Anxiety disorders and PTSD worldwide
Over one billion people globally have one or more mental disorders. The WHO reports that anxiety disorders are the most common mental disorders worldwide [1]. Anxiety disorders are frequent there lifetime prevalence ranging between 5 and 25 % of the population, and a 12-month prevalence ranging between 3.3 and 20.4%, world widely [2]. Anxiety disorders are the most common mental disorders globally especially in women more than in men [1]. Similarly, anxiety disorders are the most common mental disorders in the U.S, affecting 18.1% of the population every year. People with an anxiety disorder are six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders and three to five times more likely to go to the doctor. It is well established that anxiety disorders develop from a complex set of risk factors, including personality, genetics, and life events. [3]
Some anxiety disorders, in particular phobias, social anxiety, and separation anxiety have a very early age of onset, range from 5–10 years of age. while others (generalized anxiety disorder (GAD), panic disorder (PD), and post-traumatic stress disorder (PTSD)) tend to have a later age-of-onset distribution (median 24–50), with a much wider cross-national variation. [2]
Moreover, anxiety disorders are highly treatable, though only 36.9% of those suffering receive treatment. It affects 25.1% of children between 13 and 18 years old. Besides, Researchers found that untreated children with anxiety disorders are at higher risk of being engaged in substance abuse, perform poorly in school, miss out on essential social experiences. In the U.S, 45.9% of women and 65% of men who got raped are likely to develop the disorder. [3]
As well as, researchers found lower psychiatric treatment levels in an updated survey for 24 communities in 21 countries from WHO surveys in lower-income countries. Also, 41.3% of those with 12-month anxiety perceived a need for mental health care; only 9.8% received possibly adequate psychiatric treatment. 9.8% had a 12-month anxiety disorder, 27.6% of whom received mental health care and treatment. [4]
Because of: their relatively high prevalence, their tendency towards chronicity , and substantial comorbidity, anxiety disorders are associated with significant disability and poor quality of life [5]. Anxiety disorders are also very costly. It has been estimated that the total costs of anxiety disorders were € 74.4 billion for 30 European EU countries in 2010 [6].
The standard Anxiety disorder treatments are First of all, psychotherapy which includes cognitive- behavioral therapy and psychodynamic psychotherapy. Then, the pharmacological treatment which includes Selective serotonin reuptake inhibitors (SSRI), Benzodiazepines, non-addictive anxiolytic, Buspirone, Beta-blocker, Tetracyclic antidepressant (TCAS) [7]. Furthermore, Narrative Exposure Therapy which is a short-term psychological treatment for PTSD that has been investigated in various contexts especially for torture survivors, particularly in the Middle East and North Africa (MENA) region where health systems are unable to meet the increasing needs of mental health disorders caused by war and displacement. [8]
However, many barriers limit the effective treatment of anxiety disorders and PTSD. Structural and health system weaknesses, includimg scarcity mindset as well as lack of awareness and costs of treatment and stigma perceived by the people who experience anxiety disorders, further limit their treatment. [9]
Anxiety Disorders in Arab and Muslim Countries
Anxiety was discussed by some famous Islamic scholars in ancient history such as al-Razi, Imam Al-Ghazali, Ibn Kathir, Muhammad 'Uthman Najati, and others [10]. According to Imam Al-Ghazali, anxiety is a mental disease developed by the heart. It grows from an unhealthy soul of a human being. It is similar to other diseases such as anger, hatred, envy, sadness, pride, and others. He characterized anxiety as fear towards certain things which lead to restless and frustrated feelings [11]. Imam Al-Ghazali also discussed several types of anxiety for example the fear of old age, fear of death, fear of Allah, fear of poverty, fear of losing status and jobs, and fear of being different from others. He described all these fears as coming from a peaceful heart when someone does not give full trust in destiny (Qada and Qadar) set by Allah and does not have complete reliance on Allah.
