The study was conducted in field practice areas of Government Medical College, Srinagar, Jammu and Kashmir which consists of three medical blocks: Ganderbal, Hazratbal and Lar. Out of these, Ganderbal and Lar blocks constitute rural and hilly areas while as block Hazratbal represents urban and urban slum areas. 3400 Patients were screened (1880 males and 1520 females). The study was cross-sectional in nature and was conducted in two phases.

Phase First: In each block all the comprising villages were line listed, then 10 per cent of these villages were taken up for the study by the method of randomisation sampling. Out of 10 per cent villages, 10 per cent of household were taken again by systemic random sampling. In the selected household, all adult population (18 years and above) was taken up and screened by using life event check list, which was specially designed for the study.

Phase second: In the second stage, the patients who screened positive for PTSD in stage 1 were assessed. Diagnosis were confirmed by consultant psychiatrist in Government Psychiatric Disease hospital, an associated hospital of Government Medical College, Srinagar. General description, demographic data and psychiatric history was recorded using the semi-structured interview which was pretested. Firstly, informed consent were taken from the patient. Then the patient were interviewed using the structured questionnaire. Diagnosis was done as per Diagnostic statistical manual of mental disorders (DSM 4 TR) and Clinical administered PTSD rating scale (CAPS scale) was used to assess the severity of PTSD symptoms. CAPS is a semi-structured interview that is designed to assess the essential features of Post-traumatic Stress Disorder as defined by the DSM-IV (American Psychiatric Association, 1994) [2]. Patients were also assessed for comorbid depression, anxiety disorders and somatization disorders. Patients were also asked for possible causes of trauma. After line listing the positive cases, prevalence rates of PTSD were calculated.

A secure computerized database was established and maintained throughout the study. Patient names were replaced with unique identifying numbers to ensure confidentiality. All statistical analysis were performed using SPSS software version 16.0 (SPSS, Chicago, Illinois, USA) and tests of statistical significance were two-sided and differences were taken as significant when p-value was less than 0.05. Statistical analysis were performed using the SPSS, version 16.0 for Windows. Data were analyzed by the Pearson chi-squared test and t-test. p<0.05 was considered as the significance level in the evaluations.

Communities that are affected by mass violence, sexual assault, exposure to combat zone and other types of trauma are at increased risk for PTSD (post-traumatic stress Disorders) [8]. Kashmir is an area, which is pre-disposed to disasters, exposed to war zones, and hence is at increased risk for PTSD [11].

The study was done to assess the Sociodemographic factors, clinical profile and comorbid psychiatric disorders in three block area of Kashmir–Ganderbal, Hazratbal, and Lar [Table/Fig-1]. The mean age of the patients in the study was 44 years, which is similar to other study done PTSD was found more in females, married, illiterate population and in lower socio-economic class in all the three blocks of Kashmir [Table/Fig-2]. This finding is in accordance with Kessler et al., who also found lifetime prevalence of PTSD more in subjects who were married, unemployed and with lower literacy rate [8]. Jammu and Kashmir is one of the states with lower literacy rates (54.46%) than the average in India (65.38%). The discrepancy is higher for women (42% compared to national average of 54%) than for men (66% against 76%) [12]. This might be one of the reason for higher prevalence of PTSD in females.

In the study, a total of 3,400 adults of three blocks were screened.The number of cases that were diagnosed as PTSD was 128. The prevalence PTSD in the study was 3.76% which is similar to the study done by Richard F Mollica et al., who found prevalence of 3% among Bosnian refugees and David Kinzie et al., who also found prevalence of 3.2% among the non-wounded veterans [13,14]. Further the prevalence of PTSD in females was 6.2 % while as prevalence in males was 1.8% [Table/Fig-3]. The finding is in agreement with Kessler et al., Margoob et al., who also reported increased prevalence of PTSD in females [2,8]. Trauma can also result in development of other psychiatric disorders like major depressive disorders, anxiety disorders, somatisation and dissociative disorders [8]. PTSD doesn’t occur alone [15]. Association of other psychiatric disorders with post-traumatic stress disorder is found in 50% of cases [16].

