrast, the dominant justification of current wars is based on the different identities of the conflict partners, based on their membership of different ethnics groups, cultures or religions. For example, no different ideology separated Serbs, Bosnians and Croats in the Balkan wars.
Instead, the ethnic identity discriminated between the war parties. Myths about ancient rivalries and wars between the ethnic groups were used to motivate the public for the war.
Kaldor admitted that during the World Wars the national identities played a major role as well, but there was always a kind of ideological vision tied to the different parties.
Warfare targets civilians
Warfare in current wars cannot be described by the traditional view of two oppos- ing armies fighting each other with heavy weapons at a clear frontline to gain territory.
The main means of gaining power in new wars is controlling the civil population, by frightening the population and expelling civilians who do not belong to the powerful group. Heavy weapons are not necessary for this type of warfare. The current worldwide availability of small weapons was caused by the excessive equipment of many armies by the super powers during the cold war and the increasing trade in small weapons after the breakdown of many former socialist countries after the cold war.
Whereas former civil wars that were fought in the context of social revolutions in- volved guerilla fighters who aimed at winning the “hearts and minds” of the civil popula- tion in order to move amongst them like “fishes in the water”, this strategy is rarely to be found in current civil wars. Instead, all sides seem to use an anti-guerilla tactic, involving frightening the civilians and expelling opponent groups.
The strategy of new warfare thus includes systematic atrocities like massacres and mass rapes to frighten the civilians and to make regions uninhabitable for the group to be expelled. The widespread use of landmines and destruction of monuments are other means
of achieving this goal. Another reason for the prevalence of atrocities in current wars is the assumption that they help to unify the group committing the atrocities. Once a person has participated in committing war crimes, it is almost impossible for this person to leave the group, since he will always be rejected by others because of what he has done. In the be- ginning of the Rwandese genocide in 1994, which resulted in the killings of more than 800 000 Tutsis by the Hutus, there was a high pressure on every individual Hutu to participate in the killings. Many reports state that the children who were recruited as soldiers were forced to commit atrocities in their own village. This prevented the children from fleeing from the forces and returning to their home villages, since they would be rejected if they returned.
Economic factors
The observation of current wars suggests that rational motives cannot explain these excessively violent conflicts. Nevertheless, detailed analyses of these wars show that these wars are not wild and fanatic fighters killing each other randomly, but that tangible inter- ests motivate the main actors to machinate these wars. In particular, economic factors play an increasing role in the onset and maintenance of wars. In a global economy, the war par- ties are usually not autarkic but get resources from supporting foreign countries and exile communities. Very often, the conflicts are fought to win and keep control over local re- sources like diamonds, minerals, oil and drugs. This consequently leads to powerful war- lords who do not depend on governments. As the war offers them the opportunity to keep power and to gain money without the control of any regulating institution, they do not have an immediate interest in a termination of the war. Consequently, many wars are ex- tended by the deliberate delay of peace negotiations and the unwillingness of both war par- ties to fight deciding battles against each other.
“New wars” are not new
The term “New War” has become increasingly popular to describe modern con- flicts. Some authors, especially experienced war researchers who have been observing con- flicts for many years, criticized this development (e.g. Gantzel, 2002). Whereas there is no doubt that the warfare in most common wars is very different from the common public view on wars, it was pointed out that this kind of warfare is not at all a new phenomenon.
Analysis of typical warfare since World War Two reveals that the “New War” characteris-
tics just describe common warfare in inner-state conflicts. Most conflicts have presented these characteristics for decades but have typically gone unnoticed by the public in indus- trialized countries.
Table 2.1 illustrates the prevalence of exposure to different war events of represen- tative samples of civilian war survivors. The studies represent Kosovar Albanians (Lopes Cardozo, Vergara, Agani, & Gotway, 2000), refugees from Cambodia who lived in Thai camps (Mollica et al., 1993) as well as refugees from Bosnia who lived in Croatian camps (Mollica et al., 1999; see chapter 3.2 for details about these studies). The table shows that whereas the distribution of specific events is clearly different between the groups, almost all survivors in all groups reported the experience of one or more severe events. The data reflects that the war and persecution in Cambodia as well as the Balkan war aimed at the Table 2.1. Prevalence rates of exposure to events related to war and persecution in survivors of the Kosovar, Bosnian and Cambodian conflicts
Event Kosovar Albani-
ans during war (%)
Bosnian refu- gees during war
(%)
Cambodian refu- gees during Pol Pot
regime (%)
Lack of food/water 67 28 96
Combat situation 67 35 43
Ill health/no medical care 48 23 87
Murder of family member 26 17 54
Shelling attacks 31 83 31
Lack of shelter 57 85
Being close to death 62 63
Murder of stranger 24 37
Rape/ sexual abuse 4 17
Hiding from snipers 75
Hiding outdoors 63
Forced labor 88
Brainwashing 87
Torture 36
violation of the civil population. The experiences of those victims who did not survive the war have naturally not been assessed. As all three conflicts caused considerable numbers of casualties among the civil populations (20-40% of the total Cambodian population died during the Pol Pot regime), the prevalence rates still represent an underestimation of the actual violence that occurred during these conflicts.
