Correlates of post-traumatic stress and physical symptoms in Nepali adults under political turmoil

The Australasian Journal of Disaster
and Trauma Studies
ISSN:  1174-4707
Volume : 2005-1

Correlates of post-traumatic stress and physical symptoms
in Nepali adults under political turmoil

Elaine Duncan Department of Psychology, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK	Yori Gidron Department of Psychology, University of Southampton, University Road, Highfield, Southampton, UK
Roshan Prakash Shrestha Department of Microbiology and Immunology, Faculty of Health Sciences, Ben-Gurion University, Israel	Timothy Aryal Head of Department of Psychology and Philosophy, | Trichandra Campus (T.U) Post Box: 5888, Kathmandu Nepal

Abstract

This study investigated whether there is a relationship between the political violence that took place in Nepal and symptoms of posttraumatic stress disorder (PTSD) and physical symptoms. Eighty-five Nepali citizens completed brief questionnaires assessing background information, whether they were directly exposed to political violence, the presence of PTSD-like symptomatology as well as physical complaints. Participants also completed a measure of perceived psychological proximity to the political events using a novel application of the Pictorial Representation of Illness and Self-Measure (PRISM). Old-age, little education and residing in a rural village were associated with more PTSD-like symptomatology. Both direct exposure and perceived psychological proximity to the political violence were associated with more PTSD-like symptoms. Most parameters were unrelated to physical symptoms. Interestingly, PRISM-distance moderated the effects of exposure to violence on PTSD-like symptoms: in participants exposed to violence, those with big PRISM-distances reported lower PTSD-like symptoms than those with little PRISM distances. The theoretical, methodological and cultural aspects of these results are discussed.

Correlates of post-traumatic stress and physical symptoms
in Nepali adults under political turmoil

Introduction

Complaints consistent with symptoms of minor and major mental illnesses, such as post-traumatic stress disorder, (PTSD) are known to increase in the presence of chronic stress as well as in response to specific catastrophic and acute events (van der Kolk 1994). In Nepal, terrorist attacks would almost certainly constitute acute and chronic stressors and torture of those alleged to be involved in political activity may have existed in Nepal for decades (Lykke & Timilsena, 2002). Terrorist attacks, whether sudden (acute) or part of a more prolonged campaign (chronic), are well established as being associated with the development of PTSD, major depression, substance abuse and generalized anxiety (Tucker, Pfefferbaum, Nixon, & Dickson, 2000). A recent review of the prevalence of PTSD following terrorist attacks proposed an estimate of 28.2%. However this figure was offered tentatively on the basis of variability within the seven studies included in that review (Gidron, 2001). Political turmoil, perhaps not surprisingly, has also been found to be associated with long-term poor mental health (Cairns & Lewis, 1999) and with PTSD symptoms (e.g., el Sarraj, Punamaki, Salmi & Summerfield, 1996). Allegations of torture and/or displacement of citizens from remote mountain villages to Kathmandu lead us to believe that the prevalence of PTSD symptomatology could be high.

A number of factors appear to have an influence on the likelihood of one developing PTSD. These have been identified as severity and degree of exposure to traumatic events (Yehuda, et al., 1995; Kluznick, Speed, van Valkenburg, & Magraw, 1986), having incurred physical injury (Desivilya, Gal, & Andreski, 1991), previous trauma exposure (Robinson, et al., 1994), prior psychiatric history (Helzer, Robins & McEvoy, 1987), and of greatest importance peri-traumatic dissociation (Emily, Best, Lipsey, & Weiss, 2003). Studies over the last decade have shown that those suffering from PTSD tend to be more likely to report non-specific somatic complaints than do those without PTSD (e.g., Baker et al., 1997; McFarlane, Atchison, Rafalowicz, & Papay, 1994; Shalev, Bleich, & Ursano, 1990).

Van Ommerman and colleagues, in co-ordination with the Centre for Victims of Torture (CVICT), Nepal have investigated torture and made recommendations for treatment and intervention programmes (van Ommerman et al,. 2001; Shrestha et al,. 1998; van Ommerman et al,. 2002). This work has primarily involved Nepali-speaking Bhutanese refugees in Nepal, but they also documented the extent of coping, social support and somatic symptom reporting in a smaller sample of native Nepalese help-seeking torture survivors (Emmelkamp, Komproe, van Ommerman, & Schagen, 2002). To the best of our knowledge these have been the only investigations of prevalence of political turmoil and its impact on physical and psychological sequelae in Nepal.