The most common psychiatric disorder associated with PTSD is found to be alcohol abuse. Alcohol use occurs in an attempt to self-medicate the pain full experience of post-traumatic stress disorder [17], known to elevate mood and is a anxiolytic [18]. However in the study it was found to be in minority (0.78 %) as Kashmir is a Muslim majority state. Alcohol abuse is not considered culturally appropriate [2]. However use of nicotine (17.18%) was found in the study apart from cannabis (3.90%). This is in accordance with Roszell et al., who found increase use of cigarettes in people affected with PTSD [18]. Increased stress, elevates levels of corticotrophin releasing factor (CRF) in blood, which in turn causes depressive and anxiety features [19]. PTSD also leads to poor self-esteem, which can also contribute to depression [2]. Most of the patients presented earlier with complaints of depressive and somatic features, which were subsequently diagnosed as PTSD on subsequent follow ups. Somatic Symptoms were found more with PTSD in the study. This finding of ours is in accordance with Young et al., [18].

The somatic symptoms associated with PTSD were headache (89%), gastric symptoms (58%), musculoskeletal pain (82%) [Table/Fig-4]. This finding of ours is in accordance with Arshad et al., [20]. Further Wesley related somatic symptoms in PTSD for loss of work and productivity [20].

The most common causes of PTSD in our study was death of near ones (55.5%), followed by exposure to firing (26%), near death experience (11%) [Table/Fig-4]. Margoob et al., found firing and exposure to war as most important causes of trauma [21]. The most common cause of PTSD in females is known to be rape [16] [Table/Fig-4]. But in our study it was found less (6%). Perhaps the females would hesitate in reporting cases of rape, because of sociocultural factors. This finding is in contrary to Margoob et al., [21] who reported high prevalence of PTSD due to rape (12%). Exposure to natural disasters was also found less (5%) in our study, contrary to Margoob et al., who found 12% of cases attributing natural disasters (earthquakes)as cause of trauma. This might be due to the fact that last major earthquake in Kashmir occurred in 2005, one year after Margoob (2006) conducted his study [21].

There have been periods of insurgency and political turmoil from 2010 to 2011 which caused tension and stress among common masses, leading to various stress related disorders. Thousands of people got injured and many got killed during this insurgency period. Frequent clashes occurred between the police and common masses, leading to various types of physical injuries. Defective coping strategies due to stressful life events increased mental health problems in the turmoil period, compared with the pre turmoil period. Insurgency affects education and employment sector, which have negative consequences on youth [22].

Twenty seven percent of cases of PTSD had previous history of psychiatry disorders [Table/Fig-5]. Breslaau (1998) reported previous history of psychiatric illness as one the important risk factors for PTSD, especially affective disorders, anxiety disorders and substance abuse [23]. In our study previous history of psychiatric illness included major depressive disorder and anxiety disorders. This is also in accordance with Breslau [24].

The symptoms present in PTSD included avoidance, hyper arousal and re-experience. However avoidance and re-experience symptoms were more in the study compared to hyper arousal symptoms [Table/Fig-3]. Avoidance symptoms included avoidance of thoughts (88%), followed by diminished interest (83%), avoidance of places and people (80%). The findings of this study are in agreement with Margoob et al., [11,25].

Hyper arousal symptoms included sleep problems (66%) and difficulty in concentrating (56%) which is supported by Margoob et al., [11,25]. The explanation for this could be that commonest re-experiencing symptoms were distressing dreams/nightmares.

Majority (89%) of patients in the study had a re-experiencing of traumatic event in the form of intrusive thought and disturbing dreams/nightmares (88%). The findings of our study are in agreement with Cuffe et al., who reported distressing recollections as the most re-experiencing symptom [26].

The results of the present study suggest that people living in conflict zone must be carefully evaluated for mental health problem. Patients in the study presented with varied symptoms and with different comorbid disorders in different sex and age groups. Avoidance symptoms were common in our subjects. PTSD is a highly prevalent disorder in the developing world as well, in the areas of conflict zone and disaster prone regions. There is no doubt that movement of turbulence has affected every aspect of the life in the state of Jammu and Kashmir. Life is still going on between the turbulence and trauma culture. There are different coping mechanisms of absorbing the daily violence and trauma in our culture like talking to friends and sharing thought. Collective social sharing decreases stress and play a key role in decreasing the sufferings and trauma. People in Kashmir have developed a sort of resistance against trauma as they have faced multiple traumas during these insurgency periods. This might be reason that prevalence of PTSD has decreased over the last few years, despite persistent traumatic events. People have now developed resilience to various traumatic events that explains the lower prevalence of PTSD in our study.