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The hidden side of violence

One in every ten victims of hold-ups, kidnappings or other forms of aggression develops post-traumatic stress

LAURA DAVIÑAJosé Orleans Cruz’s living hell began at the end of a peaceful afternoon seven years ago. He left around 5:40 to pick up his wife from her work and arrive in time for his first lesson in the pre-university entry course he had started a few months previously; twenty years after finishing high school and helping his brothers to study he was finally planning to go to law school. As he changed down to go over an obstacle a rapid sequence of events turned his world upside down and shattered his dreams. Four men suddenly appeared from nowhere on motorcycles as if they had sprung up out of the asphalt, and surrounded his car. Pointing their guns they shouted for him to open the doors. Cruz had become a kidnap victim, something he thought was unlikely to happen to a middle class citizen and only happened to big businessmen. On the way to the hideout he was hit over the head and abandoned at the entry to a shanty town after the kidnappers discovered the police were following them. Before freeing him they beat him up some more. Cruz received kicks and punches and fell into the mud, his legs numb, his vision hazy and unable to move. He only recovered consciousness when three people helped him. A young couple gave him water with sugar and called the police. The third person, a young man, offered to look after his automobile but tried to steal Cruz’s CD player. “I was very weak and that lad acted in that way”, says Cruz. His disappointment was so profound that it changed his life. “I started mistrusting everybody.”

During his recovery at home the following week Cruz began to receive death threats by telephone and little by little he came to feel unsafe everywhere. He locked himself in his home and spent four years without visiting his brothers who lived in the neighboring district. He did not even have the courage to go to the front gate. “When someone approached I broke into a cold sweat and had palpitations”, he says. He once fainted on the sidewalk when he noticed a motorcyclist close by. A prisoner in his own home he started to eat compulsively. In no time at all he gained more than 50 kilos, became a diabetic and developed high blood pressure. Three years ago he concluded that it was no longer worth living. He went up to the 15th floor of the building he had moved to and sat on the parapet, ready to jump. The only reason he did not throw himself off was because he remembered his mother who, in the confirmation lessons, had taught the children that suicide is the greatest of sins.

Two days after escaping death for the second time Cruz went for a consultation to the Violence Help and Research Program (Prove) at the Federal University of São Paulo (Unifesp), taken by his wife to whom he has been married for 16 years. There he discovered that in addition to the physical pain of the first few weeks, the kidnapping had left deep emotional scars that would take a lot longer to heal. The psychiatrist who attended him explained that he was suffering from the so-called post-traumatic stress disorder, a highly incapacitating emotional disturbance generally seen in former war combatants, which has only started being investigated in Brazil over the last few years.

In the group therapy sessions Cruz became calmer when he discovered he was not alone, nor was he the only one to not able to free himself of the recollections of that night that insisted on reappearing despite his efforts to forget them or the fear of strangers that he started feeling. In São Paulo one in every ten people who have suffered violent episodes that put their lives at risk over the last year (hold-up, kidnapping, physical aggression or sexual abuse) shows signs of post-traumatic stress disorder, according to the first ever survey into the occurrence of the problem carried out in the country. Coordinated by psychiatrist, Jair de Jesus Mari, from Unifesp, this study is based on the assessment of 2,530 residents from different regions and socio-economic segments of the São Paulo state capital (a representative sample of the population of São Paulo) and was presented in the city at the end of June at the 1st International Symposium on Violence and Mental Health. “These data supply a valuable argument for demanding more effective public policies”, says anthropologist, Alba Zaluar, from the University of the State of Rio de Janeiro, an academic looking at the causes of violence in Brazil.

Caio Guatelli/Folha Imagem The increase in violence exposes the population to an emotional disturbance that is common in warsCaio Guatelli/Folha Imagem

When extrapolated to the population of the biggest metropolis in South America these 10% of post-traumatic stress sufferers correspond to 1.1 million people who over the last 12 months have suffered or witnessed violent situations and developed debilitating emotional problems that are sufficient to prevent them from leading a normal life – they often abandon their work – and alter the daily life of members of their family. It is as if each year the population of a city like Campinas, the second largest in the state, were to fall sick to the point of needing medical or psychological help. When the researchers extended the period analyzed to the whole life, the occurrence of post-traumatic stress more than doubled: 26% of residents of Sao Paulo, the equivalent of 2.8 million people, almost the population of Salvador, Brazil’s third most populous city, had signs compatible with this emotional problem triggered by violence. Neither Mari, nor many from the group he coordinates, which includes some 50 researchers from São Paulo, Rio de Janeiro, Pernambuco and Ceará, expected such high rates, almost three times higher than the rate estimated for the North American population.

