Diagnosis and curing of Post - Traumatic Stress Disorders in the Injured People

War is one of the oldest phenomena that have been paid attention to in all human societies. Post – traumatic disorders have been one of the most important issues of the new wars. Usually the physical problems of war are to some extent curable; but the psychological issues involve not only that person but also his family as well as his society. Therefore providing medical services for these groups of war injuries is one of the most important duties of the officials of that country. There is no such thing as optional medication; rather medications should be based on scientific findings as well as principles. From the point of psychology the rise in behavioral and characteristic disorders, Post – traumatic stress, stress disorders are some of the terrible consequences of violence and war that might be consistent until many years from that time onward. These will have great effects on the person, social relations, economical and cultural effects.

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پنجشنبه - ۱۴ بهمن ۲۰۰۹ / 2009 14 November

Introduction:

The occurrence of the psychological disorders resulted from the war were taken in to consideration since the second half of the 19th C.

The consequences of the World War II and the wars of Korea and Vietnam have made a condition for the professional Psychiatrists and social sciences to investigate the effects of strong psychological stress resulted from the wars on the health and illness as well as the character of thousands of human beings. The post – traumatic Stress Disorder is one of the most important disorders which have resulted in terrible experiences. Regarding this disorder many investigations have been conducted theoretically; but there has been little progress in curing the misfortunes of this kind (Lindsay and Paul, 1994). During the war of Iraq against Iran this disorder was one of the most noticeable psychological disorders that have been viewed in the warriors. The people who are afflicted with this disorder have witnessed a lot of deadly events that have caused a lot of injuries in them. Or they have experienced the morose taste of terrible events that were accompanied by strong fears and hopelessness as well as their fears. The other signs might include depression, stress and cognitive problems. The people who are afflicted with these traumatic happenings always remember their nightmares and memories; they try very hard to prevent them from happening again to the extent that is possible. The stress that causes Post – Traumatic Stress Disorder is so strong that it is enough to disable even the strongest men. War, captivity, torture, and mind wash are some of the most important reasons for P. T. S. D. But this disorder can occur in reacting to whatever condition that might be harmful.

The History of Traumatic Disorders against Wars

Some signs similar to P. T. S. D. have been described during the American Civil War; it was mentioned in the name of “Irritable Heart Syndrome” with signs of boredom, Asthma, hear beating, headache, extreme sweating, feeling dizzy, disorderly sleeping as well as feeling weak. The reason why it was called so was because heart signs which were due to over – activity of the automatic system of the body. Jacob Dacosta has called it irritable heart in 1871. In the years 1900 – 1901 it was called Threatening Nevers; this syndrome was called by the English colonel Frederic Moot explosion wave.

He believed that these reactions such as presence conditions occur during mind bleeding. It was at first believed that this syndrome occurs due to the explosion of the cannon balls (Colman 1376). During the Second World War the interest in studying the psychological problems that wars may cause. Abraham Cardiner has described the signs of this illness in the Second World War. At those times it was advised to the psychiatrists to use Barbiturates, Insulin, Ether, Amphetamine and CO2 as well as general medication in curing the patients. The similar signs to those of P. T. S. D. in the beginning investigations as "Camp Syndrome" as well. In the Second World War expressions such as War nevers and boredom of operation were common. It was estimated that 10% of the soldiers who took part in that war showed signs of war boredom. In the Korean War it was 3. 7 %. (Colman, trans. By Hashemian, 1376) It was at the end with the retirement of the soldiers who participated in the Vietnam War that the concept of P. T. S. D. formed. Table No. 1 shows the most prevailing signs in the six wars of: 1. First World War (1914 – 1918 ) 2. Second World War (1939 – 1945) 3. the War of Vietnam (1964 – 1973 ) 4. The Fourth War of the Arabs and Israel ( Ramadan 1973 ) 5. The War of Lebanon 6. Six Years of Imposed War. The conference of Dr. Mohajer about the New Years Day in 1363 quoted by Fabod Badaei.

