Since the Iraq War and the Arab Spring, the Middle east has been experiencing repression, terrorism and conflicts, The tragic situation in many Middle Eastern countries caused not only increased trauma related mental health problems but also reduction of the professionals and facilities that could help treat these problems due to the migration of qualified medical and psychological staff looking for security for them and their families somewhere else. This in addition to the targeting and destruction of many health and mental health facilities. There is as a result a lack of both pharmacological and psychotherapeutic treatments and very few specialist mental health centres or mental health assessment tools of any description.

The refugee crisis also has created massive mental health problems in its own right where even when therapists are trying to help these refugees they do not find appropriate place to hold psychotherapy sessions. One of the main recommendations of this paper is that the only way to meet Middle east people’s and refugees’ trauma mental health needs is through a Middle East EMDR project similar to the Mikong Project in South East Asia which not only trains therapists but also employs them [1].

Abdul-Hamid W (2018) Trauma in the Middle East: Arab Spring, winter or summer. JSM Burns Trauma 3(2): 1043.

Ancient Mesopotamia, which covers large parts of what are modern day Middle eastern Syria and Iraq, was discovered recently to be the birth place of the first ever recording of the symptoms of Posttraumatic Stress Disorder (PTSD) symptoms 3.500 years ago. The many symptoms described by Assyrian physicians could now be identified in current diagnostic classification systems as symptoms of post-traumatic stress disorder, including flashbacks, sleep disturbance and low mood [2].

The Middle East is part of the Third World where Trauma is more common, more difficult to treat or research. Whereas most trauma treatment and research resources are in Europe where there is only 7% of the World population [3]. Everly suggested that the psychological consequences of trauma outweigh the physical consequences by the factor of 4:1 [4]. In fact, the stigma of mental health problems in the Middle East is much more prominent than many parts of the world which complicates the treatment of trauma and non-trauma mental health problems [5]. If we add to this the fact that the Arab Spring have created a very chaotic states and failing states with conflicting ethnic, cultural and religious group, we will then understand the difficulty of dealing with repeated and recurrent traumas on the population of this region [6]

As Vietnam triggered the students uprising in France and other European countries in the late 1960s,the Iraq war with the atrocities and crimes against humanity that was associated with it (like Abu Graib prison scandal and the use of prohibited weapons and the complete destruction of the town of Fallujah), which were condemned by the whole world at that time [7], had sensitised the region’s youth against similar atrocities practiced by the regimes that governed them and led to the Arab Spring. An example of such practices; the Human right Watch report on Syria in 2012 showed the level at which torture was practised by the Syrian regime on the Syrian people. This report had identified 27 torture centres in Syria [8]. The report has quoted the experience of one of the victims of these torture centres: ‘The guards hung me by my wrists from the ceiling for eight days. After a few days of hanging, being denied sleep, it felt like my brain stopped working. I was imagining things. My feet got swollen on the third day. I felt pain that I have never felt in my entire life. It was excruciating. I screamed that I needed to go to a hospital, but the guards just laughed at me.’

The work of Ellen Gerrity had highlighted the mental health consequences of torture in her book The mental Health Consequences of Torture. In this book she concluded that the long term psychological consequences of torture could be worse than the torture itself [9]. One of the most important consequences of torture is post traumatic stress disorder PTSD. Significant number of the victims of this disorder if untreated might kill themselves [10]. In addition to torture and its consequences in the Middle East, the increasing ethnic and religious conflict and violence that continue to go on since the Arab Spring increases the rate of complicated PTSD even more.

As the hypothesis of this study is that trauma is not only the result of the Arab Spring but also the cause of it as explained in the introduction, we have included all studies on PTSD in the Arab world most of them are before the Arab Spring. All literature on trauma and PTSD was search on Medline and Psych Lit was reviewed for the purpose of this review narrowing the search to the Middle East and Arab countries and also the names of individual Arab countries which resulted in the studies that were used in this review.

