Validity of the construct of post-traumatic stress disorder in a low-income country

Summary

The validity of the clinical construct of post-traumatic stress disorder (PTSD) has been questioned in non-Western cultures. This report describes in-depth interviews exploring the experiences of women who were traumatised by the communal riots in Ahmedabad, India, in March 2002. Three specific narratives are presented which describe experiences that closely resemble re-experiencing, avoidance and hyperarousal. Thus, symptoms described as characteristic features of PTSD in biomedical classifications are clearly expressed by the women in our study, and are attributed by them to trauma and grief. We conclude that PTSD may be a relevant clinical construct in the Indian context.

On 27 February 2002 communal riots struck Ahmedabad, in the state of Gujarat in west India, and continued for 3 months. It is estimated that over 1200 people were killed in the riots, several thousands were injured, and more than 30 000 households and around 100 000 individuals were internally displaced to relief camps. The aim of our study was to document the mental health of women living in these relief camps, and to elicit open-ended descriptions of experiences of their emotional and cognitive worlds, in their own language. Our objective was to use emic data to study whether the women's experiences approximated the hallmark symptoms of the clinical construct of post-traumatic stress disorder (PTSD), a diagnostic category that has been criticised as having limited cross-cultural validity (Patel, 2000).

METHOD

We conducted in-depth interviews with 55 women in relief camps in the city of Ahmedabad to elicit their subjective experiences of the trauma and associated emotional experiences. These were recorded verbatim in the local language. The interviews were preceded by an introductory comment: ‘Events like riots may generate strong feelings and distress. Talking about this may help relieving this. Once you tell us about your experience we may consider what we can do to reduce your distress by further talking and/or medication.’ Open-ended questions were: ‘What were you doing at the time of riots?’ ‘What happened to you; what did you see, hear, smell and what did you do?’ ‘What were your feelings at that time?’ ‘How are you feeling now?’ ‘What are the effects of riots on your mind?’ Informed consent was obtained for each interview. Medications and counselling were given if a formal mental state examination following the interview revealed the presence of a mental disorder.

RESULTS

Three narratives are presented below to illustrate these experiences.

Case 1: married woman, aged 32 years

‘I was sleeping with my mother-in-law when I heard a commotion outside. I arose and came out: there was a strong smell of petrol from all sides. The sides. The next day my brother-in-law came with his rickshaw and told me that everywhere in the city there was a disturbance, and we should move to his home. Before he could finish we saw a crowd rushing towards our house. Without any thought we just got in a rickshaw and fled. We saw that there were two people riding a motorcycle with waving swords, swords, shouting ‘Victory to Shree Rama! Victory to Shree Rama!’, and chasing us. With much difficulty we reached my brother-in-law's house and lived there for 10 days. The situation there was no better, hence we came to the camp. My husband later went to our home with the police, but everything was looted, nothing remained, the house was set on fire. Still today I see two people, faces masked and carrying swords, repeatedly before my eyes and all of a sudden I get a strong smell of petrol. They do not leave me alone, even in dreams. I wake up screaming, bathed in perspiration. If someone talks about the disturbance I feel dizzy, there are tremors all over my body. I feel that someone will come and kill us. I do not enjoy anything. I always remain alert. If a child cries or if there is some soft sound, I am afraid as if a bomb has exploded. What will happen? I brood over this only. I feel scared when I go out. I dare not go to my street and see the burnt house.’

Case 2: married woman, aged 30 years

‘They came and before my eyes they cut my neighbour to pieces. I saw all this with my eyes. I fled away with my family; crossing the railway tracks, my foot got stuck in the track, and Ifell to the ground injuring my foot and face. Somehow we reached Viramgam, and when the disturbance cooled, and we came back, there was no house, only ashes. I remember everything vividly. Scenes of my neighbour's killing with swords come again and again before my eyes, his helpless cries for help stillhaunt my ears. My head feels dizzy, my breath gets choked, I perspire and my body shivers with terror. I wish to forget all memories of the disturbance but they come continuouslyin my mind;I get frightening dreams, terrified, I awake from my sleep. My heart is not at rest, the tears do not stop. I do not even wish to talk about it.’

Case 3: widow, aged 65 years

‘When our street was attacked we fled without shoes on our feet. At last we reached the camp. In my dreams, too, I see the people with swords and tridents who came to our street on the day of the attack. There were shouts of “Kill! Cut to pieces!” They were abusing us, some had disrobed and shouted,“Send your daughters to us!” They were making obscene gestures. Some pulled the hair of beards of old men. All this comes to mind repeatedly. I do not wish to wish to talk about all this now. I cannot concentrate on anything. Constantly I am afraid that a crowd is about to come. Even if a pigeon flutters its wings, my heart beats violently. How can I stand my burnt house? I do not get proper sleep. I awake from sleep several times. I do not want anything. I pray to God to call me to him.’

DISCUSSION

Post-traumatic stress disorder has been the focus of a number of studies from developing countries in populations exposed to a diverse range of traumatic events such as earthquakes, cyclones, ethnic conflict, bombs and forced migration (e.g. Sharan et al, 1996; World Health Organization, 2002; de Jong et al, 2003). These studies have mainly relied on quantitative methods. Despite this evidence base, there are criticisms regarding the validity of PTSD as an ‘invented diagnosis’, the medicalisation of psychological distress and stigmatisation based on the diagnosis (Summerfield, 2001). Eisenbruch (1991) argues that it is impossible to define and measure complex human experiences such as alterations of affect, consciousness, self-perception and perception of perpetrators without correcting for culture. There is a need for better understanding of how trauma reactions vary across cultures.

We describe here the findings of in-depth interviews to study the emotional experiences of women who had been exposed to extreme trauma. The three narratives presented in this paper are typical of the narratives we elicited from most women. These narratives not only vividly illustrate the experiences that are typical of the symptoms of PTSD as described in psychiatric nosology – notably re-experiencing, avoidance and hyperarousal – but also express their association with the traumatic events. Thus, when women were asked what they thought had caused their current emotional distress, they invariably mentioned two factors: gham (bereavement) and sadma (sudden trauma). The women had sought the help of a mental health provider team, indicating that they associated their experiences with a mental illness. We believe that these observations provide support for the cross-cultural validity at least of the core symptoms associated with the psychiatric category of PTSD.