How are the symptoms of post-traumatic stress disorder (PTSD) expressed among Sub-Saharan African populations, and in what ways do these manifestations differ from the diagnostic criteria outlined in the DSM-5?

A systematic literature search was conducted between October 2022 and June 2024 across multiple databases, including PubMed, Google Scholar (used to capture additional regionally accessible sources), APA PsycInfo, Springer Link, SAGE Journals, ScienceDirect, and ProQuest. The search utilized standardized search strings combining keywords such as PTSD, Sub-Saharan Africa, war trauma, sexual violence, anthropology, culture, and expression of trauma. Medical Subject Headings (MeSH) were applied only in PubMed, while equivalent keyword-based strategies were adapted for the other databases. In addition to the database searches, we conducted a hand search of reference lists from included articles and selected journals to identify additional studies that may not have been captured through electronic searches. This approach helps ensure comprehensive coverage of relevant literature, particularly studies published in regionally focused journals or sources with limited indexing. Including this step enhances the rigor and completeness of the scoping review and aligns with best practices recommended for culturally specific research.

Publications identified through the search strategy were downloaded and imported into Zotero. Duplicate entries were then removed. Two researchers (JC and JF) independently screened the titles and abstracts of the articles based on pre-defined inclusion and exclusion criteria. Studies were included only when both researchers reached an agreement. Any discrepancies were resolved through consensus. Additionally, JC and JF conducted a full-text review, and any uncertainties regarding eligibility were settled through mutual agreement. This dual independent screening ensured inter-rater reliability and minimized selection bias.

The selection of studies followed the PCC model (Population, Concept, Context):

A data-charting form was designed to extract key variables relevant to the study. These variables included literature characteristics such as the author, year of publication, country, study design, and key themes reflected in the research. Additionally, the form captured the study's aim, a detailed description of PTSD symptoms and their cultural manifestations, as well as a comparative analysis of these symptoms with the diagnostic criteria outlined in the DSM-5.

The analysis focused on identifying recurrent themes across studies and contrasting clinical interpretations with sociocultural explanatory models. JC and JF engaged in iterative discussions to refine emerging categories until a shared consensus was reached.

Finally, a summary of collected data and an explanation of the findings and the meanings attached to them are reported, along with research gaps that should be addressed by future studies, as well as policy and practice implications. To report the results, we used PRISMA Extension for Scoping Reviews (PRISMA-ScR; Tricco et al., 2018).

Unlike systematic reviews, our scoping review approach did not aim to synthesize or aggregate findings. Instead, we provide a narrative account structured around thematic analysis to address our research questions. Two search strings were developed. The first was applied in PubMed (n = 117) using MeSH terms, as follows: ((((sub Saharan Africa) AND (war trauma OR sexual violence))) AND ((anthropology, cultural[MeSH Terms]) OR (assimilation, cultural[MeSH Terms])) AND (y_10[Filter])) OR ((((culture) OR (customs) AND (y_10[Filter])) AND ((ptsd) OR (TSPT) AND (y_10[Filter]))) AND (expression trauma AND (y_10[Filter])) AND (y_10[Filter])). The second search string was developed using equivalent keyword-based terms, adapted for databases that do not support MeSH. These included Google Scholar (n = 54), APA PsycINFO (n = 17), Springer Link (n = 27), ProQuest (n = 18), SAGE Journals (n = 13), ScienceDirect (n = 6), and Records identified from hand search (n = 16) as presented in Figure 1 and Table 1.

We identified 268 articles through search engines and other hand search. We screened titles and abstracts, excluding studies based on title and summary (n = 207), those that were not original studies (n = 33), those focused solely on immigrants (n = 6), and those addressing children/adolescents (n = 7), resulting in 15 included studies (see Figure 2). The number of subjects studied in those fifteen studies ranged from 1 to 212 cases. The selected publications were mainly conducted in the Burkina Faso (n = 1), Cameroon (n = 2), Democratic republic of the Congo/DRC (n = 4), the Ivory Coast (n = 2), Kenya (n = 1), the Republic of Congo/Brazzaville (n = 1), South Africa (n = 3) and Togo (n = 1) as presented in Table 1. The analysis of the included studies identified three central thematic domains (Table 2): symptoms presented by individuals who experienced psychotrauma; the cultural and anthropological interpretations of these symptoms in African contexts, and the role of clinical psychologists in Sub-Saharan Africa.

