somatic panic-attack equivalents in a community sample of rwandan widows who survived the 1994...

Psychiatry Research 117(2003) 1–9

0165-1781/03/$ - see front matter� 2002 Elsevier Science Ireland Ltd. All rights reserved.PII: S0165-1781Ž02.00301-3

Somatic panic-attack equivalents in a community sample ofRwandan widows who survived the 1994 genocide

Athanase Hagengimana, Devon Hinton*, Bruce Bird, Mark Pollack, Roger K. Pitman

Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

Received 4 March 2002; received in revised form 25 October 2002; accepted 12 November 2002

Abstract

The present study is the first to attempt to determine rates of panic attacks, especially ‘somatically focused’ panicattacks, panic disorder, symptoms of post-traumatic stress disorder(PTSD), and depression levels in a population ofRwandans traumatized by the 1994 genocide. The following measures were utilized: the Rwandan Panic-DisorderSurvey (RPDS); the Beck Depression Inventory(BDI); the Harvard Trauma Questionnaire(HTQ); and the PTSDChecklist (PCL). Forty of 100 Rwandan widows suffered somatically focused panic attacks during the previous 4weeks. Thirty-five(87%) of those having panic attacks suffered panic disorder, making the rate of panic disorder forthe entire sample 35%. Rwandan widows with panic attacks had greater psychopathology on all measures. Somaticallyfocused panic-attack subtypes seem to constitute a key response to trauma in the Rwandan population. Future studiesof traumatized non-Western populations should carefully assess not only somatoform disorder but also somaticallyfocused panic attacks.� 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Panic disorder; Stress disorders, post-traumatic; Depression; Rwanda; Holocaust

1. Introduction

«But the fact is that most of the massacres were carriedout using more basic weapons: machetes, knives, axes, hoes,hammers, spears, bludgeons or clubs studded with nails(known asntampongano or ‘without pity’). I don’t need todwell on the horror of these deaths, the frightful noise ofskulls being smashed in, the sound of bodies falling on topof each other. Every Rwandan still has these sounds etched

*Corresponding author. Revere Counseling Center, 265Beach Street, Revere, MA 02151, USA. Tel.:q1-617-738-9055; fax:q1-781-286-5636.

E-mail address:[email protected](D. Hinton).

in their memory, and will for a long time: the screams ofpeople being killed, the groans of the dying and, perhapsworst of all, the unbearable silence of death which stillhangs over the mass graveswSibomana, 1999x.

Rwandans endured one of the worst genocidesof the 20th century. In 100 days in 1994, almostone million people perished, one seventh of thecountry’s population(Keane, 1995; Taylor, 1999).Tutsi were slaughtered, raped, terrorized andmaimed by the Hutu majority(Gourevitch, 1998;Keane, 1995; Sibomana, 1999). Death occurredby decapitation, clubbing, starvation and drowning,among other methods. Then, after the war andsubsequent displacement to the camps, large num-

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bers of people died of illness; for instance, 50 000Rwandans died of cholera and exhaustion in a 2-week period while many suffered starvation(Sibomana, 1999). To this day, Hutus and Tutsisremain in a state of hypervigilance and trepidation,keenly aware that genocidal hostilities between thetwo ethnic groups might occur again.Given the degree of trauma experienced by the

Rwandan population, surprisingly few studies haveassessed levels of psychopathology. One investi-gation of children and adolescents(Dyregrov etal., 2000) documented an extreme degree of trau-matic exposure, with 79% of those surveyed scor-ing over 17 on the Impact of Event Scale(Horowitz et al., 1979), suggestive of post-trau-matic stress disorder(PTSD). The General HealthQuestionnaire (Goldberg and Williams, 1988)scores of Rwandan adults surveyed in a refugeecamp suggested that 50% suffered severe mentaldisorder(de Jong et al., 2000).Several recent investigations emphasize the

