She cowered in a corner every time someone raised their voice.

Even watching TV shows, where people debated and argued, would set her off. Her heart rate would increase and she would relive her trauma, her body would immediately go into a heightened sense of alertness, yet at the same time it would be paralysed with fear.

It’s as if every nerve in her body was now conditioned to assume that shouting always leads to beatings.

He was interviewed by a news syndicate. He told them all about his nightmares.

He couldn’t live in his village any longer; he had to move. But, he’s not happy in the city either, it is not home.

Currently, he cannot sleep at night. During the day, he cannot concentrate at work. He can still hear the drones.

The ground shook beneath them and the walls around them started to crumble in heaps.

They were trapped for an hour or two, maybe even a day. They felt the weight of the rubble on top of them and the distant sound of human cries as they laboured to taking shallow breaths, as if trying to save some dust-laden air to last a little longer.

If they live, how will they ever get beyond this?

A quick Google search for the term PTSD (post-traumatic stress disorder) will flood your screen with news of war veterans.

Many in my clinic erroneously believe that PTSD is a malady that affects only those who have seen combat. This, however, is not the case.

What is PTSD?

PTSD afflicts a person when he/she goes through an event of extreme nature where his/her life and safety have been threatened. Nightmares, flashbacks where one relives the event, being edgy and anxious and getting startled easily and being jumpy are some of the symptoms associated with PTSD patients.

After witnessing a traumatic event, many people will have a hard time adjusting to their daily routines for a while, but not everyone develops PTSD. With time and support, most people generally bounce back.

But those whose symptoms of anxiety, nightmares and insomnia get worse over time and get in the way of their day-to-day functioning have this disorder.

Why is it relevant to Pakistan?

The list of factors and types of incidents that suggest why PTSD has become increasingly relevant in today’s Pakistan is endless. Terrorism, sectarian violence, targeted killings, floods and earthquakes are few among these factors.

The country’s annual death toll from terrorist attacks peaked at 3,315 in 2009, steadily declining to 2,314 in 2014. At least 1,800,000 Pakistanis have been displaced internally due to violence and 771,000 displaced due to natural disasters.

Also read: PTSD in Peshawar — The long road back

During 2008, 59 suicide bombings killed 889 people and injured another 2,072 people in Pakistan. During the same year, there were nearly 34 drone attacks killing many civilians along with the insurgents.

Additionally, popular news TV channels repeatedly broadcast scenes of violence across the country which creates a unique exposure to trauma.

There is of course incidence of other traumatic events, the kind that don’t make it to international media. Children witnessing their parents become victims of religious intolerance, jilted lovers throwing acid on women’s faces, gas stove 'accidents', 'honour' killings and a myriad of other forms of domestic violence. All of these have the potential to cause PTSD.

In a study conducted on 1,200 people after the 2005 earthquake, 55.2 per cent women and 33.4 per cent men suffered from PTSD. Living in a joint family provided protection against the malady. Living in a tent was associated with general psychiatric morbidity, but not with PTSD.

Another cross sectional survey of 300 earthquake survivors from districts close to the epicentre of the 2005 earthquake found that after 30 months, PTSD prevalence among people in the area was extremely high.

Being female, older, unmarried, head of the family, unemployed or having low income and living in temporary housing were associated with higher risks of PTSD. Religious inclination appeared to be a protective factor.

Also read: Mental illness in Pakistan — Exorcising the jinn of stigma

Another study found an almost 30 per cent incidence of depression and that women were twice as likely as men to develop PTSD and four times more likely to have depression. Collecting data on over 1,100 children in the earthquake area, yet another study highlighted that 64.8 per cent children had symptoms significant for PTSD 18 months after the earthquake, 34.6 per cent of the children showed signs of emotional and behavioral problems.

The data from the 2005 earthquake is exquisitely relevant today given the recent earthquake. However, a lack of data on PTSD pertaining to other man-made calamities in cities like Karachi is conspicuous in its absence.

The number of psychiatric disorders caused by violence experienced almost on a daily basis remains unidentified and hence unaddressed.

Pitfalls and barriers

Lack of infrastructure and planning make relief efforts for natural calamities a major problem. As a consequence, there is overflow of patients with physical and mental trauma in understaffed hospitals with overworked employees.

Throw into that mix a heavy dose of stigma related to mental illness, a social construct of shying away from any talk related to trauma to “protect” the victim from further anguish and labeling those who express difficulty as having weakness of faith and you have on your hands the perfect recipe for neglectful healthcare seeking behaviors.

The challenge is further compounded by the unavailability of trained personnel who can work with the emotional needs of these patients.

Other social constructs like Gher ki baat gher mai (problems of the house should stay within the house) hinders victims of abuse from seeking care. The typical Karachiite by now knows well to develop a thick skin and keep moving forward.

How to proceed

On a macro level, the government needs to focus on creating infrastructure and train physicians and other healthcare providers for crisis management and intervention. It is important to consider that the primary mode of treatment for PTSD is therapy. Depending on each case, individual or group therapy may be helpful.

There are various pharmacological approaches to control symptoms of PTSD but one should always be wary of polypharmacy. Much like in my other posts, I cannot stress enough upon the importance of the appropriate use of medications following doctors’ orders, not buying medicine without your doctor’s advice and avoiding unsupervised or overuse of addictive medicines.

Why don’t you help?

I started writing these blogs to spark a conversation about mental illness in an effort to destigmatise the issue. I have been amazed at the candid responses and comments on the blog. It’s heartening to see that more and more people are willing to talk about this important topic. This is the only way we will reach critical mass from which positive change can come about.

I have noticed a growing sense of disappointment at the lack of access to this writer via email, etc. Although I appreciate the vote of confidence, I think all who want to seek help for yourselves or your loved ones deserve much more than someone miles away communicating via a medium which does not relay the tone and the context and the nuances of your experiences. These are extremely important in psychiatry. I would not be doing you any favours, merely a disservice.

Alternatively, below is a basic guide for when you want to seek help:

• Seek help from qualified mental health professionals: Most medical colleges have departments of psychiatry and large urban cities have both psychologists and psychiatrists in private practice.

• Take a second opinion: If you don’t feel comfortable with the first mental health professional you meet, seek a second opinion. Look for someone who communicates clearly and explains things in a way that you understand best.

• Research their credentials: Find out where your mental health professional went for training.

• Beware of polypharmacy: Take care not to use polypharmacy or overdose of multiple medicines even when prescribed by doctors. Ask for rationales behind frequent medication changes. And finally;

Be an advocate for yourself. In the mean time, I will keep the conversation going.