Table No. 1: Comparing the Signs in Different wars:

First World War

Second World War

the War of Vietnam

The Fourth War of the Arabs and Israel

The War of Lebanon

Six Years of Imposed War

Stress

*

*

Morbidness

*

*

*

Fear

*

*

*

Limitation of the Sense

*

Nightmares

*

*

*

Extreme Boredom

*

Lack of Appetite

*

Abdominal Ache

*

Headache

*

*

Jumping Reaction

*

Disorderly Sleep

*

*

Psychological and moving Changes

*

Shrinking

*

*

Changing Reaction

*

*

*

Bewilderment in time and Place

*

Breakthrough Reactions

*

Separation from Society

*

Anti – Social Acts

*

Source: psychology and War: ( 1364)

Shakespeare has talked about the signs of P. T. S. D. which has been described in DSM – IV, in his Henry IV. The first medical source to discuss P. T. S. D. was Silas Michel who has described the answers of the male and female soldiers, who have survived the civil war, to the stress. These people were used to using Alcohol and drugs to control the signs that they see in themselves. It was in 19th C. when Herman Wenham said that the signs related to P. T. S. D.  Have organic and structural origin. Jane Sharko thinks that the origins of these signs are psychological. The psychotherapy theory was in agreement with this idea because nevers were not possible to occur in the childhood except with serious damages. This means that there should be a positive background for this illness to grow up.

Some of the victims of wars who have shown the reaction to war stress during the war could have the background to be afflicted with P. T. S. D, especially when the victim of CSR accepts the label of being an ill person; such person accepts wholeheartedly the danger of P. T. S. D.  Or in whatever way it might happen (Gal and Mengelsdorf, 1381). . . . . . . . It should be noted that the intentional physical and emotional torture have very dangerous psychological effects comparable even worse than the war itself or the other kinds of trauma. The captive people have for most of time experienced punishment, emotional aches, inhuman cruel behavior, malnutrition, forced movements, observing the others being beaten, terrible and downgrading conditions of living. It has been more common to use a mixture of physical and psychological tortures.

Torture causes fear, feeling inability and in the end psychological weakness (Sokr Kon Hussein and etal. 1994 (1373 ). The researchers agree that the severity and the period of P. T. S. D. will, most possibly, be further if the stressor is a human being. The studies also show that the tortures always accompany depression and stress. The other psychological complaints were mostly including physical tortures, whimsical – forceful signs, anger, enmity, phobias, paranoid thinking and psychic problems (Kaplan and Sadook, 2003).

The term P. T. S. D. has been discussed since 1980 after the compilation of DSM – III. P. T. S. D. is distinguished among the old soldiers by a mixture of the coinciding the new experience, excitement and signs of vapidity, and preventive signs. High excitement in most of them causes lack of sleep as well as lack of concentration and lack of occupational performance. Being too provocative and in some cases psychological forgetfulness sometimes occur as a result of this perversion. Anyway the old soldiers of the World War II are still looking forward to finding a solution for this even if it is 60 years passed since those times (Lasset and Hersen, 1999 (1378).

Most of the concentrated studies on the dangerous factors of P. T. S. D.  have been making use of the studies which have a glance over the past researches. There are few studies which have focused on the investigation of the immediate or latent dangerous factors of facing with the traumatic events. Hindez and his colleagues have conducted a research in 2005 and tried to identify the predictive dangerous elements for the signs of P. T. S. D. and the accompanying pathologic signs in 43 professional firefighters as a group which have high risk immediately after education and then in 6 , 9 , 12 , and 24 after starting their works. The group under study has been investigated according to the signs of P. T. S. D, depression, stress, and personal characteristics such as depression, personal capability and enmity. The activity of endocrine neurotic gland system such as the daily discharge of the Cortizole and the excretion of Ketkolamins have been investigated. The analysis and investigation of the linear regression to analyze the signs of P. T. S. D. in a 24 months period as the performance of this disorder has been used. The high scale of enmity and the low scale of personal adequacies in the basic line were the signs for 42% of variance of P. T. S. D during two years. The test takers who have signs of being risky had a lot of general signs and depression and showed a meaningful rise in the signs related to P. T. S. D such as depression, stress, general psychological illness, the severity of general signs and the sense of depression. The biological characteristics in this investigation did not predict the increase in psychological signs.

According to the latest scientific definitions of P. T. S. D there are a large group of Iranian warriors and self sacrificial heroes who are suffering from this trauma. In addition to this group the number of who reaches 756, 158, 2 there are a lot of people who are living in the west and south of the country that are afflicted by the traumatic incidents during the 8 years of holy defense war. They are now living with us and in different cities while they have the sings of P. T. S. D. and all of then need professional medications. (Noor Mohammadi and Jebli Sinki, 2006 (1385). Ahadi and his colleagues have shown in their research conducted in 2006 that 45. 5 percent of the injured people of the imposed war are afflicted with P. T. S. D. They are not at all satisfied with their marriage; they have shown that there is a positive relationship between the severity of the signs of P. T. S. D and the dissatisfaction of marriage life. (P < % 5). Sexual problems and the severity of the signs of P. T. S. D. are the most important factors in predicting the degree of marriage dissatisfaction among the injured people of the war who are afflicted by P. T. S. D.

