1. Running Head: PTSD PERU
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PTSD in Peru: Yaguas or Fetal-Trauma Syndrome
Nechama B. O’Brien
University of Chicago

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Abstract
1980-2000 is infamously considered the bloodiest time in Peruvian history. The prolonged
traumas of the political terrorist groups and the military primarily affected the indigenous
Quechuan populations, putting them at high risk of developing PTSD. Ancient psychiatric
concepts of mental illness, such as La Enfermedad de Susto or the Fear Illness and Yaguas, or a
native form of PTSD derived from fetal-trauma, influence the Quechuans’ contemporary
subjective experience of PTSD. The paper will address several psychological studies on PTSD in
Quechuan populations that will elaborate on the effects of prolonged exposure to trauma during
political turmoil and empirically compare and contrast the DSM or Western subjective
experience of PTSD with the local Quechuan subjective experiences. It will then examine
ancient concepts of mental health and discuss their roots in terms of the contemporary subjective
experience of PTSD. Throughout the paper there is a discussion of globalization as a reciprocal
exchange of PTSD diagnosis and treatment. Finally, there are suggestions of potential PTSD
community based group therapy treatment plans and a possible future challenge due to a
combination of Yaguas and the potential trauma of pregnant mother’s as a result of the Zika
epidemic.
Keywords: PTSD, Quechua, Peru, Yaguas, Zika, Fetal-trauma

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PTSD in Peru: Yaguas or Fetal-Trauma Syndrome
The formation of Peru’s first terrorist insurgent groups in 19801 combined with the
extreme natural disaster impacts brought on by the climate phenomenon El Niño in 1982, the
country’s crippling bankruptcy 1988-19902 and Peru’s long history of illicit narco trafficking3,
border wars, and violent military coups, made 1980-2000 the “bloodiest” time period of Peruvian
history (Timeline: Peru). This 20-year period, characterized by severe human rights violations of
Peruvian citizen, ended only sixteen years ago. The widespread civilian exposure to traumatic
events related to political violence puts the Peruvian population at high risk of Post-Traumatic
Stress Disorder (PTSD). The following paper will (1) compare United States and Peru on their
definitions, prevalence, recognition, and treatment of PTSD (2) explore the ancient indigenous
concepts of PTSD such as La Enfermedad de Susto, or the fear illness, and Yaguas in order to
examine sociocultural differences in the subjective experience of PTSD, its etiology and its
treatment (3) how this investigation advances Western sociocultural knowledge of PTSD that
may direct future studies and may reach a currently overlooked PTSD population (5) recommend
strategies to improve access to psychiatric care and reduce the burden of PTSD in Peru (6)
suggest unique and future challenges of PTSD in Peru.
1
In response to the terrorism of the armed rebel organizations, Sendero Luminoso (SL) which translates to Shining
path and Túpac Amaru Revolutionary Movement (MRTA), President Alan García Perez administration
implemented an unsuccessfulmilitary solution that has been found guilty of numerous of human rights violations
(Peru Insight Crime).
2
According to “World Hyperinflations,” a mass data analysis of over 50 hyperinflations conducted by top economic
professors at Johns Hopkins University, Hanke and Krus in 2012, Peru’s hyperinflation of 1990 falls within the top
15 worst hyperinflations in global history. The Hanke-Krus Hyperinflation Table shows that Peru’s hyperinflation
began in September of 1988 with a peak monthly inflation rate of 114% such that it took on average 27.7 days for
prices to double, but by the summer of 1990, the hyperinflation reached its peak monthly inflation rate of 397%,
which means it took only 13.1 days for prices to double.
3
Since the 1980s, Peru has been the world’s largest supplier of cocaine, growing ⅔ of the world’s cocaine crops
which it ships through Columbia to the US and Europe (Peru Insight Crime).

