In the psychiatry department of Dr L H Hiranandani Hospital in Mumbai, the trickle has already started to swell. A 13-year-old arrives with a persistent headache, well after her parents were rescued from a terrorist-hit hotel. A lady who heard a taxi explode has not slept since. Even a man who just watched south Mumbai fall under siege on television on the night of 26 November complains of excessive fear and insomnia.
For many of these people, the diagnosis is likely to be post-traumatic stress disorder, or PTSD, a malady that is commonly—and mistakenly— thought to be the sole preserve of war veterans. “But you know, nobody is untouched,” says K. Sekar, a Bangalore-based psychiatrist. “Even a child who saw the Mumbai attacks happen from the street needs to talk to somebody about it.”
Illustration by Jayachandran / Mint
In many people, the symptoms may not even be apparent as yet. Following the 1993 blasts in Mumbai, just a loud mention of the word “smoke” alarmed 28 women enough to jump out of their train to their death. After the extensive floods in the city in 2005, fear ignited a stampede in a slum. Both incidents were marked up to the hyper-vigilant state that characterizes PTSD.
Sekar, head of the department of psychiatric social work at the National Institute of Mental Health and Neuro Sciences (Nimhans) in Bangalore, considers such psychological reactions inevitable in witnesses or survivors of severely traumatic events such as the Mumbai attacks. “These are normal reactions to abnormal situations,” he says, “And they need to be vented in a proper manner.”
But Sekar offers a nuanced explanation of what exactly a “proper manner” might be. It does not mean, he insists, that everybody make a beeline for personal therapists and intensive counselling sessions. “We do not have the one-to-one type of infrastructure that’s present in the West, but we also don’t need that,” he says. “There is a resilient support system available in the Indian family. It just needs people who are willing to listen and empathize.”
Mumbai-based Harish Shetty, a veteran of counselling disaster survivors in India, has seen PTSD-affected people seeking help from yoga therapists, their family’s spiritual advisers, and “quasi-religious systems”. Many of them, he says, would benefit from just reassurance, support, relaxation exercises, yoga and meditation.
Only 10-15% of the people affected, directly or indirectly, may even need serious professional counselling, Sekar says. Indeed, some may not need it at all. New Delhi-based M. K. Malhotra, who was trapped in the Taj Mahal Palace and Tower hotel for close to 40 hours, was preparing to return to Mumbai the very next week, back on his job. “It depends on the psychology of each person,” Malhotra says. “Even on Day 1, I had mentally conditioned myself that my chances of survival were low, and once I condition my mind to something, I go by it.” Within an hour of being rescued from the Taj, he says, he had forgotten that he was even there.
This may be an exceptional case, but for those afflicted, there is a counselling infrastructure in place. In Mumbai alone, for example, Shetty estimates that there are around 250 psychiatrists in private practice and an equal number of psychologists. There are also psychiatry departments in four major hospitals and some peripheral hospitals, he says.
In previous crisis situations, initiatives to rapidly groom grief counsellors and deploy them have also proved quite effective. In the aftermath of the tsunami in 2004, the Christian Counselling Centre, based in Vellore, conducted eight-week training sessions. “When we had a refresher course for them, we found they were doing great work,” says Meena Prashantham, associate director of the centre.
Undetected or untreated, PTSD has been known to lead to chronic depression and emotional instability. “Such patients lose the ability to feel both pleasure and sadness,” Shetty says. “The loss of meaning in life is a common consequence.” Medication can help, but if the counselling is good and sustained, doctors are insistent that drugs are necessary only in a fraction of cases.
The importance of talking
The true challenge lies in simply convincing people that they need to talk. Clinical psychologist and psychotherapist Seema Hingorrany, who runs a clinic in Bandra, Mumbai, observed several people approach a clinic with symptoms such as insomnia and depression but immediately recoil when they were told they may have a disorder. “The word ‘disorder’ is what scares them away,” says Hingorrany. Potential sufferers, she explains, often assume that having a disorder means they have a “mental problem”. She says increased awareness of PTSD will help dispel all these myths.