In sub-Saharan Africa, mental illness and trauma are often conceptualized through communal, spiritual, and ancestral frameworks (Nguimfack and Mbarga, 2021). Sow, as cited by Nguimfack and Mbarga (2021), posits that PTSD manifests as elements of persecutory violence perceived as external to the victim. This perception operates on three interconnected levels: the imaginary, daily reality, and the symbolic world. Individuals may experience a sense of being possessed by the spirits of the deceased, which can often result in extreme behaviors. (Desjardins et al. 2022), (Koudou et al. 2019), (Mouanga et al. 2018), and (Nguimfack and Mbarga 2020) further explain that possession experiences can result in violent outbursts, During these episodes, the individual may have no recollection of their actions. Knettel et al. (2020) highlight that these episodes are often accompanied by acute anxiety attacks, including palpitations, excessive sweating, and trembling. Understanding these culturally specific interpretations is crucial for developing effective mental health interventions in the region.

In many sub-Saharan African cultures, dreams are integral to understanding personal and communal experiences (Koudou et al., 2019). Encounters with ghosts in dreams are common. However dreams that evoke intense emotions, especially linked to persistent psychological trauma, are considered abnormal. These dreams often become focal points for community discussions (Mavinga et al., 2022). Individuals experiencing such distressing dreams frequently seek guidance from cultural authorities or traditional healers (Al Joboory et al., 2019; Maisha et al., 2017). These cultural interpreters may attribute the distress to spiritual disturbances or unresolved ancestral issues. These interpreters may attribute the distress to spiritual disturbances or unresolved ancestral issues. Subsequently, rituals are performed to alleviate suffering and restore harmony (Maisha et al., 2017). This approach contrasts with the DSM-5, which primarily associates recurrent distressing dreams with traumatic events and emphasizes individual psychopathology.

By adopting an anthropological perspective, evil spirit possession is a representation of mental illness in Africa (Adansikou et al., 2017). Indeed, a significant proportion of the population (40%) considers mental illness to be of magico-religious origin (Nguimfack and Mbarga, 2021). PTSD symptoms are therefore interpreted as relational difficulties between the ancestor and the psycho-traumatized individual, often linked to prohibitions or violations of traditional rules (Adansikou et al., 2017; Grevisse et al., 2019). Maisha et al. (2017) emphasize that rape is seen as a profound transgression. It defiles the victim and disrupts their connection with ancestral spirits. Such acts are believed to invite malevolent forces, causing mental disturbances. Victims often experience intense guilt and fear of stigmatization, anticipating ostracism from families and communities. Koudou et al. (2019) report that PTSD symptoms in sub-Saharan Africa include persecution dreams, nightmares, and hallucinations. Any perceived separation from the ancestor may immediately lead to trauma. Treatment often involves consulting a fetishist, a person capable of neutralizing harmful witchcraft. Delusional reconstructions such as nightmares and hallucinations arise when the fetishist identifies the assailant. This power infiltrates the victim's essence through sorcery, threats, and the use of bark, human or animal bones, teeth, and red or black fabrics. Experiences such as torture, violence, and other potentially traumatic events are often perceived as integral aspects of life rather than isolated incidents (Mouanga et al., 2018; Nguimfack and Mbarga, 2021).

