Appraisal of traumatic experiences (Second section)

Assessing Trauma in Sierra Leone

Exposure to traumatic events

Graph 3 shows what situations the respondents have faced. Incidents include: attack on village (84%), exposed to cross fire (84%), explosion of mines (28%), aerial bombing (83%), mortar fire (65%), burning of properties (62%) and destruction of houses (73%), indicating that large groups of the population of Freetown have been caught in direct war. In addition to the direct threats caused by the hostilities, the lack of food and other commodities forced people to take extra risks (74%). A smaller number of people (57%) had to walk long distances to find a safer place. The risk of abduction was clearly present since 43% of the respondents reported having been exposed to abductions. Generally half of the respondents indicate that the event had taken place more than three times.

Coping with traumatic events is more difficult when people themselves experience immediate life-threatening circumstances (Kleber, Brom; 1992). Graph 4 shows what life-threatening traumatic experiences some of the respondents survived.

The respondents were allowed to report on all items. The percentages are related to the number of people having experienced that event as a proportion of the total number of respondents. Several people suffered from multiple life-threatening experiences.

A high percentage of respondents directly experienced at least once an event threatening their physical integrity, either by maltreatment (39%) torture (16%) or amputations (7%). 40% of the respondents have seen their houses burned down; 33% were taken hostage. The percentage of people reporting abduction is, in contrast to the above, relatively low (7%). The relatively low report on rape (2%) should not be misinterpreted. Rape is, as in most other countries, a taboo topic. Rape victims usually do not report this crime to avoid serious repercussion from their family or to evade the stigma communities and society impose on these victims.

The dire food situation is by far the highest life threatening experience, as it was reported by almost all the respondents (99%).

Loss and witnessing

Conflict and violence are closely related to loss. Loss of loved ones and witnessing their violent death might be one of the most serious risk factors for
PTSD. Graph 5 gives an overview of both.

The percentage of people lost increases with the number available. The loss in the nuclear family (partner (5%), father (5%), mother (7%), child(ren) (9%) and siblings (16%)) is reported less then the loss of more "distant" family members (aunt, uncles (14%)). The percentages reported on death of neighbors (53%) and friends (50%), is clearly higher, since there are more of them. These data indicate that at least 50% of the respondents lost someone they knew very closely. Many respondents witnessed the death of a close person: 30% witnessed the death of a friend, 41% that of a neighbor. Additionally 7% witnessed the death of their child.

To create terror a perpetrator often demands others to witness the atrocities. The psychological impact of actually witnessing horrific events imposes a serious psychological stress. Deliberately or not, witnessing at least once events such as torture (54%), execution (41%), (attempted) amputations (32%), people being burnt in their houses (28%) and public rape (14%) often results in traumatic stress or even PTSD. Almost all respondents reported to have seen wounded people at least once (90%). Graph 6 gives an overview.

Impact of Event Scale (Third section)

The inhabitants experienced horrific events. The third section measures the prevalence of traumatic stress responses through the Impact of Event Scale questionnaire (Horowitz, Wilier & Alvarez, 1979). The PTSD score as outcome of the Impact of Event Scale (I.E.S.), is constructed around two clusters of reactions. Intrusions such as flashbacks, nightmares and reliving the event are indicators of the preoccupation with the events that often characterize survivors of violence. Complaints like "I can't stop thinking about it" combined with the unpredictable occurrence of flashbacks often provoke feelings of having lost control or becoming crazy.

To compensate for the agony of ongoing intrusions, survivors try to avoid situations, places, conversations or people that remind them of the
events. The avoidance as well as the intrusions has a debilitating effect on the survivors' social life. Social withdrawal and a life obsessed by fear and avoidance may be the destiny of those that suffer from severe, chronic PTSD.

The overall PTSD scores registered on the I.E.S. are high. When the cut of scores (no problem: 0-10, at risk: 11-25, PTSD: 26-75) for Western Europe are applied, no one reports to having "no problem." Two people have scores indicating a risk for developing PTSD. All other respondents (99%) have scores on the I.E.S. that are associated with PTSD in a Western European setting. In the current survey most people (111, 27%) have scores between 36 and 45, which is similar to the number of people having scores between 46 and 55. Graph 7 shows the scores on the I.E.S. No significant differences were found between the contribution of intrusions and avoidance on the overall PTSD score. There were 16 respondents who were not able to give a clear answer on one of the questions composing the PTSD scale; these respondents are excluded from the total PTSD score. The average score on the PTSD scale was 47.6, with a confidence interval of 45.6-49.6 (95% confidence level).
This result shows good precision.

The results on the I.E.S. are consistent with the conclusions on the appraisal of traumatic experiences. The reported high numbers of traumatic experiences may explain the high scores on the I.E.S. However, this conclusion has to be read with care. The I.E.S. is not validated in Sierra Leone and may therefore be subject to differences in understanding some questions. Moreover the cut-off scores may prove to be quite different then the ones used by us. Despite these considerations, high levels of traumatic stress are evident, since even when the cut of score is raised to 55 (more then doubled), 63 people (25%) still suffer from severe traumatic stress or even PTSD.

Physical health (Section 4)

People suffering from traumatic stress and PTSD often have physical complaints like headache, stomach problems, body pain, dizziness or palpitations. Frequently the complaints cannot be related to a physical disease or disorder. Nevertheless, the physical complaints are expressed in frequent visits to the overburdened health care settings. People continue to search for a physical cure to alleviate their emotional problems. Medical people are not aware of or feel powerless against the somatizing patient and offer medication. Despite the costs both to the patient and the health system, this situation is frequently found in health settings in violent contexts. Some indicators of physical health and medical needs are described below.

Since the onset of the violence, the majority of the respondents (85%) perceived their health to be worse than before. Consistent with this finding is the occurrence of unclear physical symptoms reported by the majority of the respondents (78%). As a result, 42% of the respondents visited the health post or clinic at least twice in the four weeks prior to the survey.

UN-HEALTHIER 19 (8%) 19 (8%) 132 (54%) 74 (31%) 244
UNCLEARSYMPTOMS 33 (13%) 21 (9%) 125(51%) 66 (27%) 245
HEALTH POST VISIT 100 (41%) 35 (14%) 76 (31%) 27 (11%) 238

Table 1 is an overview of perceived health, the occurrence of unclear symptoms and the number of health post/clinic visits (Rarely = 1; Sometimes= 2.3; Often= 4 ).

The results of the fourth section (physical health) confirm the tendencies reported earlier. Traumatic stress associated with physical complaints (like headache (39%) and body pains (12%)) is reported most frequently. The visits to health facilities are relatively high (42%). The majority takes medication (e.g. paracetamol, panadol, vitamins, chloroquine).