Post Traumatic Stress Disorder (PTSD)

Experiencing a traumatic event or witnessing something distressing is unfortunately very common in one’s life, especially in a disaster-prone and resource constrained country like Bangladesh. After any distressful event, a person will experience symptoms of grief and stress for some time; it is part of the natural grieving process. Within a few weeks, depending on how traumatic the experience was, these symptoms tend to disappear. Unfortunately, some people have trouble coming to terms with the trauma and they end up suffering from the symptoms for a prolonged time. When these symptoms of stress brought on by trauma persist longer than usual, it is called Post-Traumatic Stress Disorder or PTSD.

PTSD is a mental health condition or anxiety disorder that occurs following a frightening, stressful or traumatic experience. It can occur immediately after the troubling event or even weeks, months or years after.

Here are a few of the many causes of PTSD:

Serious road accidents

Surviving natural or man-made disasters (floods, cyclones and in case of Bangladesh, incidents of building collapsing and political turmoil)

Violent personal assaults, such as sexual assault, mugging or robbery

Prolonged sexual abuse, violence or severe neglect

Witnessing violent deaths

Military combat

Being held hostage

Terrorist attacks

Natural disasters, such as severe floods, earthquakes or tsunamis

It should be kept in mind that PTSD is not usually related to situations that are simply upsetting, such as divorce, job loss or failing exams.

Bangladesh being a disaster-prone country makes PTSD a relevant concern. Terrifying events occur frequently. These range from natural calamities like cyclones and floods to disasters such as factory fires and building collapses that have plagued the textiles industry. In the aftermath of the horrific Rana Plaza collapse back in April 2014, it appears that many of the survivors and rescue workers have suffered or are suffering from PTSD. With the recent political instability in the country, the unfortunate victims of arson attacks are also prone to suffer from the condition.

Unfortunately, like in many other nations, mental illness is a major stigma in Bangladesh. Often times, it reaches such levels that it is considered taboo to speak of or be associated with such illnesses. For this reason, we should all make ourselves aware of this condition and do our part as a community to help those who are encumbered by this mental affliction.

Experiencing a traumatic event or witnessing something distressing is unfortunately very common in one’s life, especially in a disaster-prone and resource constrained country like Bangladesh. After any distressful event, a person will experience symptoms of grief and stress for some time; it is part of the natural grieving process. Within a few weeks, depending on how traumatic the experience was, these symptoms tend to disappear. Unfortunately, some people have trouble coming to terms with the trauma and they end up suffering from the symptoms for a prolonged time. When these symptoms of stress brought on by trauma persist longer than usual, it is called Post-Traumatic Stress Disorder or PTSD.

The symptoms of PTSD can hamper a person’s daily life and activities. These usually appear within a month of the trauma or as mentioned previously, may take several months or years to appear. Some individuals experience symptoms on an “on and off” basis, meaning they will feel bad at certain periods and will feel fine at most other times. There are some who experience the symptoms constantly. The symptoms vary widely from person to person, but can be generally be categorized in the following manner:

1. Re-experiencing:

This is the most common symptom amongst sufferers of PTSD. It entails involuntarily and vividly re-living the trauma by means of flashbacks, nightmares or distressing images and sensations. The “re-experience” can be triggered by certain reminders of the trauma, such as, in case of rape, the smell of their rapist’ cologne, rape jokes, sexually violent scenes on TV etc. It also leaves the sufferer wondering why the event happened and whether they could have done anything to prevent it also with feelings of guilt or shame. Some people also have physical manifestations such as pain, sweating, trembling, etc.

2. Panic attacks:

These are characterized by attacks of intense anxiety where the person hyperventilates, trembles, becomes nauseous, sweats, or experiences chest pain. Re-experiencing and panic attacks often occur together.

3. Avoidance and emotional numbing:

This is a very common finding amongst people suffering from PTSD. It involves trying to avoid factors that would make the person relive the event. Avoiding people, places or conversations related to the event is common. People suffering from PTSD often to try not feel anything at all. This sort of “emotional numbing” can lead to a person becoming isolated and withdrawn or results in them giving up activities that would previously bring them pleasure.

4. Hyper-arousal:

Sufferers of PTSD are often found to be in a state of anxiousness, find it difficult to relax or in a sate of constant vigilance. This is characterized by being easily startled, always feeling stressed, having regular headaches, insomnia, irritability, sudden weeping, sudden outbursts of anger, etc. Being in this state of hyper-arousal can significantly affect a person’s daily activities as well relationships with people in their lives.

5. Others:

People with PTSD may also suffer from:

· Depression, anxiety, phobias

· Drug or alcohol misuse

6. Symptoms in children:

Children, like adults, can also suffer from PTSD. Most symptoms have been found to be the same amongst children and adults. These include, insomnia, upsetting nightmares, losing interest in previously enjoyed activities. Physical symptoms like headaches or stomachaches are also common.

However, the following are a few symptoms that are specific to children:

· Bedwetting

· Being unusually anxious or afraid about being separated from a parent

· Re-enacting the traumatic event through their play

PTSD occurs after experiencing or even witnessing a traumatic event. The following are a few of the many possible causes:

Serious road accidents

Surviving natural (floods, cyclones, tsunamis) or man-made disasters (in case of Bangladesh, incidents of building collapsing and political turmoil)

Violent personal assaults, such as sexual assault, mugging or robbery

Prolonged sexual abuse, violence or severe neglect

Witnessing violent deaths

Military combat

Being held hostage

Terrorist attacks

The condition is said to develop in around 1 in 3 people who experience trauma. Although the precise mechanism as to why PTSD develops is uncertain there are certain theories. Certain precipitating factors seem to be involved. These include: pre-existing depression, anxiety, unsupportive family members or sometimes even a genetic predisposition appears to be linked.

