The Assessment Of Post Traumatic Stress Disorder Among Internally Displaced Persons

Medical and Health Science Project and Seminar Material

The Assessment Of Post Traumatic Stress Disorder Among Internally Displaced Persons


This project was conducted in Jos North Local Government Area of Plateau State, the assessment of Post Traumatic Disorder Among Internally Displaced Persons in Jos North Local Government Area of Plateau State. This research was conducted to the benefit to humanity, chapter one covers the background of the study and it stated the problem of people that are internally displaced in Jos North Local Government Area of Plateau State. Chapter two covers the review of relevant literature of Post traumatic stress disorder and the theoretical background. In chapter three based on the findings of this study it was recommended that the following Internally Displaced Persons (IDP) victims of conflict, insurgency and natural disaster, it should include both chemotharaphiy and psychotherapy in order to keep body and soul together and avert increasing incidence of mental disorder, and the victims should be highly compensated.

Chapter One


1.1 Background Of The Study

Many communities in Africa continue to be affected by long-standing conflicts with mass traumatization of their populations. Nigeria, as a country has a variety of low grade conflicts that result in chronic bloodletting without the country actually being in an open state of war. Over the past decade, the political crisis over ‘indigene’ rights and political representation in Jos, capital of Plateau State, Nigeria, has developed into a protracted communal conflict Krause, 2011). This recurring conflict often involves maiming, killing, burning of houses, motor vehicles and other properties. The effects of these crises include injuries, emotional trauma, and disabilities, loss of homes and livelihood as well as death. At least 4,000 and possibly as many as 7,000 people have been killed since late 2001, when the first major riot in more than three decades broke out in Jos. After the 2008 riot, more than 10,000 were displaced, while violence in 2010 resulted in about 18,000 people becoming internally displaced. All sides suffer a massive loss due to livelihoods destroyed (Krause, 2011)

The intensity of internal displacement has become a global problem. It has emerged as one of the great human tragedies of the 21st century. It has been estimated that almost 50 million people had been internally displaced worldwide due to conflicts or violations of human rights by the year 2010 (World Health Organization, 2009). According to several organizations, the number of victims range between one and nine million people. In addition, social, economic, political, legal, psychological, and health problems related to internal displacement still exist. Conflicts and wars have ineradicable changes in societal dynamics (Somasundoram, 2009). Therefore, this kind of societal traumas experienced by the victim of conflict and disasters affected most internally displaced persons (IDPs). To provide useful assessments of the IDPs, the approached most take into account the effects on the individual and social aspects (Summerfield, 2003).

Internally displaced persons (IDPs) are person who have been forced or obliged to flee or to leave their homes or places of habitual residence in particular as a result of or in order to avoid the effects of armed conflict, situation or generalized violence, violation of human rights or natural or human made distress, and who have not crossed an internationally recognized state border (Office of the High Commissioner for Human Rights, OHCHR, 2007). It is therefore, necessary to distinguished between refugees and IDPs. If the displaced persons cross international border and falls under one of the relevant international legal instrument, they are considered refugees. IDPs reflect two factors; the coercive or otherwise involuntary character of movement and the fact that such movement takes place within national border. First, some of the common causes of involuntary movements are armed conflict, violence and human right violation and disaster (NRC, 2009).

The history of Nigeria, immediately after attaining our republican status had been greeted with various kinds of political violence and conflicts. The implication is that men, women and children had been on the receiving end of all these problems. Nigeria remains a multi-ethnic nation which has between 350-500 linguistics groups and Populated by fairly half Christians and Muslims (Salawu, 2010; Paden, 2008; Tiffen, 1968; Hansford, Bendor-Samuel & Stanford, 1976). With a history of ethno-religious conflict in Nigeria, the past year has witnessed an alarming upsurge in the level of violence and its impact on civilians. Almost one year after spiraling violence between mainly Muslim cattle herders and Christian farmers in central Plateau state left possibly more than 1,000 people dead and 258,000 temporarily displaced, many of those who fled are still too scared to return to their villages and residential areas.