This research, which began in 2006, is not restricted to collecting information about the population of São Paulo. At the Federal University of Rio de Janeiro (UFRJ) the team of psychiatrist Ivan Figueira is concluding a similar survey with 1,500 residents from different points in the Rio de Janeiro state capital, from beach-front buildings to Rio’s slum-covered hills. It is expected that the result will be similar.

“These are the numbers of a country at war”, says Marcelo Feijó de Mello, a psychiatrist from Unifesp, a specialist in post-traumatic stress disorder and a member of the Brazilian network that is investigating the effects of violence on the mental health of the population. Mello’s comment is not just a metaphor. The occurrence of psychiatric disorders in the two Brazilian cities with the highest absolute indices of violence is close to – and sometimes greater – than those seen in countries that have recently gone through war or armed internal conflicts, like Algeria, Cambodia and Ethiopia. In these countries the rate of post-traumatic stress in the population is 37%, 28%, and 16%, respectively.

Except that Brazil is not at war, at least not a declared war. “While in the United States and in Europe violence comes from terrorist attacks or the participation of military personnel in conflicts abroad, in Brazil it is the consequence of a type of urban warfare”, comments Mari. Even though it is difficult to measure the full extent of this form of violence, recent studies have managed to detect at least its more obvious and lethal face: murders.

AFP PHOTO/AGIF-Bruno GonzalezMortality data from Saúde Brasil 2006 [Brazil Health, 2006], a document compiled by the Health Ministry, indicate that 1 in every 20 people who die in the country is the victim of murder, in most cases murders involving the use of fire-arms; almost 50,000 Brazilians died in this way in 2004 alone. It is a problem that has been growing over the last few decades: the rate of people who lose their lives through aggression has gone from 14.1 deaths for every 100,000 inhabitants in 1980 to 27.2 per 100,000 in 2004; this is three times higher than the worldwide average for murders as calculated by the World Health Organization and this rate only reflects the national average. In cities like Rio, São Paulo and Recife the rate is very much higher, especially among young men, at times reaching figures higher than those of Cali in Colombia, which at the beginning of the 1990s was considered one of the most violent cities in the world.

It is an urban war in which everybody loses. Those who die lose as do those who survive the Far West style shoot-outs in Brazilian metropolises – in São Paulo alone there were 36,000 violent crimes (murders, hold-ups and rapes) in the first quarter of 2008 – and later they have to face the collateral effects of the violence, like anxiety, depression and post-traumatic stress. The steady march of violence over the last few decades has left cities with an emotional problem that until the middle of the last century was thought to be restricted to battle fields. What today the mental health diagnostic manuals treat as post-traumatic stress disorder, a serious life-threatening picture of anxiety arising from a situation of extreme stress, was initially described at the end of the 19th century by French neurologist and psychologist, Pierre Janet. Marked by nightmares, insomnia, irritability and recurring and unwanted recollections of the situation that generated it (or even by an exaggerated reaction to sounds and images associated with the situation) this would later become known as war neurosis or combat stress and would attract the  interest of another renowned neurologist, Austrian Sigmund Freud, the creator of psychoanalysis.

During the First World War Freud and other psychoanalysts were able to monitor combatants who reached hospital with paralysis, tremors, recurring nightmares and a loss of sexual desire. The common thread running through all of these patients was that they had been through a traumatic situation, generally the loss of colleagues or proximity to death during the fighting, in addition to intense deprivation and physical exhaustion. Because of the influence of veterans from Vietnam, in 1980 combat stress would enter the Diagnostic and Statistical Manual of Mental Disorders (DSM) for the first time, under the name of post-traumatic stress disorder.

In the trenches or in the streets of our cities post-traumatic stress disorder is triggered by a specific characteristic: the threat of death. “During the violent episode those people who develop post-traumatic stress have a clear perception that they are going to die or that at the very least something has been lost forever and life has changed”, says psychiatrist, José Paulo Fiks, from the Unifesp team that carried out the survey in São Paulo. From the point of view of psychoanalysis an extreme and unforeseen threat, like that of death, can produce an affective impact in the individual that is so intense that he cannot assimilate and incorporate it into his life’s history, explains Sidnei Casetto, professor of Freudian theory from the Department of Health Sciences from Unifesp in Santos. As a result he starts repeatedly reviewing the event that generated the trauma in an attempt to give it meaning and to forget it, thereby becoming a type of time prisoner.

