War On Gaza

Survey study 

“Death anxiety, PTSD, Trauma, grief, and mental

health of Palestinians victims

of War on Gaza”

* Thabet, A, A, MD, PhD

Consultant Psychiatrist

Edward K. Rynearson, M.D.

Medical Director of Virginia Mason Medical Center

Abu Tawahina, A, PhD

Clinical Psychologist

El Sarraj, E, MD

Psychiatrist

Gaza Community Mental Health Programme

Panos Vostanis

Professor of Child and Adolescent Psychiatry, University of Leicester, Greenwood Institute of Child Health, Westcotes House, Westcotes Drive, Leicester LE2 OQU, UK

Tel 0116 2252885; Fax: 0116 2252881; E-mail: pv11@le.ac.uk

Abstract

Purpose: Exposure to war trauma has been independently associated with posttraumatic stress (PTSD) and grief in children and adults. The aim of this study was to establish the relationship between war traumatic experiences due to last war on Gaza, PTSD, traumatic grief, death anxiety, and general mental health.

Methods: The study was conducted in the Gaza Strip, in areas exposed to war for 23 days The sample included 374 adults aged from 22 to 65 years with mean age 40.13. Participants completed measures of experience of traumatic events (Gaza Traumatic Checklist-War on Gaza), PTSD, Grief inventory, Arabic Version of Death Anxiety Scale, and GHQ-28.

Results: Palestinians experiences variety of traumatic events: The most common reported traumatic events were: 95.7% said they hear of shelling and bombardment of the their area, 94.7% reported watching mutilated bodies in TV, 92.8 % reported seeing the bombardment effects on ground, 71.7% said they had lack of water, food and electricity during the war, and 72.2% said they moved to save place during the war. Each person reported 13.80 traumatic events.  The results showed that no one felt safe at home, 2.1% of fathers said they were able to protect their children, while 2.8% of mothers said they were safe at homes. The study showed that 3.1% fathers were able to protect their children compared to 6.6% of mothers, 2.8% of fathers were able to protect themselves compared to 6.1% of mothers, and 3.1% of fathers said that someone outside the home were able to protect him compared to 2.8% of mothers.

The study showed that 71 persons lost someone from their family included extended family which represented 18.8 % of the participants and 303  did not loss anyone (81.2%) from their families (first, second, third relatives) during the war compared.

The study showed that mean grief reaction was 11.52 (SD = 4.82). The study showed that mean grief reactions reported by male were 10.1 and mean in female was 12.69. There was statistically significant differences toward females in grief reactions.

Using scoring of DSM-IV of one intrusion symptom, three avoidance, and two arousal symptoms, 248 people rated as PTSD which represented 66.6 % of the sample and 125 persons reported no PTSD (35.5%). The results showed that PTSD was reported more in females compared to males. The results showed that mean death anxiety in males was 37.4  compared to female mean = 44.9. There were statistically significant differences toward females .

The study showed than mean GHQ-28 was 15.6, somatization mean was 4.3, anxiety mean was 5, social dysfunction mean was 3.2, and depression mean was 3.2. Using the previous cutoff point of the GHQ-28 (4/5), the result showed that 90.9% were rated as cases and need further investigation, while 9.1% were not cases.

Conclusions: This study revealed that adult's victims of last War on Gaza and living in area of conflict and war for long time are exposed to different traumatic events ranging from indirect to indirect trauma and the international laws to protect the civilians during the conflict and establishing save haven for families caught in war. New programs for women who were at risk of PTSD, death anxiety, and grief to improve their mental health and coping strategies to deal with such reactions.

Key words: War on Gaza, trauma, traumatic grief, adults, death anxiety, PTSD, GHQ-28

Introduction

Palestinian families, like families in other societies, are subject to all forms of natural and man-made disasters and traumatic events. Review of the literature on the relationship between psychological disorders and exposure to political and military violence showed that anxiety, psychosomatic, and depression symptoms seem to be shared by most families who were subjected to political or military violence irrespective of their ethnic or cultural background.