importance of recognizing panic disorder in traumavictims (Falsetti et al., 1995; Falsetti and Ballen-ger, 1998; Falsetti and Resnick, 1997; Hinton etal., 2000, 2001a). Dr Hagengimana, who is one ofonly two psychiatrists in Rwanda, has observedthat the Rwandan reaction to trauma is oftensomatic and not infrequently involves panic symp-toms. Even when a Rwandan has an attack that istriggered by a trauma cue or accompanied by aflashback, often the main focus of concern is acutebodily dysfunction. Just as somatoform disorder isprevalent among certain cultural groups inresponse to trauma(Escobar et al., 1992), unique,somatically focused panic attacks also appear tooccur with frequency.Ataques de nervios in His-panic populations, often constituting panic attacks,would seem to be one example(Guarnaccia, 1993;Guarnaccia et al., 1996; Guarnaccia and Rogler,1999; Norris et al., 2001). A study of Khmerrefugees demonstrated that headache-, dizziness-and gastrointestinal-focused panic attacks occurredfrequently (Hinton et al., 2000). Another studydocumented high rates of dizziness- and headache-focused panic attacks among Vietnamese refugees(Hinton et al., 2001a).The present investigation evaluated the hypoth-

esis that Rwandan holocaust survivors frequently

experience the sudden appearance of somaticsymptoms that form part of a panic attack. Thepresent study classified these attacks according tothe somatic focus. Additionally, rates of panicattacks and panic disorder, as well as levels ofPTSD and depressive symptomatology, wereassessed.

2. Methods

2.1. Participants

One hundred members of a Rwandan Widows’Association who had lost a husband during thegenocide but who were not currently receivingmental health services were randomly invited toparticipate. Almost without exception, widows inRwanda join these village-based organizations.Each of the widows in the sample had lost herhusband during the genocide. Each met DSM-IVPTSD criterion A.1(i.e. a traumatic event capableof causing PTSD). None had sustained head injurywith loss of consciousness. The average age was29 (range 18–50); and the average number ofchildren was 2.2(range 0–5). The average edu-cational level was fifth grade and 65% wereliterate. None of the women had remarried, inlarge part due to the low ratio of males to femalesin the country, as a result of the targeted executionof males during the genocide. The women in thesample typically survived through financial assis-tance provided by the husband’s family(e.g. theuse of land), the widow’s own family and self-employment: 90% of the widows in the samplemade a living from agriculture(e.g. growingbeans) and animal husbandry, whereas 10%worked in small trade at the market. No interna-tional financial help was presently available to thewidows. The survey was conducted in 2001, 7years after the genocide. Each participant receivededucation about the potential meaning of hersymptoms, and if deemed appropriate, referral toa local mental health clinic.

2.2. Procedures

Questionnaires were administered by Rwandanmental health workers with college degrees and atleast 3 years’ experience who were trained in the

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use of the survey instruments by Dr Hagengimana.He was present during the evaluation of the initialcases to assure that the instruments were adminis-tered correctly. The survey was approved by theRwandan institutional equivalent of an InternalReview Board. All participants gave writteninformed consent.

2.3. Instruments

Dr Hagengimana translated and then had back-translated, with comparison of the two versions,as per standard procedure(Mollica et al., 1987;Westermeyer, 1985), a special panic-attack ques-tionnairewi.e. the Rwandan Panic-Disorder Survey(RPDS)x, the Beck Depression Inventory(Beckand Steer, 1987), the Harvard Trauma Question-naire(Mollica et al., 1992) and the PTSD Check-list (Blanchard et al., 1996).

