Posttraumatic stress disorder correlates among internally displaced Yazidi population following Islamic state of Iraq and Syria attacks in Iraq

At the beginning of 2014, the so-called Islamic State of Iraq and Syria (ISIS) took over large areas of northern and central Iraq, and they controlled one-third of the territory of Iraq by the end of 2014 [1]. The continuous armed conflict in the country led to the displacement of thousands of Iraqi people. The United Nations (UN) estimated that 3.2 million Iraqis were internally displaced persons (IDPs) by the end of 2015 [2]. On August 3, 2014, ISIS launched a very large attack against Yazidi and gained control of the city of Sinjar and the surrounding villages in northwestern Iraq [3]. Almost 6800 people were abducted by ISIS, and approximately half of them were later rescued. Approximately 200,000 people were displaced within a few days, and the majority of them were Yazidis. Yazidis are a religious minority who speak Kurdish and inhabit northern Iraq, Iran and Syria and southeastern Turkey [3]. They refuse religious conversion, which is why they have faced many genocides in their history. The bulk of the displaced people resettled in refugee camps around the city of Duhok in northern Iraq [4].

Refugees and IDPs are a population that is highly vulnerable to mental disorders compared to native and other migrant populations [5]. Exposure to traumatic events in the homeland, such as persecution; torture; combat; imprisonment; threats because of ethnicity, race, or religion; lack of food, water and shelter; separation; and violence to or death of family members, is a common reason for displacement [6]. Posttraumatic stress disorder (PTSD) and depression are the most commonly reported mental disorders with a wide range of occurrence rates [7].

PTSD can be defined as a mental disorder that can occur if an individual experiences, witnesses, or confronts a traumatic event. Patients with PTSD may suffer from intrusive thoughts about the traumatic experience and flashbacks as well as avoidance behavior and hyperarousal symptoms such as irritability and disruptions in sleep and concentration [8]. PTSD is highly prevalent among refugees, immigrants and asylum seekers at a rate of 9–36% compared with the rate of 1–2% in the general population [9]. In addition to severe traumatic events and lack of social support during such situations, the common predictors of PTSD among traumatized individuals are being young, female, having lower socioeconomic status, a family history of psychiatric disorders, and being of a minority race [10, 11]. The number and types of experienced traumatic events are associated with different rates of PTSD [12].

Although many studies have investigated the psychosocial consequences of mass traumas and displacement in different population samples, we aimed to investigate the mental health impact of mass displacement in a population with a long history of multiple genocides added to decades of exposure to internal and external conflicts and political instability. Our study highlights the necessity of mental health assessment, care, and follow-up among this specific population group because although refugee camps provide safe accommodations, displaced people need physical and mental health care. We examined the prevalence of PTSD and investigated the possible correlated factors of PTSD among Yazidi IDPs resettled in refugee camps in Duhok, Iraqi Kurdistan.

Table 1 demonstrates the sociodemographic characteristics and mental disturbances of the participants at the time of the study. The mean age was 33.71 (SD = 12.84) years, and the range was 77 (18–95) years, but most of the participants were young (18–40 years). There were slightly more males than females (56.4% vs 43.6%). Most of them were married (77.6%). A total of 361 (44.3%) of the participants were illiterate, 33% had completed primary school, and a few had completed high school or held a higher academic degree. The majority were unemployed (n = 687, 86.2%). Most of the participants were from large families, and the mean number of siblings was 7.23 (SD = 3.26).

Only 3.9% had a positive past psychiatric history, and 6.5% had a family history of psychiatric disorders. The PTSD scores measured on the HTQ are also shown in Table 1. PTSD had a mean score of 2.27 (SD = 0.51, R = 1–4). Avoidance and intrusion symptoms had the highest means (M = 3.16, SD = 0.86, R = 1–4 and M = 2.63, SD = 0.59, R = 1–4, respectively) compared to numbing and hyperarousal symptoms.

Table 2 displays typing and subtyping of common traumatic events, item loading, and frequencies and percentages of experiencing or witnessing among the participants. Prior to the PCA step, the frequencies and percentages of exposure to traumatic events were studied. Traumatic events that were extremely rare (experienced by less than 5%) were deleted because they did not provide enough information to maintain a meaningful grouping of items. From a total of 48 items, 25 were deleted. Examples of uncommon traumatic events were sexual violence; brainwashing; forced labor; witnessing the torture, murder, arrest or execution of others; witnessing chemical attacks; being confined to home; being forced to pay for bullets used to kill family members; receiving the body of a family member and being prohibited from mourning and burial rites; and having someone inform against a participant. Another item (suffering ill health without access to medical care) was also canceled because its primary loading was less than 0.30 on the same factor. As a result, 21 variables remained that were suitable for PCA.