Cumulative figures for internal displacement are provided by the National Commission for Refugees (NCFR). In February 2014, it reported that there were 3.3 million IDPs in the country as of 31 December 2013. It has not provided figures for 2014. The Presidential Initiative on the North-east (PINE) and the National Emergency Management Agency (NEMA) reported that Boko Haram had displaced 1.5 million people in the north-east (OCHA, 23 September 2014). No independent estimates are provided, either by the UN resident humanitarian coordinator’s office or the Abuja regional branch of the Office for the Coordination of Humanitarian Affairs (OCHA).

In addition to creating large numbers of immediate direct casualties in combatants and civilians, these conflicts have the potential to influence public and mental health outcomes in several ways (Davis, Kuritsky,2002; Kalipeni, and Oppong,1998). The mental health effects of armed conflict on civilians are enormous and can last a lifetime. One major mental health effect of conflict is post-traumatic stress disorder (PTSD) Musisi, (2004). PTSD is an anxiety disorder which consists of a syndrome that develops after a person sees, is involved in, or hears of an extreme traumatic stressor. The person reacts to this experience with fear and helplessness, persistently relieves the event, and tries to avoid being reminded of it Association, (2013) and Hodes,(2000). The disorder usually develops within weeks, months or even years after the occurrence of the traumatic event. Symptoms of PTSD can include nightmares and flashbacks, insomnia, lack of concentration, and feelings of isolation, irritability and guilt Obilom, Thacher,2008; Rehn, Sirleaf,2002).

Prevalence of PTSD is about 8% in the general population while lifetime prevalence rates range from 5-75% among high risk groups whose members experienced traumatic events Steel, Chey, Silove, Marnane, Bryant,2009; Kessler, Sonnega, Bromet, and Hughes, (1995). The Center for Disease Control and Prevention, (CDC) Atlanta, reported that about 30-70% of people who have lived in war zones suffer from symptoms of PTSD and depression Prevention, (2014). Studies carried out among offspring of Holocaust survivors revealed that there was a higher prevalence of mental disorders such as mood, anxiety and substance abuse disorders as well as PTSD among them than in the general population of Jews who did not experience the holocaust (Yehuda, Bell, Bierer, and Schmeidler, 2007). A study carried out among residents of Jos, Nigeria some months after the first major ethno-religious riot in 2001 found a prevalence of PTSD symptoms of 41% Obilom, and Thatcher, (2008). Lifetime PTSD prevalence rates are generally higher in populations exposed to chronic conflicts or recurrent natural disasters (Margoob, Sheikh, 2006; Yaswi, and Haque,2008).

Furthermore, events that are threatening to life or bodily integrity will produce traumatic stress in its victim. This is a normal, adaptive response of the mind and body to protect the individual by preparing him to respond to the threat by fighting or fleeing. If the fight or flight is successful, the traumatic stress will usually be released or dissipated allowing the victim to return to a normal level of functioning. PTSD develops: when fight or flight is not possible; the threat persists over a long period of time; and/or the threat is so extreme that the instinctive response of the victim is to freeze. There is a mistaken assumption that anyone experiencing a traumatic event will have PTSD. This is far from true. Studies vary, but confirm that only a fraction of those facing trauma will develop PTSD (Elliott 1997, Kulka et al 1990, Breslau et al 1991). What distinguishes those who do not is still a hot topic of discussion, but there are many clues. Factors mediating traumatic stress appear to include: preparation for expected stress (when possible), successful fight or flight responses, prior experience, internal resources, support from family, community, and social networks, debriefing, emotional release, and psychotherapy. PTSD is a relatively new diagnostic category in the history of psychology. ‘