2.3.1. Rwandan Panic-Disorder Survey (RPDS)Several studies have demonstrated the impor-

tance of somatic probes in the evaluation of panicdisorder in somatizing populations(Katon et al.,1987; Katon, 1989, 1994). The RPDS is a specialpanic-attack questionnaire modeled after the Cam-bodian Panic-Disorder Survey(CPDS) (Hinton etal., 2000) and the Vietnamese Panic-Disorder Sur-vey (VPDS) (Hinton et al., 2001a), which werecreated to better delineate panic attacks and panicdisorder symptoms typically reported by Indochi-nese refugees. The RPDS was created with specificreference to the Rwandan population. The somaticprobes utilized in the RPDS appear in Fig. 1. Forthe purpose of this study, each complaint that wasendorsed by a participant was treated as a potentialcross-cultural equivalent of the DSM-IV panic-attack criterion, ‘a discrete period of intense fearor discomfort.’ The complaint then was evaluatedfor its status as a panic-attack equivalent by admin-istering a portion of the Panic-Disorder Module ofthe Structured Clinical Interview for DSM-IV(SCID; First et al., 1995) with regard to thatcomplaint (see Fig. 2). If the complaint satisfiedpanic-attack criteria, the number of such episodesin the last 4 weeks was ascertained(see Fig. 2),and the sufferer was evaluated for panic disorder

using the rest of the SCID Panic-Disorder Module(see Fig. 2).

2.3.2. Beck Depression Inventory (BDI)The BDI is a commonly used questionnaire that

rates the severity of each of 21 depressive symp-toms during the past week from 0 to 3(Beck andSteer, 1987; Sederer and Dickey, 1996). Totalscores of 0–9 indicate no to minimal depression,10–16 mild depression, 17–29 moderate depres-sion and 30–63 severe depression.

2.3.3. Harvard Trauma Questionnaire (HTQ)The symptom portion of the Harvard Trauma

Questionnaire comprises DSM-IV PTSD and othertrauma-related symptoms and has been used inmany countries to assess victims of violence(Mol-lica et al., 2001). The 30 items are rated from 1(not at all distressed) to 4 (extremely distressed),with a range of 30 to 120. The conventional cut-off for identifying PTSD is a total score of 75.

2.3.4. PTSD Checklist (PCL)This questionnaire has been used in multiple

studies of trauma victims(Blanchard et al. 1996;Forbes et al., 2001). It consists of the 17 DSM-IVsymptom criteria for PTSD, each rated on a scalefrom 1 (‘not at all’) to 5 (‘extremely’), with arange of 17–85. The conventional cut-off forcombat-related PTSD is 50(Forbes et al., 2001).

3. Results

3.1. Prevalence of panic-attack subtypes

During the 4 weeks prior to evaluation, 40 ofthe 100 Rwandan widows studied had suffered oneor more somatic-complaint attacks in combinationwith sufficient DSM-IV criteria to qualify for apanic-attack equivalent. Attack subtypes appear inTable 1. The total number of subtypes endorsedwas 95 for the 40 widows with panic-attack equiv-alents. This means that, on the average, each ofthese widows had suffered 2.4 different panic-attack somatic subtypes during the previous month(range of 1–5). In 45 (47%) of the 95 panic-attack equivalent subtypes endorsed, the personfeared death during the attack.


Fig. 1. Panic probes of the Rwandan Panic-Disorder Survey(RPDS).

3.2. Frequency of episodes of panic-attacksubtypes

Table 1 also presents the mean number ofepisodes per month of each of the panic-attacksubtypes. Of note, widows who had headache- andgastrointestinal-focused panic tended to suffermany such episodes each month.

3.3. Rate of panic disorder

Thirty-five (87.5%) of the 40 Rwandan widowsreporting panic-attack equivalents met the criteria

for panic disorder. This represents 35% of all 100widows studied.

3.4. Other psychopathology

Table 2 presents the mean BDI, HTQ and PCLscores of widows with vs. without panic-attackequivalents. The former had significantly greaterscores on all three measures. Also, rates of PTSDwere significantly higher in widows with vs. with-out panic-attack equivalents. Using an HTQ cut-off score of 75 to classify a subject as havingPTSD, 20 of the 40(50%) subjects with panicattacks had PTSD, whereas, 15 of the 60(25%)


Fig. 2. Outline of the Rwandan Panic-Disorder Survey(RPDS), a SCID-based module, to determine the presence of panic attacksubtypes, the frequency of the panic attacks and whether the panic attacks meet panic attack disorder criteria.

of those without panic attacks had PTSD(Ps0.02, Fisher’s exact test). Using a PCL cut-off of50, 26y40 (65%) of the widows with panic-attackequivalents were classified as PTSD vs. 20y60(33%) of the widows without panic-attack equiv-alents (Ps0.002). Alternately stated, of the 35subjects with PTSD according to the HTQ, 20(57%) had panic attacks, whereas of the 65 sub-jects without PTSD, only 20(31%) had panic

attacks. Of the 46 subjects with PTSD accordingto the PCL, 26(57%) had panic attacks, whereasof the 54 subjects without PTSD, only 14(26%)had panic attacks.

