Post Traumatic Stress Disorder (PTSD) and beyond

Dr Nelson Loitongbam *

To date, conflict is causing extreme social crises worldwide, with women and children representing the most vulnerable group, often experiencing severe trauma and violence in conflict-ridden areas. Posttraumatic stress disorders (PTSDs) are the most widely reported psychological problem in the aftermath of conflict.

Current research suggests that major Depression & Post-Traumatic Stress Disorder (PTSD) is prevalent and chronic among refugee and displaced populations. Research also shows that the impact of trauma is long-term and some researchers postulate that these ‘invisible wounds’ can leave a society vulnerable to a recurrence of violence.

Traumatic events and the way people cope with them have a crucial role in the development of Post Traumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Somatization, and Dissociative Disorder.

Post Traumatic Stress Disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances.

An individual may experience this as emotionally or physically harmful or life-threatening and may affect mental, physical, social, and/or spiritual well-being. Examples include natural disasters, serious accidents, terrorist acts, war/combat, rape/sexual assault, historical trauma, intimate partner violence and bullying,

PTSD has been known by many names in the past, such as “shell shock” during the years of World War I and “combat fatigue” after World War II, but PTSD does not just happen to combat veterans. PTSD can occur in all people, of any ethnicity, nationality or culture, and at any age. PTSD affects approximately 3.5 percent of U.S. adults every year. The lifetime prevalence of PTSD in adolescents ages 13 -18 is 8%.

An estimate one in 11 people will be diagnosed with PTSD in their lifetime. Women are twice as likely as men to have PTSD. Three ethnic groups – U.S. Latinos, African Americans, and Native Americans/Alaska Natives – are disproportionately affected and have higher rates of PTSD than non-Latino whites.

PTSD in Manipur: An Earlier Experience

The North East (NE) region of India is one of the World’s regions worst affected by violent ethnic conflict. More than a decade ago a horrendous and terrible ethnic conflict occurred between two ethnic groups in NE India, it affected the states of Manipur, Nagaland and parts of Assam but Manipur bore the brunt of the violence.

A study of those affected by the violence was conducted around that time and it was found that of those exposed to trauma: 60% of females and 21% of males were affected by PTSD, Widows were worst affected, Younger age group ( <35 years) were more affected (63%), Rural inhabitants and less educated (87%) were found to be more affected by PTSD. Most common co-morbidity in PTSD patients was Depression, Anxiety followed by Somatoform disorders.

The recent bout of violence has also seen an increased number of patients having symptoms of PTSD, Acute Stress Disorder attending the out patients department along with Depression, Anxiety, substance use disorders and Somatoform disorders.

People with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.

A diagnosis of PTSD requires exposure to an upsetting traumatic event. Exposure includes directly experiencing an event, witnessing a traumatic event happening to others, or learning that a traumatic event happened to a close family member or friend. It can also occur as a result of repeated exposure to horrible details of trauma such as armed forces/police officers/ media persons exposed to details of child abuse cases.

Symptoms and Diagnosis

Symptoms of PTSD fall into the following four categories. Specific symptoms can vary in severity.

1. Intrusion: Intrusive thoughts such as repeated, involuntary memories; distressing dreams; or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are reliving the traumatic experience or seeing it before their eyes.

2. Avoidance: Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that may trigger distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.

3. Alterations in cognition and mood: Inability to remember important aspects of the traumatic event, negative thoughts and feelings leading to ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); distorted thoughts about the cause or consequences of the event leading to wrongly blaming self or other; ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; feeling detached or estranged from others; or being unable to experience positive emotions (a void of happiness or satisfaction).

4. Alterations in arousal and reactivity: Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being overly watchful of one’s surroundings in a suspecting way; being easily startled; or having problems concentrating or sleeping.

Many people who are exposed to a traumatic event experience symptoms similar to those described above in the days following the event. For a person to be diagnosed with PTSD, however, symptoms must last for more than a month and must cause significant distress or problems in the individual’s daily functioning.

Many individuals develop symptoms within three months of the trauma, but symptoms may appear later and often persist for months and sometimes years. PTSD often occurs with other related conditions, such as depression, substance use, memory problems and other physical and mental health problems.

Related Conditions: Acute Stress Disorder

Acute stress disorder occurs in reaction to a traumatic event, just as PTSD does, and the symptoms are similar. However, the symptoms occur between three days and one month after the event. People with acute stress disorder may relive the trauma, have flashbacks or nightmares and may feel numb or detached from themselves.These symptoms cause major distress and problems in their daily lives.

About half of people with acute stress disorder go on to have PTSD. Acute stress disorder has been diagnosed in 19%-50% of individuals that experience interpersonal violence (e.g., rape, assault, intimate partner violence).

Treatment

Psychotherapy, including cognitive behavior therapy (CBT) can help control symptoms and help prevent them from getting worse and developing into PTSD. Medication, such as SSRI antidepressants can help ease the symptoms.

The Way Forward

Conflict increases mental disorder prevalence, so besides Psychiatric/ Psychological treatment we must also keep in mind that,

o Mental disorders reduce social capital by hindering active community participation,
o Weak social capital can increase mental disorders by destroying support systems and increasing stress, while strong social capital can have the opposite effect.
o Mental disorders are disabling, reducing productivity and increasing poverty.

We must recognize the importance of the linkage between poverty, conflicts, social capital, mental and psychosocial well-being and dysfunction. We should demonstrate that there are feasible interventions that can reverse this dysfunction, and that they will lead to increased productivity of those who are treated and that they are cost effective.

Below is the ‘excerpt’ from the “WHO Declaration of Cooperation on Mental Health of Refugees, Displaced and Other Populations Affected by Conflict and Post Conflict Situations”

o Given the magnitude and the nature of the problem, the fact that the reactions of populations affected by conflict are expected reactions to extraordinarily abnormal situations, and the shortcomings of other models, community-based psychosocial approaches are recommended.

o They must be sensitive to gender, to culture, and to the context. They must be empowering, mobilizing and supporting the refugees and other populations affected by conflict to continue taking responsibility for their lives and strengthen social cohesion within the communities.

Therefore, it is a humble suggestion that the concerned authorities should keep all these in mind while formulating a long term solutions to these problems.