2.3 Torture
Torture has often been called the “scourge of mankind”. The history of the Euro- pean juridical systems shows that torture has been a tool of persecution and punishment for centuries. It was widely applied in the Middle Ages and the most terrifying episodes of the history of torture included the Spanish Inquisition in 15th century and the witch-hunt in Germany that escalated in the 16th century. It was not before the 18th century that the Enlightenment philosophers turned against the use of torture. Unfortunately, Victor Hugo’s proclamation in 1874 that “torture has ceased to exist” (Jacobsen & Smidt-Nielsen, 1997) proved to be a rash conclusion, as torture is still evident in many countries of the world.
There are various definitions of torture in different international treaties. The most prominent definition was proposed by the UN convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (UN, 1984):
For the purposes of this Convention, the term "torture" means any act by which severe pain or suffering, whether physical or mental, is inten- tionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimi- dating or coercing him or a third person, or for any reason based on dis- crimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering aris- ing only from, inherent in or incidental to lawful sanctions.
This definition relates to torture that is committed by government agents or by people who act with official sanctions. Other organizations have broadened this definition to make it applicable to other organized groups like rebel armies (Amnesty International, 2003). They point out that the traditional image of political prisoners being tortured in an interrogation chamber does not fit all the observations of human rights organizations that
increasingly document torture in refugee camps and public places, as well as in people’s homes.
Amnesty International noted that in more than 100 countries torture is systemati- cally used by state organs (Amnesty International, 2002). The aim of torture is to generate a general high level of fear within a population to intimidate opponents of the ruling re- gime. In this context, torture is only one means of human right violations. Other common instruments are the imprisonment of nonviolent opponents, the conviction of opponents without the opportunity of a fair trial, secret imprisonments without contact with the world outside the prison, the application of death penalties, extralegal executions and dis- appearances.
Reports about many dictatorships and even democracies (like Turkey) indicate that torture has evolved into a systemized means of handling political prisoners. Sophisticated torture methods have been developed and torture specialists were trained. Hariotos- Fatouros (1988) has studied the practice of torture during the regime of the Greek Junta (1967-1974). The interviews with former professional torturers after the overthrow of the Junta showed that torture was not restricted to occasional excesses of interrogators and prison wards but that there were elaborated institutions for the selection and training of torturers. Trainees were carefully selected according to their beliefs and their socioeco- nomic status, making them susceptible to propaganda and monetary rewards. The trainees underwent a sophisticated training including their own violations and humiliations, and being fed propaganda, as well as receiving systematic rewards and punishments. In this way, they could be trained to be obedient torture specialists and to fulfill their roles within a systematic system of persecution.
The specialized torture methods have in common that they allow the infliction of maximum pain on the victim whilst and at the same time leaving a minimum of visible physical after-effects (Jacobsen & Smidt-Nielsen, 1997). The lack of enduring physical scars interferes with efforts to document the human rights abuses and makes it difficult for the victim to prove torture experiences when he applies for asylum in an exile country. It is well documented that in very many cases physicians and other health professionals partici- pated in torture (British Medical Association, 1992). Their responsibility ranges from delib- erately withholding necessary treatment in prisons and issuing false medical certificates, to the direct participation in torture sessions with the task of preventing the victim from dy-
ing. Medical treatment in torture prisons is often reduced to the single purpose of making the victim ready for further torture.
Resulting from their clinical experiences in the treatment of torture survivors, Vesti, Somnier and Kastrup (1992) have classified the torture techniques reported by survi- vors. They distinguish between deprivation techniques (depriving victims of fundamental bodily needs like sleep, nutrition, hygiene and health care), coercion techniques (forcing victims to take part in degrading activities, like witnessing torture, eating excrement, etc.), communication techniques (verbal abuse, alternating rough/gentle treatment), pharmacol- ogical techniques and sexual torture techniques. Usually a torture victim has to undergo a large variety of different techniques at unpredictable time-points during an imprisonment.
