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The Shrinking Universe

Dealing with trauma

Photo: AFP

Feeling helpless: A survivor of the recent blasts in Ahmedabad.

As I write this, the nation is reeling under the horrific impact of the bomb blasts that rocked the vibrant cities of Bengaluru and Ahmedabad. Unsuspecting and vulnerable citizens have been caught in the crossfire of somebody else’s war and have ended up sacrificing their lives or suffered grievous bodily harm for doing nothing other than being in the wrong place at the wrong time. Even though the overall damage may not have been as devastating as it was in earlier terrorist attacks such as the one in Mumbai a few years ago, the recent blasts have left in their wake huge physical and mental trauma that the survivors and the families of the departed have to deal with. I don’t propose to examine the causes of the blasts or remedial interventions against terrorism, as these are beyond the scope of this column. But what concerns me is how the survivors are going to deal with the mental trauma of the blasts, and how many of them are going to experience the potentially debilitating consequences of what psychiatrists refer to as Post Traumatic Stress Disorder or PTSD.

This phenomenon came to the attention of mental health professionals during the war years, when it used to be called “Shell Shock” and “Battle Fatigue”. As its symptoms were studied in greater depth post-war, especially in the context of natural as well as man-made disasters (earthquakes, fires in nightclubs, cyclones, nuclear leaks, airplane accidents, hijacks, terrorist attacks etc.), this psychological condition came to be recognised as a distinct psychiatric entity and was given the name PTSD.

The word trauma has come to be used for a variety of situations today, but PTSD refers to extraordinarily traumatic events that would involve actual or threatened death, serious injury or rape, and not the many frequently encountered traumatic stressors that are severe but not extreme (e.g., losing a job, divorce, failing in school, death of a loved one). Today, any mental health professional dealing with a person who has survived such a hugely traumatic event as a bomb blast will look for the tell-tale signs of PTSD, particularly when the individual who survived the event experienced intense fear, horror and a sense of helplessness during the trauma. PTSD usually starts a few weeks to three months after the traumatic event and untreated, can even last several years. Women seem to be more affected by PTSD than men.

As detailed by the Expert Consensus Guideline Series that appeared in the Journal of Clinical Psychiatry in 1999, the symptoms of PTSD fall in four categories. The first of these are referred to as symptoms of Intrusion and include intrusive, distressing recollections of the event; flashbacks (feeling as if the event were recurring while awake); nightmares (the event or other frightening images recur frequently in dreams); heightened emotional and physical reactions to triggers that remind the person of the event; and survivor guilt. The second set of symptoms refer to Avoidance Behaviour and include avoidance of activities, places, thoughts, feelings, or conversations related to the trauma as well as avoidance of relationships. These are often accompanied by symptoms of Emotional Numbing such as loss of interest, feeling detached from others and restricted emotions. The fourth set of symptoms concern Hyper-arousal and comprise sleeping disturbances, irritability or outbursts of anger, difficulty concentrating, hyper-vigilance and a heightened startle response.

As can be seen, all the symptoms of PTSD relate to the horror, suddenness, unexpectedness and sense of helplessness surrounding the event. Two of the most typical symptoms of PTSD — flashbacks and survivor guilt — merit greater elaboration. It is not uncommon, even several weeks after the event, for trauma survivors to experience ongoing and recurrent nightmares of the event. But these happen during sleep. Sometimes, it appears that the survivor is actively re-experiencing the horror, fear and helplessness of the event in the form of “flashbacks” which could happen any time during waking hours. The emotions associated with the trauma just don’t seem to go away. Flashbacks tend to happen more when the survivor has had to be “strong” for others and has not had an opportunity to work through the horror of the event. Survivor guilt is another very distressing phenomenon associated with PTSD. Survivors of the event, particularly when they have lost loved ones to the disaster, feel extremely guilty that they alone have survived. They blame themselves for not having saved the victims of the tragedy and feel they have no right to live when their loved ones are dead. To get a sense of what these emotions are all about, try and recall what happened when you first heard about the bomb blasts and saw those horrifying images splashed across your newspapers and flashed on your television screens. All the emotions that we, at a distance from the tragedy experienced, arose as a result of this phenomenon called survivor guilt. But what we experienced was only a miniscule fraction of the guilt that PTSD victims feel and have to come to terms with.

Fortunately, help is available for victims of PTSD. Mental health professionals experienced in dealing with such disasters have worked out different modalities of treatment for the victims. Most of these treatments focus on getting the individual to talk about the trauma and share their emotional experience with trained professionals who then help them put things in perspective, change the way they think about the event and overcome whatever fears are residual in the minds of the victims. Teams from various national mental health facilities in the country have acquired experience in managing PTSD beginning with the aftermath of the Bhuj earthquake a few years ago, and have, along with other mental health professionals and non-governmental organisations, organised such interventions for survivors of the Tsunami, Godhra and other national disasters, in order that they may lessen the impact of PTSD on their distressed minds. Interventions could include both medication as well as psychotherapy and counselling. Medication can help in allaying the anxiety and terror such individuals experience and get them into a slightly calmer state of mind, which facilitates a more beneficial response to counselling and psychotherapy. In such situations, psychotherapy is very focussed and encourages the individual to ventilate and express the terrifying emotions that have been experienced and works towards prevention of nightmares, flashbacks and survivor guilt. Also, special techniques are used to help the individual out of an avoidance pattern of behaviour and facilitate return to near-normalcy.

It is never easy to deal with PTSD. Even though most of us are filled with a burning need to help our fellow citizens who have been forced to endure the kind of horror they never imagined for themselves or their loved ones, the best thing we can do, even as we wait for higher and better trained authorities to figure out who was responsible and how they should be brought to book, is to try and look for symptoms of PTSD and gently persuade the victims to visit the nearest mental health professional. It has been comprehensively demonstrated that medical and psychological interventions do help a lot in the prevention and management of PTSD and we could do the victims of such devastating disasters an exceptional service by ensuring they received the benefits of these, even as they limp back to manage the aftermath of the unimaginable trauma they have suffered.

The writer is a psychiatrist, columnist and author. His latest book The New Indian Marriage: Laying the Foundations is due out in late 2008. He can be contacted at vijay.nagaswami@gmail.com

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