Moreover, According to al-Ghazali, meditation can deepen 'ma'rifatullah' (knowing Allah) in the heart which is the beginning of purification in the soul. Prophet Mohamed has been practicing this meditation while he was in the Cave of Hira '. Here, he has found a peace that he had never experienced before. He also received the first revelation from Allah [12]. Furthermore, Ahmed ibn Sahl al-Balkhi (m. 934M)’s famous book Masalih al-Abdanwa al-Anfushas discussed the relationship between body and soul and describes the spiritual and psychological health[13]. Also, Ali al-Tabari (m.923M), a famous medical practitioner who developed Islamic psychotherapy to heal patients suffering from mental disorders. This has been mentioned in his famous book entitled 'Firdaus al-Hikmah’.[14]
On the other hand, the Holy Quran stated among the ways to apply in the psychotherapy process to treat general anxiety disorders through performing Salat (prayer). Through Salat, the person would be able to express all the hope by asking help from Allah during difficult situations. If the Salat is performed sincerely, then it can purify the heart and transform one's life to be calm, confident, and disciplined. [15]
In short, anxiety disorders are generally caused by mental or emotional instability. On the other hand, the Islamic view considered it a soul disease to some extent rather than a mental disorder as promoted by the psychiatrists from the West. [16]
The following paragraphs will present some studies conducted in different Arab and surrounding countries regarding anxiety disorders and PTSD. By using a stratified random sampling technique, 1552 adolescent school-age boys and girls in Abha city, southwestern Saudi Arabia, were screened for mental health using an Arabic validated version of SCL-90-R. Their ages ranged between 14-19 years. The most frequent mental symptoms were phobic anxiety (17.3%). The researchers found the insignificance prevalence between girls and boys. Some sociodemographic conditions such as father education, mother working status, ranking among brothers and sisters, and type of school were significantly affecting mental health. They also showed secondary school students enrolled in Islamic schools have 1.5 times the risk to have obsessive-compulsive compared to those enrolled in general school. An interaction between genetic and environmental factors might explain the increase in behavior disorders in boys. [17]
Also, generalized anxiety disorder (GAD) was found with highly prevalent among children and adolescents. An Egyptian study aimed to explore the prevalence and socio-demographic risk factors related to anxiety disorders especially (GAD) in adolescents and children. The tools which were used in this study: the general health questionnaire (GHQ, 28 items with cut point 14), the anxiety scale; prepared by Castello and Comrey, 1953, the structured clinical interview for those obtained 15 degrees and above in GHQ or 75 degrees and above on anxiety scale, and the Psychiatric disorders evaluation questionnaire. The study was conducted among 1200 students. The sample consisted of 493 who were males and represented 44.7% and 611 who were females and represented 55.3% and their ages ranged from 12-18 years. The researchers used different anxiety scale. The researchers found that depression was the most prevalent 23.8% and then anxiety which was 6.69%. According to psychological diagnosis, anxiety disorders were prevalent in the age group from 15- 16 years and GAD was more common in males. The study also showed that the increased family size leads to increased occurrence of psychological disorders. As well as the dead of the father may lead to the marriage of the mother and consequently the stressors were increased. [18]
Moreover, another study conducted using a descriptive cross-sectional design was carried out among high school students in Irbid, Jordan. The study aimed to explore the prevalence of mood and anxiety disorders and to investigate their association with gender and other socio-demographic factors. The sample consisted of 1103 adolescent students. Their ages ranged between 13-18 years. More than half of the students were females. The study showed a prevalence of 16.3% for any anxiety disorder. Female adolescents were significantly more likely to have mental disorders than males. Moreover, adolescents who were living with both parents were significantly more likely to have mental disorders than those living with one parent or other people. However, the researchers presented an explanation which might be that when both parents are present, any conflict between them might affect the mental health and anxiety levels of their adolescent offspring. [19]
On the other hand, some studies were carried out to explore the prevalence of anxiety disorders and PTSD in particular after being exposed to several traumas such as war and conflict. According to a study conducted by assessing 3048 participants post-conflict communities in Algeria, Cambodia, Ethiopia, and Palestine. PTSD and other anxiety disorders were the most frequent problems and reported most in people who had experience of violence associated with armed conflict. For example, it was associated with higher rates of disorder that ranged from a risk ratio of 2.10 for anxiety in Algeria to 10.03 for PTSD in Palestine. [20]
Moreover, Arab immigrant women are vulnerable to posttraumatic stress disorder (PTSD) because of a higher probability of being exposed to war-related violence, and immigration stressors. These findings were showed in a descriptive study conducted among Arab Muslim immigrant women, particularly those from Iraq and Lebanon, who have been exposed to war. The sample consisted of 546 women. All data were collected from face to face interviews by Arab women. They used different measurements of anxiety. The researchers found over a third of the participants (44%) reported living through or witnessing three or more traumatic events. The most commonly reported types were military combat or war zone (88.6%). Also, women who lived in a refugee camp were more at risk of PTSD than other women [21]. Furthermore, in Afghanistan, more than two decades of war which affected negatively women's freedom of movement, access to healthcare, and education have affected the mental health status. The prevalence of PTSD was higher in women than in men (48% met diagnostic criteria compared to 32%) in data from the Centers for Disease Control and Prevention's (CDC) 2002 national survey of postwar Afghani mental health. [22]
In summary, it was not clear if the prevalence of anxiety disorders and PTSD are similar or not between males and females in different Arab countries. However, it was clear that some multiple sociodemographic conditions and environmental factors significantly play a role in affecting and causing mental health disorders in particular anxiety disorders. Also, anxiety disorders may exhibit high levels of lifetime comorbidity with one of the other disorders, for example, anxiety disorders with Depression. So understanding the underlying causes of these disorders can provide insight into the etiology and inform classification and treatment. Moreover, PTSD was also detected after being exposed to war-related violence in some Arab and Muslim countries which harmed several aspects of life, especially psychological status.