This perspective is deeply rooted in the communal and spiritual fabric of sub-Saharan societies. Adversity is viewed as a collective experience requiring communal resilience and support (Knettel et al., 2020). Fear associated with violence, torture, and rape is seen not as a medical condition, but as a state of helplessness or a situation that can cause harm (Adansikou et al., 2017). Bodily injury, risk of disease, or pregnancy are often of greater concern to the victim than the violence itself (Maisha et al., 2017). Trauma is considered pathological only when it leads to biological or physical consequences (Klimcik et al., 2020). Symptoms that the DSM-5 classifies as psychological, such as reliving experiences or persecution dreams, are often managed through prayer or other cultural practices (Bihabwa and Kangami, 2018; Mouanga et al., 2018; Nguimfack and Mbarga, 2021).

In most cases, trauma is shared by the entire family (Maisha et al., 2017). This contradicts the individual-level conception of PTSD in DSM-5. Individuals are not seen as autonomous entities but as having a familial self. Experiences are considered in the intersubjective domain of the group rather than at the individual or intrapsychic level (Adansikou et al., 2017; Bihabwa et al., 2019; Grevisse et al., 2019; Koudou et al., 2016; Maisha et al., 2017; Mouanga et al., 2018). Beloucif (2021) explains that the mind and body are interdependent in Sub-Saharan African culture. Illness is primarily perceived as a physical condition, while the psyche is less recognized as affected. Consequently, victims predominantly express traumatic suffering through somatic symptoms. PTSD is therefore seen less as a psychological diagnosis and more as a condition influenced by spiritual factors (Knettel et al., 2020). Women survivors of sexual or domestic violence often present with internalizing symptoms such as guilt, shame, silence, and social withdrawal, often framed through spiritual or cultural lenses. Men exposed to conflict or displacement may display externalizing symptoms such as aggression, substance use, or behavioral withdrawal (Maisha et al., 2017; Mouanga et al., 2018).

DSM-5 presents victims of traumatic events as passive sufferers at the individual level (Grevisse et al., 2019). In contrast, PTSD in sub-Saharan Africa is understood in relation to external factors, such as angry ancestors or spirits seeking appeasement. Nightmares or paranoia are attributed to witchcraft or spiritual attacks rather than internalized past experiences (Nguimfack and Mbarga, 2021). Experiences of trauma and avoidance behaviors are often interpreted spiritually, linked to supernatural forces (Allon, 2016). While DSM-5 integrates somatic and psychological dimensions, victims in Sub-Saharan Africa primarily attribute trauma to spiritual causes when no physical explanation is found (Grevisse et al., 2019). DSM-5 directs victims to psychologists and psychiatrists (American Psychiatric Association, 2016). Conversely, African societies adopt a holistic perspective, where help is sought from medical doctors, religious leaders such as pastors, or traditional healers like fetish priests (Grevisse et al., 2019; Knettel et al., 2020; Nguimfack and Mbarga, 2021; Womersley and Kloetzer, 2018; Grupp et al., 2018).

Six studies explore the role of clinical psychologists in Sub-Saharan Africa. Traditional practitioners address PTSD symptoms through witchcraft, community rituals, and prayer as part of the healing process (Allon, 2016; Caizzi and Ciambellini, 2017; Nguimfack and Mbarga, 2020, 2021; Yagi et al., 2022). These symptoms are often interpreted as the effects of a fetish, malevolent magic, or a curse inflicted by an enemy. Alternatively, they may be seen as consequences of cultural transgressions or sins, depending on individual beliefs (Grevisse et al., 2019; Morrison and Dwarika, 2022; Mouanga et al., 2018).

Most victims of rape have reported turning to traditional healers for purification rituals or to receive magic potions for their healing. This practice was a strategy or customary rule for the reintegration of victims into their families and communities. For some couples, even though the husbands were Christians and their faith was crucial in their decision to stay married after a rape, this traditional integration ritual remained essential for husbands to accept their raped wives (Maisha et al., 2017). This situation creates a dilemma for sub-Saharan African clinical psychologists trained in Western models. Victims often expect them to act as healers or intercessors, rather than as mental health professionals who provide support through listening and counseling (Sikkema et al., 2018). Furthermore, the psychologist's role outside medical and spiritual realms is not yet fully recognized. When victims cannot find relief through doctors, traditional practitioners, or pastors, they often turn to God and their ancestors (Klimcik et al., 2020). In sub-Saharan regions drugs are central to medical treatment. Many believe that if medication is unavailable, a condition cannot be cured unless it is spiritual. As we know, psychologists do not provide drugs to the patients, only psychiatrists do, which complicates understanding their role in this context.