4. Discussion

Multiple studies have demonstrated high ratesof somatic symptoms in trauma victims(Lin and


Table 1Rwandan widows with panic attacks(ns40) endorsing various somatic subtypes

Number Frequency Range

Mean (S.D.) Minimum Maximum

Headache 18 6.8ymonth (7.0) 1 28Gastrointestinal symptoms 17 4.4ymonth (2.9) 2 10Dizziness 15 2.1ymonth (0.7) 1 3Palpitations 18 2.5ymonth (0.4) 1 5Shortness of 17 2.4ymonth (1.6) 1 5breath

Other 10 2.5ymonth (1.1) 1 4

Table 2Group mean age and psychometic scores

Total sample(ns100)

PA (ns40) NPA (ns60) PA (ns40) vs. NPA (ns60)

Mean (S.D.) Mean (S.D.) Mean (S.D.) P* Student’s (d.f.)

Age 32.1 (10.5) 33.9 (11.9) 31.0 (9.3) ns 1.4 (98)BDI 18.6 (10.7) 22.9 (10.2) 15.7 (10.2) -0.001 3.5 (98)HTQ 62.3 (22.0) 72.3 (18.2) 56.4 (25.3) -0.001 3.8 (98)PCL 45.2 (17.6) 51.0 (17.3) 41.4 (7.0) -0.011 2.6 (98)

*Significance of the difference between Rwandan widows with panic attacks(PA) as compared to Rwandan widows withoutpanic attacks(NPA). BDIsBeck Depression Inventory, HTQsHarvard Trauma Questionnaire, PCLsPosttraumatic Stress DisorderChecklist, and d.f.sdegrees of freedom.

Cheung, 1999; Shrestha et al., 1998; Van Ommeranet al., 2001). Results of the present study supportthe hypothesis that Rwandan holocaust survivorsfrequently experience the sudden onset of somaticsymptom(s) that form part of a panic attack.Moreover, 87.5% of the participants who reportedsomatically focused panic attacks met DSM-IVcriteria for panic disorder. The DSM-IV criteriarequire a ‘discrete period of intense fear or discom-fort’. Falsetti and Resnick(1997) reported thatamong 60 consecutive patients who presented to atrauma clinic for treatment(of whom 61% metPTSD criteria), 69% had suffered a panic attackin the previous 2 weeks. In that group, 38% ofthose who suffered panic attacks feared dying ofa heart attack during the panic attack. In the presentstudy, 40% of the Rwandan holocaust widows whowere surveyed had experienced a panic-attackequivalent, and in 47% of the 95 experiencedpanic-attack subtypes, the Rwandan feared death.The high HTQ, PCL and BDI scores in the group

with panic attacks reveal that these persons expe-rience considerable other psychopathology as well.The present study also found a high rate of

panic disorder in the trauma-exposed Rwandanwidows. Kessler et al.(1995) found that womenwith PTSD had a lifetime panic-disorder comor-bidity of 12.6%. However, in their review ofstudies of persons suffering PTSD, Deering et al.(1996) found that lifetime comorbidity rates ofpanic disorder as high as 55% have been reported.In summary, the present study found high rates

of somatically focused panic attacks and panicdisorder in the trauma-exposed Rwandan widows.Elsewhere, we have elaborated a model of panic-attack generation among trauma victims(Hintonet al., 2000, 2001a,b,c,d, 2002a) based upon Bar-low (1988) and Clark(1988) to explain the highrates of somatically focused panic attacks foundin trauma-exposed Southeast Asians. First, anarousal-reactive symptomwi.e. a symptom madeworse by arousal,(e.g. dizziness)x may activate