Table 2.2. Forms of torture reported by Turkish torture survivors (from: Basoglu, Paker, Paker, Ozmen et al., 1994; selection from a total of 43 different torture forms assessed using a checklist)
Form of torture Prevalence (%)
Verbal abuse 100
Beating 100
Blindfolding 96
Alternating gentle/rough treatment 93
Forced standing 87
Threats of further torture 85
Electrical torture 78
Witnessing torture 75
Being stripped naked 71
Threats of rape 58
Threats against family 53
Hanging by wrists 51
Sham executions 38
Fondling of genitals 31
Submersion in water 15
Often prisoners are forced to confess to deeds and to betray other opponents during tor- ture. These coercions are a means of inflicting feelings of guilt and shame, and most torture victims report that giving in does not protect them from further torture. Instead, they are left in a completely helpless state without any means of stopping the humiliations.
Table 2.2 illustrates the occurrence of typical torture experiences as reported by Turkish torture victims (Basoglu, Paker, Paker, Ozmen et al., 1994). As it is not possible to select a representative sample of torture victims, these data may be biased, but they give an impression of what victims of systematic torture have to endure. The survivors reported a mean of 23 different forms of torture, with multiple exposures to each method. The survi- vors in this study rated a mean total of 291 exposures to torture during a mean of 47 months of imprisonment.
2.4 Survivors of organized violence as refugees
An obvious consequence of organized violence is that many people have to flee from their region of origin because of war or persecution. Very few war reporters dare to visit current war regions as it is usually not possible to guarantee security. Consequently, there are almost no photographs and films of combats, atrocities and torture. Media reports of overcrowded refugee camps are probably the most common confrontation with the con- sequences of organized violence for the western public. In 2001, the United Nations High Commissioner for Refugees (UNHCR) counted 21 million people who were fleeing worldwide (UNHCR, 2002b). The UNHCR differentiates between three groups of fleeing people. According to the UNHCR definition, refugees are persons who leave their home countries and find a more or less stable exile. During 2001, the size of the refugee popula- tion as estimated by the UNHCR remained unchanged at around 12 million. The other groups are asylum seekers who have submitted an application for asylum but have not yet received a decision and internally displaced persons (IDPs) who had to flee from their homes but did not leave their country of origin.
Most of the armed conflicts take place in non-industrialized countries. Conse- quently, the majority of refugees (86% in the past decade) originated from developing countries. At the same time, only a minority of refugees managed to flee to industrialized countries; 72% of all refugees stayed within the developing world, mostly in Asia or Africa.
About half of all refugees live in camps. As a result of the long duration of many conflicts, many camps have developed into refugee settlements that provide a home for many refu- gees who remain there for years or even decades.
No matter where the refugees flee to after war and persecution, most of them do not find a safe and accommodative exile. Many reports indicate that initial receptions by host government authorities and humanitarian agencies are impersonal and threatening, and that refugees assume roles of dependency and helplessness (Doná & Berry, 1999).
Whilst developments of social networks, family reunions and permanent settlements do occur (Castles & Miller, 1993), harsh living conditions, continued anxiety about forced re- patriation and uncertainties regarding resettlement can cause considerable stress for the refugees. Host country refugee policies are often dictated by domestic concerns, usually of a foreign policy nature and not necessarily determined by security and protection concerns or by the wishes of host communities in receiving countries (Tandon, 1984).
There are many reports that refugee camps breed violence and refugees are often victims of violent acts perpetrated by the army, militias, humanitarian workers and by their hosts (Malkki, 1995; Turner, 1999; UNHCR, 2002a). For many women and children, the very act of going to communal latrines (Forbes Martin, 1991) or collecting firewood and water can be extremely dangerous.
Refugees who flee to industrial countries to apply for asylum also live under very stressful conditions (Baker, 1992; Kammerlander, 1997). Many organizations caring for refugees in these countries complain about living conditions below the level of people who receive social welfare, unfair and delayed acceptance proceedings and direct offences by rac- ist opponents of refugees. Baker (1992) introduced the term “triple trauma“ for refugees who apply for asylum in industrialized countries. According to this concept, the asylum seekers have to suffer not only from their traumatic experiences from their homeland, but also from stressful events and losses caused by the flight as well as stressful living conditions in their exile country.
3 Psychological consequences of organized violence
3.1 The concept of posttraumatic stress disorder
3.1.1 Historical overview
The idea that stress contributes to mental diseases is not new and was held by many clinicians and scientists long before the concept of posttraumatic stress disorder (PTSD) was introduced to the DSM III in the 1980s. Different authors postulated that stressful life events can contribute to mental diseases, but the common agreement in psychiatry was that the psychopathological impact of life events was restricted to vulnerable individuals. The main cause of the illness was seen as the genetic predisposition or developmental vulner- ability and the role of stressful events was generally reduced to a nonspecific trigger that contributed to the onset or maintenance of a disease.
In the history of psychiatry, several authors opposed this view and suggested that traumatic events could cause mental diseases in normal individuals without the necessity of a predisposing vulnerability. Janet (1889) was the first to describe dissociation as a specific psychiatric consequence of traumatic events. In his early account of hysteria, Freud and Breuer (1895) suggested that the experience of sexual abuse was the main cause of this dis- order. Later, Freud rejected this view in favor of developmental models.