Studies on PTSD in the Arab World

The research studies that look at the prevalence of the PTSD in the Arab World can be divided into two type according to where they were conducted:

Those studies that were undertaken in the Arab World:A study was conducted in suburban area of the Governorate of the capital Algiers in Algeria which was the scene of a large massacre where author interviewed a stratified random sample of 653 individuals to study the prevalence of PTSD. Using the composite international diagnostic interview which is based on the DSM IV and the study showed the prevalence of PTSD to be 37.4% of the sample [11]. Another community survey was conducted in postconflict settings in Gaza in Palestine, on 944 school age children (10-19 year old) who were exposed to ongoing violence was assessed and the results were classified by severity levels. It has found that 33% of the population had an acute or high level of PTSD, 49% had a moderate level, and 15.6% had a low levels of the disorder [12]. Another study on randomly selected school age children (12-16 year old) in the whole of the occupied Palestinian territories and the results showed a prevalence of PTSD in the sample to 34%4. This study found that poorer children and particularly those living at refugee camps are more at risk of PTSD (Table 1)

Similarly, in the post 2006 War in Lebanon a study that was conducted in South Lebanon to assess the prevalence of PTSD. The prevalence of PTSD was found to be 29.3% [13]. On the other hand, in the Dhafor area of Sudan two hundred displaced 10-18 years old school children and adolescents were randomly selected from a resettlement camp in Al Geneina City, Western Sudan, and the prevalence of PTSD was found to be 55% [14] (Table 2).

PTSD Studies on Arabic refugees

A study of the prevalence rate of PTSD amongst the Sudanese refugees in northern Uganda had shown a prevalence of 50.5% among 1.831 Sudanese refugees, in comparison to a prevalence of PTSD of 44.6% of in a sample of Sudanese nationals still resident in the Sudan and 23.2% of Ugandan nationals resident in north Uganda [15]. In their study [16], studied 116 Iraqi refugees in the United States who were in touch with mental health services in the states. They used multiple measures to assess mental health problems including PTSD. The Study found that 54% of the male refugees suffered from PTSD compared with 11.4% in the female refugees.

Norris & Aroian investigated the prevalence of PTSD in 435 Arab immigrant women residing in Detroit, US and the author suggested that 40% of these women fitted the DSM IV criteria for PTSD using the Post-traumatic Stress Diagnostic scale-PSD. On the other hand [17], studied the prevalence of PTSD in 519 Somali refugees in Uganda. He found using the PSD also that the prevalence of PTSD to be 48.1%. Regester et al. [18], reported a UN study on 754 Iraqi refugees in Syria that estimated the prevalence of PTSD among these refugees as 67.6% [18].

A more recent study by Gokay et al. [19], assessed a random sample of 352 refugees (aged 18 to 65) from among the 4,125 Syrian refugees who live in the Refugee Camp in Gaziantep, Turkey. Using DSM-IV-TR diagnostic criteria, the study found that 33.5% of the sample to have had PTSD. PTSD was found to be acute in 9.3% of individuals and chronic in 89%. The average number of traumatic events that these refugees experienced was 3.71 events. Most traumatic events (66.2%) were related to living in a conflict zone area and involved such events as witnessing the death of a close friend or family member in 66.2% of individuals, being abducted or taken hostage in 48%, or being a subject of or the witnessing of torture in 42% of the sample. Another survey of trauma and PTSD was conducted on 155 Syrian refugees living in refugee camps in the northern part of Jordan. The findings showed that the severity of PTSD was greater in female refugees and in those who are educated and married. Also, having firsthand experience of the trauma and being affected or hurt also increase the severity. Also, the refugee having relatives who were physically hurt or lost in the traumatic events was another predictive factor [20].

Also, in a recent survey was conducted on mental health professionals, from high trauma Middle Eastern countries, used quantitative and the qualitative questionnaire. This study found that post traumatic problems were reported as being seen by 65% of the participants. Post traumatic problems were the most prevalent problem as seen in the patients of 80% of the Iraqi participants and 69% of the Syrian participants. Participants felt that they were only able to meet 39% of trauma-clients’ needs [21,22].