The diagnosis of PTSD first appeared in 1980 in the internationally accepted authority on PTSD, the DSM (American Psychiatry Association, 1980). At that time the DSM had a limited view of what could cause Post Traumatic Stress Disorder, defining it as developing from an experience that anyone would find traumatic, leaving no room for individual perception or experience of an event. This definition was expanded when the DSM III was revised in 1987, and the DSM IV (APA, 1994) provides even broader criteria. Post Traumatic Stress Disorder as presented in the DSM IV accepts that PTSD develops in response to events that are threatening to life or bodily integrity, witnessing threatening or deadly events, and hearing of violence to or the unexpected or violent death of close associates. Events that could qualify as traumatic, according to the DSM IV, include: combat, sexual and physical assault, being held hostage or imprisoned, terrorism, torture, natural and manmade disasters, accidents, and receiving a diagnosis of a life threatening illness. The DSM IV adds, “The disorder may be especially severe or long lasting when the stressor is of human design (e.g. terrorism, torture, rape) APA, 1994. Symptoms associated with PTSD include;

  1. Re- experiencing the event in varying sensory forms such as flashbacks,
  2. Avoiding reminders associated with the trauma, and,
  3. Chronic hyper arousal in the Autonomic Nervous System (ANS). PTSD is present when these symptoms last more than one month and are combined with loss of function in areas such as job or social relationships. (APA 1994)

Recent events have focused the world’s attention on the psychological effects of terrorism. Elevated rates of posttraumatic stress disorder (PTSD) symptoms have been found in the aftermath of major terrorist attacks in the United States (Galea, Ahern, Resnick, Kilpatrick, Bucuvalas, Gold & Vlahov, 2002). These symptoms as noted tend to subside with time (Silver, Holman, McIntosh, Poulin & Gil-Rivas, 2002); DSM-IV-TR asserts that PTSD may be especially severe or long lasting when the stressor is of human design (p. 464). It further suggested that stressors occurring at aftermath of traumatic events contribute to the occurrence of the disorder. Repeated act of terror are associated with significant distress in affected communities and thereby might interfere with the recovery from early PTSD symptoms and lead to a higher incidence of PTSD.

Political violence and war affect all sections of the country and it is not particular to any ethnic group. Most recently, a post election violent conflict in Northern Nigeria led to resettlement of internally displaced persons (IDPs) in a camp in Kaduna, and Plateau state. In contrast to what she had to go through with ethno religious crises, Plateau state provided a safe place for some IDPs running from the boko haram terror in the northeast. This study is set out to assessed prevalence and socio-demographic factors associated with post-traumatic stress disorder (PTSD) among IDPs. We also determined types of psycho-trauma experienced by the IDPs and their psychosocial adjustment.

1.2 Statement Of Problem

The increasing spread of nefarious activities of the Boko Haram sect, ethno religious conflict and natural disasters which has resulted to destruction of lives and property is a serious issue that could not be dismissed with a wave of hand. The activities of the Boko Haram group caught the attention of international community following series of violent attacks in Nigeria since July 2009. The attacks lead to massive displacement of persons mostly from the northeastern Nigeria. Most of the Internally Displaced Persons (IDPs) had to flee from the danger zones to safer places (Jimmoh, 2011).

Consequently, it is commonly observed during armed conflict and disasters that valuable properties are destroyed and scores of deaths recorded. However, the mental state of victims who are displaced due to attacks cannot be ascertain by mere observation and as a result less attention has been paid to the psychological wellbeing of the internally displace persons, often the government is quick to supply relief materials to the IDPs spread across mostly northern state such as Plateau state due it relative peace it enjoys. Little is done to assess and rehabilitate the IDPs Psychologically by the Government and other relevant bodies, there seems to be lack of comprehensive information on IDPs’ psychological status, situation which left many IDPs in a difficult position as they seek to adjust in their host communities by suppressing the painful experiences. This paper therefore, seeks to assess the PTDS among IDPs living in Jos North Local Government of Plateau State Nigeria.

1.3 Purpose Of The Study

The main purpose was to determine the rate of PTSD among IDP displaced by armed forces from rural areas of conflict to the city of Jos North LGA of Plateau state.