Among the first victims of traumatic events to be systematically studied were vic- tims of organized violence, the survivors of the Holocaust (see Levav, 1997, for an over- view). In 1948, Friedman was the first to describe a specific disorder he called “Buchenwald- Syndrom“ that included sleeping difficulties, high arousal and affective numbing in survi- vors. In 1964, Eitinger pointed out symptoms like concentration difficulties, irritability and a chronic fatigue in survivors living in Israel and Norway. He still avoided, however, the notion that these symptoms indicated a psychiatric disorder caused by the experience of traumatic events. Instead, he assumed a physical condition to be responsible for the symptoms. This suggestion was supported by the fact that the survivors of concentration camps he studied had also been exposed to malnutrition, physical attacks and diseases dur-
ing their persecution. Some years later, the American psychiatrist Krystal defined the “sur- vivor syndrome“ that included acute anxiety, nightmares, depression and hypochondria.
When the classification system diagnostic and statistic manual (DSM) was intro- duced by the American Psychiatric Association 1952 as a variant of the International Clas- sification of Diseases (ICD 6), the term “gross stress reaction“ was included to account for the immediate reaction to extremely stressful events. This diagnosis, like the consecutive diagnosis “transient situational disturbance” introduced in DSM II, was restricted to the acute upheaval that could be observed in individuals immediately after the experience of a traumatic event. Long lasting consequences of traumatic events were considered to be re- stricted to vulnerable individuals who developed an anxiety or depressive neurosis later on.
In the late 1970s there was a fundamental change in the view of the consequences of traumatic events. A lot of research was stimulated at this time mainly by the finding that a great proportion of the Vietnam veterans who returned home had major difficulties reinte- grating into their prewar roles. At the same time, researchers influenced by the women’s movement noted the prevalence of rape in the society and started to examine the resulting psychological symptoms in detail. This development was supported by the increasing ac- knowledgement of the suffering of traumatized individuals in society.
Different conceptualizations of the psychological symptoms related to specific events, like the “rape trauma syndrome“ (Burgess & Holmstrom, 1974) and the “delayed stress syndrome“ of former combatants (Horowitz, 1976) evolved. The major break- through in research into the consequences of traumatic events was when the psychiatric field realized that the different syndromes defined so far had much in common and should be seen as a single disorder. Consequently, the term posttraumatic stress disorder (PTSD) was introduced into the third version of the Diagnostics and Statistical Manual of Mental Disorders (DSM-III) to integrate the different classifications that had been offered before.
3.1.2 PTSD in DSM-IV
The current definition of PTSD in DSM-IV requires six criteria for the definition of PTSD. The first criterion (A) refers to the traumatic event. PTSD can only be diagnosed when the symptoms resulted from an experienced or witnessed event that involved the ac- tual or perceived threat for the life or physical integrity of the person or another person. In
addition, the immediate reaction of the victim must involve fear, terror or helplessness.
This event criterion was introduced to differentiate between traumatic events like rape and combat experiences from other stressful events like bereavement and the loss of a job. The idea between this discrimination is that normal stressful events may play a role in the onset and maintenance of psychiatric diagnoses like depression and schizophrenia but that the development of these disorders is restricted to vulnerable individuals whereas traumatic events could cause PTSD in anyone (Yehuda & McFarlane, 1995).
The second criterion (B) is related to intrusive symptoms. In the context of PTSD, intrusive symptoms describe the chronic re-experiencing of the traumatic event in the form of nightmares, flashbacks, stressful thoughts as well as the emotional and physiological re- activity to reminders of the event. Recent research showed that intrusive memories are not restricted to patients with PTSD, but that other stressful conditions could also cause the unwanted reliving of painful episodes (Brewin, Watson, McCarthy, Hyman, & Dayson, 1998). In contrast, reliving as flashbacks, in the form of multiple sensory qualities and in- cluding the feeling of being back in the traumatic situation, seems to be unique to PTSD (Brewin, 2001).
Criterion C relates to the avoidance behavior associated with PTSD. Contrary to the current classification, a factor analysis of PTSD symptoms suggested the subdivision of avoidance symptoms into two different factors (Foa, Riggs, & Gershuny, 1995). The first factor includes active avoidance of reminders of the traumatic event, like people and places that are associated with the event and the avoidance of talking and thinking about the event. In contrast to these phobic reactions are the symptoms of passive avoidance or numbing. These phenomena, which are also related to dissociation phenomena, include general emotional numbing as well as detachment from other people. According to the fac- tor analysis, these symptoms of numbing are more directly associated with the other PTSD symptoms than is phobic avoidance.
