1. Faces and Manifestations of Psycho-trauma Emilio Ovuga GuluUniversity

2. Objectives Share my experience, thoughts Post-traumatic stress disorder is not a psychiatric entity?! Leave the audience in suspense 8/19/2011 2 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

3. Introduction Traumatic stress is classified as natural or manmade Natural disasters occur outside the control of humans 8/19/2011 3 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

4. Forms of Traumatic Stress Several forms of traumatic stress Some dramatized more so than others Emphasis is mainly on war, organized violence, rape, childhood sexual abuse, and natural disasters Trauma in the hands of powerful members of households in the equally powerful and secretive environments of homes are more common These are perhaps the most destructive, most crippling, and most painful of all traumas Physicians often manage traumatic stress in the context of households at their own peril 8/19/2011 4 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

5. Manmade Disasters Manmade disasters are inflicted on humans by fellow-humans Pervasive, carefully planned; executed in cold blood, without emotion/feeling Victims cannot usually escape however hard they try, only thing in their power is to surrender to the will of their aggressors Accounts of manmade traumatic stress leave one wondering whether perpetrators have human hearts and souls 8/19/2011 5 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

6. Racism as Mental Disorder 1 Black psychiatrists in America suggested that racism be classified as a mental disorder at an Inaugural Meeting of African Psychiatrists in the Diaspora at Massachusetts General Hospital, November 2001 The suggestion was understandable given the degrading and traumatic experiences that African slaves and their descendants went through in the hands of their white slave masters/owners 8/19/2011 6 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

7. Racism as a Mental Disorder 2 My lone response then was: “If racism is classified as a mental disorder, what about the ethnic violence that is currently going on in Northern Uganda?” I received no answer. The lack of an answer then was perhaps equally understandable given the commonplace experience of traumatic stress in public and domestic domains 8/19/2011 7 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

8. Manmade Trauma Despicable Beyond the understanding of the sane Destroys victim’s attachments Victims are left helpless and without foundation Erodes victims’ confidence and sense of security; shakes the foundations of trust in the social order Alienates victims beyond words; victims left feeling abandoned 8/19/2011 8 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

9. Examples 1: Powerful Parent Tortures own Child 8/19/2011 9 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

10. Example 2: Rape Leads to Phobia A successful graduate and career woman sought professional help for lack of sleep, nervousness, and inability to perform her usual work. The primary problem was fear of closed spaces that generalized to fear of flying; she felt her fear would prevent her from travels abroad. The woman gave history of repeated rape in her room in the house of her married sister by a brother-in-law at night. She feared to raise the alarm in order to save her sister’s marriage. In her anguish she asked during therapy: “Why should someone rape you when you had all along protected and kept yourself intact waiting for the man you would marry?” 8/19/2011 10 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

11. Example 3: Rape by Paternal Uncle A student reported to a female confidant the experience of repeated rape that she and her younger sisters were subjected to by a paternal uncle. The girls had lost both parents to AIDS and they depended on their paternal uncle for education and general survival. Despite their anguish and wish to escape from their paternal uncle, the girls declined a suggestion for therapy and professional advice. 8/19/2011 11 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

12. Example 4: Hate Turned Unto the Self A four-year-old boy was brought to a mental hospital with each hand securely crepe-banded into a fist. The boy presented to hospital with severe recent and old scars in both temporo-frontal areas of his face; worse on the right. At the age of 2½ years the child had reacted to the birth of a rival sibling with apparent jealousy, rage and perhaps, hate 8/19/2011 12 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

13. Example 4 Continued: Hate Turned Unto the Self In one of his several attempts to push the sibling neonate from the mother’s lap the boy brutally hit and scratched at his follower and attempted to sit on it. The mother with maternal instinct to save the newborn hit the boy with such force that the boy apparently instantly turned his hate onto himself The boy began slapping and scratching himself almost without rest; whenever he got tired, he walked to the mother or other adult and silently tried to use the hand of the adult to hit him in the side of the head 8/19/2011 13 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

14. Example 5: Former Child Soldiers In December 2007 a group of former child soldiers were admitted to Gulu Regional Referral Hospital with what appeared to be mass hysterical behavior. Assessment indicated that the children presented with mass psychotic or dissociative disorder following a noisy prayer session in the evening. (Ovuga et al 2008) 8/19/2011 14 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

15. Nature of Traumatic Stress Traumatic stress is defined as being beyond the tolerance of the average person However: What is tolerable to one average person may not be so to the next average person Definition in primary care does not often take account of the lived experience of victims The meaning attributed to traumatic experience may influence the symptom patterns of emotional/mental disorders Parental experience of traumatic stress predisposes offspring to similar experience 8/19/2011 15 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

16. Example 6: Battered Woman Relives Domestic Violence Through Own Little Son The little son of a couple who saw his mother battered by his irate father apparently internalized the suffering, fear, helplessness of his mother. Whenever the mother was angry at the little boy for minor mistakes she would yell and swear at him just like her husband did. In response the little boy looked apprehensively at his mother. Unfortunately the boy’s eyes resembled the eyes of his irate father, and this reminded his mother of her traumatic experiences (de Zulueta, 2011) 8/19/2011 16 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

17. What Is Post-traumatic Disorder? A diagnostic entity? A variant of a major psychiatric disorder, e.g. Anxiety Disorder as currently recognized? How does traumatic stress that leads to other mental disorders qualitatively differ from the one that leads to PTSD? How does traumatic stress that leads to PTSD qualitatively differ from the common place experience of stressors in daily life? 8/19/2011 17 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

18. Traumatic Stress Ordinary Stress Traumatic Stress Trust and confidence in social support system Stressor understandable to the victim Victim recalls all aspects of the stressor at will Victim feels safe in recall of events of stressor Loss of trust and confidence in social order Stressor alien and not understandable Victim cannot freely recall aspects of stressor Victim feels insecure in recall of events of stressor 8/19/2011 18 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

19. Post Traumatic Stress Disorder Other Mental Disorders Post Traumatic Stress Disorder No evidence of flight or fight reaction Hyperarousal, reexperience or avoidance of situations or reminders not usually evident Evidence of degrading, humiliating traumatic stress usually not available Traumatic stress leads to flight or fight reaction Reaction characterized by hyperarousal, reexperience of traumatic event and avoidance of reminders or situations Fragments of traumatic stress available to history unlike in most anxiety disorders 8/19/2011 19 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara

20. Conclusion Traumatic stress is extremely common in daily life Post traumatic stress disorder is perhaps more common than recognized PTSD may present with unusual symptoms However culture specific definitions are required to recognize victims and clients 8/19/2011 20 Global Health Center Symposium, MGH, Lake View Hotel, Mbarara