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.
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).
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
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.
- acute and limited in time
- occurring in series over an extended period of time
- chronic intermittent stressors
- chronic permanent stressors
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
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 distress||Number of reported|
symptoms 0 - 7
|Moderate||1 - 3||50|
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
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 nightmares||36||34||35|
|Irritability, nervousness and/or anxiety||49||44||46|
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 nightmares||16||35|
|Irritability, nervousness and/or anxiety||15||46|
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.
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|
|Gaza without camps||20||53||27|
|West Bank without camps||34||50||18|
|Greater gaza city||23||58||19|
|West Bank town||30||49||21|
|West Bank villages||35||49||16|
|West Bank camp||58||31||12|
|Refugees outside camps||30||46||24|
|Weekly consumption of meat|
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 arrested||High||Moderate||No|
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
|No children injured||28||25|