The impact of war on the mentally ill in Tunisia
during the 1991 Gulf War
Sarah Benzineb, Jamil Taktak, Saida Douki. Razi Psychiatric Hospital. Tunisia
Introduction
1991 Gulf War : no more “geographically limited” conflicts. 24 h/24 broadcasting all over the world into civilians’s homes War commanded by the UN unusually intense and wide emotional involvement. Civilian societies passionate reactions Geographical distances : no longer an important variable when dealing with psychological shock Directly exposed people : no longer the only victims.
Maghrebian societies
Reminiscence of the old West vs Orient fight (Ghorbal M,
1977)
Medieval Crusades (Baghdad once again capital of the Arab-Muslim civilization) Considerable scientific interest : social, anthropological, historical and psychological consequences Much fewer studies dealing specifically with the impact on psychiatric patients.
(Sher L, 2000; Bohlken J, 1991; Kelly C, 1996)
Method
Data from emergency and outpatient registers from the Razi Psychiatric hospital :1981 to 1991. Plus Inpatient sample : August 02, 1990 to April 31, 1991. Inclusion criteria patients with psychopathology directly related to the war :
Chronological relationship between war events and the beginning of current psychiatric symptoms. Imputation of current psychiatric episode to the Gulf War at the exclusion of any other precipitating factor.
Results : Outpatients’ register
First trimesters Second trimesters
Results : Admissions Register
New patients Former patients
Results : Clinical Sample
14 patients meeting inclusion criteria. 6% of total admissions during the same period
Results : Socio-demographic variables
Sex ratio : 8 male for 6 female patients (1.3 : 1). Mean age : 36 years (16 to 65). School level : primary school Professional status: All women but one unemployed. Majority of men non-skilled workers Civil status: All women married. Men : 1 widow, 3 married, 4 single. Mean number of children : 3. Mean duration of marriage : 10 years
Results : clinical variables
8 patients / 14 : previous history of psychiatric disorder. Time elapsed from the last episode : 1 to 7 years. All 8 patients were doing well during this period. 7 patients /14 : family history of psychiatric disorder.
Results : Medical History
1 sexual impotence 1 case of secondary sterility 1 primary sterility (oligospermy).
1 female patient menopaused. 1 primary sterility. 2 previous tube ligature. 1 history of miscarriage
8 patients /14 : medical incapacity to procreate Plus incapacity due to circumstances all 14 patients unable to procreate during that particular period
Results : Chronology of psychopathology
Beginning of overt psychiatric symptoms : from November 1990 to February 1991, with a peak during January 1991
Results : Nature of psychopathology
Case N°
Gender Age 1st epis.
Diagnosis
Reproductive status
1
2 3 4 5 6 7 8
M
M M F M F F F
16
27 37 36 24 59 40 23
yes
yes yes no no yes no no
Brief psychotic disorder
Bipolar D. Manic episode Brief psychotic disorder Bipolar D. Manic episode Bipolar D. Manic episode Bipolar D. Manic episode Bipolar D. Manic episode MDD recurrent
Single
Single
Leaves far away from wife and daughters
IUD Single Tube ligature Miscarriage Sexual impotence
Brief psychotic disorder (Asd?) Tube ligature
9
10 11 12
F
M M F
64
34 31 39
no
no no no
Bipolar D. Depressive episode Widow - Mnp
Bipolar D. Depressive episode Prim. infertility Brief psychotic disorder (Asd?) Prim. infertility
13
14
M
M
41
20
no
no
Bipolar D. Manic episode
Bipolar D. Manic episode
Widow – no children
Single
Case Vignettes
Case Vignette 1
Raoof : 16 years boy Admitted in emergency on February 5, 1991. No prior history of any mental disorder. Conflictual relationship with family. Recently dismissed from job. Psychopathology started abruptly, 3 days before admission. Acute psychotic syndrome. Delusions focused on the Gulf War, with both hallucinatory and interpretative mechanisms: “I saw a hair stuck on the floor… It meant the war would have ended in favour of Iraq…I saw an angel with a beard…I saw a bright light, on the seas and the lands…I immediately realized that Saddam’s triumph was imminent and that it just takes to me to invoke God to achieve victory. When I watch TV, I can see the presenter is crying tears of fright because the destruction of Israel is impending” Brief psychotic episode. Complete remission within a few weeks.
Case Vignette 2
Mrs Fayza D., 36 years. Admitted on March 7, 1991. Prior diagnosis of bipolar disorder, but not taking any mood stabilizer. Presented with severe mania suddenly immediately after the cessation of the conflict. “I threw a handful of sand to free Saudi Arabia, Kuwait and Iraq... But again they quarrelled… So again I threw sand to bring them peace. (…) Then I locked Saudi Arabia (…) Two days later, the King Hussein of Jordan told me that Saddam agreed to renounce to Kuwait. (…) I locked again… and told Bush to shut up, not to talk anymore to the other Presidents (…) When Gorbatchov speaks at the UN, he doesn’t know that I’m the one who puts the words in his mouth (…) I want Palestine to be independent… I threw sand to command Bush to free Palestine (…) God will fulfil my wishes because I have extraordinary powers from Sidi Ali El Jahay (a local Saint)…”
Case Vignette 3
Mr L., 34 years Admitted in emergency on January 5, 1991, for attempted suicide (electrification). Recurrent major depressive disorder. Current episode was severe with psychotic and melancholic features. The episode began insidiously in November 1990, after Mr L. was arrested for taking part in a non-authorized street demonstration supporting Iraq. He reported an extreme preoccupation with the future of the Arab nation (the Umma) and with his own future too. He had always been a scrupulous believer and rigorous Muslim, but was so troubled that he ended up by denying the very existence of God: “If God had really existed he could not let this happen (…) he would help the Muslims and the Iraqi (…) “
Discussion
Well-known overall drop in expressed need to care during critical periods (Lefèbvre, 1979) Better integration and lesser stigmatisation of mentally affected persons.
Discussion
Only 6% of total admissions Influence on the contents of delusions in many other patients, but without directly triggering the current episode
Discussion
Frequency of affective psychopathology (6 manic and 3 depressive episodes) central role of psychodynamic factors. Loss and grief at the centre of depressive as well as manic symptomatology: “The loss of the Other’s love and the loss of Selfesteem” (Abraham) is at the origin of depression, while mania and “grandeur illusion” is nothing but an attempts to repair this loss.
Discussion
Overt solidarity expressed by all patients with Iraqi people problems of community and identity Reactualization of the “basic cultural conflict” (conflit culturel de base) described by Ghorbal (1977)
Discussion
Permanent or momentary procreating problems at the time of admission. Additional factor of vulnerability towards psychiatric disorders May uncover the relationship between war and our instinct of conservation as a species War = annihilation of our inner illusion of immortality (Freud) Inability to conceive = 2 losses (ability to procreate + hope for children) Frequency of PTSD in couples facing reproductive problems (Bartlik et al., 1999)
Conclusion
Media-induced psychopathology on geographically distant populations and on specially vulnerable populations Psychiatric inpatients observation influence on psychopathology although maybe not as frequent as expected in comparison with the emotional reactions in the general population. War mainly influence the contents of delusional ideas (persecution, grandeur) Predominance of affective and brief psychotic disorders No patients with Schizophrenia : indifference to the surrounding reality and numbing of affect. Afford special attention to the psychodynamic factors underlying the delusions.