Symptoms of Distress - Mental Health

Although there exist some studies on mental health effects of uprisings, civil strife and conflict, as well as numerous works on refugee populations and military occupations, few of these, if any, can be directly compared with the present report. There are a few other studies of mental health among Palestinians in the occupied territories, but differing research methods and aims limit the value of comparison (Hein 1993, Baker 1990, Punamaki 1990a, Punamaki 1990b).

Stress and Health
Most illnesses have multiple causes. Stressful conditions and life events may have positive effects, neutral effects, or may indeed contribute to the development of an illness. Stress produces illness only when certain other conditions are present, among which the most important are biological susceptibility and individual vulnerability. A stressful event rarely produces a specific disease, mainly influencing the timing of its onset rather than its type, which may be determined by other factors. Life event studies generally show that populations experiencing high numbers of negative life events suffer from high morbidity. In studies of mental disorders, the typical finding is that people who meet diagnostic criteria have experienced stressful life events more frequently in the period preceding the onset of the disorder than others have.

Psychic Trauma
The effects that stressful life events can have on mental health are consistent and strong only with regard to extreme situations. Severe experiences, such as bereavement of loved ones by "unnatural" death, military combat, imprisonment, torture, imminent threat of death, and severe illness, are generally bound to cause distress to nearly all human beings. Subsequently, psychiatric morbidity among people who have experienced such situations may be very high. The rate of morbidity in severely distressed populations depends on protecting factors, but it frequently reaches 20% or more (Weiseth, 1991). Psychic trauma is understood as a confusion of thoughts and loss of the sense of coherence and cohesion, overwhelming excitements, psycho-physiological exhaustion, and disturbed behavioural responses, all of which conditions that can be produced by stressful events. Extreme and prolonged stress, lasting for several months or years, may increase mortality and general morbidity for decades thenceforth.

In contrast to the most extreme life conditions, responses to moderate stressors show much greater variability. What is stressful to some, is not so to others. This is even more true during times of uprising, society conflict, occupation or war. The meaning of the event - and the sense of social cohesiveness -is crucial in determining how stressful a situation is to each individual (Lazarus and Folkeman 1984, Antonovsky 1992).

Protective Factors
Stress tolerance in situations involving physical danger, i.e. threats to one's health or life, increases along with the quality of cohesiveness of the group to which one belongs. Similarly, it is influenced by the degree of trust in the leadership of the group, the strength of one's motivation for the cause at hand, the ability of those involved to handle the tasks and challenges that arise, the quality of available protective equipment, of first aid and of medical services, and by several other conditions. In some instances of hardship, such as warlike situations, factors like resilience come more fully into play than under more ordinary circumstances. As a consequence, the mental effects of moderate warfare, or of other conflicts, may be surprisingly small. Mental health has even been shown to improve during war (Ødegaard 1954, Eitinger 1990).

Uncertainty and Lack of Control
Two decisive intervening variables can be identified in most stressful life events, namely experience of uncertainty and of lack of control. Severe and particulary prolonged uncertainty and lack or loss of control, i.e. inpredictability and inability to influence one's environment, strongly reinforce the effects of the stressor. Psychic traumas are called forth in situations characterized by severe helplessness and hopelessness.

Post-traumatic Stress Disorder and Late Psychic Sequels
Stressful life events can be classified as

  1. acute and limited in time
  2. occurring in series over an extended period of time
  3. chronic intermittent stressors
  4. chronic permanent stressors
While acute time-limited traumas typically produce immediate reactions and entail a risk of developing post-traumatic stress disorder (PTSD) during the first year, chronic stressors allow the individual to mobilize defences and adapt to new circumstances. In this case, if the threat has been severe and constant, so-called late psychic sequels may appear after a long period of time. Thus, typically, the final and full-scale consequences of such experiences may only be known after the stressful period is over and some years have passed.

The present study may provide a baseline for generating hypotheses as to how Palestinians in the occupied territories react to the stressful conditions under which they live. Many of them have experienced traumatic events, but, as it has been important to guard the anonymity and security of all respondents, the survey questions were not posed in a way that would make it possible to identify the particular stressors that each respondent has been or is exposed to.

Because subjective factors are important in determining stress responses, the method of recording self-perceived symptoms is considered valid, maybe more so than for the study of somatic illnesses. The reliability of the report may, however, be reduced by motivational and other factors, and one has to recognize the problem of objectivity confronting the respondents. As in all self-reporting the answers may be influenced by the wish or need to be seen as a socially acceptable person. In the case of recording psychiatric problems, this may cause under-reporting. On the other hand, specific post-traumatic stress reactions may be less stigmatizing if they reflect stress exposures that are seen as admirable or heroic by the surroundings.