Thabet et al (2008a) in study of 200 families from North Gaza and East Gaza who had exposed to continuous shelling in 2006, the results showed that parents reported a mean number of 8.5 traumatic events, 60% of parents had symptoms of potential clinical significance. Of PTSD, and 26.0% reported severe to very severe anxiety symptoms.

Siege was one of the new measures against the Palestinians in the Gaza Strip in which borders were closed and only few basic needs were allowed to enter through the gates between Israel and Gaza, while Rafah entrance to Egypt was closed most the time and only was open in irregular bases for humanitarian cases. Few studies were carried out to investigate the effect of siege on Palestinians well-being. Thabet et al (2008b) in a study aimed to investigate impact of siege on Palestinians live in Gaza Strip and quality of life.  A random sample of  386 subject were selected from the entire Gaza Strip. The age ranged from 18 to 64 years with mean age was 41.53 years. The results showed that impact of siege items were: prices are sharply increased (97.67%), I feel I am in a big prison (92.23%), I can not find things I need in the market (91.70%), I quitted some purchased daily needs (88.30%), and social visits are less than before (85.23%). No statistically significant sex, place of residence, marital status differences in mean impact of siege. The results showed that only 11.8% of Palestinians were satisfied with their general health and only 8% said that they enjoy their life. Out of them, 38.9% were satisfied with their personal relationships, 30.91% had negative feelings, such as blue mood, despair, anxiety, depression,  30.5% satisfied with their spirituality, religion and personal beliefs,  29.09% satisfied with their bodily appearance, and 26.5% had pain and discomfort. The results showed that quality of life scores mean was 64.19, psychical domain mean was 18.37, psychological domain mean was 17.67, social domain mean was 8.71, and environmental domain mean was 19.47. Males scored more in social domain. The results showed no statistically significant sex differences in mean quality of life, physical, psychological, and environmental domain. However, there was statistically significantly difference toward males in social domain. The results showed no statistically significant between refugee and citizens, place of residence, and marital status  in mean quality of life (refugee vs. citizen) physical, psychological, social domain, and environmental domain. The results showed that there were statistically significant negative correlation between total siege scores and quality of life in which people that scored more in siege items had less total quality of life, physical domain, psychological domain, social domain, and environmental domain. The following items of impact of siege were predicated bad QOL suffering of being not able to receive proper medical care, can not find some of the necessary things for my children (Milk, napkins, etc), feel in a big prison, went to Zakat organizations and other organizations to get the food,  and started doing the papers for immigration. 

Using the same previous data collected for the first study Thabet, A.A., Abu Tawahina., A., El Sarraj, E., Vostanis, P. (2008c), tried  was to investigate the impact of siege of the Gaza Strip on Palestinians feelings of anger and anger state in relation psychological symptoms in relation to other socioeconomic variables. The sample of include 386 adults  who interviewed using BSI. The results showed that the psychological symptoms ranged  from 4 to 186 symptoms (mean = 81.19), somatization  (mean = 10.88), obsessive compulsive symptoms  (mean = 11.30), interpersonal sensitivity (mean = 4.89), depression   (mean = 8.62), anxiety (mean = 10.00), hostility (mean = 7.31), phobic anxiety (mean = 7.53), paranoid (mean = 7.16),  and psychosis (mean = 6.90). The results showed females reported more somatization, obsessive compulsive disorder, and phobic anxiety.  Palestinians live in camps reported more general psychological problems, somatization, obsessive compulsive problems,   interpersonal sensitivity, depression symptoms, anxiety, hostility,  phobic anxiety, paranoid ideation than those in cities and village. However, psychosis symptoms were more common in people live in villages than in camps cities and. The results showed that there were statistically significant positive correlation between total siege scores and BSI  in which people who scored more in siege items had more psychopathology, somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, panic (phobic anxiety), paranoid ideation, and psychosis.  The study showed that the most common anger state were: I feel upset (18.4%) and I barely burned from the inside (10.4%).  While trait of anger items were: I feel upset when my work is not appreciated (21.1%), I became angry when I did a good job and get the estimate is weak (19.9%), and I am angry when mistakes of others delayed my work (16.1%). The results showed no statistically significant sex , citizenship, relation to place of residence, and marital status differences in mean anger state and anger trait.