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Peru and USA both follow the Diagnostic Statistic Manual (DSM) in diagnosing PTSD.
PTSD is one of the few mental health disorders that the DSM-V, the latest edition (2013),
defines more so by its origin than by its symptoms. PTSD is the unrelenting persistence of the
cognitive, somatic, and emotional reactions to trauma(s), which are described as the actual
infliction or perceived threat of death, serious injury, or sexual violence (Friedman, 2013). The
trauma can be experienced either firsthand as an actual or a perceived victim or as an in-person
witness, or experienced secondhand, by learning of a traumatic event that occurs to a close
relative or friend or through repeated exposure to aversive details of the event that is typically
work related such as a “paramedic collecting body parts” or a social worker repeatedly facing
details of child abuse (it does not include exposure to media or movies) (Friedman, 2013). In
relation to the traumatic event, there are four symptom categories of PTSD4: intrusion, persistent
avoidance, negative alterations of cognitions and moods, and alterations in arousal or reactivity,
which result in functional impairment (e.g. inability to maintain personal hygiene, disruption of
inter-personal relationships, or deterioration of work performance) (Friedman, 2013). These
symptoms are diagnosable only if endured longer than one month after the trauma and are not
due to medication or drug/alcohol consumption (Friedman, 2013). PTSD can develop at any age
and expresses itself by extending the feelings, bodily responses, and altered sense of reality that
interfere with basic functioning and can, if untreated, last the rest of the person’s life.
4
Intrusion is experienced by at least one of the following five symptoms: “pervasive and involuntary recollections,”
invasive nightmares, “dissociative reactions such as flashbacks” or fainting, prolonged distress or physiological
reactions to trauma stimuli. Avoidance is characterized by the effortful evasion of trauma-related (a) thoughts or
feelings or (b) stimuli such as “people, places, objects,conversations,activities, or situations” (Friedman, 2013).
Deterioration in cognitions or moods are characterized by two of the following seven symptoms, given they last
longer than a month,: (1) trauma-related memory blocks (“dissociative amnesia not related to head injury, alcohol,
or drugs”), (2) distorted perception of self or the world such as “I am bad” or “the world is completely dangerous,”
(3) ill-directed blame for the trauma or its consequences,(4) “negative emotions such as shame, guilt, horror, or
anger,” and (5) diminished interested in previous activities, (6) feeling socially alienated, (7) inability to experience
positive emotions (Friedman, 2013). The changes in arousal must take two of the following six forms: (1)
irritability and aggression (2) self-destructive behavior, (3) “hypervigilance,” (4) “exaggerated startle response,” (5)
difficulty concentrating,(6) sleep disturbances (Friedman, 2013).

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It has become increasingly more complicated to interpret the accumulating PTSD study
results as the diagnostic definitions of trauma and PTSD symptoms evolves over time. For
example, While DSM-IV anchored its diagnosis in a single traumatic situation, which
underestimated the prevalence of potential traumas, the DSM-V has evolved to include PTSD
that develops from a combination of traumatic conditions (Norris, 2013). This change was made
in order to encompass repeated trauma exposure such as partner-violence or military combat, yet
it is less clear how the combination of situationally and chronologically unrelated traumas such
as rape and a severe car accident will affect the epidemiology of PTSD (Norris, 2013). However,
according to a study comparing the diagnostic criteria of PTSD between the DSM-IV and the
DSM-V, Kilpatrick and colleagues (2013) reviewed a national probability sample of 3,000 US
participants who were diagnosed with PTSD under DSM-IV criteria and found that 97.5% of
those individuals were still considered to have PTSD under the DSM-V criteria. Over half of the
PTSD cases no longer eligible under the DSM-V were due to the invalidation of the DSM-IV
criteria that previously considered the indirect learning of a loved-one’s unexpected non-violent
death to be a trauma (Norris, 2013). The other major cause of this slight change in prevalence is
due to the new requirement of at least one avoidance symptom (Kilpatrick, 2013). In spite of the
changes in diagnostic criteria, the prevalence of PTSD has remained pretty consistent.
When comparing PTSD between Peru and the US, such as their incident rates,
demographic distributions, and lifetime prevalence, it is important to keep in mind the definitions
that underlie the population estimates when assessing changes in PTSD both overtime and across
cultures. PTSD develops from a trauma that cannot be separated from the greater economic,
political, and social contextualization of the traumatic origin, development, and symptom
recovery. The US and Peru have vastly different economic, political, and social climates such

