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PTSD … the war without end Still taking casualties

Few of those who witnessed the horrendous scenes of destruction after the Iraqi occupation of Kuwait would have believed the country would look so good again in such a relatively brief period of time. Physically, Kuwait made a remarkable recovery. What was not immediately obvious was the degree of damage done to the psyche of many who experienced captivity or torture or witnessed the cruel acts of the occupying forces. Buildings and installations, it turned out, are much easier to repair than the mental health of human beings.

Recent studies have shown that more than two decades after the liberation some twenty five per cent of Kuwait's population still suffers from the debilitating condition known as Post Traumatic Stress Disorder (PTSD). According to psychiatrist Dr Abdullah Al Hammadi, PTSD is a long-term affliction from which the people of Kuwait will suffer for years to come, as do many American veterans of the Vietnam War, and even those of World War II.  Speaking to the Arab Times in his office at the Kuwait Center for Mental Health, Dr Al Hammadi said, "We are following the studies and literature from the United States and we see the same patterns, so we know that PTSD is not peculiar to Kuwait. The disease is the same, whether the patient is in America, Kuwait, or anywhere else in the world. The condition is definitely on the rise worldwide due to the large number of armed conflicts as well as natural disasters."

PTSD develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the victim or the person may have witnessed a loved one or even a stranger being harmed. PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic or violent incidents, such as mugging, hijacking, rape, being kidnapped, child abuse, a car accident, plane crash, bombings, or natural disasters such as floods, fires, earthquakes, typhoons, hurricanes, or tsunamis.

Dr Al Hammadi points out that whereas the percentage of those who develop PTSD after a natural disaster is relatively low at around twenty per cent, the figure climbs dramatically to around eighty per cent for survivors of violent incidents such as rape and torture. In the latter cases the victims suffer pain and humiliation, and endure the fear of losing their lives. Studies have shown that it is particularly the survivors of man-made traumas that often feel a lasting sense of terror, horror, endangerment, or betrayal. 

PTSD is widespread in Kuwait as a result of the brutality of the Iraqi occupation of August 2, 1990 to February 26, 1991. According to Dr Al Hammadi, the symptoms range from anxiety, depression, irritability, insomnia and aggression to emotional withdrawal, loss of memory, and the sense of a foreshortened future. Symptoms usually begin within three months of the traumatic incident but occasionally there is a delayed onset and they don't start to manifest themselves until years after the initial traumatic event. They can surface at any time and even a mildly stressful event can ignite the original trauma and cause an individual to be retraumatized, as was the case when Saddam Hussein frequently threatened Kuwait during the years after the occupation.
 

As Dr Al Hammadi recalls, "This threatening behavior made people in Kuwait suffer from feelings of worry, fear, and insecurity. The painful memories were made to recur time and time again." However, according to Dr Al Hammadi, even the death of the perpetrator of the violence, in this case Saddam Hussein, does not bring an end to the misery of those affected by PTSD. "These people have undergone biological changes in the brain. They have actually been physically damaged and they are suffering from a real illness that needs to be treated. Unfortunately, this fact is often not recognized or understood and we look at someone with PTSD differently than someone who has had a fracture or a cardiac condition, for example. We need more information campaigns to educated the public about this condition."
 

A pioneer in the field of PTSD treatment in Kuwait and the first doctor in the country to establish a specialized PTSD clinic, Dr Al Hammadi says there is a wealth of new information about this disease. He points to recent findings in the American Psychiatric Society's Diagnostic Statistical Manual of Mental Disorders which are making mental health professionals look at PTSD in different ways. According to Dr Al Hammadi, psychiatrists are taking a closer look at conditions linked to PTSD including acute stress disorder, adjustment disorder, reactive attachment disorder, diminished social engagement disorder, and trauma related disorders. "If we had had such knowledge when we began our PTSD screening in Kuwait in 1991 our study design would have been different," he says.

In 1991 the Kuwait government established Al Riggae Specialised Center in order to rehabilitate the survivors of Iraqi torture. As the Director, Dr Al Hammadi supervised a team of adult and pediatric psychiatrists, clinical psychologists, social workers, general physicians, and nurses who worked to help those afflicted with PTSD. Dr Al Hammadi states that during the occupation some 15,000 people were captured by the Iraqis and later released. At the end of the war, more than 6,000 Kuwaiti prisoners returned home from Iraq. A large number of them had been subjected to physical or psychological torture, or both, and many were in need of treatment for PTSD.

In 1993, when the Center conducted a screen study to determine the incidence of PTSD in the community, it became apparent that the problem was more widespread than initially suspected. The medical team noted that while some individuals made a spontaneous recovery from PTSD, others went on to develop a variety of symptoms. Painful memories often occur in the form of vivid flashbacks or recurrent nightmares that can be accompanied by rapid heartbeat, sweating, and anxiety attacks. Some PTSD sufferers shy away from people, places, or activities that trigger these memories and they may become forgetful and withdrawn or even feel numb and unable to experience emotion.

"Patients with PTSD may have problems with their social integrity and relations with family members, colleagues, or friends," says Dr Al Hammadi. "They may have trouble communicating with their spouse or their children, relations deteriorate, and there is a rise in divorce cases. The condition can also affect their work and we have seen a rise in early retirement. Since Kuwait is a small country and we are losing a significant number of people who were trained in specific jobs this has even resulted in a disturbance of the country's work force."

According to the psychiatrist, those with PTSD are more likely to have health problems such as diabetes, high cholesterol, high blood pressure, and other coronary issues. Certain sufferers of PTSD may also be more likely to practice substance abuse. "Although the consumption of alcohol is not usual in our society, it is significant and proven that those with PTSD are more in contact with alcohol and drugs. This is a reality that shouldn't be hidden or shied away from. These people are suffering and their alcohol and drug abuse is an attempt to numb themselves and escape from the intrusive memories."