Thabet et al (2009b in press) in a study aimed to investigate the effect of political violence on Palestinians in the Gaza Strip. The study population included 420 adult Palestinians living in the Gaza Strip. The data was collected during August 2006.The study showed that the most common traumatic events were, watching mutilated bodies and wounded people on TV (97.1%), hearing the sonic sounds of the jetfighters (94.7%), and witnessing the signs of shelling on the ground (93.2%). Participants reported a mean number of 7.7 traumatic events.  Participants reported different reactions to traumatic events, the most common reactions being:  upset by reminders  (62.7%), distressing dreams (59.8%), and amnesia (50.2%). Mean PTSD items were 50.45, intrusion mean = 17.1, avoidance mean = 18.9, and arousal mean = 14.5. Considering a cut-off score of 50 or more on the PTSD scale, 222 parents (54.4%) had symptoms of potential clinical significance of PTSD. The result showed that there were no statistically significant differences in total PTSD scores, intrusion, avoidance, and hyperarousal and sex. Subjects mean Taylor anxiety scale was 28.05.  Following the cut-off point of 33 and more as severe to very severe anxiety, 26.5% of subjects scored as severe to very severe anxiety. The result showed that there were no statistically significant differences in total anxiety scores and sex, number of sibling, place of residence, and family monthly income of participants.

On 27^th December 20008 a new chapter of the conflict started to be written in which a new wave of violence erupted with at least 1340 Palestinians were killed and 5500 were injured in the Gaza Strip. This war on Gaza continued for 23 days.

Death distress, or a negative attitude toward death, is associated with different emotional states, mainly anxiety and fear. The academic research literature on death-related topics is dominated by studies purporting to investigate death anxiety (Kastenbaum, 1987). Similarly, among 75 Kuwaiti college students, a general high-loaded factor of death distress included death anxiety, death depression, and death obsession (Abdel-Khalek, 2004b). Abdel-Khalek  and Abdulla, (2006) in study of Palestinians in the West Bank found that women had higher mean scores than their men counterparts in death obsession,  which was congruent with previous investigations on Kuwaiti and Lebanese participants, but contradicted the non-significant gender differences on the death obsession among Egyptian (Abdel-Khalek, 1998), Syrian (Abdel-Khalek & Saleh, 1999), American (Abdel-Khalek & Lester, 2003), samples. However, in the Palestinian sample, it is possible that women, especially if they are mothers, may experience a heightened level of death obsession for their children than men do. Heightened death concerns among women have been reported by the majority of researchers who have examined gender differences. A widely cited early review by Polack (1979–1980) concluded that most previous studies reported gender differences, with women consistently reporting greater death anxiety than men. In his commentary on death concern, Kastenbaum (2000) found the gender effect so consistent that, ‘‘In lieu of impressive data to the contrary, it seems reasonable to conclude that the higher self reported death anxiety for women is a robust finding’’ (p. 119). Moreover, results from Irish and Canadian students suggest that the effect generalizes beyond American culture (Lonetto et al., 1980).

The aim of this study is to investigate the psychological reactions in relation to loss, grief, and death anxiety in Palestinians victims of War in Gaza Strip.

Methods

Setting and Sample

The Gaza Strip is a narrow elongated piece of land, bordering the Mediterranean Sea between Israel and Egypt, and covers 360 km². It has high population density. About 17% of the population lives in the north of the Gaza Strip, 51% in the middle, and 32% in the south area. There is high unemployment, socioeconomic deprivation, family overcrowding, and short life expectancy. Nearly two-thirds of the population is refugees, with approximately 55% living in eight crowded refugee camps. The remainder lives in villages and towns. Since September 2005, the population of the Gaza Strip has been exposed to regular incursions and shelling, resulting in at least 200 deaths and many more injuries, in the last six months alone.