Jafar Mirzaei and his colleagues have also conducted a research in 2004 (1383) based on the accessible sampling; they have investigated 20 persons of the war injured people who are afflicted with simple P. T. S. D. and 20 other persons who are afflicted with advanced P. T. S. D. Then they have conducted the questionnaire of M. M. P. I. and the interview of P. T. S. D.

The results confirmed that those persons who are afflicted with advanced P. T. S. D. have gained the highest mark in the basic signs of P. T. S. D. The other 20 persons of the war injured people who are afflicted with simple P. T. S. D. have gained high marks in excitement, limiting the differentia of emotions, flash back, and problem in concentration as well as physiologic reactions. In addition, regarding the comparison of the psychological and clinical M. M. P. I.., there were no meaningful differences in other factors except for the factors of K – Hs – Ma among the two groups.

Noor Mohammadi and his colleagues 1981 (1360) in a descriptive study during 4 month had studied 34 warriors taken from 25 army, brigade and battalions who have fought in different operational areas according to the latest diagnostic and statistical criteria by the use of P. T. S. D. interview and recognized that they test takers have torrid P. T. S. D. They have then investigated them by the use of a questionnaire having 55 questions made by the researchers themselves. The results showed that from the point of view of personality 26 % of the test takers have been introverts and 76 % of them were extroverts. These people showed the following psychological signs more than the others; these signs were headache ( 67 % ), fear ( 58 % ), having nightmares ( 52% ), anger and aggression ( 47 % ), lack of appetite, hear beat ( 41 % ) and respiration ( 38 % ). The research of Shakeri and Sadeghi 2003 ( 1382 ) focused on determining the relationship of stressful events and the ways to prevent the reversion of P. T. S. D. in 100 injured warriors (50 injured warriors with the reversion of P. T. S. D. and 50 injured persons without the reversion of P. T. S. D.). The results showed that the injured warriors without the reversion of P. T. S. D. have experienced more stressful factors. P<% 0001, 6. 39 = 98 t. These two groups have meaningful differences P<% 0001, 2. 7 = 98 t. From the point of view of contrast the injured warriors with the reversion of P. T. S. D. use more the contrastive method of avoidance – escape. Khaghani Zade and Sirati 2004 ( 1384 ), have investigated 138 injured warriors who have had psychological problems; these people had the record of reversion of the illness on three dimensions such as private, familial, social and economical dimensions and they found that  37% of them are afflicted with P. T. S. D. and 1.4 % of them were afflicted with psychic problems. According to the variants of this research 85 % of them consider the irregular use of medications, 9. 64 % consider avoidance of referring to the doctors, and 97. 3% consider the loss of their jobs as the effective elements on worsening the effective elements. Lack of harmony, lack of compatibility and lack of respect on the part of the wife had a percentage of 3. 91%.

Parande and his colleagues 2006 (1385) have conducted a research to study the effects of educating them to solve the problems for the sake of safety and improvement of the life quality of the wives of the injured warriors who are afflicted with P. T. S. D. In this experimental study 28 women (wife of those warriors who are afflicted with P. T. S. D.) have been chosen from the Baghiat Allah Hospital and Sadr Psychiatric Center at random; they have been categorized into two groups: opponent group and witness group. The result of T – Test showed that the average of the life quality before meddling with the two groups under study have had no meaningful difference (P > % 05). But after meddling with the two groups this test showed a meaningful relationship between the two groups (P= % 001 ). The Even T – Test showed that the average of the life quality scales before and after meddling with the test taking groups are different. P = 0. In addition the statistical test of Freedman showed that the average of life qualities in the meddling group in three stages of study showed meaningful difference. P = % 0001. With regard to the results of the study the researchers suggested that in order to improve the safety scale and the life quality of the people in society especially the quality of the life of the injured warriors’ families some educational programs to solve the problems were used.