1.4 Significance Of The Study

Psychological research are conducted to benefit humanity, similarly this study is significant in the following:

  1. The findings of this research would provide useful information to psychological centers, and clinical psychologist who seeks to offer therapeutic services to help victims of Boko Haram to deal with the traumatic experiences.
  2. This study will provide useful literature for further researchers who will conduct related research in the future.
  3. Nongovernmental organizations also would benefit from this study even as they worked with IDPs. The research will help the NGO to know to help those who suffer psychologically as a result of what they experienced that necessitate displacement from their homes.
  4. This study will provide useful information to the general public. It will provide useful educational materials in the libraries.

1.5 Definition Of Key Study Variables

1.5.1 Post Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a debilitating psychological condition triggered by a major traumatic event, such as rape, war, a terrorist act, death of a loved one, a natural disaster, or a catastrophic accident. It is marked by upsetting memories or thoughts of the ordeal, “blunting” of emotions, increased arousal, and sometimes severe personality changes.

In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and, the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition.

1.5.2 Internally Displaced Persons

Internally displaced persons are “persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border (OCHA 1999).

Chapter Three

Discussion, Conclusion, Limitation And Recommendations

3.1 Discussion

This study revealed that most of the respondents had witnessed some form of violence or the other during the various ethno-religious conflicts occurring in the state. This high level of exposure to violence may be because tensions between ethnic groups rooted in allocation of resources, electoral violence, frequent Boko Haram attacks, fears of religious dominance, and contested land rights often explode into violence at the slightest of provocation. These conflicts often erupt over the most flimsy of reasons ranging from arguments and misunderstanding among residents, theft, and even just mutual suspicion. Reprisals attacks are also a common occurrence in the study area. This finding is similar to that of a study carried out among residents of Kashmir, India which reported lifetime prevalence for any traumatic experience of 58.69% and specifically exposure to combat or war zone as 73.23% (Margoob, Firdosi, Banal, Khan and Malik, 2006). In another study carried out among residents of East Timor who had endured 25 years of Indonesian Military occupation, the results revealed that 76% of them had experienced direct exposure to combat situation (76%) (Modvig, Lopez, Rodenburg, Salud and Cabigon, 2000). Seeing someone get killed was the most often reported form of violence in this study by 36.8% of the respondents and 41.7% of those who had experienced this form of violence had PTSD. Our study also revealed that experience of violence was found to be statistically significantly associated (p<0.001) with the presence of symptoms of PTSD as 77.1 % of those with PTSD had witnessed violence compared with 57.4% of those without PTSD. This finding is corroborated by Yaswi and Haque who found that there was a statistically significant relationship between presence of PTSD symptoms and exposure to direct violence following the longstanding conflict in Kashmir, India (Yaswi, and Haque,2008).
Prevalence of PTSD in this study was 46.1% and this is slightly higher than the findings in an earlier study by Obilom and Thatcher carried out among Jos residents where prevalence of PTSD was found to be 41% ( Obilom, and Thacher, (2008)]. This implies that the level of PTSD among the residents of Jos may have increased since the year 2001 when the conflict first began. Repeated exposure to mass violence may be responsible for this increase. Another reason for the high prevalence may be because the population we studied was among those most severely affected by these recurring conflicts. Other studies carried out in Kashmir, East Timor and Timor-Leste among populations exposed to recurrent violence revealed the prevalence of PTSD to be 15.9% [Margoob and Sheikh,2006; Margoob, Firdosi, Banal, Khan and Malik,2006) ,34% (Modvig, Lopez, Rodenburg, Salud and Cabigon,2000), and 16.7% (Silove, Liddell, Rees, Chey, and Nickerson A,2014) respectively. In a study carried out among Sudanese refugees living in Uganda, prevalence of PTSD was found to be as high as 50% (Karunakar, and Neuner, 2004). The prevalence of PTSD may be expected to decline if there are no more exposures to violent events or trauma.
Studies have previously shown that interpersonal violence is more likely to provoke PTSD than accidents and natural disasters (Yehuda, 2002). Being witness to a form of ethno-religious violence was found to be statistically significantly associated with the presence of PTSD in our study. This is also corroborated by Obilom and Thatcher who found out that victimization and witnessing a personal attack was significantly associated with PTSD symptoms (Obilom, and Thacher, 2008). We also found out that Loss of property or means of livelihood, death of a friend or family member and relocation as a result of insecurity were all statistically associated with the presence of PTSD. This was not consistent with the findings of Obilom and Thatcher who did not find any association between witnessing the death of a relative and PTSD.

