29 May,2011 08:25 AM IST | | Dhamini Ratnam
Diagnosed on the battle fields of World War I, Post Traumatic Stress Disorder has traced its lineage down through bloody wars fought across the world, including the Vietnam war, the Gulf War and more recently, in the 'war against terror' in Iraq and Afghanistan. But urban households in Mumbai are no strangers to the mental condition, psychotherapists tell Sunday MiD DAY
I don't feel anything," says Uma, eyes tearing up. "I feel numb."
The 36 year-old homemaker moved to Mumbai after her husband was offered a higher-paying position in his company three years ago. Within a year, they had their second child and gradually fell into the rhythm of living without in-laws -- for the first time since they had been married 12 years ago.
Imaging/ Satish Acharya
Last year, a few days before their wedding anniversary, Uma walked in on her husband kissing his female colleague in their bedroom. Fifteen months on, she is as anguished by the incident as she was on the day she discovered her husband's affair.
In March, Uma, who has been seeking therapy for depression, was diagnosed with Post Traumatic Stress Disorder -- a condition that was first diagnosed among World War I soldiers. Then called Shell Shock, psychiatrists over the years have identified symptoms and causes of Post Traumatic Stress Disorder (PTSD) -- as it came to be known -- affecting war veterans, including those who fought World War I, the Vietnam war, and more recently, the 'war against terror' in Afghanistan and Iraq.
Strangely, the battlefield isn't the only place where PTSD is rampant.
According to city psychotherapists, Mumbai's households aren't strangers to the condition.
As research on the condition continues -- the distinction between complex and simple PTSD, for instance, was only made in the 1990s -- Mumbai's clinicians are now able to diagnose the condition.
Also, as a greater number of urban professionals seek therapy, a large number of PTSD cases are now being discovered, with causes ranging from traumatic one-time incidents like the breakdown of a marriage, rape or witnessing an accident to sustained trauma as in the case of child sexual abuse.
Different kinds of trauma
"Trauma is caused by events that pose a threat to the physical and emotional safety of the person. This includes harm from people, and could include domestic abuse, rape, constant emotional demeaningu00a0 or natural catastrophies like floods, tsunamis and earthquakes.u00a0 Being a helpless witness to similar threats to another person, such as witnessing a horrific accident, murder, or a child watching his mother being beaten or abused, can also cause trauma," says psychotherapist Rani Raote, who has been treating patients with complex PTSD since 1992.
Psychiatric counsellor Dr Rukhsana Ayaz says she has witnessed an increase in PTSD cases in the city, and puts it down to the incidents Mumbai has faced in the last few years, including the floods of June 2005, the 2006 train bombings and the November 26 terror attacks in 2008.
Unlike simple PTSD, which is the result of a single traumatic incident, complex PTSD is caused by a history of sustained trauma, such as neglectful parenting or child sexual abuse. "It is certainly not uncommon in urban households and is often accompanied by other conditions like anxiety or depression," says Raote.
"Complex PTSD is a disorder of the present and the future where the past keeps intruding. It affects one's emotional, physical and social functioning, leading to a drop in personal efficiency," she adds.
In the case of 35 year-old Saira, it did more. Last year, Saira, who had finally conceived after three In Vitro Fertilisation (IVF) attempts, miscarried in one-and-a-half months. Her therapist attributes this to PTSD, a condition she was diagnosed with last week.
Saira's brother was treated for schizophrenia in 2001, and a few years ago, she began to have nightmares about him.
"I dreamt that he was screaming for me to take him home after undergoing shock therapy. I also dreamt that he hadn't really improved and he was tricking all of us. I stopped visiting him, although he lived right behind my building. But my dreams didn't stop," says Saira.
In March 2010 -- around the same time that Saira's third IVF attempt was successful -- her brother was re-admitted on account of excess dehydration. In May, Saira suffered a miscarriage.
Nightmares, avoidance of issues and delayed symptoms are classic indications of the disorder (See handbook).
"PTSD takes time to diagnose, because the symptoms take time to develop," says psychiatrist and hypno-therapist Dr Dayal Mirchandani.
In Nitesh's case, for instance, the symptoms only emerged after his family set a wedding date, last year. Nitesh, who was sexually abused by his uncle when he was barely 10, began to suffer from nightmares, and ultimately refused to get married.
However, not all kinds of trauma are negative and require therapy, cautions Mirchandani, just as not everyone who undergoes traumatic events ends up suffering from PTSD.
"Several people react positively to trauma. For instance, they could come face-to-face with the death of loved one, and that could lead them to examine their life, and do away with the things that don't make them happy. The mind has its own coping mechanism," he says.