Epidemiology:

The breakout of the P. T. S. D. during life can afflict 8 % of the general population. The breakout of this illness among women during life is about 10 % – 12 % and among men it is about 5 % - 6 %. (Esmaeil Ali Pour and Lorestani, 2005 (1384). An extensive analysis of the psychological disorders resulted from the war is fairly new. The epidemiologic studies were conducted on the male and female Vietnamese soldiers in the mid 1980s. This studies showed that the rate of P. T. S.  D. among the soldiers who have served for 10 – 20 years of their lives in the war has been 15 % for males and 8 % for females. The prevalence of P. T. S.  D. during the rest of the life of the male participant soldiers has been more than 30 % and among the female soldiers it has been 25 %. The reported rate of P. T. S.  D. in people who have been tortured is 36 % more than the average prevalence in the life time. 10. 1 % P. T. S.  D. has been viewed in the participant of the Persian Gulf in 1995 – 1997 who have had responsibilities in the war. In the war of Somalia between the years 1992 – 1994 about 8 % of the American soldiers have been afflicted with the P. T. S.  D. Nowadays the rate of P. T. S.  D. among the American soldiers returned from the war of Iraq is between 15. 6 % to 17 . 1 %. (Freedman, 2004). In some groups the prevalence of P. T. S.  D. has been reported more than usual. For example the prevalence of the P. T. S. D. among the American soldiers who participated in the Vietnamese war has been about % 30 . The rate of affliction with P. T. S. D. has been reported among the captives and those who have been tortured to be about 75 %. (Esmaeil Ali Pour and Lorestani, 2005(1384) and Colman 1997 (1376). There is no exact statistics about the prevalence of this illness in Iran (Esmaeil Ali Pour and Lorestani, 2005(1384). Regardless of almost any complication about 15 % of the old soldiers who took part in wars have been afflicted with P. T. S. D. (Ashley 2004 (1383). The most influential factors on this disorder include the time and the closeness of the person to the real Trauma. Therefore paying careful attention to identifying the inured warriors who are afflicted with P. T. S. D. and curing it is a necessity and a need.

P. T. S. D. and the Accompanying Disorders:

There are some prevalent psychological disorders that have been reported to accompany.  In some cases it is said that the accompanying disorders with P. T. S. D. is itself a rule. What is really certain is that in about 75 % of the cases P. T. S. D. has been accompanied with other disorders. The disorders that are said to accompany P. T. S. D. have been named as depression, drug addiction and alcoholism, stress disorders especially feeling terror, aggression, feeling and thinking about suicide, paranoid thoughts, strong disorders in performance, daily works and occupational and social disorders. (Esmaeil Ali Pour and Lorestani, 2005(1384) and Ashley 2004 (1383). Disorder in familial duties is one of the most important disorders. Remembering the painful events out of the blue causes anger and aggression and this causes the afflicted person to be terrorized a lot. Remembrance of the war scenes in sleep as nightmares and in one’s dreams causes shouting and yelling and etc. This causes fear and threat among the other members of the family and indeed makes a terrible condition in the family. The person who is afflicted with P. T. S. D. feels that no body loves him and because of having problems in showing his own emotional sensations he unwillingly cause this kind of emotion to come down among the members of his own family. Socially he prefers solitude and the only excitement that such a person might show is anger. He feels that he has no individuality and thus of no importance for the family members and due to his defensive behaviors with regard to the members of his family, he always behave aggressively. His aggressive and violent behaviors towards his wife cause his aloofness from his wife emotionally and this sometimes entails legal problems. In the children of the afflicted people with P. T. S. D. signs of aggression, educational downfall, lack of concentration, feeling no body loves them, taking care of parents and addiction as well as alcoholism are seen . . . . . The afflicted person due to his lack of emotion and seclusion imposes the feeling of emptiness of emotion to his family members. Lack of liveliness in the family environment, existence of a great gap in having emotion and sensation towards each other, waking up late at night, passing quite a lot of time in front of the TV, lack of attention to each other as well as seclusion and lonliness are seen a lot. (Esmaeil Ali Pour and Lorestani, 2005(1384) and Ashley 2004 (1383).

Cause Analysis:

P. T. S. D. is one of the few psychological disorders that have been defined based on reason. Of course this illness can not come into existence without the existence of a stressor or damage and . . . . . In any way the eventful incident by itself can not be enough to the diagnosis of this illness; there are many people who are under stress but they are not afflicted with this disorder. Possibly there is an interaction between the event and the victim. There is a strong relationship between the signs of P. T. S. D. with the importance and the meaning that the person concerned considers for the stressor i. e. he considers it serious towards his immunity. There is not a direct relationship between the strength of the stressor and the signs of P. T. S. D. Those who are fearful, those who feel lack of protection, those who are embarrassed or those who feel, have a higher potential for P. T. S. D.