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that the vastly different statistics of PTSD reflect not only the culture’s differences in the
concepts of trauma related disorders, but reflect the disparities in the countries structures that
affect mental health. The challenges present in a cross-cultural study of PTSD is even more
complicated because PTSD is particularly westernized in its origin and interpretation. PTSD
entered the DSM-III as a diagnosis in 1980 based on observations made of Vietnam War
veterans and thus represent a Western subjective experience of dealing with trauma. Classifying
PTSD in the DSM, externalized the etiology of the symptoms from what the Veterans had
considered an inherent weakness to an external situation. While both Peru and the US follow the
DSM to diagnose PTSD, they differ in the prevalence, duration, and incident rate (those who
develop the disorder from the at risk population). This paper will discuss the mental health
implications of using the Western diagnosis of PTSD on the indigenous peoples of Peru5.
It is a common misconception that it is rare to experience or witness a traumatic event.
However, according Kilpatrick’s national sample of about 3,000 US citizens in 2013, 89.7%
were exposed to DSM-V trauma and more often multiple traumas (Kilpatrick, 2013) of whom
only 10.6% developed PTSD (Kilpatrick, 2013). In contrast, of the 83.7%6 exposed to political
traumas in Huancavelica, the poor countryside of Peru, 23.2% developed PTSD under DSM-V
(and 25% under DSM-IV, if including the 4.8% without an avoidance symptom) (Herrera-
Lopez, 2013). In addition, the lifetime duration of PTSD in North Americans is an estimated
8.3% (Kilpatrick, 2013), while in Huancavelica it is 25.6% (Herrera-Lopez, 2013). The widely
different incident rate, or the number of people who develop PTSD from those who are at risk
5
Although my research is limited by the fact that I am Western speaker and thinker, the research investigations I
cite conducted its interviews and surveys in Quechuan, the indigenous language-family of the Incan empire, and
then published the articles in either Spanish or English.
6
The exposure rate in Peru seems lower than that of the US, because this percentage excludes exposure to traumas
not related to politics. However, when including physical violence, accidents,witnessing and learning of family
death, the percentage of trauma exposure in the sample of community members increases to 100%.

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from having experienced traumatic event(s), and lifetime prevalence rate is more than double in
Peru as compared to the US. Although this is beyond the scope of this paper, a better way to
draw conclusions and try to understand the resilience of Peruvians would be to compare these
statistics to those of countries more similar both in the economic, social, and political structures
as well as in the type of prolonged trauma inducing the PTSD.
Huancavelica is not, and was not meant to be, a representative of the Peruvian nation.
The Truth and Reconciliation Commission declared that Huancavelica along with Ayacucho and
Apurímac were the areas primarily affected by the armed conflict between the terrorist insurgent
groups and the military (Herrera-Lopez, 2013). There are only 229 community members
remaining after an estimated 69,280 were killed during the armed conflict (Herrera-Lopez,
2013). Huancavelica is in the countryside where 83.5% of the population is employed in
agricultural work (Herrera-Lopez, 2013). 43% of those sampled in the study built their livelihood
on farmland and domesticated animals, which, devastated during the armed conflict, left these
families impoverished, without food or any source of income, forced to migrate and
consequently destroying social support. Although the conflict ended sixteen years ago,
Huancavelica remains one of the most impoverished communities of Peru where participants
make a monthly average salary of only 24.4$ (Herrera-Lopez, 2013). The National Ministry of
Health in Peru did a comprehensive study of over 50% of the Huancavelica population on PTSD
and its comorbidity (Herrera-Lopez, 2013)7.
7
This study found that compared to peers who developed PTSD, the prevalence of Generalized Anxiety Disorder
went from 7% to 42%, chronic depression went from 16% to 42%, and panic attacks went from 13% to 29%
(Herrera-Lopez, 2013). However, unlike previous studies on PTSD and its comorbidity, there was not a significant
link between PTSD and alcohol consumption (Herrera-Lopez, 2013). Those suffering from PTSD tend to become
dependent on substancesas a means of self-medication in order to reduce symptoms such as anxiety, nightmares,
hyper-vigilance. The lack of a connection between PTSD and alcohol dependency suggests a cultural point of
departure in the ways of coping with mental illness. Anotherinterpretation surpris ing statistical result, may be that
the poorof Huancavelica cannot afford alcohol. The article suggests that this difference could be due to a high rate
of migration after the conflict (Herrera-Lopez, 2013).