Are women more prone?
A 2010 study undertaken by researchers from University of Southern Denmark and Odense University Hospital, Denmark, and published in the Annals of General Psychiatry, found that women in their 50s are more prone to PTSD than men. Another one conducted by researchers from University of Connecticut School of Medicine, and University of Pennsylvania School of Medicine in 2005 and published in Psychological Bulletin, found that men have a higher risk of experiencing traumatic events, but women have higher rates of the disorder.
However, therapists say PTSD is not a gender-specific condition.
"I get male clients who have been bullied or faced abuse as children," says Mirchandani. "In the face of trauma, men shut down and are reluctant to seek help; that's actually a sign of weakness, not strength. That's probably why the statistic of patients with PTSD is gender-skewed -- because women seek help, men don't."
Raote agrees. "We need to remember that we live in a society where women are 'allowed' to seek help, while men are expected not to cry or express their emotions."
Ayaz also points out that individuals have different susceptibilities to trauma -- what may be traumatic to some, may not be so for others. Uma is a case in point. What Uma perceived as traumatic is actually acceptable in some circles, where swapping partners is hardly looked down on, Ayaz points out.
(Some names have been changed on request)
Typical events leading to PTSD
>>Breakdown of a marriage
>>Rape
>>Witnessing an accident
>>Sustained trauma as in the case of child sexual abuse
The handbook
Signs that say you may suffer from PTSD
People have different susceptibilities to trauma -- the same trauma may not cause PTSD to someone, and may to some others. Usually PTSD is diagnosed when the following symptoms are experienced for three to six months at a stretch.
>> Re-experiencing the traumatic event through flashbacks, including physical symptoms like a racing heart, or sweating, or bad dreams.
>> Avoidance symptoms such as staying away from places, events, or objects that are reminders of the experience, feeling emotionally numb, losing interest in activities that were enjoyable in the past.
>> Hyperarousal symptoms such as being easily startled, feeling tense, having angry outbursts.
Simple PTSD is the result of a single traumatic incident. Complex PTSD is caused by a history of sustained trauma, and can be gauged based on the kind of abuse a person faced, who the perpetrator was (the closer the relation, the greater the trauma), the frequency and duration of the events, and the kind of support system a person has.
A snapshot of the 20th century: From shell shock to Post Traumatic Stress Disorder
The term was coined in 1917 by Charles Myers, a medical officer for the British Army, which dealt with over 80,000 cases of shell shock by the end of World War I. Back then, it was believed to be the result of a physical injury to the nerves, such as being buried alive or exposed to heavy firing. However, psychiatrists soon realised that even men who hadn't been in the front lines suffered symptoms of Shell Shock and the focus shifted to the psychological aspect of the condition. At the same time, Shell Shock was looked down upon -- as a 'non-manly' reaction, and 'treatment' often included suggestions to take up outdoorsy activities like sports or manual labour, to shake oneself out of it.
Virginia Woolf's classic 1925 Modernist novel Mrs Dalloway, best exemplifies this response through the character of Septimus Smith, who has returned from World War I and exhibits symptoms of Shell Shock, and is adviced by his psychiatrist to play cricket and take walks in the park.u00a0u00a0
According to some reports, the early years of World War II witnessed a 300 per cent increase in psychiatric casualties compared with World War I, despite the fact that men were rejected before induction. "At one point in the war, the number of men being discharged from the service for psychiatric reasons exceeded the total number of men being newly drafted," goes an article posted in an online PTSD support group.
By the end of the Vietnam war, common symptoms were seen among soldiers who'd been fighting on foreign soil for years, in five-year and a 20-year follow-up -- intense anxiety, battle dreams, depression, explosive aggressive behaviour and problems with interpersonal relationships.
During the same period in the 1970s, the civil population too was experiencing varying traumatic episodes such as plane crashes, natural disasters, fires, acts of terrorism etc. Since the symptoms were almost identical, the Diagnostic and Statistical Manual III -- the handbook of psychiatric illnesses -- published the category 'post-traumatic stress disorder, acute, chronic and/or delayed' based on the research done by various veterans' task forces and recommendations by those involved in treating civilian post-trauma clients.
Judith Lewis Herman, a professor of clinical psychiatry at Harvard University Medical School and Director of Training at the Victims of Violence Program in the Department of Psychiatry at the Cambridge Health Alliance in Cambridge, Massachusetts, coined the term complex PTSD to include the syndrome that follows upon prolonged, repeated trauma, in her book Trauma and Recovery (1992). Up until then, the condition was seen as resulting from experiencing a short-lived trauma.