The last group of symptoms consists of the arousal symptoms (criterion D). They include the consequences of a high general level of arousal, including sleeping and concen- tration difficulties, an exaggerated startle response and the enduring feeling of threat.
Criteria E sets a time frame for PTSD, as the symptoms must last for at least four weeks. The additional diagnosis of acute stress disorder (ASD) was introduced for the acute
reactions to traumatic events that could be diagnosed within the four weeks period after the event. The symptoms of ASD are similar to the PTSD symptoms but put more stress on dissociation symptoms as these seem to better predict long-term consequences. Finally, criterion F relates to the clinical significance of the disorder as it requires a remarkable re- duction in functioning for the diagnosis of PTSD.
3.1.3 Assessment of PTSD
Qualified research and treatment of a psychiatric disorder depends on the availabil- ity of reliable and valid instruments for the diagnosis of the disease. Several standardized procedures have been developed for the assessment of PTSD. These instruments generally consist of a set of standardized questions about traumatic events and the symptoms of PTSD. There are two types of these instruments. Structured interviews are constructed to provide a standardized set of questions to an expert or a trained lay interviewer. They are generally considered to be the gold standard of psychiatric diagnosis. Some of these instru- ments, e.g. the SCID (Structured Clinical Interview for DSM-IV; First, Spitzer, Miriam, &
Williams, 2001) and the CIDI (Composite International Diagnostic Interview; WHO, 1997) have been developed to cover a large range of different psychiatric diagnoses in one interview. The advantage of these instruments is that a more or less complete picture of comorbidity can be assessed in this form. Unfortunately the completion of the full inter- view lasts up to two hours, so in many studies on traumatic stress only the PTSD part of the whole interviews is selected.
The diagnoses obtained through these structured clinical interviews are considered to be the most reliable and valid forms of diagnosis. Unfortunately they do not offer an estimation of the severity of the disease. The severity of the disease is most important for treatment studies that aim at the reduction of the severity of certain symptoms. The CAPS (Clinician Administered PTSD Scale; Blake et al., 1995) is an instrument that fulfills both requirements, a reliable and valid diagnosis and an expert rating of the severity of symp- toms and the disorder.
There are plenty of self-report forms for the assessment of PTSD. These instru- ments are filled in by the respondents themselves, usually in a paper-and-pencil form. They provide a severity rating of the symptoms and PTSD. Some of these instruments (e.g. the
Posttraumatic Stress Diagnostic Scale, PDS; Foa, 1995) can function as screening instru- ments for the diagnosis of PTSD with a satisfying accuracy, but the reliability and validity of the diagnoses are worse than those obtained through expert interviews. Other instru- ments, like the often used Impact of Event Scale (latest form: IES-R; Weiss & Marmar, 1996) don’t closely match the DSM-IV criteria and thus can not provide a diagnosis.
3.1.4 Epidemiology in industrialized countries
In industrialized countries, traumatic experiences like accidents, physical and sexual violence as well as war experiences of veterans can cause PTSD. In the US, epidemiological studies that used recent diagnostic criteria and instruments for the assessment of PTSD, found lifetime prevalence rates between 7.8% (Kessler, Sonnega, Bromet, Hughes, & Nel- son, 1995) and 9.2% (Breslau et al., 1998). There is no large-scale epidemiological study of PTSD in Europe. A study of adolescents carried out in the Munich region suggests that the prevalence of PTSD might be smaller in Germany than in the US, as the general level of violence is lower and fewer people have participated in recent wars (Perkonigg &
Wittchen, 1999).
Epidemiological studies showed that not all persons who experienced a traumatic event develop chronic PTSD. The most adverse event seems to be rape as it leads to PTSD in about 56% of the victims, followed by war participation (39%) and childhood abuse (35%) (Kessler et al., 1995). Epidemiological studies have found that PTSD is accompanied by one or more comorbid psychiatric disorders in more than 80% of the cases (Kessler et al., 1995). Among the most prevalent lifetime comorbid disorders identified in this study were major depression (men: 48%, women 49%), alcohol abuse (52%, 28%), simple phobias (31%, 29%), social phobias (28%, 28%), and conduct disorder (43%, 15%).
The fact that not all victims of a traumatic event have posttraumatic stress disorder has stimulated a lot of research into predictors for the development of PTSD. In a recent meta-analysis of risk factors in trauma exposed individuals, Brewin, Andrews, and Valen- tine (2000) concluded that the risk factors identified so far only have a modest effect size for the prediction of PTSD. Pre-trauma vulnerability factors like education, previous trauma, childhood adversity, psychiatric history and family psychiatric history predicted PTSD consistently over several studies but only to a small extent. Factors operating during
the event (trauma severity) or immediately after the event (lack of social support) seem to have stronger effect sizes, but still their explanatory power is small. The fact that pre- trauma vulnerability has an effect on the development of PTSD challenges the original as- sumption that people could develop PTSD without a predisposing vulnerability (Yehuda &
McFarlane, 1995). Current knowledge can neither confirm nor reject this assumption. We know that developmental factors can modulate the probability for PTSD but we do not know whether there is a type of trauma with such a high severity that all of the victims de- velop PTSD. Until now, no study has identified such an event and even among torture vic- tims the prevalence of PTSD is well below 100%.