It is necessary to consider the previous biological factors, social and emotional factors before the event, characteristics of the stressor, time and place of the accident, situational and personality characteristics and the conditions of the post trauma should be considered. In addition the intrinsic meaning of the stressor is also important. The survivors of an incident may feel the sense of guilt and this can prepare them to be afflicted with depression and even P. T. S. D. and even . . . . . .may worsen the conditions.

P. T. S. D.  Usually appear after the stroke. This time may take a small amount of time such as a week or take a longer time such as 30 years. These signs may change and they might be under stress as well. About 30 % of the ill people may recover completely and there may remain weak and average signs in 40 % and 20 % respectively; in addition 10 % of the ill people will remain without any change or their conditions become worse (Kaplan and Sadook 2003). All in all in epidemiology of P. T. S. D. it is necessary to pay careful attention to stressors, biologic factors, Sympathetic activities, neurotic – gland performances as well as psychological factors.

There are three psychological models based on the theories of psychological mobility and cognitive psychology (processing information) and behavioral psychology. In the psychological mobility method it is believed that as a result of a stroke a hidden but unresolved complex will be activated. Freud and other psychiatrists have tried to solve the signs and causes of epidemiological nevers. The rejuvenation of the childhood nevers will be activated due to regression in the ideas of the psychiatrists. Prevalent defense mechanisms are: rejection, separation, oppressing the events, neutralizing the events in the dreams and forceful recurrence of the damage. These are some more efforts to comply with the event and how to siphon off the energy.

The P. T. S. D. has been based on the idea that the afflicted people are unable to solve or process or justify the stroke that has caused the acceleration of the disorder.

The information analysis model explains the way that the illness progresses or develops. It is possible that fear is stored in the memory and there is the possibility that the information about the stimuli is also stored in the mind. Because the dangers that threaten life create strong responses. The gap border between what is dangerous and what is not remains dim and those who are under these fears may feel the loss of their control and with regard to their environment they may lose their predicting power.

The behavioral psychological method . . . . . . supposes the creation of this disorder in two stags: the first stage is the stage of confrontation with the danger (unconditional motive) which accompanies the conditional motives (and this includes the basic events, pictures and thoughts as well as situations that are similar to the danger). Then the afflicted person avoids both of unconditional motives and conditional motives through learning and this process continues because it decreases stress and increases conditionality to a great extent. This theory has proved to be beneficial in curing P. T. S. D. (Tavallei Zavare, 1997 (1376 ).

Diagnosis:

The complex signs of P. T. S. D. may not show themselves until some weeks later. There is the possibility of re – experiencing the signs of that trauma in the beginning days of facing a difficult experience. In some cases the signs appear afterwards. The strong stress was discussed in DSM – IV for the first time. In investigating P. T. S. D. it is necessary for the afflicted person to pay close attention to the quality of the signs, continuation, regression and un – pleasantness of the signs. The diagnosis can be done through diagnostic interviews or through psychological tests. There is no acceptable reason to say there might be differences in the signs in different people based on their age, gender, race or clan as well as the kind of the trauma. It is possible that the physical signs of P. T. S. D. are seen in people from different cultures and the children as well. The diagnostic criteria based on the edited version of the fourth version of DSM – IV – TR for T. S. D. are:

A – A person is imposed on a traumatic incident in which the following two factors are available:

1. That person has experienced or observed a phenomenon or phenomena that was / were related to real death or threat to death or they have been witnessing a serious threat or he / she has observed something that was a threat for his own being or for the others.

2. The reaction of that person has been accompanied by strong fear, depression or fear. Attention: It is possible to see restlessness and uneasiness in case such a thing happens to them.

B. The harmful events are experienced again in one or many other ways continuously:

1. Remembering terrible events that may cause worry repeatedly.

2. Repeated dreams about the terrible events that may cause worry. Terrible dreams are extant in children without specific content.

3. An action or a feeling that may impart the sense that as if an event is taking place. This may include feeling the experience again, sensational mistakes, dreams, and a be – latent analytical period such as those that might happen in awaking or those which occur during being poisoned.

4. Strong psychological worries in facing the inner and outward signs that are the symbol or like and an aspect of that terrible event.