Regardless of the terminology or symptomatology, trauma continues to be a major problem due to the current situation in the Middle East. Following the Iraq War, the Arab Spring erupted in response to decades of dictatorship and the despotic practices of the regimes, violation of citizen’s human rights, political corruption. Protecting populations from mental health problems and treating their physical, psychological and social consequences is a noble aim that should be addressed. Traumabased services will not only meet the needs of the community that for long has been traumatized by the oppression and aggressive practices of the despotic regimes but will also help mental health services with newly established themes and objectives to reverse the trend of stigma associated traditionally with the old mental health services.

There is a tragic situation in many Middle Eastern countries where increased rates of trauma related problems and as a resulted, an increased number of mental health problems that has associated with a corresponding reduction in the professionals and resources that could facilitate their jobs and the migration of qualified medical and psychological staff due to the security situation in these countries and also the destruction of many health and mental health facilities. There is a lack of both pharmacological and psychotherapeutic treatments and nonexistence of specialized mental health centres or mental health assessment tools of any description.

The Arab Spring and recent conflicts that followed have increased the need for mental health professionals and services but these have, paradoxically, been driven out of the area as a result of war and adversity. The refugee crisis has created massive mental health problems in its own right where even when therapists are trying to help these refugees they do not find appropriate place to hold psychotherapy sessions.

The only way forward lies in providing training in mental health for primary care providers and (non-clinical) psychologists and in encouraging the development of mental health knowledge and specialism in social work and occupational therapy. There is also the need to train lay people and community workers and leaders on basic mental health awareness and psychological first aid in order to provide psychological health education to the community and reduce stigma. Medical and health professionals can be trained in WHO MHGAP and then om EMDR. The early adoption of EMDR in the region could then be trained to provide supervision to those others working in their area

Mental disorders are closely associated in Muslim society with spirituality and religions. Those with psychiatric disorders are more likely to consult faith healers rather than a psychiatrist or a psychologist [23-26]. This fact makes it necessary for mental health services to incorporate traditional methods of healing and to integrate traditional healers into the newly established mental health services

Following the economic crisis in Europe and the Gulf Arab states, I was repeatedly told, through my regular online supervision that I have with the mental health professionals that Trauma Aid UK trained in the Middle East, that many of the charities that work with refugees have since closed many mental health facilities. This is leaving many of the professionals who Trauma Aid UK and other charities trained unemployed and unable to help the traumatised refugees as they lost their jobs. In view of the magnitude of trauma problems in the region, the only way to meet refugees’ trauma needs is through Middle East, is an EMDR project similar to the Mikong Project in South East Asia which not only trains therapists but also employs them [1,26-29].

1. Matthe B, Helga, Sodemann Ute. Trauma-Aid, Humanitarian Assistance Program Germany. J EMDR Practice Res. 2014; 8: 225-232.

2. Abdul-Hamid W, Hacker Hughes J. Nothing new under the sun: Post Traumatic Stress Disorders in the Ancient World. Early Science and Medicine. 2014; 19: 549-557.

3. Norris FH, Murphy AD, Baker CK, Perilla JL. Postdisaster PTSD over four waves of a panel study of Mexico’s 1999 flood. J Trauma Stress. 2004; 17: 283-292.

4. Everly GS, Barnett DJ, Sperry NL, Links JM. The use of psychological first aid (PFA) training among nurses to enhance population resiliency. Int J Emerg Ment Health. 2010; 12: 21-31.

5. Sartorius N, Schulze H. Reducing the stigma of mental illness: a report from the Global Programme of the World Psychiatric Association. J Can Acad Child Adolesc Psychiatry. 2005.

6. Abdul-Hamid W, Turky J, Hacker Hughes J. Trauma-Based Mental Health Services for the Arab World. Egyptian Journal of Psychiatry.2013; 34: 143-147.

7. Brigham, Robert. Is Iraq another Vietnam. New York: Public Affair. 2006.

8. Solvang, Ole, Neistat, Anna. Torture Archipelago Arbitrary Arrests, Torture, and Enforced Disappearances in Syria s Underground Prisons since March 2011. USA. Human Rights Watch. 2012.