The study population included 374 participants living in areas exposed to 23 days of shelling, incursion, and bombardment, in the entire Gaza Strip. Families were selected randomly from the five areas of the Gaza Strip. One street was selected in each area, and every other household that fulfilled the family selection criteria. In larger buildings, one flat from each floor was selected.

The data collection was carried out by 8 trained professionals, under the supervision of the first author. The data was collected during Feb 2008.  Families were interviewed in their homes. One of the difficulties of this study was that, throughout the interviews, there were strong feelings of hostility, anger, and intolerance to interview in the selected areas, for which reason the interviews had to be discontinued and repeated later.

Measures

· Demographic questionnaire

Demographic information about the participants was obtained using a survey developed by the authors. This questionnaire includes sex, age, number of children, and education level. 

● War on Gaza Traumatic Events Checklist was used, describing the most common traumatic experiences families could have faced in the Gaza Strip during the last war on Gaza, including shelling of their area of residence, internal displacement. The checklist was revised from a version used in earlier research, adapted for the nature of traumatic events occurring during the current period.  The participants answer with Yes (1) and no (0). The scoring of the scale is considered by summing all the answers.  The internal consistency of the scale calculated using Cronbach’s alpha, was a=0.88 and split half was 0.79.

● The Posttraumatic Stress Disorder Checklist contains 17 items adapted from the DSM-IV   PTSD symptom criteria. The 17 PTSD symptoms are rated by the participant for the previous month on a scale indicating the degree to which the respondent had been bothered by a particular symptom from 1 (not at all) to 5 (extremely). Items can be categorized as follows: items 1-4, 17: criteria B (intrusive re-experiencing); items 5-11: criteria C  ( avoidance and numbness); and items 12-16: criteria D (hyperarousal). Respondents are asked to rate on a 5-point Likert scale (1 = not at all to 5 = extremely) the extent to which symptoms troubled them in the previous month. Using the recommended PCL cutoff score of 50,  Blanchard found cut of point of 44 (Blanchard, 1996).  Previous research (Blanchard et al, 1995) has suggested using as a minimum sum either a score of 3 or 4 on a symptom for it to count as positive towards the diagnosis. This scale was used in previous studies in the are and shoed high reliability and validity (Thabet et al, 2007, 2008).

· Maternal mental health:  Ratings based on the General Health Questionnaire (GHQ-28).  It covers severe depression and suicidal risk, anxiety and insomnia, social dysfunction, and somatic symptoms (59). Emphasis is on changes in condition, so items compare the present mental state to the person’s normal mental health status.  GHQ-28 scores above the cutoff of 4/5 are considered to be possible psychiatric ‘cases’ (Kent et al, 1999).  In  a previous study, Cronbach’s alpha was 0.91 and test–retest coefficient after six months was 0.90 (Dowell, 2006).  Validation of GHQ-28 as determined by comparison with the Clinical Interview Schedule yielded a sensitivity of 88.0 percent and specificity of 84.2 percent (Dowell, 2006). This scale had been validated in Arabic culture and showed reliability and validity (Thabet et al, 2005). The internal consistency of the scale calculated using Cronbach’s alpha, was a=0.91 and split half was 0.88.

· Grief screening Scale (GSS; Layne, Steinberg, Savjak, & Pynoos, 1998)

The GSS is a 10- item self-report screening inventory of grief symptoms in adolescents and adults. The scale is a revised version of The UCLA Grief Inventory (Pynoos,  Nader,

Frederick & Gonda, 1987) and is composed to two factor-analytically derived subscales containing five items each: One subscale measures symptoms of normal grief, and the other measures symptoms of complicated grief. Symptoms experienced during the past 4 weeks are measures on a 5 point Likert-type frequency scale consisting of 0 = never, 1 = rarely, 2 = sometimes, 3 = often, 4 = almost always.  Layne et al. (2006) reported a full-scale Cronbach’s alpha of .86 and good convergent validity. The internal consistency of the scale calculated using Cronbach’s alpha, was a=0.69 and split half was 0.68.