The present preliminary study is unique in that it sampled a cross-section of Nepalese society as opposed to only registered torture survivors. It seeks to examine the effects of the escalation of the Maoist insurgence and destabilisation of power on psychological and physical well-being from 2 perspectives; (i). direct exposure to political terror or violence, and, (ii). perceived psychological proximity to the stress of political violence, adopting a previously unused measure which is described in detail below. For the purposes of this study the former is defined as, having suffered physical injury and/or relocation due to destruction of property, land and/or home by politically related agents. In contrast perceived psychological proximity to the stress of political violence is defined as the extent to which a person appraises the political climate to be part of his/her daily life. For clarification the first perspective relates to actual experience and is factual, while the second explores appraisal processes about the extent to which surrounding events touch ones day-to –day life irrespective of actual exposure. Thus, this study seeks to explore the relationship between these exposure and appraisal variables with PTSD-like symptoms and physical symptoms. We hypothesized that reported levels of direct exposure or perceived psychological proximity to political violence would be positively correlated PTSD-like symptoms and with physical complaints.

In the present study although such variables as previous trauma exposure and psychiatric history are not included we do measure degree of exposure, resultant physical harm and extent of somatic complaints

Method Procedure

Participants
Data for this study were collected in July 2002. Eighty-five Nepalese people (65.9% male and 34.1% female) completed two questionnaires and a visual task as described below. The sample included of 24 hunger strikers, who claimed to have been victims of physical violence. At the time displaced in Kathmandu they were campaigning to raise awareness of alleged Maoist atrocities. In addition there were a further 46 student participants drawn from an undergraduate psychology programme and a professional skills course, both based in Kathmandu. A further 13 participants were teachers recruited from a school in Kathmandu and a village primary school some distance from Kathmandu. Two further participants were from one of the many internet cafés in Kathmandu. Although random sampling was not used the participants represent various segments of Nepalese society. The age categories can be observed in Table 1. Each participant was also asked which level of education they had achieved. This was categorized as not having received formal education, leaving after some years at school, being presently a student on an academic or professional course or having already graduated from some form of higher education.

Questionnaires/Measures
Background data gathered included age, gender, years of education, number of languages, and geographical location (rural, town, city). In addition, participants were asked to indicate whether they had been directly exposed to political violence adopting the operational definition given above. A further 2 short questionnaires and a visual task were adopted. The first questionnaire was the Physical Symptom Index, (Moos, Cronkite & Finney, 1990). This is a 12 item list consisting of the following symptoms: weakness, fever, erratic or racing heart rate, loss of appetite, feeling fidgety or tense, restlessness, indigestion, cold sweats, trembling, headache, constipation, and insomnia. Participants were invited to rate how often they experienced these in the last month on a 4-point scale (1 = “not at all” and 4 = “fairly often”). Individual symptoms are normally summed to create a global symptom index representing self-reported physical symptoms with higher values indicating greater symptomatology. However due to misunderstanding of the response format, we could only count the number of symptoms acknowledged. Hence, this ranged from 0-12.

The second questionnaire was based on the Post-traumatic Diagnostic Scale (Foa, Cashman, Jaycox & Perry, 1997). The original questionnaire has 17-items that yields both a PTSD diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders and a measure of PTSD symptom severity. For the present study, we selected 6 items from the full scale using data of a previous study conducted by Gidron et al., (2001). Two items from each sub-scale, with the largest corrected item-total correlation with the full scale, were selected. This yielded the following 6-item PTDS questions: re-experiencing, physical reactions, avoidance, reduced interest, sleep difficulties, and anger-attacks. When developing the scale with the previous data of Gidron et al., (2001), the six-item PTDS achieved high internal reliability (Cronbach’s alpha =.93). A high correlation was obtained between the full and brief scales (r = .96). In order to reduce subject attrition we intended to use this 6-item scale however in the translation process to Nepali one item was omitted by mistake. In responding to this questionnaire participants were asked to refer to the political events. Each item was rated on a 1-4 frequency-scale where 1 = Never, 2 = Often, 3 = 2/3 times a week and 4 = More than 5 times a week. It should be noted that the final set of items provides an indication of PTSD-like symptomatology and is not meant to be operating as a diagnostic tool for the prevalence of PTSD in the present study.

