The Experience and Prevalence of PTSD in Palestinian Adults Living in the Gaza Strip Talal El ...

333 Pages·2017·3.23 MB·English

Running Head: PTSD IN PALESTINIAN ADULTS

The Experience and Prevalence of PTSD in Palestinian Adults Living
in the Gaza Strip

Talal El-Deeb
Thesis submitted for the degree of Doctor of Philosophy
College of Health and Life Sciences
Brunel University
June 2017
Running Head: PTSD IN PALESTINIAN ADULTS
DECLARATION
I hereby declare that this thesis has not been and will not be submitted in
whole or in part to another University for the award of any other degree.
Chapter 4 (Study 1) presented in this thesis have been submitted for
publication under review in the PLOS Journals.

i
Running Head: PTSD IN PALESTINIAN ADULTS
ACKNOWLEDGEMENTS
This thesis would not have been possible without the guidance,
support, encouragement, and inspiration from the following people.
First, I would like to thank my supervisor Dr.Terence Dovey (Terry) I
am grateful for his tireless and unending support and guidance. I
would also like to extend my thanks to my supervisory team,
Professor Taeko Wydell, Dr. Michel Price, Dr.Tara Marshall. I am
grateful for their support, guidance, discussions, encouragement to
try new ideas of research, and most of all, their belief in me and this
work when I was short of it myself. Their advice and teachings have
shaped me into a better researcher, academic, psychologist and
writer. I have the utmost gratitude for Professor Abu Hein and his
team for their efforts in collecting the data from Gaza on my behalf.
Without him and his great team, this research would not have been
possible. I would also like to thank all the participants in this
research, for their participations.
On a personal note: This thesis is dedicated to the memory of my
father who passed away in Gaza in 2004, without seeing him. At this
point of my life, I would say: father, your dream became a reality; I
have achieved your wish. Great thanks to my family. I am grateful to
my mother, brothers and sisters who are living in Gaza. I am
especially grateful to my lovely wife Naila, and to my dearest and
beloved sons Mohammed, Ahmed, Mahmoud and to my wonderful
and lovely two daughters Lana and Dina, for their support and belief
in me during this challenging period.
I am deeply grateful to all the friends who have heartily stuck with
me through many difficult years of research. I am especially
profoundly indebted to my friend Clive Hambidge for his unequivocal
friendship, kindness and support during proofreading sessions. I am
Running Head: PTSD IN PALESTINIAN ADULTS
also grateful to Soraya Boyd for her wonderful encouragement
during this testing time and for her great donation. I would also like
to express my deepest gratitude to Samir and Lena Lojain and
Khalid Salah, Dr. Mohammed Hassona for his unequivocal
friendship, Kindness, great efforts, help and support. Big thanks for
those how helped and donated money towards my tuition fees,
especially Um Ali (Ghada Hammad); Fawzia Badass; Hafez (Um
Ahmed), Najeeb Abu Nahil (Abu Ghazi) Dr. Iyad Bardaweel, Dr.
Myssara Bahja, Rajab shamlak and my dear brother
Mohammed Ghazal and Naima Ghazal and last but not the least,
brother Zejad Mehanovic. God bless you all. Finally, I would like to
thank the many unnamed individuals for their assistance and
encouragement in completing this research.
Running Head: PTSD IN PALESTINIAN ADULTS
Abstract
Objective: This study aims to explore the traumatic experiences and to
estimate prevalence and predictor factors for PTSD, depression and general
psychiatric morbidity amongst Palestinian adults living in the Gaza Strip.
Method: A total of 500 Palestinian adults were recruited from four areas of
the Gaza Strip using a snowball sampling. The same sample was used for
both quantitative studies. Four scales were employed to identify predictors for
trauma, PTSD, depression and general mental health. Participants were
divided into three age groups: young adults (18 to 25 years), adults (26 to 49
years) and older adults (50 to 65 years). The third qualitative study was
aimed at exploring the traumatic experiences of adults living in the Gaza Strip
to expand upon the outcomes from the quantitative studies.
Results: For Studies 1 and 2, the prevalence rate of PTSD symptoms was
90% and 36.7% met the criteria of DSM-IV for PTSD. Study 2 found
depression was 38.4%, and general mental health comorbidity was
67.1%. Study 2 revealed significant differences in PTSD between age
groups. Novel results were found amongst adults and older adults on the re-
experiencing subscale for PTSD. Participants who lived in Gaza City scored
significantly higher on the PTSD subscale for hyperarousal compared to
those living in the middle Gaza region. Study 3 expanded on the
psychometric data through interviewing members of the Gaza community.
When analysed five main themes were identified: Siege related stressors;