5. Physiological answers in facing the inner and outward signs which brings that event symbolically back to the mind.

C. Avoiding continuously the motives related to the event and decreasing the general reply on the part of the ill and this was not previously existent before the ailment. This might be clarified according to at least three points:

1. Avoiding the thoughts and feelings related to the event.

2. Notable decrease in interest or participating in important activities.

3. Failing to remember a very important aspect of the event.

4. A decrease in the interest or lack of interest in the important activities.

5. Feeling separated and being lonely and rejecting to participate in relationship with others.

6. Limitation of the emotions.

7. Feeling that the future is cut shorter or feeling that every thing is impossible (for example one does not expect to find a job, to marry and to have children as well as to have natural life period).

D. Continuous signs of progressive motivation that have not been existent before the event and that is clarified based on the two or three signs recorded as below:

1. Having problem in sleeping and having a continuous sleep

2. Motivation or angry attacks

3. Having problems in concentration

4. Being on guard very strongly as if waiting foe s. th. that will happen

5. The increase in jumping reaction

E. The period of this disorder is more than one month.

F. This disorder may cause severe worries or damaging social, occupational and other performances in the afflicted person.

The P. T. S. D. will be bad if it is less than 3 months.

The P. T. S. D. will be chronic if it takes more than 3 months or more for the signs to show.

The P. T. S. D. will be latent if it takes at least 6 months for the signs to appear before the event itself.

The diagnostic factor DSM – IV – TR about emotional pressure is to some extent is similar to P. T. S. D. except that the signs of the disorder take about at least two days and at most four weeks. In addition to this, of the other signs of P. T. S. D. it has to have three of the following characteristics:

mental feeling of boredom, separation as well as exciting answering.

decrease in the environment information or feeling bewildered such as becoming silent.

rejecting reality

rejecting of personality

inability in remembering an important part of the event

Thirdly the signs of high stress should not be due to using drugs or illness either it should not be the worsening of the previous psychological ailment of the person concerned.

In diagnosing it is necessary to distinguish P. T. S. D. from stress, depression, fear disorder, sensational – forceful disorder, analytical disorder, edging characteristic disorder, artificial disorder, feeling sick as well as physiological disorders.

The latent P. T. S. D.

By latent or late P. T. S. D. it is meant that there is a gap of at least about six months from the event itself to the time that the signs are felt.  This kind of P. T. S. D. is rare but the possibility of its existence has been proved. Among the soldiers survived the wars and the victims of sexual harassments has this kind of P. T. S. D. been reported. The reason for the creation of this kind of P. T. S. D.  is not specifically clear. It is possible that the disorder starts 30 to 40 years after the damage. In these cases the motives that initiate the ailment may be the un – resolved aspects of the initial damage or when a person is retired or has a physical problem, or he has not social or material ability, the previous ( past ) memories would come in to being again. In addition P. T. S. D. is always accompanied by other psychological disorders the activation of which may cause the activation of the P. T. S. D.

Procedure and Pre – Knowledge

All in all, children and old people will have more problems in dealing with the damaging problems in comparison to the middle – aged people. For example 80 % of the children who are scorched or scalded will show signs of P. T. S. D. a year or two years after the incident while this rate is about 30 % for the middle – aged people who are scalded. Lack of access to social protections will also be effective on the emergence, severity and duration of the P. T. S. D. Generally, the ill people who have a good social protection will not basically be afflicted with this disorder and if they are afflicted they would not show its developed signs. Being aware of this ailment is good when the following conditions are available:

The signs start immediately after the damage (less than six months since the event).

Before the ailment the performance of the ill person should have been good.

Good and strong social protections are available.

There should not be other psychological disorders or previously existent disorders did not exist.

There should not be malnutrition and addiction to the drugs.

About 30 5 of the ill people who are afflicted with P. T. S. D. will recover the illness. 40% will have weak signs, 20 % average signs and in about 10 % of them will show no change in their signs and even the signs would change for worse.

The Syndrome of the Persian Gulf War

The Persian Gulf War has started in 1990 against Iraq and it ended in 1991. There were about 700000 American soldiers participating in the coalition forces. Upon their return to the United States more than 50000have reported a large scale of signs in healthcare issues such as feeling severe boredom, asthma, muscle harms and physical hurts, migraine, lack of sleep, abdominal problems, loosing hair, forgetfulness, as well as lack of concentration among other signs. These signs were called all in all the syndrome of the Persian Gulf. Soldiers attributed these signs to the biological and chemical factors such as chemical e physical complaints and psychiatric problems among the soldiers who participated in the Persian Gulf War compared to those who participated in the German and American bases who have been afflicted with this syndrome. This has been proved even with the anthropological considerations. (Kaplan and Sadook, 2003).