· The Arabic Scale of Death Anxiety (ASDA) (Abdel-Khalek, 2004)

The Arabic Scale of Death Anxiety (ASDA); (Abdel-Khalek, 2004) consists of 20 statements. Each item is answered on a 5-point intensity scale anchored by 1 (no) and 5 (very much). Alpha reliabilities ranged from .88 to .93, and item-remainder correlations ranged between .27 and .74; the 1-week test–retest reliability was .90, denoting high internal consistency and temporal stability.. The total score can range from 20 to 100, and a high score denotes high death anxiety. Among college students from Egypt, Kuwait, and Syria, alpha reliabilities ranged from .88 to .93, and the one-week test-retest reliability was .90, denoting high internal consistency and temporal stability. The correlations between the ASDA and Templer (1970) Death Anxiety Scale ranged between .60 and .74, denoting high convergent validity.  The internal consistency of the scale calculated using Cronbach’s alpha, was a=0.93 and split half was 0.87.

Statistical Analysis

All data were analyzed using SPSS 14.0 statistical software. Frequency, mean, and standard deviation were used to describe the demographic data. We used t-tests to compare the differences of all variables between two groups and the PTSD, death anxiety, anxiety, depression. A P value less than 0.05 was considered statistically significant.

Results

Sociodemographic characteristics of study population (N = 374)

The sample consisted of 374 subjects, 193 were males (51.6%)  and 181 were females 48.4%.  The age ranged from 22 to 65 years with mean age 40.13 (SD = 8.8). According to place of residence, 34.2 % were from North Gaza, 24.9% were from Gaza city, 15.8% were from middle area, 7.8% from Khan Younis, and 17.4% were from Rafah area. According to type of living, 44% live in cities, 20.9% live in villages, and 34.8% live in refugee camps. According to family monthly income, 60.9% had less than 300 US $ monthly, 26.% had 301-650 $ monthly, and 13.1% had 651 and above

Table 1

Sociodemographic characteristics of study population (N = 374)

	N	%
1. Sex
Male	193	51.6
Female	181	48.4
Mean = 41.53 (SD = 7.48)
2. Place of residence	128	34.2
North Gaza	93	24.9
Gaza	59	15.8
Middle area	29	7.8
Khan Younis	65	17.4
Rafah area
3. Type of residence
City	166	44.4
Village	78	20.9
Camp	130	34.8
4. Education
Preparatory	52	13.9
Primary	96	25.7
Secondary	141	37.7
University	52	13.9
Postgraduate	33	8.8
5. Job
Unemployed	76	20.3
Simple worker	34	9.1
Skilled worker	36	9.6
Employee	64	17.1
Merchant	9	2.4
Housewives	155	41.4
6. Family monthly income
Less than 300 US $	190	60.9
301-650 $	81	26.0
651$ and more	41	13.1

Traumatic events experienced

The most common reported traumatic events were: 95.7% said they hear of shelling and bombardment of the their area, 94.7% reported watching mutilated bodies in TV, 92.8 % reported seeing the bombardment effects on ground, 71.7% said they had lack of water, food and electricity during the war, and 72.2% said they moved to save place during the war.

Table 2

The most common traumatic events due to War on Gaza

Types of traumatic events	No.	%
Threatened to death by being used as human shield to arrest your neighbors by the army	48	12.8
Hearing shelling of the area by artillery	358	95.7
Watching mutilated bodies in TV	355	94.9
Hearing the sonic sounds of the jetfighters	354	94.7
Witnessing the signs of shelling on the ground	347	92.8
Moved to save place during the war	270	72.2
Deprivation from water or electricity during the war	268	71.7
Witnessing firing by tanks and heavy artillery at neighbors homes	266	71.1

Palestinians experiences variety of traumatic events,  the traumatic events ranged from one to 30, total number of traumatic events experienced by each participants were 13.8 traumatic events (SD =6.1). The results showed that mean traumatic events reported by males was 13.92 (SD =6.28) compared to mean in female =13.71 (SD = 6.04). No significant differences between males and females in reporting traumatic events (t=0.32, p = 0.74).