Dr Al Hammadi states that while no studies have been done in Kuwait regarding PTSD and increased levels of violence and aggression, medical literature has shown that there is an association. Further screen studies of the incidence of PTSD in Kuwait's population were carried out in 1994 and 1998, with statistics remaining at a steady twenty five per cent. "There is no need to conduct any further screenings as we can presume, based on the findings of studies in the US, that the rate will stay the same," Dr Al Hammadi says. In 1994 Dr Al Hammadi and his team at Al Riggae Specialised Center published a book based on their study findings and analysis titled "The Traumatic Events And Mental Health Consequences Resulting From The Iraqi Invasion And Occupation Of Kuwait".  A special section was devoted to the effects of PTSD on children. "Trauma during childhood definitely affects the child and increases the rate of personality disorders including attention deficit hyperactivity disorder (ADHD) and PTSD," Dr Al Hammadi states.

Al Riggae Specialised Center was closed and the treatment team of mental health professionals was shifted to the government hospital near the Al Sabah Hospital compound.  So what is being done to help those suffering from PTSD? "We have adapted a multi-modal, multi-disciplinary approach that includes psychotherapy, mainly cognitive behavioral therapy (CBT), and pharmacology," Dr Al Hammadi explains. 
Psychotherapy is often referred to as "talk therapy." Included in cognitive behavioral therapy, for example, is exposure therapy which helps people face and control their fears. Cognitive restructuring is another facet of CBT that helps people make sense of their bad memories. Stress inoculation training is a CBT therapy that attempts to reduce PTSD symptoms by teaching a person how to reduce anxiety.

Other therapies that benefit some PTSD patients are strategies to help them identify and deal with guilt, shame, and other feelings about the trauma; relaxation and anger control skills; and advice focusing on exercise habits, diet, and how to get better sleep. According to Dr Al Hammadi, since depression is a major symptom of PTSD, the drugs commonly prescribed for the condition are non-addictive antidepressants. Finally, it is not just the PTSD patient who is adversely affected; the condition may also take its toll on close family relationships and friendships. "That's why one of the major areas we try to address is to help patients adjust their social functions regarding their marriage and relations with family, friends, and co-workers," Dr Al Hammadi says.

If you have a friend or family member who has PTSD, what can you do to help? Educate yourself. Psychiatrists who are specialized in treating PTSD can also help you better understand and deal with someone suffering from this difficult condition. The more you know, the better you and your family can handle PTSD. Websites like the US Department of Veterans Affairs National Center for PTSD offer a wide variety of coping strategies. They include advice ranging from engaging in physical activity and exercise together, to being a patient and positive listener, and forming a support system by encouraging activity with family and friends. They also remind you to take care of yourself and ask for help if you need it.

With the global increase in violent crime, terrorist incidents, and armed conflict on the one hand, and more and more severe natural disasters on the other, an ever growing number of individuals will have to deal with PTSD and its consequences. In Kuwait, twenty three years after the liberation, many people still struggle with the symptoms of PTSD by themselves, either due to the stigma of seeking medical help, or because of a refusal to recognize their condition, or because they don't know there is a cure for it. Dr Al Hammadi recently opened a specialized center to treat PTSD and other psychiatric disorders, the Alhammadi Clinic for Mental Health, for patients who do not want to go to the government Psychiatric Hospital.

"Some people are embarrassed or feel uncomfortable about going to the hospital so I want to give them an alternative," he says. "I provide private consultations at a reasonable cost, or sometimes even pro bono. After more than twenty years treating PTSD patients my aim is not to make money but simply to help these people, to make them feel better and improve their quality of life." For Dr Al Hammadi and other health care professionals treating PTSD patients, greater public acknowledgement and understanding of the condition is of utmost importance. "Here in Kuwait we need to understand that there are many types of trauma that can trigger PTSD, but in this country the Iraqi occupation is the major cause. The Iraqis are our neighbors and we will always have to deal with them, and yes, we need to try and build respect between our people, but we cannot say the invasion didn't happen. We cannot simply remove it from the minds of the people. More than two decades after it occurred, we still have to deal with it."

PTSD is widespread in Kuwait as a result of the brutality of theIraqi occupation of August 2, 1990 to
February 26, 1991. According to Dr Al Hammadi, the symptoms range from anxiety, depression, irritability, insomnia and aggression to emotional withdrawal,loss of memory, and the sense of a foreshortened future. Symptoms usually begin within three months of the traumatic incident but occasionally there is a delayed onset and they don't start to manifest themselves until years after the initial traumatic event. They can surface at any time and even a mildly stressful event can ignite the original trauma and cause an individual to be retraumatized, as was the case when Saddam Hussein frequently threatened Kuwait during the years after the occupation.  As Dr Al Hammadi recalls, "This threatening behavior made people in Kuwait suffer from feelings of worry, fear, and insecurity. The painful memories were made to recur time and time again."

However, according to Dr Al Hammadi, even the death of the perpetrator of the violence, in this case Saddam Hussein, does not bring an end to the misery of those affected by PTSD.  "These people have undergone biological changes in the brain. They have actually been physically damaged and they are suffering from a real illness that needs to be treated. Unfortunately, this fact is often not recognized or understood and we look at someone with PTSD differently than someone who has had a fracture or a cardiac condition, for example. We need more information campaigns to educated the public about this condition."
 

By Claudia Farkas Al Rashoud
Special to the Arab Times


By: Dr Abdullah Al Hammadi

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