war related trauma; psychological negative effects; re-experiencing initial
event and coping strategies.
Conclusions: The findings indicated that blockade was the predominant
cause of the increased prevalence rate of PTSD. These studies found that
the Palestinian adult participants in Gaza had been exposed to a variety of
traumatic events on an ongoing basis that was having a detrimental impact
on their mental health.
Running Head: PTSD IN PALESTINIAN ADULTS
Contents
Chapter 1: General Introduction ............................................................ 1
1.1 Children and adolescent studies in the Palestinian territories ....... 6
1.2 Adults studies in the Palestinian territories ................................... 6
1.3 Quantitative studies (Study 1 and Study 2) ................................... 8
1.4 Qualitative study (Study 3) .......................................................... 11
1.5 General Aims of the Current Research ....................................... 13
1.6 Research Questions ................................................................... 14
1.7 Overview of the Current Research .............................................. 14
1.8 Outline of the content of the thesis ............................................. 16
Chapter 2: Literature Review ............................................................... 19
2.1 Introduction ................................................................................. 19
2.2 Definitions of trauma and PTSD ................................................. 20
- Trauma Definitions .................................................................. 20
- PTSD Definition ....................................................................... 22
- Definition of Complex PTSD................................................…...22
- Definition of ChronicPTSD………………….………………..…..23
- Etiology of Complex PTSD and Depression ............................ 23
2.3 Development of Trauma and PTSD in the DSMs ........................ 29
- DSM-5 (2013) ............................................................... 29
- DSM-IV-TR (2000) ........................................................ 30
2.4 Alteration and Comparison between DSM-5 and DSM-IV .......... 31
2.5 Depression .................................................................................. 35
- The Definition of Depression in DSM-IVTR
(2000)………………………………………………………………….35
Running Head: PTSD IN PALESTINIAN ADULTS
2.6 Types of Depression……………………………………………… ..36
- Comorbidities of depression…………………………….……..37
2.7 Post – Conflict Environments in Different Countries ................... 45
- Comparative Studies in Four Post-Conflict Countries ...... 48
- Comparative Studies of PTSD in Gaza ............................ 50
2.8 Risk Factors Leading to Complex PTSD – Gaza ........................ 51
- Exposure to War-Related Traumatic Events ........................ 57
- Political Conflict and Mental Disorders in Gaza .................... 58
2.9 Lifetime Prevalence Rates of PTSD in Gaza and Israel.............. 60
- Palestinian Epidemiological Studies in Gaza ....................... 63
- Sociodemographic factors ................................................ …68
2.10 Summary .................................................................................... 71
Chapter 3: Methodology ....................................................................... 73
3.1 Introduction ................................................................................. 73
3.2 Quantitative studies (Study 1 and 2) ........................................... 74
3.2.1 General Research Hypotheses ........................................ 75
- Cognitive Theory of Trauma and PTSD ................................ 75
- The Cognitive Theory of Depression: Arabic version ............ 77
- Rationale of using DSM-IV TR (2000) ................................... 77
- Justification of the quantitative studies’ variables .................. 79
- Ethical Considerations ............................................................ 81
3.2.2 Methods ........................................................................... 81
3.2.3 Materials ......................................................................... 83
3.2.4 Procedure ........................................................................ 91
Running Head: PTSD IN PALESTINIAN ADULTS
3.2.5 Data Analysis ................................................................... 93
3.3 Qualitative study (Study 3) .......................................................... 94
3.3.1 Justification of Qualitative approach ................................ 94
- Justification of Transactional model of stress and coping.…..95
- Justification of the thematic analysis model…….…………..…96
- Justification for the Qualitative
Variables…………….……………………………………………..…98
- The validity in thematic analysis …….……………………….…99
- Ethical Issues………….…….………………………...…….101
3.3.2 Methods. ....................................................................... .101