Table 3

T independent test of differences in traumatic events according to sex

	Sex	N	Mean	SD	t	p
Traumatic events	Male	193	13.92	6.28	.32	.74
	Female	181	13.71	6.04

Correlation test was don the results showed that total traumatic events were correlated with total PTSD scores (r = 0.08, p = 0.01).

Safety of families

The results showed that no one felt safe at home, 2.1% of fathers said they were able to protect their children, while 2.8% of mothers said they were safe at homes. The study showed that 3.1% fathers were able to protect their children compared to 6.6% of mothers, 2.8% of fathers were able to protect themselves compared to 6.1% of mothers, and 3.1% of fathers said that someone outside the home were able to protect him compared to 2.8% of mothers.

Table 4

Safety of families

No.	Safety	Male		Females
		Yes	No	Yes	No
1	Feel safe at home	2.1	97.9	2.8	97.2
2	Able to protect children	3.1	96.9	6.6	93.4
3	Able to protect self	2.6	97.4	6.1	93.9
4	Others were able to protect him	3.1	96.9	2.8	97.2

Loss of family members

The study showed that 71 persons lost someone from their family included extended family which represented 18.8 % of the participants and 303  did not loss anyone (81.2%) from their families (first, second, third relatives) during the war.

Grief symptoms

The results showed that (61.1%) were enjoying good memories of lost person, 45.8%  feel that, even though he/she is gone, he/she is still an important part of his life,  40.3% can't stop thinking about the person who died when I want to think about other things, and 34.7% think about getting revenge on whoever is responsible for his/her death.             

Table 5

Grief Inventory items for lose people (N =71)

	No	Rarely	Some-times	Usually	Always
1. I enjoy good memories of him/her.	5.6	4.2	11.1	18.1	61.1
4. I feel that, even though he/she is gone, he/she is still an important part of my life.	4.2	6.9	18.1	25	45.8
3. I can't stop thinking about the person who died when I want to think about other things.	6.9	13.9	29.2	9.7	40.3
9. I think about getting revenge on whoever is responsible for his/her death.	22.2	18.1	20.8	4.2	34.7
5. Unpleasant thoughts (bad or upsetting thoughts) about how the person died get in the way of enjoying good memories of him/her.	13.9	13.9	34.7	13.9	23.6
7. I enjoy thinking about him/her.	33.3	9.7	22.2	12.5	22.2
2. I do not do positive things (or good things) that I want or need to do because they remind me of the person who died.	23.6	9.7	40.3	5.6	20.8
10. I have pleasant or comforting dreams about the person who died.	27.4	16.4	31.5	6.8	17.8
6. I avoid (try not to) talking about the person who died because it is too painful to think about him/her.	37.5	12.5	30.6	5.6	13.9
8. I have upsetting or scary dreams about the person who died.	44.4	22.2	13.9	8.3	11.1

The study showed that mean grief reaction was 11.52 (SD = 4.82). T independent test was done to find differences in grief reaction and sex of the participants. The study showed that mean grief reactions reported by male was 10.1 (SD = 5.19) and mean in female was 12.69 (SD = 4.19). There was statistically significant differences toward females in grief reactions (t = -2.12, p = 0.03) .

Table 6

T independent test of Grief inventory and sex (N = 71)

	Sex	N	Mean	SD	t	p
Total grief	Male	35	10.31	5.19	-2.12	0.03*
	Female	36	12.69	4.19

* p< 0.05, ** p< 0.01, *** p<0.001

In order to find the correlation between trauma and grief, Peasrons coefficient correlation test was performed between total grief items and total traumatic events. The results showed no statistically significant correlation between trauma and grief ( r = 0.11, p = 0.32).