3.1.5 “Complex” PTSD
Looking at the diversity of traumatic events, Herman (1992) has suggested differen- tiating between two different types of traumas. Type I traumatic events are those events that lead to pathological consequences after a single exposure, like a car accident or rape.
The more severe type II events include those events that either occur in childhood (like sexual abuse), or occur repeatedly over a long time-period, like torture experiences. Her- man suggested that whereas type I events cause “simple” PTSD, type II events can lead to a more complex pattern of symptoms. She suggested the introduction of a new diagnostic category of complex PTSD to refer to the symptoms that are thought to occur in addition to the usual PTSD symptoms in victims of type II events (van der Kolk, Roth, Pelcovitz, &
Mandel, 1993). Complex PTSD was subsequently also called “disorder of extreme stress (DES)”. It includes difficulties in affect regulation, extended dissociation symptoms, soma- tization symptoms, changes in identity, interpersonal problems, the tendency to expose oneself to further threat and the general loss of meaning of life. A structured interview for the diagnosis of DES was developed (Pelcovitz et al., 1997), but evaluation showed that not all the new symptom categories could be reliably diagnosed. Until now the suggestion of DES has not stimulated much research and it cannot yet be considered to be a valid diag- nostic category. Nevertheless, the similar category “personality changes under extreme stress” was included in ICD 10.
3.2 PTSD in populations affected by organized violence
One to two months after the September 11 terrorist attacks in New York City, the prevalence of PTSD related to the attacks among the inhabitants of the region near the World Trade Center (Manhattan south of the Canal Street) was 20%, whereas attacks- related PTSD in the other areas of New York was 7.5% (Galea et al., 2002). The investiga- tors who arrived at this conclusion used telephone interviews for the assessment and se- lected the respondents using random-digit dialing, which may restrict the validity of the diagnosis and the random selection. Nevertheless, this study shows that organized violence in the form of terrorist attacks has severe consequences for the mental health of the popu- lation even in industrialized countries, at least in the immediate aftermath of the event.
Notwithstanding the attention this attack received in the industrialized world’s public, these kinds of terrorist attacks are still the exception to most organized violence.
The dominant forms of organized violence are wars and persecution that can cause forced migration. Carrying out epidemiological research in these populations is a difficult en- deavor. Most victims of organized violence live in war regions that are dangerous to access.
Drawing representative samples within war populations is complicated as there is usually no valid demographic background information on the households and inhabitants. For tor- ture victims this problem is almost impossible to solve, as there are naturally no complete lists of torture survivors in their home or exile countries. The diversity of local languages in developing countries and the lack of fundamental mental health research in these coun- tries poses a challenge for the application of standardized psychiatric instruments and the interpretation of the results.
Nevertheless, several studies have tried to overcome these problems. Table 3.1 summarizes studies that examined mental health in populations with experiences of war, persecution and forced migration. Prevalence rates of posttraumatic stress ranged between 2% (Hauff & Vaglum, 1995a) and 99% (K. de Jong, Mulhern, Ford, van der Kam, & Kle- ber, 2000) in these populations. These studies differ in the type of population studied, the selection procedure and the instruments used to assess PTSD. A closer look at the most se- rious studies is necessary to estimate the impact of organized violence. In the following re- view, a selection of the more influential publications that examined PTSD as a consequence
of organized violence are presented to illustrate the state of the current knowledge and the methodological difficulties in epidemiological refugee research.
3.2.1 Populations living in war regions
Most people who are affected by organized violence live in regions that are affected by wars or have a recent history of war. Only a few epidemiological studies have examined war-torn populations that remained in the war region. Among these studies, there are many articles with limited explanatory value. One example is the study of K. de Jong and coworkers (2000) which found a prevalence of 99% of severe posttraumatic stress in Sierra Leone. Although reported in a major medical journal, this finding cannot be taken seri- ously, as the instrument applied in this study (Impact of Event Scale, IES) does not allow a diagnosis of PTSD and there is almost no information about the sampling of the 245 re- spondents.
Somasundaram and Sivayokan (1994) examined PTSD and other psychological dis- orders in 101 randomly selected respondents in Sri Lanka. They found a prevalence rate of 27%. Unfortunately, there is no information about the selection procedure, the authors state that they were randomly selected but this statement requires further explanation as sampling is not straightforward in a war-torn population. Furthermore, they used the Stress Impact Questionnaire (SIQ) to diagnose PTSD, but this instrument has not been validated for use with the Sri Lankan population.