Gender was not a factor in the occurrence of symptoms of PTSD experienced by the respondents in this study. This is because exposure to the Jos conflict has been almost equal for both male and female residents. This is different from the findings of studies carried out in Uganda, Kashmir and the United States where women were found to have a higher prevalence of PTSD symptoms than men (Karunakara UK, Neuner F (2004); Breslau N, and Anthony, 2007). In another study carried out in Calgary Canada among respondents exposed to trauma, females were more likely to have PTSD than the males studied (Voges, and DM,2003). A history of hospitalization following injuries sustained during the violence was also not statistically significantly associated with presence of PTSD. Possible explanation for this may be that those who were hospitalized may have received some form of psychotherapy in the hospital which may have helped with coping with the situation unlike those who had no contact with medical care.

More than 63, 000 Internally Displaced Persons are taking refuge in various camps in Plateau, Alhassan Barde, the Executive Secretary, Plateau State Emergency Management Agency, said in Jos on Monday. Mr. Barde said the IDPs were from Borno, Adamawa, Yobe, Nasarawa, Taraba and Plateau States. He explained that those from Borno, Adamawa and Yobe were victims of Boko Haram attacks, while IDPs from Nasarawa and Taraba were displaced by ethno-religious crises, and the others from Plateau were victims of violent midnight attacks. The executive secretary said there are 5,508 IDPs displaced by insurgent attacks and 4,450 were taking refuge in Jos North Local Government Council.“Nine hundred and forty persons are in Jos South Local Government while 118 are in Jos East,” he added.The official also said that 18,000 IDPs displaced by ethno-religious crises were camped in Quan’Pan Local Government, 3,000 in Shendam, 1,626 in Langtang North, 1,074 in Langtang South, while Mikang area hosts 3,145. Speaking further, Mr. Barde said that 300 IDPs were in Wase, 2,448 in Kanam and 1,380 in Kanke.

3.2 Conclusion

The occurrence of a wide variety of psychological symptoms and syndromes in the populations in conflict situations is widely documented by available research. Also, this research provides evidence about the increase incidence psychological consequences of armed attack, conflict among civilian population. There is no doubt that the populations in war and conflict situations should receive mental health care as part of the total relief, rehabilitation and reconstruction processes with special attention to be paid to females victims. As happened in the first half of the 20th century, when war gave a big push to the developing concepts of mental health, the study of the psychological consequences of the wars of the current century could add new understandings and solutions to mental health problems of general populations.

3.3 Limitation

Limitations of this study include the fact that it concentrated on IDPs in Jos which is small sample size which may also explain the relatively high rate of PTSD found. This study was conducted among the members of the population who were most affected by the recurring conflict. Thus, the prevalence rates of PTSD among them may not be reflective of the general population to which inferences are made. Also, no questionnaire was used for data and designed for screening of PTSD in clinical primary care settings and May thus result in inherent biases with respect to fully exploring the symptoms of PTSD among the Internally Displaced Persons.

3.4 Recommendations

Based on the findings of this study it was recommended as follows:

That health services offered to IDPs who are victims of conflicts, insurgency and natural disasters, it should include both chemotherapy and psychotherapy in order to keep the flesh and the soul together and avert increasing incidence of mental disorders. Victims of attacks and communal conflicts should be adequately compensated to at least provide succor that would reduce their psychological pains that may gradually result into chronic mental problems. Governments at all levels, non-governmental organizations, religious bodies and all well meaning individuals should step out campaigns against armed attacks and conflicts and educate the masses on the need to live together in peace and harmony as sure way of promoting good mental health. Security agencies should intensify efforts towards arresting perpetrators of violence and make them to face the wrath of the law to serve as deterrent to others.

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