Hingorrany now sends emails to those who were scared away by the prospect of a “disorder”. “The emails have links to more information on PTSD and symptoms. We tell them to read up, compare symptoms and then decide for themselves if they need more help,” she explains. As Sekar says, “They just need to be told that it is good for them.”
PTSD therapy normally involves a combination of medication, sleep and dietary discipline and talk therapy. Many patients, Hingorrany explains, also undergo progressive muscle relaxation or PMR. “PMR is useful for patients who are suffering from high levels of anxiety and need calming. Basically we use heavy breathing exercises to relax all the muscles of the body,” explains Hingorrany.
In the wake of the terror attacks in Mumbai, psychotherapists will also be receiving training on a cutting edge therapy method called eye movement desensitization and reprocessing (EMDR). A team of German experts will soon come to the city to impart training. “EMDR is still an experimental therapy which uses eye movements to take care of disturbing life experiences. But we think it will be very useful for PTSD cases right now in the city,” says Hingorrany, whose clinic has seen patient numbers almost double since the terror attacks unfolded.
Even simply being part of a group therapy session can help. A teacher at a south Mumbai school, who wanted to remain anonymous, attended one such session, and while she says she didn’t talk as much as the other members of her group, she admits that it helped.
“Really, each person is in their own world, and each person has unique thoughts and fears, and they take their own time to come out of it,” she says. “But I definitely think people should go through it.”
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• Jamsetji Tata Centre for Disaster Management, Tata Institute of Social Sciences, Malti and Jal A.D. Naoroji (new campus), Lala Jamnadas Gupta Marg, off V.N. Purab Marg, P.O. box 8313, Mumbai - 400088; phone, 022-25563289-96; email: jtcdm@ tiss.edu
• Swanchetan, D1 / 1017, Vasant Kunj, New Delhi – 110070; phone, 011-26123931 / 26135296 ; email: email@example.com
• National Institute of Mental Health and Neuro Sciences, Department of Psychiatric Social Work, Hosur Road, Bangalore – 560029; phone, 080-26995200 / 26995255
• In a post-traumatic disorder, people are not completely functional for at least three-four months
• Try to normalize routines as much as possible—walks, work, food, social commitments
• New projects with tough deadlines and delivery schedules should be avoided
• Family support should not be overbearing
• If unable to resume normal life in six months, consult a psychiatrist and take medication, especially for restoring sleep patterns
• Guard against “learned helplessness”—a condition where the mind gets programmed to be helpless, to feel trapped and be unable to, say, open a door and rush out in case of a fire, either expecting help to arrive or the flames to consume one. Taru Bahl
Physiological reactions to trauma can include sudden sweats, insomnia, a dependence on drugs or alcohol, heart palpitations, and a tendency to be alarmed easily by loud noises. It could also be characterized by aches and pains such as headache, backache, stomach ache, or changes in sleep patterns, loss of appetite, lack of interest in sex, constipation or diarrhoea and generally weakened resistance. Emotional reactions, harder to pin down, include constant fear or anxiety, nightmares, emotional distance from loved ones, survivor’s guilt, flashbacks, deep introversion, constant grief or numbness.
Traumatic brain injury may lead to an increased risk of developing symptoms such as those of Alzheimer’s disease, Parkinson’s disease and other disorders. Led by George Rutherford of the University of California, San Francisco, a committee of the Institute of Medicine reports there is evidence that such injuries at moderate and severe levels may leave a person at higher risk of dementia, such as that experienced by people diagnosed with mind-robbing Alzheimer’s. It also says research indicates these injuries at moderate and severe levels can make someone more likely to develop symptoms similar to those of Parkinson’s disease, which affects nerve cells in the brain that control muscle movement. Reuters