Thus, if the medical doctor does not find a medical cause for the victims' symptoms, the victim often searches for the cause in the spiritual world, seeking help from God or ancestors (Caizzi and Ciambellini, 2017; Grevisse et al., 2019; Womersley and Kloetzer, 2018). This belief is established early in life through childhood initiation rites, both traditional and religious starting in the family and continuing in the community. These practices are considered non-negotiable and constitute a dynamic organization of an individual's life within their developmental environment (Mouanga et al., 2018). Therefore, African psychologists must prove that they can bring added value to earn their place in a healing model that differs from the Western-inspired professional training that they have received.

The DSM-5 provides a universal, medicalized approach to diagnosing trauma-related disorders (Forkus et al., 2023), in contrast, African cultural contexts interpret PTSD symptoms through traditional and religious beliefs (Sikkema et al., 2018). Table 3 summarizes the key differences between the DSM-5 framework and the Sub-Saharan African cultural context. It shows contrasts in symptom conceptualization, etiology, cultural significance, and treatment strategies across the two contexts. The table illustrates that DSM-5 uses standardized diagnostic criteria, whereas sub-Saharan societies incorporate spiritual, communal, and ritual dimensions in understanding and addressing trauma.

Understanding PTSD symptoms in Sub-Saharan Africa requires examining them within cultural, familial, gender and spiritual frameworks. Across the reviewed studies, gender consistently emerged as a key social determinant shaping both trauma exposure and interpretation. Female gender emerged as a robust predictor of PTSD (Bihabwa and Kangami, 2018; Di et al., 2022; Dozio et al., 2016; Tesfaye et al., 2024). Similarly, in a high-adversity cohort of South African women, women were more likely than men to exhibit probable PTSD, even when exposure levels and co-occurring depression were controlled (Altare et al., 2020; Hiscox et al., 2021; Langevin et al., 2018; Nguimfack and Mbarga, 2020). Unlike the DSM-5, which defines PTSD through neurobiological and psychological mechanisms, Sub-Saharan African perspectives often link these symptoms to failures in fulfilling traditional rituals and spiritual obligations. PTSD is frequently interpreted through religious and ancestral beliefs rather than psychological paradigms (Nguimfack and Mbarga, 2020).

This divergence illustrates how diagnostic constructs are mediated by local ontologies of personhood, whereas the DSM-5 privileges internal psychological processes, many African frameworks locate suffering in disrupted social or spiritual relationships. Such contrast suggests that integrating cultural formulation interviews or ethnographic assessment tools into PTSD diagnostics could enhance cross-cultural validity.

In the Democratic Republic of Congo, particularly in Kinshasa, mental distress is frequently attributed to supernatural causes such as witchcraft or ancestral spirits rather than medical conditions (Wiel and Slegh, 2024). Generational differences have also been observed: older participants often endorsed beliefs in demonic possession and witchcraft, while younger cohorts showed more openness to medical explanations (Slewa-Younan et al., 2022). In the Sahel region, including parts of Mali and Senegal, Islamic spiritual healing traditions similarly frame trauma as a form of spiritual imbalance. Practices such as dhikr (remembrance of God) and Quranic recitation have been shown to promote mental well-being and alleviate conditions like anxiety and addiction (Zahir and Qoronfleh, 2025). In Pentecostal and charismatic Christian settings, particularly in South Africa, experiences such as insomnia, visions, or dissociative states are often understood through spiritual lenses, attributed to demonic interference or the need for deliverance rather than conceptualized as clinical manifestations of PTSD (Captari and Worthington, 2024). Similarly, traditional healers and urban spiritual practitioners, especially in cities like Johannesburg, frequently interpret mental distress as arising from supernatural causes, including ancestral displeasure or witchcraft, and prescribe rituals aimed at restoring spiritual balance (Galvin et al., 2023). Taken together, these culturally embedded explanatory models underline the importance of complementing DSM-5's cultural formulation framework with deeper engagement in anthropological and local contexts.