Seven Symptoms of Distress
In this study, relatively few psychic symptoms or stress reactions have been recorded, and no standardized instruments have been used that could measure the severity of symptoms or define cases. Seven symptoms have been recorded (table 4.13), and presence or absence of each symptom noted. Headache and fatigue were included because these symptoms frequently express psychological or psychosomatic distress. None of the symptoms are specific. Thus they may reflect underlying conditions of various kinds, such as physical illness, organic brain conditions, psychosocial problems, or psychiatric conditions such as neurosis, post-traumatic stress disorder or clinical depression.

Measuring Degree of Distress
In order to obtain a quantitative measure of the dependent variables, we have used the following procedure: An index has been calculated for each respondent by assigning equal weights (i.e. zero = absence of symptom, one = presence of symptom). Based on the frequencies and distributions of the symptoms and the index in the population, and on clinical experience, the index scores are divided into three subgroups (table 4.12).

Table 4.12 Construction of index expressing degree of distress
Degree of distressNumber of reported
symptoms 0 - 7
No symptoms020
Moderate1 - 350
High4 -730

Persons with no symptoms are assigned to the group with 'no distress'. Persons with 1-3 symptoms are grouped as having a 'moderate degree of distress', and persons with 4-7 symptoms fall into the group with a 'high degree of distress'. The term distress is used in order to avoid misinterpretations. The degree of distress does not imply any simple causal relations, it does not reflect a particular division between somatic and psychic factors, and it does not reflect clinical psychiatric diagnoses. Although we expect people with psychiatric conditions to be present in the highly distressed group, this survey does not allow specific estimations of prevalences of psychiatric illnesses.

Table 4.13 Frequencies of symptoms of distress by gender.Per cent (number of persons affected)
Women (1198)Men (1243)Total (2441)
Sleep disturbances and/or nightmares363435
Irritability, nervousness and/or anxiety494446
Impaired concentration272526
Impaired memory282024
General tiredness524750

High Degrees of Distress
The frequencies of various symptoms of distress appear to be relatively high in Palestinian society (tables 4.13, 4.14).

Table 4.14 Frequencies of symptoms of distress in the occupied territories and in Norway Per cent (respondents)
Sleep disturbances and/or nightmares1635
Irritability, nervousness and/or anxiety1546
General tiredness1650

Rough comparisons can be made with the results of the Norwegian Health Survey of 1985 (Norwegian Central Bureau of Statistics). The Hopkins Symptom Check List (HSCL) has been employed in this survey, and some of the questions are similar to those used in the occupied territories. In Norway, a representative sample of the population aged over 16 was interviewed (n=8096). 25% of the Norwegians reported having headache, in contrast to 42% among the Palestinians, 15% of Norwegians and 46% of Palestinians reported nervousness, 16% of Norwegians and 35% of Palestinians reported sleep disorders, and 10% versus 29% respectively, reported being depressive. While 16% of Norwegians reported lack of energy, as much as 50% of Palestinians claimed general tiredness. This means that the Palestinians report between 1,5 and 3 times higher rates of symptoms than Norwegians do (table 4.13). Considering the very different age distributions of the two populations, the differences in frequencies of psychological symptoms become even more striking.

In the study of the occupied territories the rates of men and women do not differ as much as is often found in other studies (Moum et al 1991, Hernes & Knudsen 1991).

Even young people report high frequencies of distress. In the age group 15 - 30 years only 26% report no symptoms (table 4.15). The effects of increasing age are considerable, particularly amongst women. While the number of moderate scores is practically constant in all age groups, the number of persons reporting no distress is very low in the highest age bracket.