9. Gerrity, Ellen T, Keane, Terence Martin, Tuma, Farris. The Mental Health Consequences of Torture. New York: Plenum Publishers. 2001.

10. Krysinska K, Lester D. Post-traumatic stress disorder and suicide risk: a systematic review. Arch Suicide Res. 2010; 14: 1-23.

11. de Jong JT, Komproe IH, Van Ommeren M. Common mental disorders in post conflict settings. Lancet. 2003; 361: 2128-2130.

12. Qouta S, Odeb J. The impact of conflict on children: the Palestinian experience. J Ambul Care Manage. 2005; 28: 75-79.

13. Farhood L, Dimassi H, Lehtinen T. Exposure to war-related traumatic events, prevalence of PTSD, and general psychiatric morbidity in a civilian population from Southern Lebanon. J Transcult Nurs. 2006; 17: 333-340.

14. Abdel-Rahim FA, Abdelmonium AB, Anwar M. Post-traumatic stress disorder in a school in Darfur, Western Sudan. Sudan Med J. 2009; 45: 27-34.

15. Neuner F, Schauer M, Karunakara U, Klaschik C, Robert C, Elbert T. Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees. BMC Psychiatry. 2004; 4: 34.

16. Jamil H, Farrag M, Hakim-Larson J, Kafaji T, Abdulkhaleq H, Hammad A. Mental health symptoms in Iraqi refugees: posttraumatic stress disorder, anxiety, and depression. J Cult Diver. 2007; 14: 19-25.

17. Onyut LP, Neuner F, Ertl V, Schauer E, Odenwald M, Elbert T. Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement - an epidemiological study. Confl Health. 2009; 3: 6.

18. Regester K, Parcells A, Levine Y. Iraqi Refugee Health Cultural Profile. 2011.

19. Gokay A, Ahmet U, Feridun B, Eser S, Yasin B, Abdurrahman A, et al. Post-traumatic stress disorder among Syrian refugees in Turkey: A cross-sectional study. Int J Psychiatry Clin Pract. 2015; 19: 45-50.

20. Al-Shagran H, Khasawneh OM, Ahmed AK, Jarrah AM. Post-Traumatic Stress Disorder of Syrian Refugees in Jordan. International Journal of Liberal Arts and Social Science. 2015; 3: 36-48.

21. Abdul-Hamid W, Hacker Hughes J, Morgan S. The need for traumabased services in the Middle-East; A pilot study. Jacobs Journal of Psychiatry and Behavioral Science. 2016; 2: 15.

22. Abdul-Hamid W, Hacker Hughes J, Morgan S. The Syrian Refugees Need for Trauma-Based Services, A Survey of Mental Health Professionals. Psychiatria Danubina. 2018; 30: 249-252.

23. Johnsdotter S, Ingvarsdotter K, Ostman M, Carlbom A. Koran reading and negotiation with jinn: strategies to deal with mental ill health among Swedish Somalis. Ment Health Religion Cult. 2011; 14: 741- 755.

24. Saeed K, Gater R, Hussain A, Mubbashar M. The prevalence, classification and treatment of mental disorders among attenders of native faith healers in rural Pakistan. Soc Psychiatry Psychiatr Epidemiol. 2011; 35: 480-485.

25. Karunakara UK, Neuner F, Schauer M, Singh K, Hill K, Elbert T. Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the West Nile. Afr Health Sci. 2004; 4: 83-93.

26. Khamis V. Post-traumatic stress disorder among school age Palestinian children. Child Abuse and Neglect. 2005; 29: 81-95.

27. Sondergaard HP, Ekblad S, Theorell T. Self-Reported Life Event Patterns and Their Relation to Health among Recently Resettled Iraqi and Kurdish Refugees in Sweden. J Nerv Ment Dis. 2001; 189: 838- 845.

28. Cook F, Ciorciari J, Varker T, Devilly GJ. Changes in long term neural connectivity following psychological trauma. Clin Neurophysiol. 2009; 120: 309-314.

29. Mollica RF, Caspi-Yavin Y, Bollini P, Tniciig T. The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture trauma and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992; 180: 111-116