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Huancavelica high rate of PTSD amongst the trauma exposed participants, may be, in
part, an effect of prolonged exposure to armed conflict as opposed to non-repetitive traumas that
may be more typical of PTSD in the US. During the armed conflict, the sampled participants
suffered serious injury (15%), witnessed massacres or a family member murdered (4.9%), victim
of torture (9%), forcibly displaced by the military (43.8%), forced recruitment either to join the
military or an insurgent group (40.5%), suffered unlawful imprisonment or detainment (9%),
victim of kidnapping or a family member’s forced disappearance (15.7%), and victim of sexual
abuse (2.4%) (Herrera-Lopez, 2013). Each community member experienced on average 2.26
traumatic events related to political violence (Herrera-Lopez, 2013), but in a context of
unrelenting danger. On the other hand, the most frequent traumas experienced in the US are
53.1% physical/sexual assault (it is unclear how many of these are repeated victimizations),
51.8% due to death of a family member or close friend in a violent manner or in an
accident/disaster, 48.3% accident/fire, 50.5 disaster (Kilpatrick, 2013). Of the most frequent
traumas, the overwhelming majority are singular unexpected events rather than a repeated event
under political and economic chaos. The Huancavelica PTSD researchers themselves suggest
that the rate may be biased due to a high proportion of population migration (Herrera-Lopez,
2013), but I suggest that there is likely an influence on the incident rate and prevalence of PTSD
due to the greater context in which the trauma took place.
A previous study (2009) compared the Western and the Quechuans of Ayacucho
subjective experiences of PTSD and found that the diagnosis of PTSD is valid for this
indigenous population in certain respects, but that there is a dimension of the experience of
PTSD that is culturally rooted. As mentioned above, Ayacucho was one of the indigenous
populations that the Truth and Reconciliation Commission found to have experienced one of the

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highest numbers of civilian deaths and material losses. Quechuans of Ayacucho relied on a
bartering economy that was destroyed through mass displacement (180,000) and murder
(25,000) during the two decades of the armed conflict (Tremblay, 2009). The study interviewed
and surveyed (in Quechuan) a sample of 373 individuals from the half million survivors of a
representative mixture of migration statuses: returnees, refugees, migrants, and “resistant
communities”8 (Tremblay, 2009). Of the breadth of credible diagnostic tools used (1) the
General Health Questionnaire (2) the Hopkins Symptom Checklist and (3) a Trauma
Questionnaire based off Harvard's’ Cambodian questionnaire, it is the third that explores PTSD
both from a culturally particular perspective (Tremblay, 2009).
The questionnaire was divided into two parts: (a) the set of questions related to the
Western subjective experience of PTSD as categorized by the DSM-IIIR (b) the set of questions
phrased to reflect the local Quechuan subjective experience of PTSD by using Local Idioms of
Distress (LID). I attached the questionnaire to the end of the paper so that you can see the two
subjective experiences described, at least through the questions, in concrete way. LID was
analyzed against DSM-IIIR in order to determine the specificity (77.2%), sensitivity (74%),
positive predictive value (84.5%) and negative predictive value (63.8%). Over half the variance
on account of the DSM-IIIR statistical model came from the following indicators: (1) Irritability
(2) Recurrence (3) Avoidance, while the LID indicators that provided over half the variance
were: (1) Llaqui or distress, sorrow, suffering (2) Susto or fear (3) Alkansu which translates to
“reached by an evil spirit” (Tremblay, 2009). The LID rates are relatively low in comparison
with DSM-IIIR which would suggest that they are testing different subjective experiences of
8
Comunidades resistentes,or resistant communities, were mainly farmers who remained defiant against the both the
terrorist groups and the military.