fear networks(i.e. catastrophic cognitions, trau-matic associations and interoceptive conditioning),resulting in a surge of anxiety. Second, theincreased arousal associated with this surgeincreases the arousal-reactive symptom yet more.Third, an augmentation of the arousal-reactivesymptom leads to yet more activation of the fearnetworks. Through this positive feedback loop, anescalating spiral of arousal leads to panic. Highlevels of stress will increase both the experiencingof arousal symptoms and the probability that arous-al symptoms may escalate to panic(Bouton et al.,2001; Katon, 1989, pp. 33–34).Such a model of panic generation can be applied

to the Rwandan case. As an example of a culturallyspecific catastrophic cognition, Rwandans ofteninterpret the shortness of breath during a panicattack to indicate the presence of the culturalsyndrome known as ‘Ihahamuka’, translated as‘lungs without breath’(Wulsin and Hagengimana,1998). Because they regard this syndrome aspotentially lethal, experiencing shortness of breathcan generate great fear. Furthermore, following thegenocide, the location of most bodies wasunknown, and traditional burials were often notperformed. In the Rwandan culture, shortness ofbreath may be interpreted as caused by an ancestorwho never received proper burial, the deceasedlater returning as a spirit to strangle a livingrelative as punishment for not having conductedthe necessary rites(Bagilishya, 2000; Uwanyiligi-ra, 1997). As another example, to Rwandans aheadache may be regarded as a harbinger ofinsanity (per Dr Hagengimana’s clinical experi-ence). Of further note, muscle tension, a contrib-utor to headache, is an arousal-reactive symptom(Taylor, 1994). As an example of the linking oftraumatic event to specific symptom, during thegenocide widows frequently witnessed their hus-bands’ or other relatives’ heads’ being bashed witha club. Furthermore, by the mechanisms outlinedin the paragraph above, the high rate of panicamong Rwandan widows may partially result fromhigh levels of current stress. Current stressesinclude the need to find food and adequate shelterwithout the help of a husband in an extremelypoverty-stricken country and the constant threat of

renewed hostilities between the Hutu and Tutsipopulation.In an edited volume devoted to cross-cultural

aspects of the effects of trauma(Marsella et al.,1996), several contributing authors noted that theDSM-IV category of PTSD may not represent thefull spectrum of response to trauma in othercultural contexts. Rather, there is a need to eluci-date not only universal responses but also culture-specific responses to trauma(Keane et al., 1996;Kirmayer, 1996; Marsella et al., 1996). Investigat-ing panic-attack subtypes in different traumatizedgroups may be one way in which the local mani-festations of the response to trauma may be bettercharacterized. The present study suggests that if atraumatized individual from a non-Western groupappears to have a somatoform disorder(Escobar,1995), the differential diagnosis should includepanic attacks(and panic disorder) that center onthat symptom. Even among English speakers,patients with panic disorder are often treated ashaving somatization or somatoform disorder when,in actuality, the symptom represents part of a panicattack. For this reason, Katon(Katon et al., 1987;Katon, 1989, 1994) suggests using somatic probesto ascertain rates of panic among somatizing pop-ulations, an approach also advocated by Barsky etal. (1999). The extensive literature documenting asomatization tendency in non-Western groups(Chung and Singer, 1995; Escobar, 1995) wouldindicate an even greater need for differential diag-nostic care in this regard.One possible shortcoming of the present study

is that a highly psychologically focused panic-attack may not have been detected by the survey.In the present study, after the five probes, we didask a more general probe question. Nonetheless,Rwandans in the survey with psychologicallyfocused panic attacks accompanied by minimalsomatic symptoms may not have answered affir-matively to any of the probes. This could haveresulted in an underestimate of the incidence ofpanic disorder in this population. However, it isDr Hagengimana’s clinical experience that, as alsofound by studies of other non-Western groups,(e.g. Chung and Singer, 1995; Escobar, 1995),distress is strongly somatically focused in theRwandan context.


Acknowledgments

Dr Hagengimana’s work was supported by agrant from the National University of RwandaGenocide Research Committee.

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