Cultural beliefs in fate, witchcraft, and sorcery diverge from DSM-5's psychological interpretations, which attribute PTSD symptoms to biopsychological processes (American Psychiatric Association, 2016). Because illness is frequently conceptualized as spiritually driven, some individuals may prefer ritual or spiritual healing over psychological care. Instead, they turn to traditional rituals and spiritual healing, reinforcing the view that PTSD is a spiritual disorder characterized by somatic symptoms, persecution dreams, aggression, and muteness (Mavinga et al., 2022).

This preference does not necessarily reflect rejection of biomedical models but rather an attempt to restore moral and relational order within the community. As such, help-seeking behaviors are embedded in moral economies of care rather than purely medical logics.

In Sub-Sahara African societies, emotional distress is often linked to physical symptoms, and when medical treatments fail, individuals seek healing from God and ancestors (Knettel et al., 2020; Koudou et al., 2019; Pireyre et al., 2019; Van der Kolk et al., 2016). While psychological care is increasingly available in urban settings, cultural ceremonies remain central to many communities in addressing PTSD (Brohm, 2017; Pireyre et al., 2019). Recognizing these perspectives is crucial for developing culturally relevant PTSD treatments.

Rituals play a fundamental role in African societies by maintaining communal bonds and restoring unity (Brohm, 2017; Kaminer et al., 2018; Mavinga et al., 2022; Pireyre et al., 2019). After traumatic events, victims often seek assistance from traditional healers (ngangas) rather than psychologists, even when the latter share their cultural background. Even when psychological treatments are acknowledged as effective, many individuals supplement them with spiritual and ritualistic healing (Desjardins et al., 2022).

This reliance on traditional healing is linked to the perception that trauma ruptures social and cosmological order rather than individual mental stability. Many African cultures view trauma symptoms as spiritually caused, prompting individuals to engage in prayer and purification rituals. These ceremonies, particularly those addressing sexual violence and misfortune, aim to cleanse both the individual and their community (Mouanga et al., 2018). Hence, collective ritual healing performs both a therapeutic and a sociopolitical function by re-establishing moral equilibrium. The collective approach to trauma treatment underscores the importance of culturally sensitive interventions.

Conducting a scoping review comparing DSM-5 and Sub-Saharan Africa explanatory models of PTSD presents both strengths and limitations.

Strengths:

Limitations:

Despite these limitations, this scoping review provides valuable insights into how PTSD is understood and treated in sub-Saharan Africa. Future research should prioritize participatory designs and community co-analysis to ensure that indigenous voices shape conceptual frameworks and intervention models. Enhancing cultural collaboration can further strengthen the validity of findings.

This review underscores how traditional beliefs shape PTSD symptoms in African populations and highlights the necessity of culturally appropriate care. Addressing PTSD in sub-Saharan Africa requires integrating cultural models into psychological interventions through a multidisciplinary approach. Importantly, the following recommendations are provided as illustrative examples from broader literature and not as findings derived from the included studies. Together, these recommendations reflect an emerging consensus in global mental health that sustainable trauma care in post-conflict Africa must bridge biomedical, spiritual, and community-based paradigms.

This review contributes to the decolonization of trauma studies by challenging the universal applicability of Western diagnostic frameworks and advocating for pluralistic, context-sensitive understandings of suffering. Recognizing the coexistence of biomedical and spiritual logics in African trauma healing may inform global psychiatry to adopt a more inclusive epistemology one that values relational and communal dimensions of recovery.