The General Cure:

When a person has experienced a terrible event or experiences his sense of aestheticism in the world is threatened and as a result his basic ideas concerning the world, the meaning of life, and his own self. Bitterness, boredom, and hopelessness will overwhelm him and as a result he does not regard himself to be a valuable person. The curing of the people who are afflicted with P. T. S. D. will be complicated a multi – dimensional. Generally it would be useless to cure such people based on a specific methodology. The basis in clinical medication of this illness is to face and stand against the damaging memories directly. (Lasset and Hersen, 1999, (1378). It is necessary to conduct clinical interview and prepare a physical, emotional, familial and private histories of the injured warriors having a special care for the drug addiction. After this, what is done is through cognitive interviews and then psychological tests which are to attest more and to make sure that the diagnosis is right and also to discover the accompanying disorders. These are done by the medical team. It is necessary to evaluate the social and emotional problems and to evaluate all the performances. Determining cases, such as lack of control over one's anger, drug addiction and finding the negative thoughts and self – degrading ideas as well as determining how the signs of P. T. S. D. have affected specific relationships, their performances in work, their social interaction and their leisure times are the primary concerns of these tests. Determining short time and long time goals with regard to the kind of the illness form the basis of the next step. Psychological meddling, psychiatric tests and familial ones are done in order of their importance or they are done at the same time. The explanation of the illness and avoiding labeling the ill person or his family are vitally important. Some facts about the terrible event will be collected step by step and with careful attention. The exciting reaction of the ill person at the time of the investigated event and the inappropriate confrontation with the terrible event such as drug addiction should be investigated. (Junksma and Peterson, 2002 (1381).

Mirzamanai (2004 (1383) ) has named some psychological steps to psychologically prevent the severity of P. T. S. D. on three levels. Regarding the bad stress it is preferred to solve the problem and the stressful event by issues such as encouragement, supporting the ill person to talk about the problem as well as to educate them about the different kinds of mechanism to face the problem.

Using drugs that cause sleepiness and calming down might also be useful. In order to cure P. T. S. D. in its progressed case there might be the need to group or personal cares based on the harmful event. The aim of this kind of medication is curing is to create emotional wholeness. Sometimes it is necessary to cure by the use of drugs. In some case that the medication method is not useful sometimes long supportive medication administered. Encouraging this people to do sport regularly and helping them know familial, social and exciting factors are effective reducing the signs. Using educational books especially to guide parents and the wives of the injured people are useful to understand the ill people and to help standing against them effectively. The person who cures these people has to give important information about source and the groups who are in the affinity of the ill people. It is necessary to give information on the names and addresses of the organizations supporting them. Paying attention to getting the trust of the ill and ensuring them that he has understood the problem very well.

Personal Psychiatrics:

Psychiatrics in P. T. S. D. he has to meddle with supportiveness, to encourage them to accept the events, to prepare and to educate, and to learn confrontational mechanism and to accept the events. Nevi (2002, 1381) quoting Eliasi believes that the curing process and meddling process in curing CSR and P. T. S. D. are based on four principles: Starting natural and compatible reactions, emphasizing on usual social protection and in case of loss he has to help them through other ways. He has to help them to understand themselves as a safe and compatible person and to help them not to consider themselves as ill people. He has also to help them siphon off the excitement. The cognitive perspective emphasizes on the reconstitution of the ill person. The psychiatric short term behavioral curing with having emphasis on the damaging emphasis is necessary. Step by step facing with the terrible events through loosing sensitiveness and conducting imagination to reduce reaction excitement against terrible events is also important. Of course studies in the medication of the illness in different societies. Therefore the results are dim and it has to be adapted to the cultural and religious characteristic of the Iranian society. Ashley believes that we have to take careful attention to the P. T. S. D. and the primary needs as well as understand their need to the immunity and the value as well as worth of the injured warriors. They would not reach worth and value until they feel immunity. In order to reach this stage it is necessary for them to change into successful men by the use of different mechanism (Ashley, 2004, (1383). The fact that the medication is short time will be effective in creating the independence and its being dangerous. In the cognitive medication, the injured people are required to write in details about the traumatic event and he is asked to read what he has written loudly in the medication session.

Another method of medication to face with the traumatic incident is to cure with the method of imaginary overwhelming. The conditions to use them are:

The ability to tolerate a severe scale of exciting or physiologic motivation.

Reaction to the damaging memories that is specific and clear.

Having ability to create mental ability.

Lack of depression along with the other disorders that exist.