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PTSD. However it would be a mistake to consider them entirely incongruent as there is still a
great deal of concordance between the two statistical models.
The book “Paleopsiquiatría Del Antiguo Perú,” which translates to paleo psychiatry of
ancient Peru, discusses “La Enfermedad del Susto” or the illness of fear that is caused by
childhood trauma (p. 65). The word susto or fear, used to describe the trauma illness of ancient
Peruvians is the same word that was found to be one of the local idioms significantly predictive
of PTSD in Tremblay’s experiment. The child who experienced a grave trauma would produce
symptoms such as inability to care for his hygiene or the stunting of physical development. A
curandero or mystic healer, would diagnose the child with the fear illness and carry out Shogpi,
the fear illness cure (p. 65). Shogpi is done by placing the child in the center of a white sheet and
surrounding him with flower petals (p. 65). In Cuzco, the province in which Huancavelica is
located, a version of the fear illness cure known as Hallapa is still implemented, although it was
influenced by Christianity brought by the Spanish conquerors (p. 65). Hallapa is conducted by
taking a bouquet of flowers that were dedicated to a saint, and use the petals to form a bed
around the sick child (p. 65). (p. 65). The word susto, used to describe the trauma illness of
ancient Peruvians is the same word that was found to be one of the local idioms significantly
predictive of PTSD in Tremblay’s experiment. The child who experienced a grave trauma could
only be diagnosed by a professional healer was thought of to cause the child’s symptoms such as
inability to care for his hygiene or the stunting of physical development. The cure for the fear
illness is called Shogpi and it is done by placing the child in the center of a white sheet and
surrounding him with flower petals (p. 65). In Cuzco, the province in which Huancavelica is
located, a version of the fear illness cure known as Hallapa is still implemented, although it was
influenced by Christianity brought by the Spanish conquerors (p. 65). Hallapa is conducted by

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taking a bouquet of flowers that were dedicated to a saint, and use the petals to form a bed
around the sick child (p. 65).
In ancient Peru there is another mental illness experienced by children who suffer
psychical traumas known as Yaguas (sometimes spelled Yahuas) (p. 65). It could be argued that
Yaguas described as a unique sociocultural form of PTSD that is part of Peru’s indigenous
populations’ experience of mental health that is not recognized by Western culture. Yaguas is an
ancient Quechuan term that describes the mental illness born out of a trauma experienced by the
mother during pregnancy that gets passed down to the fetus (p. 65). Valdizán describes the origin
of Yaguas as “the mother’s feelings during pregnancy that take over the fetus. the mother’s
sufferings and and worries get reflected in the general state of being of the child that she carries
in her womb. A deep sorrow, a very intense emotion, that the mother experiences during
pregnancy can decide, tragically, the future of the child” (p. 63). Western psychiatry has not yet
recognized fetal trauma as a possible cause of PTSD. The DSM-V added a section on PTSD in
children age six and younger, but the traumatic experiences such as child abuse, animal attacks,
“invasive medical procedures,” vehicle collisions, and witnessing violence does not extend to the
fetus (PTSD: National Center for PTSD).
In ancient times the Yaguas trauma was embedded in superstitions and the mother was
carefully guarded during her pregnancy. The ancient Peruvians believed that the mother could
become deeply disturbed or frightened by the “silhouette of hunchback” or the growl of an
animal such that the handicap of the individual or characteristics of the animal perceived by the
mother becomes embodied in the fetus (Valdizán, p. 63). During childbirth the women surround
the mother, stumbling over one another to cradle the new baby in their arms and congratulate the
new mother (p. 63). During this bustle, any of the women may diagnosis the newborn (p. 63).

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The newborn may make a sound that is like the mew of a cat or the growl of a pig or a neigh of a
horse, which would be a symptom of the specific form of Yaguas (p. 64). The cure can be carried
out only on Tuesday or Thursday and is carried out by collecting a tuft of the animal's fur or one
of its feathers (it was believed to work best if it when taken from the animal guilty of scaring the
mother) that is then waved over the child's body and he is made to sip a curios medical
concoction (p. 63). Yaguas is not limited to animals or the handicapped, but can also be caused
by any inanimate object that one of the familial midwives believes that the child resembles and
thus concludes had been possessed by said object (p. 64).
Although much of Peru’s pagan traditions have been lost to Christianity and more
modern forms of globalization, a contemporary form of this illness is still very much present in
Peruvian culture. For example, in 2009 Peru came out with a popular film called “La Teta
Asustada,” which directly translates to the frightened breast, but which is given the title “The
Milk of Sorrow” by the English version of the movie. The movie reveals that the roots of Yaguas
are still very much a part of the subjective experience of rape and political violence. La Teta
Asustada tells the story of Fausta, whose mother, an indigenous Quechuan speaker, was raped
during pregnancy as part of the military’s mass rape war tactic. According to the movie, the
mother’s milk passes on the sorrow of her trauma to the child. Fausta experiences severe PTSD
symptoms such that she avoids all men and keeps a potato in her vagina so that no man could
ever forcibly penetrate her. The movie could have followed the mother and her experience of
PTSD, but it did not. Granted the movie is considered to be magical realism, but it shows that the
cultural roots of Yaguas is still a way in which Peruvians make sense of and subjectively
experience PTSD.

