The British Journal of Psychiatry (2005) 187: 585-586
© 2005 The Royal College of Psychiatrists
Validity of the construct of post-traumatic stress disorder in a low-income country
Interview study of women in Gujarat, India
Khyati Mehta, MD and
Ganpat Vankar, MD
Department of Psychiatry, BJ Medical College and Civil Hospital,
Ahmedabad,Gujarat, India
Vikram Patel, PhD
London School of Hygiene and Tropical Medicine, London,UK
Correspondence:
Dr Vikram Patel, NPHIRU, London School of Hygiene and Tropical Medicine,
Keppel Street, London WC1E 7HT,UK. Fax: +44(0)2207 958 8111; 8111; e-mailL:
vikpat_goa{at}sancharnet.in
Declaration of interest None.
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ABSTRACT
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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.
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INTRODUCTION
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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).
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METHOD
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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.
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RESULTS
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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.’
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DISCUSSION
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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.
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ACKNOWLEDGMENTS
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We acknowledge support from Fr. Moses SJ of St Xavier’s Social
Service Society, Ahmedabad, Bal Muskan teachers and Ms Madhu Malhotra of Oxfam
UK Ahmedabad office for facilitating this work. V.P. is supported by a
Wellcome Trust Fellowship in Clinical Tropical Medicine. We thank Mark van
Ommeren for his valuable comments on a draft of this paper.
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World Health Organization (2002)
World Report on Violence and Health: Summary. Geneva:
WHO.
Received for publication November 24, 2003.
Revision received August 11, 2004.
Accepted for publication January 26, 2005.
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ABSTRACT
INTRODUCTION