NARA/USALike the First World War: combatants get sick as a result of the loss of companions and because of the risk of deathNARA/USA

Like Freud, many of those who are currently studying post-traumatic stress believe that the violent episode that triggers it, in fact, is not its principal cause. Its origin is hidden in the past, often in some trauma that occurred in infancy and that has been once again brought to the surface. “The recent situation, in which their life was at risk, would bring back a previous situation that had remained cocooned”, comments psychologist, Mariana Pupo, also from Unifesp.

Clinical data corroborate this line of reasoning. Assessing the history of those who suffer from post-traumatic stress who were attended in Prove, Mariana, Aline Schoedl and Marcelo Feijó de Mello saw that half of them had gone through extremely violent situations in infancy or adolescence: 48% had suffered from sexual abuse before they were 18. This work, which was carried out in partnership with Linda Carpenter and Lawrence Price from Brown University in the United States, also showed that the risk of developing post-traumatic stress is closely related to the phase in life when the abuse occurred. Victims of sexual violence in adolescence (between 13 and 18) presented a risk ten times greater of developing post-traumatic stress in their adult life than those who had gone through the same situation before they were 12. Sexual abuse in infancy (before 12), on the other hand, increased the probability of developing depression later in life, according to an article to be published shortly in Child Abuse and Neglect.

The survey with 2,530 residents in São Paulo also indicated that it is not always violent events considered to be the most serious, like armed hold-ups or kidnappings and torture, as experienced by José Orleans Cruz years ago, that trigger post-traumatic stress. Most of the cases identified in Sao Paulo arise from domestic aggression (fights between couples, violence against children or sexual abuse committed by the spouse or parent), according to psychiatrist, Sergio Baxter Andreoli, who is responsible for the epidemiological data of the study in São Paulo.

Specific population groups seem to run a greater risk of developing post-traumatic stress than the rest. In 2004 Deborah Maia and Ivan Figueira, from UFRJ, analyzed the occurrence of post-traumatic stress among the police from the special force in Goiás. Of the 155 police officers that took part in the study, 9% presented symptoms that characterize post-traumatic stress when they were being interviewed and a further 16% had some of the signs, which became well known by the general population with the exhaustion of Captain Nascimento, from the Special Police Operations Battalion (Bope), as played by actor Wagner Moura in the film Tropa de elite, by José Padilha. These policemen with symptoms of post-traumatic stress reported that their health had been weakened, that they had consulted the doctor more and had been hospitalized more than the rest, as the researchers set out in detail in an article published in 2007 in the Journal of Affective Disorders.

2ND LT. JACOB HARRIS/NARA/USASecond War: material and psychological devastation2ND LT. JACOB HARRIS/NARA/USA

During an armed hold-up, kidnapping or rape the emotional impact of the violence may be so intense that the victim manifests an extreme defense mechanism; the body becomes paralyzed, as if he had been instantly frozen and has no strength to react or shout. This is common with prey when faced by the predator – like a rat attacked by an eagle; this involuntary reaction may help predict how the treatment of the individual will evolve, which is generally based on sessions of psychotherapy, along with the use of antidepressant medication that acts on the neurotransmitter, serotonin, and helps in 80% of the cases. In a study involving 23 people who were the victims of urban violence (mostly cases of armed hold-ups) that was published recently in the Journal of Affective Disorders, Figueira and psychiatrist, Adriana Fiszman, from UFRJ saw that ten developed paralysis and responded badly to treatment with antidepressants.

The work of the groups coordinated by Jair Mari and Ivan Figueira is not restricted to checking the indices of post-traumatic stress in the population of the main Brazilian cities. The teams from São Paulo and Rio are also trying to better understand aspects of this emotional disturbance that are still obscure: the alterations they cause in the functioning of the organism many years after the violent episode; the identification of biological and environmental factors that might point to a predisposition for developing post-traumatic stress or protecting you from it; and more efficient medication and psychological treatment.