In a major study including data from different war-affected populations, J. T. de Jong and coworkers (2001) found PTSD prevalence rates of 37% in Algeria (n = 653), 28.4% in Cambodia (n = 610) and 17.8% in Gaza (n = 585). In this study, the assessments were carried out by local interviewers, who applied a translation of the PTSD part of the Composite International Diagnostics Interview (CIDI). The authors note that this instru- ment was carefully translated into the local languages, but there is no information about the training of the interviewers and no study confirmed the validity of the translation and the assessment procedure. Furthermore, the selection of populations within these countries was restricted by security factors as well as by the availability of a local team and psychoso- cial care. These factors limit the extent to which the prevalence rates can be generalized to the whole populations of the countries. The fact that the researchers could not access the
more insecure regions suggests that the prevalence rates might be underestimates. Never- theless, the study shows that PTSD is frequent and a severe mental health problem in con- flict areas.
Lopes Cardozo and colleagues (2000) examined mental health in 1358 randomly se- lected Kosovar Albanians who lived in Kosovo in 1998. They found a prevalence rate of 17.1% PTSD. The method included a complex and innovative sampling procedure that used information from prewar population data as well as previous village surveys to iden- tify representative rural and urban population clusters. Random sections were selected within these clusters and the households were selected by drawing a random direction (spinning bottle) from the center of the section. PTSD diagnoses were made in self-report form using the Harvard Trauma Questionnaire (HTQ), for illiterate respondents the ques- tions were read aloud. The HTQ consists of a detailed checklist of traumatic events that was adapted to the requirements of victims of war. In addition, it contains a section on PTSD symptoms that allows a diagnosis of PTSD. The HTQ has been developed and vali- dated for Cambodian refugees in the US. Although the instrument has only been validated with this population, it was widely used in refugee research in many different populations.
In this study, there was no validation of the Albanian translation of the instrument. This is a severe limitation of the study as the validity of PTSD diagnoses obtained on the basis of self-report forms has not been demonstrated for victims of organized violence.
3.2.2 PTSD in refugees living close to the war regions
As carrying out epidemiological studies in war regions is very difficult, many re- searchers preferred to study the consequences of organized violence in refugee populations.
As described above, most refugees do not flee to industrialized countries to apply for asy- lum there, but remain in regions close to their country of origin where a great percentage of them remain in camps for many years.
Mollica and colleagues (1993) examined Cambodian refugees who had fled to camps in Thailand. They used a “multistage probability area” sampling based on grid maps of a refugee camp. Within the sampling units, specific routes for the interviewers starting from a randomly assigned starting point determined the selection of single households. They achieved a response rate of 98%. The survey showed that most of the 993 respondents
(82%) had lived in the camp for more then 2 years. The HTQ was used as an instrument for the diagnosis of PTSD, which had been validated in the Cambodian translation before.
They found a prevalence rate of PTSD of 15%.
In another study, Mollica et al. (1999) examined the consequences of war and forced migration for Bosnian refugees who had fled to a camp in Croatia. 26% of them suffered from PTSD according to HTQ. They randomly chose one adult from each of the 573 fami- lies living in the camp and thus achieved a sample size of 534 respondents (the remaining minority of refugees refused to participate). Although they state that culturally validated instruments were applied in this study, they report no validation of the Bosnian version of the HTQ.
3.2.3 PTSD in refugees in industrialized countries
A minority of refugees manages to flee to industrialized countries. Some studies ad- dressed these populations. One study found a prevalence rate of 86% of PTSD among 50 Cambodians who resettled in the USA (Carlson & Rosser-Hogan, 1991). The respondents were randomly selected from a list of all refugees made by a nonprofit social services agency. They used expert interviews for the assessment of PTSD, but a non-validated checklist of PTSD criteria was used as an instrument. In addition, they excluded five of the 17 DSM-III-R criteria for PTSD because for some reason they did not consider these crite- ria to be appropriate for the group. Unfortunately, there is no explanation of which symp- toms were excluded. As the criteria for a PTSD diagnosis were considerably reduced com- pared to the standard, the results probably greatly overestimate the true PTSD prevalence.
Another group (Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997a) examined a sample of 40 refugees from different countries who applied for asylum in Australia. They used an opportunity sampling method, and selected the respondents from an English class.
As expected, this resulted in a selective group with reasonable English skills, which cannot be assumed to be representative of asylum seekers. PTSD diagnoses were made using the PTSD part of the CIDI, which was in vivo translated into the respondent’s mother lan- guage if the English skills were not sufficient. Among the asylum seekers, 37% suffered from PTSD.