PCA yielded 6 trauma components, which altogether produced a cumulative variance of 50.1%. Every traumatic event subtype had a loading greater than 0.30 on one component and did not have a loading greater than 0.30 on the next component. The traumatic events were sorted as follows: 1. Trauma to or persecution of self, 2. Trauma to or abduction of family member or friend, 3. Forced immigration, 4. Lack of basic necessities, 5. Witnessed destruction, and 6. Coercion.

Analysing the results of Part II of HTQ revealed that 335 (41.1%) of Yazidi IDPs reported that the most terrifying event experienced was witnessed the killing of people (including family members, relatives or friends) by the ISIS solders during their attacks over the city of Sinjar and the surrounding villages at the first few days of the attack (3rd -4th of August, 2014). Nearly half of participants 405 (49.7%) reported evacuation under dangerous conditions. The remaining 9.2% reported other subtypes of traumatic events.

Figure 1 shows the cumulative trauma events and rates of PTSD among the participants. The prevalence of PTSD among them according to the cutoff scores was 34%. Among those who were mildly traumatized (1–10 traumatic events), only 163 (31.2%) screened positive for PTSD compared to 68.8% who screened negative. Only 108 (38.3%) of the IDPs who experienced 11–20 traumatic events screened positive for PTSD. Of those who were severely traumatized (> 20 traumatic events), 6 (66.7%) had a diagnosis of PTSD compared to only 3 (33.3%) who did not. All these differences were statistically significant (X² = 8.469, P = 0.014).

Logistic regression analysis of subtypes of experienced traumatic event components as predictors of PTSD is demonstrated in Table 3. Among the 6 types of traumatic components yielded by the PCA method, the types of individual trauma exposure that were significant predictors of the development of PTSD were unmet basic needs and having witnessed destruction (OR = 1.393, P = 0.037, 95% CI for OR = 1.021–1.901 and OR = 1.25, P = 0.033, 95% CI for OR = 1.018–1.534, respectively). Lower PTSD scores were associated with forced migration (OR = 0.552, P = 0.003, 95% CI for OR = 0.373–0.815).

To study the sociodemographic correlates (age, gender, marital status, education level, occupation, and number of siblings) for PTSD, a binary logistic regression model was also used (Table 3). The table shows that sociodemographic variables were not risk factors for developing PTSD among the Yazidi IDPs except that being a widow was a strongly significant predictor (OR = 15.391, P = 0.001, 95% CI for OR = 3.022–78.396).

Our study provides evidence of mental distress after exposure to traumatic events endured by Yazidi IDPs resettled in IDP camps following the violent attacks by ISIS in 2014. It showed a 34% prevalence rate of PTSD. A higher number of traumatic events was associated with a higher rate of PTSD. Predictive traumatic events for PTSD were unmet basic needs and having witnessed destruction. Demographic factors did not predict PTSD except that being widowed increased the rate of PTSD by 15 times.

The high prevalence rate of PTSD (34%) found in our study is consistent with the rates of PTSD revealed in other studies performed on Iraqi refugees and displaced people after the events of 2014. A systematic review of the literature describing the prevalence rates of PTSD among resettled Iraqi refugees in Western countries finds a range from 8 to 37.2% [20]. Asylum seekers, refugees, and IDPs displaced to Iraqi Kurdistan showed a PTSD prevalence rate of 48.7% [21]. Tekin et al. [22] showed a rate of 42.9% among displaced Iraqi Yazidis. The rate was 36.4% among Yazidi children and adolescents who had immigrated to Turkey from Iraq [23]. Among other refugees inhibiting Iraqi Kurdistan camps, such as Kurdish Syrian refugees, the estimated levels of PTSD symptoms ranged between 35 and 38% [24]. This finding indicates the impact of mass conflict and displacement and the severity of the traumatic events that these respondents had experienced, including a combination of war and political, religious and ethnic violence. Several factors, such as different methodological approaches and demographic characteristics, may contribute to the differences in PTSD rates reported in other studies.

Among the 4 categories of specific PTSD symptoms, the avoidance symptoms suffered by the Yazidi IDPs participating in our study showed the highest means. Symptoms of intrusion were also relevant, with high means compared to numbing and hyperarousal symptoms. Iraqi refugees in Germany presented similarly, with nightmares as the most prominent symptom of PTSD [25].