Analyzing samples of saliva collected during the interview with a population from São Paulo Marcelo Feijó Mello discovered that people with signs of post-traumatic stress disorder had a significant hormonal imbalance, similar to the one seen in studies carried out in other countries. Probably as a result of the consequence of stress and prolonged anxiety caused by the violent episode their organism produces lower levels of the hormone, cortisol, which is associated with stress. It seems to be a contradiction, but it is not. This result suggests that these people have become more sensitive to the action of this hormone. For this reason lower levels in the blood stream cause more exacerbated effects, such as palpitations and the heightened feeling of being alert, which was felt by Cruz when he saw a motorcyclist. This effect, which may make the difference between life and death because it prepares the organism to escape an aggressor, is extremely damaging when it lasts more than a few moments because it causes the death of brain cells.

Results are still preliminary, but this cell death seems to affect an area in the brain associated with the acquisition of memory, the hippocampus. Anatomist Andrea Jackowski compared nuclear magnetic resonance images of the brain of 55 people who had been the victims of violence in São Paulo (35 had developed post-traumatic stress and 20 were healthy) and saw a reduction of up to 10% in the volume of the hippocampus, possibly associated with cell death. “We still can’t say if post-traumatic stress causes a reduction in the hippocampus, or on the contrary, if the people who already had a smaller hippocampus were more susceptible to developing the problem”, explains Andrea.

This is another apparently contradictory finding. But it is to be expected that there is no simple answer to a sickness that may be caused by various factors and that involves an organ that is as complex as the brain. If the center associated with the acquisition of memory is smaller in those suffering from post-traumatic stress should they not remember less of what happened? In fact, no. It is just that events with a strong emotional content – a gun pointed at your head with someone’s finger on the trigger, for example – also activate another area of the brain called the amygdala, which is responsible for acquiring the memory of unpleasant events. In a healthy person, the functioning of the amygdala is inhibited by the frontal cortex, the foremost region the brain, located close to the forehead. Andréa is now trying to identify if people with post-traumatic stress also have a reduction in the volume of their frontal cortex, which would explain the exaggerated functioning of the amygdala and the state of hyper-vigilance.

In a somewhat unusual twist in studies into psychiatric illness geneticist Camila Guindalini is analyzing some 1,500 saliva samples collected during interviews with people living in São Paulo who were the victims of violence and who developed post-traumatic stress, or not. She is trying to identify specific alterations in the almost 21,000 human genes that affect the functioning of the central nervous system and may favor the development of post-traumatic stress or even increase resistance to this emotional disturbance. International studies suggest that genetic factors contribute approximately 30% to the development of post-traumatic stress – the other 70% were attributed to the environment (socio-economic and educational conditions and social support). Camila also intends to see how variations in specific genes linked to the functioning of neurotransmitters or to the development of brain cells and fixing memory behave in the Brazilian population. “With such a large sample we’ll be able to identify small effects caused by genes”, she says. Even though they do not explain everything they may help us understand the problem.

Until a clear picture is arrived at as to the possible biological factors associated with post-traumatic stress that are capable of leading to changes in current treatment the team from Unifesp is testing alternative psychological group therapy with people in whom antidepressants and the more common psychological therapies have not had the desired effect. Instead of exposing the individual to situations similar to that which caused the trauma, as cognitive-behavioral therapy proposes, Rosaly Braga Campanini’s team is trying to restore the social ties (with the family, at work and in the community) that those suffering from post-traumatic stress  in general have lost. So far the 30 people who have undergone the weekly sessions of interpersonal therapy have shown a significant improvement, with a reduction in recollection of the trauma and recovery of relationships with family and friends.

Despite the advances Mari says that it is still necessary to work a lot harder to try and understand why most of the victims of violence do not develop post-traumatic stress or manage alternative treatments that return sufferers of this emotional disturbance to life in society, as happened with José Orleans Cruz.  Today Cruz has recovered and has started driving again and going out with his wife. Every week he goes to the local market, eats a savory pasty and looks at the produce on the stalls. He is even making plans for the future. He intends to retire in a few years and return to Itapagé, in Ceará, from where he came to São Paulo as an adolescent with his parents and brothers. “I’m going to rear sheep”, he says. “I want to forget the big city and what happened to me.”

The projects
Post-traumatic stress disorder: epidemiology, physiopathology and treatment (04/15039-0); Modality Thematic project; Coordinator Rodrigo Affonseca Bressan – Unifesp; Investment R$ 1,060,744.27 (FAPESP).
2. The impact of violence on the mental health of the Brazilian population; Modality Millennium Institute; Coordinator Jair de Jesus Mari – Unifesp; Investment R$ 4,204,400.00 (CNPq).