In a consecutive study in Australia, this group (Silove, Steel, McGorry, & Mohan, 1998) compared the levels of PTSD among 62 Tamil asylum seekers with 30 authorized Tamil refugees and 102 immigrants with Tamil background. The respondents were ap- proached through aid services and refugee organizations, which may lead to uncontrollable selection biases. The HTQ was used for the assessment of PTSD symptoms, unfortunately the Tamil translation was not specially validated and no diagnosis of PTSD was made. As expected, both refugee groups presented with higher posttraumatic stress than the immi- grants, but they did not differ from each other.
In a small sample of 20 Bosnian refugees in the immediate aftermath of resettlement S. M. Weine and coworkers (1995) found a PTSD prevalence of 65%. The refugees took part in a program that provided them with the opportunity to give testimony. The effect of this selection cannot be estimated, as there might be a bias either towards a specially morbid treatment-seeking group or towards a healthy group of those who present with less avoidance behavior. The assessments were carried out by experts using a translation of the Posttraumatic Symptoms Scale (PSS). An interesting result of this study is that one year later 44% of the original group still suffered from PTSD (S. M. Weine, Vojvoda et al., 1998), indicating a considerable stability of PTSD in refugees over time.
3.2.4 PTSD in patient groups
Confronted with a high psychiatric morbidity in refugees, several institutions in in- dustrialized countries provide special medical and psychological assistance for refugees.
Some of these institutions have studied their patients in detail. For example, Van Velsen et al. (1996) examined 60 patients with a history of organized violence who were referred to the London Medical Foundation for the Care of Victims of Torture. A self-constructed checklist was used by psychiatrists to diagnose PTSD. The subjects were from a wide vari- ety of national backgrounds, the largest group were Kurds from Turkey. 52% of the pa- tients suffered from PTSD. This result indicates that there is a high prevalence of PTSD among refugees who seek medical or psychosocial assistance.
3.2.5 PTSD in torture victims and former political prisoners
Torture is considered the most stressful form of organized violence. In several con- secutive studies (Basoglu et al., 1997; Basoglu et al., 1996; Basoglu, Paker, Ozmen, Tas- demir, & Sahin, 1994; Basoglu, Paker, Paker, Özmen et al., 1994), Basoglu and coworkers tried to determine the mental health effects of torture for the survivors who remained in Turkey. With 55 respondents in each group, he compared a group of tortured political ac- tivists with a group of non-tortured activists. He found a rate of PTSD of 18% among the torture victims, compared to 4% among the non-tortured activists. Considering the sever- ity of the torture experiences reported in this study (see chapter 2.3), the prevalence rate of PTSD is still remarkably low. In another group of Turkish torture victims, who were not political activists but were convicted because of criminal activities, the PTSD rate was 58%.
A comparison of the torture experiences showed that the activists were tortured much more severely than the criminals, nevertheless their rate of PTSD was much lower. The interpretation was that the preparedness of the political activists who were aware of the risk of torture could be a protecting factor. In contrast, the torture in prison was not ex- pected by the criminals and could less easily be justified on the basis of their beliefs. This interpretation was confirmed by a further analysis of the group’s cognitions and attitudes.
Nevertheless, the convenient snowball sampling procedure for the group of activists limits the explanatory power of the results. It is probable that only the less severely affected indi- viduals were ready to come to an investigation to talk about their suffering. So the 18%
prevalence of PTSD in torture survivors is almost certainly an underestimate.
In two studies, Maercker and coworkers (Maercker, Beauducel, & Schutzwohl, 2000; Maercker & Schutzwohl, 1997) examined PTSD in former political prisoners from the German Democratic Republic after the German reunion. Again, a convenient sampling procedure was applied as respondents were recruited by newspaper articles and political prisoners’ organizations. In both studies about 30% of the former prisoners presented with PTSD. Assessments were reliable and valid as they were carried out by psychologists using a standard clinical interview validated in the German language (Diagnostisches Interview Psychischer Störungen; DIPS, extended German version of the Anxiety Disorders Sched- ule; ADIS).
Shrestha et al. (1998) studied the impact of torture on Bhutanese refugees living in Nepalese refugee camps. They compared 526 refugees with torture experiences with the same number of refugees matched for age and sex without torture experiences. The authors selected the patients from an existing list of tortured refugees prepared by a nongovern- mental organization. A self-constructed interview schedule was applied by local physicians, who received brief training in the diagnosis of PTSD. Unfortunately, there was no valida- tion of the instrument and the assessment procedure. A prevalence rate of 14% was found among the tortured refugees. In comparison, only 3% of the non-tortured refugees suffered from PTSD. This result further supports the impact of torture on mental health even in a refugee population with presumably many war experiences. However, the relatively low prevalence rates have to be interpreted cautiously because of the methodological problems of the assessment.