Table 4.15 Degree of psychological distress by age and gender. Per cent

The steady increase with age almost disappears, however, when controlled for prolonged illnesses. Among people who do not report prolonged illness, the proportion of persons having a high degree of distress increases only slightly, from 19% in the lowest age group to 24% in the highest. Among those who do report prolonged illness, the increase with age is from 51% to 59%. This indicates that the main reason why the highly distressed group increases with age is probably the rising prevalence of prolonged illness. Although somatic diseases are known to be strong determinants of psychiatric symptoms (Moum et al 1991), the interpretation of this finding is not clear. Among the diseases reported as prolonged illnesses, all may in principle include illnesses that are symptoms of, or results of, psychological distress. This is particularly so for musculoskeletal syndromes and for the category including mental disorders. On the other hand, the symptoms included in the degree of distress index may well be expressions of somatic disorders. The frequency of high degrees of distress among those who do not have any specific prolonged illnesses is approximately 20%, regardless of age. This is a high rate, requiring other explanations than somatic disease.
Geographical Area,

Refugee Status and Residency in Camps
The Gaza population reports lower levels of distress than does the population in the West Bank and in Arab Jerusalem (table 4.16). This is partly explained by the higher average age in the West Bank and Arab Jerusalem, and partly by the fact that people in Gaza report less somatic illness as well. However, results reported in other chapters clearly indicate that living conditions in Gaza are generally worse than in the West Bank. So why do Gazans report fewer symptoms of distress? One possible explanation may indeed be that people in Gaza have a clearer sense of collective meaning and common purpose. A greater sense of cohesiveness, originating in a more traditional family structure, may also contribute as a protective factor. The population in Gaza may enjoy greater protection against distress as the perception of an external enemy becomes exceedingly strong. Then again, the explanation could well be that Gaza residents are less prone to recognizing and expressing symptoms of psychological distress. The degree of perceived conflict in Palestinian society is high (see chapter 9), particularly amongst women in Arab Jerusalem, where living conditions tend to be better than elsewhere in the occupied territories, and this may be seen as an expression of distress.
Refugee status does not influence the degree of distress in itself, but refugees seem to follow the trend of the population in the geographical area they belong to. Living in camps does not make a difference in itself either. However, people in rural camps in the West Bank report higher degrees of distress than others do.

Table 4.16 Geographical area, refugee status, camp residency and degree of distress. Per cent
Degree of distress
Main region
West Bank364717
Arab Jerusalem374221
Camp status
Gaza without camps205327
West Bank without camps345018
Arab Jerusalem374221
Greater gaza city235819
Gaza town/village175033
Gaza camp215920
West Bank town304921
West Bank villages354916
West Bank camp583112
Arab Jerusalem374221
Refugee status
Urban camp295516
Rural camp403723
Refugees outside camps304624
Weekly consumption of meat
1-2 kilo314920
3-4 kilo215128
>/5 kilo165628

A low educational level and a low economic status relate to high levels of distress. Wealth is here measured in a wealth index (chapter 6) and in respect to weekly consumption of meat. Educational level is measured in terms of years of education.

Arrest of Household Member and Serious Injury of Child. Traumatic Events?
The questions whether the respondent has experienced arrest of a household member and whether a child in the household has been seriously injured, cover events that are stressful to most people, and probably traumatic to many (American Psychiatric Association, 1987).

About 1 out of 3 respondents have a household member who has been arrested. A respondent who has experienced the arrest of a household member is more likely to report high degrees of distress than others (table 4.17). Interestingly, the difference is significant only among men, possibly because more men than women are arrested. Several of these may, in fact, be among the respondents.

Table 4.17 Possible effects of trauma of arrest of household member on degree of psychological distress.
Household member arrestedHighModerateNo

The relation between reported distress and experience of arrest is similar in all socio-economic groups. Thus, a high socio-economic level does not seem to be a protective factor in this case.
A very high per centage of the respondents with children aged under 12 have a child that has suffered serious injury during the last two months. These respondents also report high degrees of distress (table 4.18). Child injury, thus, significantly affects the number of symptoms for both men and women. If this is not a spurious effect, it is still impossible to say in what direction it works. As for the correlation between chronic disease and injury of children, one can assume that the chronic disease of the adult comes before the serious injury of the child. Again, there is a strong correlation between having a seriously injured child and the number of reported symptoms of distress, particularly for men. 77% of the respondents have children in the household aged 12 years or less. 18% of these respondents have children in the household who have recently (during the last 2 months) sustained serious injuries requiring prolonged medical attention. 30% of the households with injured children have more than one child that has been injured. 45% of the injured children are from 0 to 3 years old. 78% of the injuries took place inside the house and 13% outside the house, and 9% do not know where the child has been injured. Serious injury of young children seems to be an important health problem in the occupied territories.

Table 4.18 Serious injury of children. Relationship between high degree of distress and serious injury of children in the family. Per cent of persons with high degree of distress (4-7 symptoms). Only respondents with children below the age of twelve
Children injured4435
No children injured2825


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