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The DSM is considered to be the “golden standard” of mental health. But PTSD, and
likely other mental illnesses, is embedded in and characterized by the subjective Western
experience of a psychical trauma. Acknowledging the inherent Western biases in PTSD and
garnering a greater awareness of sociocultural subjective experiences of PTSD can better
advance global mental health care practices. This paper raises more questions than it answers and
can hopefully lead to studies on the remnants of Yaguas in the contemporaneous Quechuan
experience of PTSD, especially as it relates to sexual violence. The Peruvian population is at
great risk of PTSD because of long-term exposure to political traumas and it could be invaluable
to understand how PTSD is experienced in indigenous mothers, who were pregnant during the
armed conflict, and their children who may be a currently overlooked at risk population since the
Western concept of PTSD does not recognize fetal traumas. Depending on what future studies
confirm, the US may be inclined to change the way in which it assess and treat PTSD in pregnant
Indigenous Peruvian women who are seeking asylum in the US and their children.
Globalization has motivated the exchange of cultural solutions to PTSD. The U.S. has
brought forms of Western healing to Peru and some of Peru’s traditional forms of healing are
being sought out by U.S. veterans. The National Center for PTSD in the US Department of
Veteran Affairs suggests a variety of approaches to treating PTSD including various forms of
therapy and medication, which can be taken individually or together as part of a joint treatment
program. Cognitive Behavioral Therapy (CBT) is the scientifically most effective way of treating
PTSD in veterans and comes in two forms: Cognitive Processing Therapy (CPT) and Prolonged
Exposure (PE) (PTSD: National Center for PTSD). Eye Movement Desensitization and
Reprocessing (EMDR) is also widely practiced in the US and is a way of deflecting extreme
responses to traumatic stimuli through somatic training (PTSD: National Center for PTSD).

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PTSD is medicated with SSRIs, Selective Serotonin Reuptake Inhibitors that are also used to
treat Depression (PTSD: National Center for PTSD). The National Center for PTSD also offers
group therapy, brief psychodynamic therapy, and family therapy as further treatment options to
better understand the illness, its triggers, and develop coping mechanisms (PTSD: National
Center for PTSD).
A traditional Peruvian treatment of PTSD, known as Ayahuasca, is a tea made from
Chacruna leaves and Ayahuasca vine, Amazonian rainforest plants that contain DMT (Bain,
2014). It is supposed to create a safe and controlled environment in which the patient can revisit
the trauma and reconcile with it (Bain, 2014). The Shaman prepares and serves the ceremonial
tea whose effects last typically 6-8 hours and involves “vomiting, crying, or diarrhea” (Bain,
2014). In 2013 Jessica Neilson, a lecturer at a “multidisciplinary association for psychedelic
studies”, discussed Ayahuasca as a valid curative technique, showing that the globalization of
PTSD treatments is reciprocal (Bain, 2014).
A possible way to increase access to PTSD care in Peruvian indigenous populations
would be to create self-sustainable community based group therapies. Peru’s extended exposure
to trauma during the armed conflict decimated social and economic structures of indigenous
communities. These communities are greatly impoverished and have a high incident rate and
prevalence of PTSD that could be assisted through communal recognition and support. Because
the community’s support systems were destroyed, there would need to be assistance from the
government through Peru’s Ministry of Health, which could act to develop and implement self-
sustained programs by training local leaders in group therapeutic techniques and maintain
communication with these leaders to regularly assess progress and collaborate on solving
problems as they arise.

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The roots of Yaguas may present a unique challenge to the indigenous Peruvian PTSD
pregnant and fetal subpopulations. These unique challenges may become more complex in light
of the current Zika virus epidemic that affects primarily pregnant women of South America that
severely impairs the cognitive development of their fetuses. The Zika virus is spread through
mosquitos and can be sexually transmitted. It may be pertinent to explore the ways in which
contemporary experiences of Yaguas and PTSD in pregnant women may be affected by Zika as a
potential trauma in which the woman fears the safety of her child due to an epidemiological
outbreak disaster.

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