3.2.6 Material and Procedure ................................................. 102
Data Collection ………………………..………………………..…….102
- Questionnaire translation and back-translation………………103
- Transcription, Translation and Back-translation …………..…103
3.2.7 Data Analysis ................................................................. 104
3.4 Summary .................................................................................. 105
Chapter 4: Young Adults, Adults and Older Adults assessment of
trauma and prevalence of PTSD ........................................................ 107
4.1 Introduction ............................................................................... 107
4.2 Methods and Participants ......................................................... 110
4.3 Materials ................................................................................... 111
- The Gaza PTSD Checklist (PTSDC) for adults ........ 111
4.4 Procedure ................................................................................. 113
- Statistical Analysis .................................................... 114
4.5 Results ...................................................................................... 114
4.6 Discussion ................................................................................ 117
Running Head: PTSD IN PALESTINIAN ADULTS
4.7 Limitations and Strengths ......................................................... 120
4.8 Summary .................................................................................. 121
Chapter 5: Prevalence and predictor factors for PTSD, depression
and general psychiatric morbidity amongst the adult population in
Gaza ..................................................................................................... 124
5.1 Introduction ............................................................................... 124
5.2 Hypotheses ............................................................................... 127
5.3 Methods .................................................................................... 128
5.4 Materials……………………………………………….……………128
5.4.1 The Gaza Siege Checklist .............................................. 128
5.4.2 The Gaza PTSD Checklist (PTSDC) for adults .............. 129
5.4.3 General Health Questionnaire-28 (GHQ-28) ................ 130
5.4.4 Beck Depression Inventory-II (BDI-II) (Arabic version) .. 131
5.4 Procedure ................................................................................. 132
5.5 Statistical Analysis .................................................................... 133
5.7 Descriptive statistics……………………………..……….…..134
5.8 Results ...................................................................................... 136
5.8.1 Exposure to traumatic events ........................................ 136
5.8.2 Prevalence rate and severity of PTSD among Palestinian
adults in Gaza….………………………….…………………..…….137
5.8.3 Factors predicting PTSD among the three groups of
Palestinian adults ....................................................................... 140
5.8.4 General Health Questionnaire-28 (GHQ-28) ................. 143
5.8.5 Prevalence rates of general psychiatric morbidity among
Palestinian adults in Gaza .................................................... ....144
5.8.6 Prevalence rate and severity of depression ................... 149
Running Head: PTSD IN PALESTINIAN ADULTS
5.8.7 Testing the hypotheses……………………………….……151
- Psychological variables by age……......…….…………….........153
- war and siege……………………………………..……....……..153
- Location of residence……………………………...……….………….153
- Educational levels………………..………………………….…….…..156
- Marital status ....…...……………………………..….….………..…...157
5.9 Discussion………………………………………………..………... 158
- The implications of the study……………….……….…..…..…156
- Limitations and strengths……….……………………….......... 156
- Directions for Future Research……………………...…....……166
5.10 Conclusion…………………………………………………....…....167
Chapter 6: Exploring the Experiences of Adults Living in the Gaza
Strip………………………………………………………………………….169
6.1 Introduction…………………………………………………………169
6.2 Cultural considerations of war-trauma and PTSD………..…....171
6.3 Anthropological contributions to discourses on war-trauma and
PTSD ................ …………………………………………………………173
- Justification for the qualitative study……………….…….…..174
- Aim……………………………………………………….………174
- Research question………………………………….….………174
- Ethical approval……………………………………….….…….174
6.4 Methods……………………………...…………………….….......…174
6.5 Results.. ............................................................................ ..…..176
6.6 Discussion ................................................................................ 200
6.7 Strengths and limitations ........................................................... 206
6.8 Reflexivity ................................................................................. 208