A high scale of motivation and good cooperation.

Systematic cleansing of sensation (scaled confrontations) can also be effective on the effective damage. This medication can be done through mental images or in the environment.

The other model of medication is to neutralize the aggressive thoughts of the ill person or to organize them. In this method of medication the unity between the medical agent and the ill person is of great importance. The use of drug in this method is not so much. In this model it is tried to make life seem more complete and a whole by the use of life styles. In this model it is tried to decrease the aggressive and avoidable thoughts in the ill persons. Of course there are some limitations to these methods of medication such as the kind of personality, the degree of personality disorder, lack of ability to express and tolerate emotions, available protection system, cooperating with the medical person, the nature of the illness, the level of excitement and whatever that might limit the custom and the disorder in concentration and memory as well as. . . . . . . of the other methods of medication we can name psychological retelling. In this method the ill person should be encouraged to review the events and to siphon off the emotions. He should be encouraged to have plans for the future. This method will be useful if the patient has the ability to remember the damaging event of the past and he is not stressed.

It is necessary to hospitalize the patient if the crisis is very serious or there is the possibility of suicide or to kill others. Epstein (1991) and Schwartz and Prout (1991 quoted by Klinke) propose a 6 scale processes to help and stand against P. T. S. D.

Establishing a relationship with the medical officer or the supportive groups. That is, the ill person should express himself and not to abstain from talking.

Educating the patient about the process of recovering from stress.

Learning and using methods for controlling stress.

Experiencing the event for the second time and making it seem less serious.

Doing meaningful activities.

Accepting terrible events (with finding) meaning for life and believing one's own worth.

Familial Medication and Group Medication:

Familial psychiatric helps the family to pursue their life while the signs are increasing and this is very simplifying. Centralized group medication focuses on the P. T. S. D.

And it is one of the methods that is used in curing P. T. S. D.

Easing the Body:

Using the method of P. T. S. D. can increase the physiological and kinetic aspects of the disorder. The method of progressive muscle relaxation, hypnotism and bio-feedback can also be useful methods. Deep progressive muscle relaxation along with deep abdominal breaths and positive imagination are educated to create peace.

Suggestions:

Religious beliefs, one's views of deaths and the spirit of seeking martyrdom and believing in the immortality will cause differences in the reaction of different people to different damaging events, threats and threatening memories. This had helped the injured warriors to have a weaker reaction at the time of stress. Therefore it is advisory if the religious beliefs of the injured warriors are taken into accounts. It is necessary that the healthcare specialists of psychology consider the possibility of the existence of P. T. S. D. They might be very sensitive and there is the possibility that they consider this as an acceptable part of their nature.

Most injured warriors have physical problems and this entail some psychological issues. Therefore having friends that have the same fate is most effective as they are able to be compassionate towards them and this will help them in decreasing their physical and psychological hurts.

Of the psychological protections such as social and official as well as unofficial protections such as neighbors and friends, families and relatives and the cooperative groups for the use of the drug can also be useful.

Stressful events and continuous confrontation with them will cause the remembrance of the P. T. S. D. Attending to the physical and emotional as well as preparing a supportive social protection will cause emotional ease and prevents its re – happening. The released captives have many familial problems in addition to P. T. S. D.  Therefore educating effective ways to confront the stressful events and have very useful influences on curing them.

In some cases P. T. S. D. is not diagnosed correctly because of its being mixed with other emotional disorders such as stress disorders, ache disorders, physical disorder, addiction to the drugs as well as emotional disorders and in this way it leads to the mistaken medication. It is a vital necessity to distinguish this illness among the injured warriors who are emotionally damaged.

It is necessary to pay attention to the ideas ad views of the injured warriors in the contemporary situation. In some case the injured warriors are not regarded as a hero while they have had their life endangered for the sake of us and our country. In some cases because of the downgrading behaviors of some other people they refrain from telling others that they are injured warriors. This as a strong stressor has been very influential in having the disorders. Family education, especially educating the wives of the injured warriors regarding P. T. S. D., is very influential. And the increase in the v is of vital importance in enabling these people to manage their lives and this raises their knowledge about how to manage their works; this is in turn a basic step in curing and controlling this disorder and in keeping the family together.

Sources and Bibliography:

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Esmaeil Ali Pour, mohammad Lorestani,Fahime (2005) 1384. Family Hearlthcare in P. T. S. D. Tehran. Engineering and Medical Research Center of the Injured warriors.

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Written By: Abdol Ali Yagoobi