The theories are explained below:

1) Survival Mechanism:

It is thought that the symptoms of PTSD are a means of helping the individual coping with the experience and be better prepared for future re-occurrances. For example, the “flashbacks” help people remember every detail of the event so that they are better prepared if it happens again, and the state of “hyper-arousal” is thought to help the person react quicker.

Unfortunately these so called “coping mechanisms” serve as a hindrance to the person being able to process and move on from the experience.

2) Elevated Adrenaline levels:

When faced with danger, the body produces the hormone “adrenaline” that triggers a “fight or flight” response in the body, which helps to dull pain and the senses.

It is thought that people with PTSD have higher levels of this hormone, since it is secreted even when there is no danger. As a result, people suffer from emotional numbing and the hyper-aroused state.

3) Changes in the brain:

Studies have shown that, people with PTSD have an abnormality with the hippocampus, the part of the brain involved in emotional processing. Brain scans have revealed that these people have a hippocampus that is smaller in size. The poorly functioning hippocampus may prevent flashbacks and memories from being properly processed, so the anxieties sufferers generate do not reduce over time.

PTSD is a very treatable condition and appropriate treatment at the right time has shown great success and complete recovery in most people. The treatment plan involves psychotherapy and medication. Psychotherapy is usually recommended first. But if symptoms are severe, both forms of treatment are used. After an initial assessment of the severity of symptoms, which is done to ensure that the treatment is tailor-made for the person’s needs, a PTSD patient is referred to a psychologist or psychiatrist.

The following are a few methods employed in the treatment:

1) Watchful waiting:

This is used if the person has mild symptoms or has had symptoms for less than 4 weeks. It involves, careful monitoring of symptoms over a period of a few weeks to see if they get better or worse. The reason this is used is that several people with mild symptoms have gotten better without treatment within a few weeks.

2) Psychotherapy

The trained mental health professional listens to all that the person has to say and helps come up with strategies to solve the problem.

2 types of psychotherapy used are:

· Cognitive Behavioural Therapy (CBT) –

The person is helped to change the way they think and act to better cope with the traumatic event. Each session is usually 90 minutes long lasting for 8-12 months.

· Eye movement desensitization and reprocessing (EMDR) –

It involves making side-to-side movements of the eyeball usually by following the movement of the therapist’s finger, while recalling the traumatic incident. It is said to help the hippocampus better process flashbacks and memories regarding the event.

3) Medication: Antidepressants such as paroxetine, mirtazapine, amitriptyline or phenelzine are occasionally used to treat adults with PTSD.

However, these medications will only be used if:

One chooses not to have trauma-focused psychological treatment

Psychological treatment would not be effective because there is an ongoing threat of further trauma (such as domestic violence)

Little or no benefit from a course of trauma-focused psychological treatment

Underlying medical condition, such as severe depression, that significantly affects your ability to benefit from psychological treatment.

If medication for PTSD is effective, it will usually be continued for a minimum of 12 months before being gradually withdrawn over the course of four weeks or longer.

Treatment with medication is not recommended for children and young adults. They mainstay of treatment for these age groups is trauma-focused CBT.

As mentioned earlier, mental health conditions are heavily stigmatized in Bangladesh. People with such afflictions are shunned from society, thus making their situation even more difficult than it already is. As a friend or relative of a person suffering from PTSD, we could do the following to give them a helping hand:

1) Encourage them to seek psychiatric help. Treatment based on psychotherapy and medication could go a long way to solving the issue.

2) Listen to what they have to say. Allow them to recount their harrowing experience as much as possible

3) Try to be non-judgmental

4) During panic attacks, try to give them physical space, so as to not trigger the experience through touch.

The first step that a person afflicted with PTSD can take to better his/her condition is to seek and ask for help. Since talking about the traumatic experience can treat some aspects of PTSD, this help can be taken from a close friend or relative. However, in order to ensure complete recovery, it is recommended that the help is taken from a mental health professional.

Even though mental health issues are a source of shame for those suffering from them in Bangladesh, there are two renowned institutions where one can receive all forms of treatment required to recover from PTSD.

1) National Institute of Mental Health & Research (NIMH&R) – This is a government institute under the Ministry of Health and Family Welfare. NIMH&R is a tertiary level referral hospital specialized in combating mental health conditions. Along with a host of physicians and nurses, this hospital is equipped with 82 Cognitive Health Care Providers (CHCP) who specialize in the treatment of conditions like PTSD.

Address: Sher-e-Bangla Nagar, Dhaka-1207, Bangladesh

Email: nimhr@hospi.dghs.gov.bd

2) Sajida Foundation – provides counseling services through its well decorated and appropriately designed Psychosocial Counseling Support Centre located at Niketon Housing Society, Dhaka by highly qualified and well-trained counselors. It provides individual counseling, couple counseling, peer counseling, family counseling and group counseling.

The Foundation also provided counseling to the Savar Rana Plaza victims though various initiatives. Counselors from the Centre provided counseling services at the Adhor Chandra High School premise and other places to the assembled relatives and well-wishers of the dead, wounded or missing and also to the survivors on different days. This is a clear example of how the Foundation is well equipped to treat people suffering from PTSD since most of the survivors of the Rana Plaza collapse were victims of PTSD.

Address: House 28, Road 7, Block C

Niketon Housing Society

Gulshan 1, Dhaka 1212

Bangladesh

Email: sajida@sajidafoundation.org

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Maya Expert Team