Mental health care in Palestine:
Palestine (the occupied Palestinian territory) that includes the Gaza Strip and West Bank is an eastern Mediterranean country seeking independence and freedom. The social geography of modern Palestine, especially the area west of the Jordan River, has been greatly affected by the dramatic political changes and wars that have brought this small region to the attention of the world. [23]
Gaza Strip is a narrow piece of land lying on the coast of the Mediterranean Sea. The West Bank is an area of land between Israel and Jordan. The West Bank and Gaza together constitute Palestine, which is administered by the Palestinian Authority (PA).[23] Besides, refugees account for 73.1% of the Gaza Strip and 30.2% of West Bank populations [24]. Most of the population is Muslim, and common Palestinian values include strong family bonds, social identity from family and community, and a holistic outlook on life, rootedness to the land. [25]
Palestine has been under occupation by Israel since the 1948 war. It was considered by Palestinians as the beginning of ‘Catastrophe’. Palestinians have experienced ongoing suffering, traumas, and social distress. [26] In 1987, the first uprising, known as the Intifada, broke out in Gaza Strip and West Bank. In 2000, Israeli punishment measures and practices were again in place to discontinue the second Intifada. After that, in 2002, Israel started to build a physical barrier with parts of it isolating the Palestinians’ cities and villages. Israel called it a ‘fence’ and Palestinians called it a ‘Separation Wall’. [27] In 2008, 2012, and 2014, there was a prolonged siege involving movement restrictions on food and individuals, especially in Gaza Strip. Palestinians experienced violations of their human rights, loss of life, harm, and home destruction. [28]
The health care system in Palestine is complex and fragmented; basic public health and primary care are offered by four main facilities: The Palestinian Authority (Governmental), the United Nations (United Nation Relief and Work Agency for Palestinians (UNRWA)), non-governmental organizations (NGOs), and private health care services such as pharmacies or clinics. [29]
In 2002, the World Health Organization began a Palestine Mental Health Project, in cooperation with the Palestinian Ministry of Health. The WHO has been trying to develop the Palestinian health system and planning for building new community mental health centers.[29] The Gaza Community Mental Health Project (GCMHP) provides community mental health services, trains in community mental health and human rights, and sponsors field research.[30]Nowadays, mental health services in Palestine are community-based care. However, there are only 13 community mental health clinics or centers in West Bank, in addition to one psychiatric hospital in Bethlehem. [31]
The developmental challenges of mental health care vary from country to country influenced by their income. Additionally, other factors have determined the efficacy of mental health services including political decisions, social factors, and the kind diversity of cultures [32]. Considering the extremes of war experienced in Palestine over the last 70 years, a mental health system is facing specific challenges linked with occupation and political conflict. Restrictions on freedom and movement considerably limit patients from receiving care outside of their area of residence, and the cost of treatment, and inconsistent availability of medications on the WHO essential medicines list, in addition to insufficient specialists and absence of multidisciplinary teamwork present further access issues. [33]
Furthermore, mental disorders in Palestine remain underreported, under-resourced, under-treated, and mental health services underfunded. These services are unable to meet the burden of need. There is a severe lack of human and infrastructure resources, for example, the total number of psychiatrists is 20 in the West Bank. [33] According to the available researches; the mental health problems are generally high in the Palestinian population [25] According to statistics of the Palestinian Center for Counseling, the results of patients who went to psychiatry during the past three years (2007, 2008, and 2009) 25% of patients suffer from anxiety disorders. [34] Furthermore, the Community Mental Health Program in Gaza in 2017 reports the percentage of anxiety disorders among patients visiting psychiatric clinics in Gaza 26% [35]
Lack of feeling safe is the main cause of mental disorders, such as anxiety, phobias, depression, and PTSD [36]. Palestinian population especially adolescents and children were constantly exposed to a lack of security and safety due to the impact of the Israeli occupation practices [37]. The percentage of students in public schools in Area (C) which is managed by Israeli military forces suffers from psychological conditions and social difficulties 36.4% in 2011 and 69.4% in 2012. [38]
Anxiety disorders represent 32.9% of health problems that cause the most disability [39]. Furthermore, Anxiety disorders can alter behavior and cognition as well, yet little is known about the particular domains they affect [40]. According to the recent DSM-5 classification, anxiety disorders included generalized anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and selective mutism. The symptoms can interfere with daily activities such as job performance, school work, and relationships. They are characterized by excessive worrying, uneasiness, and fear of future events, such that they affect social and occupational functioning. [42] [41]
On the other way, most people who experience such events recover from them, but people with PTSD continue to be severely depressed and anxious for months or even years following the event. As well as, The DSM-5 outlines the diagnostic criteria for PTSD as having exposure to the traumatic event, the presence of some specific symptoms, persistence avoidance of stimuli, negative alteration in cognition, mood, arousal, and reactivity associated with the traumatic events. [43]
In this study, the authors aimed to summarize the literature about Anxiety disorders and PTSD in Palestine. This is the first review to summarize Anxiety disorder and PTSD in Palestine.