The association between posttraumatic stress symptoms and functional impairment during ongoing conflict in the Democratic Republic of Congo

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Abstract

The Democratic Republic of Congo (DRC) has suffered from a bloody conflict for more than a decade. More than 5,400,000 people died from war-related causes since 1998 and exposure to violence was wide-spread. This study investigated the impact of posttraumatic stress disorder (PTSD) symptoms on perceived health and physical and social functioning, filling an important gap in the current literature. Data were collected from a sample of 93 adults living in Bunia, Eastern Democratic Republic of Congo. Structured in-person interviews included the PTSD section of the Composite International Diagnostic Interview and the World Health Organization Disability Assessment Scale. Additional questions were included to assess social resources. Study recruitment was balanced to achieve equal representation of both sexes and each quarter of town. Forty percent met symptom criteria for probable PTSD. Individuals with PTSD reported poor perceived general health and had high disability scores compared to those without PTSD. Of the three PTSD symptom clusters, hyperarousal was most strongly associated with disability. Individuals with PTSD were significantly more emotionally affected by their health problems than those without PTSD (85% versus 41%), had more difficulties in activities involving social contact (54% versus 16%) and in doing their daily work (54% versus 20%). The impact of war-related violence on mental health is severe in the DRC. Psychosocial interventions developed in conflict areas might be best targeted primarily to supporting social functioning and reducing hyperarousal. Implications for clinical treatment and future directions are discussed.

Highlights

► Evaluated the impact of PTSD on perceived health and physical and social functioning. ► Data were collected from 93 adults living in Bunia, Eastern Democratic Republic of Congo. ► People with PTSD reported poor health and high disability scores compared to those without PTSD. ► Of the three PTSD symptom clusters, hyperarousal was most strongly associated with disability. ► People with PTSD had greater health problems, difficulty with social contact and functioning.

Introduction

The Democratic Republic of Congo (DRC) has suffered from a bloody conflict for more than a decade. More than 5,400,000 people have died from war-related causes since 1998, making this the deadliest documented conflict since World War II (Coghlan et al., 2008). The most violent period of the conflict was from 1999 through 2006. Exposure to violence and war increases the risk of experiencing mental health problems. The prevalence of posttraumatic stress disorder (PTSD) in low- and middle-income countries (LMIC) following war and political violence varies from 20% to 40% (De Jong et al., 2001, Pham et al., 2004, Roberts et al., 2008, Scholte et al., 2004), which is remarkably high as these estimates are obtained years after conflict had ended.

Few studies have been conducted within highly traumatized populations facing ongoing threat of violence and continued exposure to political instability and economic deprivation. The mental health consequences of exposure to protracted large scale violence within the civilian populations in the DRC are only beginning to be revealed. A large household survey in Eastern DRC found that 50% of the population met symptom criteria for PTSD and 41% for major depressive disorder (Johnson et al., 2010). Fifty-two percent of adolescents in schools in three districts in Eastern DRC met the criteria for PTSD; symptom scores were strongly related to cumulative trauma exposure (Mels, Derluyn, Broekaert, & Rosseel, 2009). However, these studies were conducted after the cessation of large-scale violence.

The effect of trauma on the social and physical functioning of people living in the DRC has not been investigated. This is true of most post-conflict settings and little is known about the extent to which the severity and type of PTSD symptoms are most significantly related to disability and functional impairment. The few studies that have explored this issue in the post-conflict populations suggest that this impairment is high. For example, in sample of Bosnian refugees living in camps who survived mass violence, 25% reported having a significant physical disability (Mollica et al., 1999). The risk for disability increased with comorbid symptoms of PTSD and depression, and with cumulative experiences of trauma.

It is important to increase knowledge about the association between PTSD symptoms and functional impairment, because there is an ongoing debate on the controversial value of PTSD diagnosis and allocation of resources for trauma-focused care during and after acute emergencies, particularly in non-Western countries with massive exposure of the population to trauma (Rajkumar et al., 2011, Summerfield, 2001, Van Ommeren et al., 2005).

The purpose of this investigation was to assess the association between PTSD symptoms and probable PTSD diagnosis on perceived health and physical and social functioning in daily life among an adult population of Bunia, Eastern DRC in 2006, during a time of ongoing conflict.

Section snippets

Procedure and participants

In November 2006, structured clinical interviews were conducted in Bunia, Orientale Province, the northern region, of the Democratic Republic of Congo. People were approached in safe public areas to participate by local interviewers hired and trained by the NGO Medair. All interviewers received training in understanding psychosocial functioning within post-conflict areas and specific training in how to administer the study interview. They received daily supervision and debriefing throughout

Sample characteristics

Ninety-three people agreed to be interviewed. Table 1 gives the age and sex distribution of the study sample. The mean number of traumatic events was 5.4 (SD, 2.1). Virtually everyone had experienced trauma related to war and the majority reported having been beaten up badly, threatened with a weapon and witnessed someone being seriously wounded or killed (Table 1). Nearly all participants reported peritraumatic anxiety (98%) and helplessness (96%) during the traumatic event(s). Thus, this

Discussion

This cross-sectional study was conducted in the main town in a conflict area in the Eastern area of the Democratic Republic of Congo in 2006. The population under study was severely traumatized and 40% of the population met the criteria for probable PTSD. This is a higher estimate than other studies conducted in contexts of ongoing violence (Hobfoll, Mancini, Hall, Canetti, & Bonanno, 2011) and in post-conflict settings (De Jong et al., 2001), but it is consistent with studies among adults (

Acknowledgement

Dr. Hall's contribution to this work was supported by NIMH psychiatric training programme grant T32MH014592-35 (PI: Zandi).

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