The third measure used was the Pictorial Representation of Illness and Self-Measure (PRISM) (Buchi et al., 2000). This is a novel visual method for assessing the overall impact of illness in ones life, originally used with patients who had systemic lupus erythematosus. Thus participants are asked for an appraisal of how proximal and relevant their illness is to their day to day life functioning. It is understood that this judgement is not necessarily relative to actual severity of the illness but may reflect more the perceived burden they are experiencing from their illness. In the present study the method is replicated but rather than an appraisal of an illness the participants were asked to judge to what extent the political climate had become part of their daily lives. The simplicity of the task makes it appropriate for the setting and for the less literate. Being a visual method it avoids some of the problems that translation may have presented. The standard task uses two disks and an A4 size card. For ease of transport and operation in the present study we chose to use two coins instead of two disks. In the original test and in the present study the A4 size card represented one’s life as it is currently. One coin represents the individual and the other coin represented the political events. The first coin (the individual) was placed in the bottom right-hand corner of the sheet of paper. Participants were then asked to place the second coin (representing the political events) in relation to the first such that it represented the extent to which they felt close to the political events such that they had become a part of their daily life. Thus the participants made a judgement of how conscious they were of events and whether they occupied their thoughts and affected their lives on a day-to-day basis. It was also made clear to the participants that this closeness did not mean geographical closeness nor membership of political parties. The distance between the two coins was then measured in centimetres. The distance between the two coins is inversely related to the psychological proximity of the political events. Buchi et al., (2000) stated that the PRISM had been successfully administered to more than 1000 patients with each participant fully comprehending the concept of burden or overall impact of illness and how it is measured. They also reported that patients show a high degree of consistency in completing the PRISM task. A recent study found this pictorial measure correlated with psychological factors like depression and quality of life (Buchi et al., 2000). The data in this present study support its use since the results are not a random set of PRISM distance measurements but are in the direction predicted. All of the above measures were translated into Nepali by a bilingual co-investigator, Roshan Prakash Shrestha. Ram Krishna, a bilingual employee of a charitable organisation, worked alongside the lead author to ensure each participant understood the questionnaires.

Ethical Issues
In view of the sensitive political situation, potential participants were given the explicit opportunity to withdraw from participation. Since the questionnaire did not ask for allegiance to political parties and policies, the content was not thought to be threatening. The PRISM task did not ask for details of specific events but only an assessment of the perceived relevance of the political events to one’s life in general; hence distressing cues to specific traumatic events were minimized. In addition, all questionnaires were completed anonymously, which helped to reduce participants’ fear concerning the authority’s knowledge of their responses.

Statistical Analysis
Pearson Correlations for continuous variables and t-tests for categorical variables were performed to establish the association between the background and exposure variables and physical complaints and post-traumatic stress symptomatology. We also examined certain interactions between predictors using an analysis of variance (ANOVA) with median-split scores on appropriate variables.

Results

Table 1 depicts the demographic characteristics of the sample in the present study. Nearly 70% of the sample were between 18 and 35 years of age, two-thirds were men, and approximately half the sample reported that they had been directly exposed to political violence.

Table 1. Demographic characteristics of the sample

Table 2 depicts participants’ means and standard deviations on the PTSD-like symptoms, PRISM and physical complaints.

Table 2. Means and standard deviations of sample for psychological and physical symptom data

As shown in Table 3, participants directly exposed to terror or political violence reported significantly more prevalent PTSD-like symptoms than those not directly exposed to terror or political violence [t(72.2) = 3.6, p < .001]. In addition, hunger strikers (N= 24) reported more PTSD-like symptoms than other participants [t(62.8) = 10.1, p < .001]. In the present sample, no gender differences were observed on any measure. However, among the background variables tested, age, area of residence and education were correlated with the outcomes tested. Age was positively correlated with both PTSD-like symptoms (p < .001) and with physical symptoms (p < .05). In addition education level was inversely correlated with PTSD-like symptoms (p < .01), but not with physical symptoms (p > .05), and area of residence was associated with PTSD-like symptoms (p < .005) but not with physical symptoms (p > .05). Participants residing in rural parts of Nepal reported more PTSD-like symptoms than those residing in towns or cities.