Traumatic events among refugees and IDPs are not presented individually, but they are usually accumulated and interconnected [23]. There is a positive correlation between the number of experienced traumatic events and vulnerability to developing mental disorders [6]. Our study presented the effect of the number of traumatic events on the rate of PTSD. Approximately 66.7% of those who had experienced more than 20 traumatic events developed symptoms of PTSD. This indicates the cumulative effect of exposure to multiple traumatic events before and during the displacement time. The cumulative trauma index accounts for the increased prevalence rate of PTSD among Iraqi refugees [19]. This finding supports the dose-response relationship between traumatic exposure and PTSD among refugees in post-conflict periods [26]. Among Syrian refugees in Turkey, experiencing 2 or more traumatic events was a significant predictor of PTSD [27].

Different subtypes of experienced traumatic events had different effects as predictors of PTSD. There were significant positive correlations between traumatic events and PTSD symptoms among Kurdish Syrian refugees in Iraqi Kurdistan camps [24]. In our study, the most significant predictors for the development of PTSD were unmet basic needs and having witnessed destruction. Unmet basic needs included becoming homeless with no access to health care and lack of food and water. This finding indicates that being deprived of basic elements of survival can have a predictive value in the development of PTSD among IDPs because of its direct impact on individuals. Having witnessed destruction included witnessing the destruction of religious shrines; the shelling, burning, or razing of residential areas; and rotting corpses. Witnessing these violent events, which are associated with losing the homeland and religious persecution, exacerbates war impacts. The most painful or terrifying traumatic event recounted by the survivors of “Anfal”, a military operation against the Kurds of northern Iraq, was witnessing murder [28]. Additionally, trauma subtypes provided even more entropy than the cumulative trauma effect in the prediction of PTSD [19]. The study showed that unmet basic needs was a stronger risk factor for depression than for PTSD.

When we searched for sociodemographic predictors of PTSD among Yazidi IDPs, marital status was the only component that acted as a predictive factor. The severity of experienced traumatic events and the short period between traumatic exposures and the assessment (less than 1 year) made the IDPs perceive the traumas more collectively and more similarly than respondents in other studies. A study conducted on Yazidis found that no sociodemographic predictors for PTSD among the surviving Yazidi women and girls except the number of family members directly affected by ISIS [4]. Being a widow increased the risk of developing PTSD by 15 times. Not having a partner is associated with poor mental health owing to the lack of the social support provided by a partner and the sense of increased responsibility for raising the children and increased worry about the future. Additionally, the widowed women may have witnessed the killing of their husbands by ISIS solders. This finding indicates that poor social support is a strong predictor of PTSD among Yazidi IDPs. Those who were widowed prior to the 2014 events may have been affected by prior loneliness and its mental consequences, aggravating their vulnerability to PTSD [29]. Following traumatic events, the incidence of PTSD is significantly higher in widows than in married women with living spouses. A systemic review of 11 studies on mood and anxiety disorders in widows revealed higher incidence of PTSD during the first year after bereavement compared to control subjects [30].

This study is not devoid of limitations. Firstly, we cannot attribute causation because of the cross-sectional design of the study. Secondly, because the sample was taken from only one IDP camp, omitting IDPs inhabiting informal settlements and within cities, it is difficult to determine whether it is representative. Thirdly, as all the 6 interviewers were males, the female respondents might have difficulty in reporting specific sensitive traumatic events. Fourthly, although those with a history of psychiatric disorders prior to displacement were excluded from participating in the study, we lack adequate information on the trauma experiences of the participants prior to the ISIS attacks that may make it difficult to determine a link between previous trauma experiences and current PTSD symptoms. Lastly, the interviews conducted 6 months after ISIS attacks and previous possible psychotherapy was not assessed which might be helpful in knowing if the recovery may play a role in the investigated associations. The strength of this study is the careful assessment of PTSD by six well-trained Iraqi psychological counselors who did not need the help of interpreters and did not use self-reported questionnaires. Additionally, they were able to select probable cases and refer them to suitable mental health services. Furthermore, this is a rare study that highlights the cumulative and qualitative effects of trauma exposure in IDPs who have recently escaped from severe terroristic attacks to displacement camps.

The results of this study provide evidence of the high prevalence rate of PTSD among Yazidi IDPs living in displacement camps in northern Iraq following ISIS attacks. The commonest PTSD symptoms among them were avoidance and intrusion symptoms. The number of experienced traumas was positively correlated with the symptom severity of PTSD. Unmet basic needs and having witnessed destruction were the most impactful traumatic events. The results of our study provide a better understanding of the mental health of Yazidi IDPs and a cross-cultural understanding of the effects of mass conflicts and displacement. They may provide an urgent warning and a call for multidisciplinary interventions for this group of people. Furthermore, the results of this article have possible applications for authorities in charge, governmental, nongovernmental organizations, health care providers and those who supply psychosocial support for Yazidi IDPs. In addition to the limited available psychological service resources in the locality, the health care professionals working in displacement camps should be familiar with trauma experiences and should be trained on psychological interventions.