Table 3. Correlates of PTSD-like symptoms and physical symptoms

*** p < .001

Scores on PTSD-like symptoms were positively correlated with physical symptoms (r = .32, p < .005) and inversely correlated with PRISM distance (r = - .44, p < .001). However, scores on physical symptoms were unrelated to PRISM distance (r = - .05, NS). We then tested whether PRISM scores moderated the effects of exposure to violence on PTSD-like symptoms. To conduct this ANOVA, we split the sample into those with high and low PRISM distances at the median. In this analysis, PRISM [F(1,77) = 12.6, p < .005], direct exposure [F(1,77) = 7.0, p < .05] and the interaction of PRISM by direct exposure significantly affected PTSD-symptoms [F(1,77) = 6.9, p < .05]. This interaction is depicted in Figure 1. Following this interaction, we found that among participants directly exposed to political violence, those with large PRISM-distance reported significantly less PTSD-like symptoms (10.4) than those with little PRISM-distance [15.4; t(36) = 4.2, p < .001]. However, among participants not directly exposed to political violence, those with large PRISM-distance reported similar PTSD-symptoms (10.4) as those with little PRISM-distance [11.1; t(22) = .6; NS].

Discussion

Our results are in line with studies showing that dose of trauma exposure is a predictor of PTSD symptomatology (e.g., Mollica, McInnes, Poole, & Tor, 1998; Porter & Haslam, 2001). We identified an additional correlate of PTSD, namely, psychological proximity to traumatic events. Clearly participants with larger PRISM distances above the median cut-off had fewer PTSD-like symptoms. It is reasonable to propose that maintaining a distant perspective from the potentially stressful context was functional. The ability to keep this perspective moderated the effects of direct exposure to political violence on PTSD-like symptoms (see Figure 1 below). Though in a different context and with other variables, another study also found prior knowledge of and preparedness for torture and strong commitment to a cause protected Turkish people from PTSD symptoms in those exposed to political trauma (Basoglu et al., 1994). We can extrapolate from these two findings that cognitive framing and attitude towards one’s psychological context may protect against adverse effects of political trauma. Maintaining perspective, or adopting alternative interpretations of trauma and exercising control and structure over memories of past the trauma are markers of adjustment in victimized populations (e.g., Burgess, & Holmstrom, 1979; Casella & Motta, 1990). Indeed, intervention studies which foster cognitive-affective coping skills and thus omit exposure to traumatic memories improve psychological functioning, (Meichenbaum, 1974; Foa, Rothbaum, Riggs, & Murdock, 1991; Hickling, Sison, & Vanderploeg, 1986).

This study has the following limitations. Although assessing prevalence rates of clinical illness was not our original aim we feel that future studies should include clinical measures of PTSD. Secondly, the generalisability of the results to other communities experiencing political violence is open to debate. We did not find any correlates of somatic complaints (except age) and this may have resulted from our inability to accurately summate incidence of symptoms due to participants’ diverse interpretations of the response format of this questionnaire. We acknowledge that age should not have been represented in categories but as continuous data. Since this study relied on self-report measures and torture victims may under-report somatic complaints and psychological distress (Weinstein, Dunsky, & Iacopino, 1996) the incidence and severity of symptoms assessed in the present study may be an underestimate. Thus additional objective measures of physical morbidity may also be needed.

However this study represents one of the few investigations of the health consequences of the political violence in Nepal. Though not a large-scale study, our sample includes Nepalese citizens from various socio-economic backgrounds and geographical locations. It is the first study to examine the extent to which the construct of perceived psychological proximity to the political context affects psychological and physical well-being. This enabled us to identify a new correlate of PTSD-like symptoms that is easily assessed in non-literate populations and in cross-cultural health investigations. The implication of our findings is that aid-workers may need to help survivors of political violence maintain psychological distance and perspective in order to reduce the potential adverse effects of such atrocities on their well-being. This may include helping survivors focus on elements of their life, not affected by such events, for which they still feel a sense of control.

Acknowledgements go to Ram Krishna our bi-lingual research associate who facilitated access to potential participant groups and worked alongside the lead author on location administering each questionnaire. Our thanks also go to Timothy Aryal, Head of the Department of Philosophy and Psychology at Tribhuvan University, Kathmandu for his early input and to Douglas Forbes of Glasgow Caledonian University for his constructive feedback on an early version of this paper.

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