Determinants of grief scores and traumatic events

In order to find out the predictive effect of traumatic events on psychological symptoms, total grief symptoms was entered as dependent variable in a multiple regression model, with traumatic events as the independent variables. The results showed that the total grief  scores was negatively positively associated with shooting by bullets, rocket, or bombs (B= .-29, p< 0.007), and positively associated with , threaten by shooting (B=.23,  p< 0.03), hearing shelling of the area by artillery (B=.28,  p< 0.01), and witnessing killing of a close relative (B= .22,  p< 0.04).

Table 7

Linear Regression analysis of grief  and traumatic events

                                                                                      Coefficients(a)

	Unstandardized Coefficients		Standardized Coefficients
	B	Std. Error	Beta	t	Sig.
(Constant)	1.997	3.353		.596	.553
17. Shooting by bullets, rocket, or bombs	-3.939	1.425	-.297	-2.764	.007
22. Threaten by shooting	2.260	1.062	.235	2.129	.037
3. Hearing shelling of the area by artillery	8.253	3.175	.285	2.599	.012
7. Witnessing killing of a close relative	2.212	1.098	.225	2.015	.048

F = 5.9, p <0.05, R²=0.26

Psychological reactions according to PTSD scale

PTSD symptoms

The study showed that 50.5% had painful images or memories of the events, 48.7% of their thoughts of the events were reoccurring, 43.6% were upset by some things which reminded them of the events, and 32.9% had difficulty enjoying things.

Table 5

PTSD reactions

Psychological reactions	Never	Rarely	Sometimes	Mostly	Always
Painful images or memories of the events.	2.4	5.1	22.2	19.8	50.5
Thoughts of the events were reoccurring.	3.5	4	21.4	22.5	48.7
Upset by some things which reminded you of the events.	4	6.4	20.1	25.9	43.6
Difficulty enjoying things.	10.4	8	24.1	24.6	32.9
Distressing dreams of the events.	9.4	13.1	32.1	17.9	27.5
Trouble falling a sleep or staying sleep.	13.1	9.6	29.9	20.1	27.3
Avoiding any thoughts or feelings about the event.	10.7	10.2	32.1	20.6	26.5
Irritable or had outbursts of anger.	7.8	10.4	32.6	23	26.2
Avoiding doing things or going into situations which remind you by the events.	12.8	13.4	27.8	20.1	25.9
Distant or cut off from others people.	19.3	13.1	28.1	17.9	21.7
Found it hard to imagine having along life span fulfilling your goals.	25.1	11.8	29.1	14.7	19.3
On edge been easily distracted or hade to stay.	17.1	18.2	27.8	18.2	18.7
Difficulty in concentration.	12.3	11.5	36.6	21.1	18.4
Physically up set by reminders of the event.	28.1	18.2	24.9	13.1	15.8
Jumble easily started.	22.2	19.3	26.7	17.1	14.7
Unable to have sad or loving feeling.	44.1	11.8	21.1	10.4	12.6
Found your self unable to recall important parts of the event.	63.9	11.8	13.4	4.5	6.4

Prevalence of PTSD and subscales

The mean PTSD-17 in males was 53.03 (SD = 13.35) compared to mean scores in females = 56.62 (SD=11.89) (t-test=-3.6, p-value<0.01(.,  Reexperiences mean on males was  17.65 (SD = 4.57) compared to 18.99 (SD =3.61) in females (t-test=-3.15, p-value<0.01(., avoidance mean scores in males was 19.99 (SD = 6) compared to 21.05 (SD = 5.64) in females (t-test=-1.75, p-value<0.08(., Hyperarousal mean scores in males  was 15.38 (SD = 4.89) compared to 16.58 (SD =4.68) in females (t-test=-2.42, p-value<0.02(.Using T independent test showed that females were diagnosed probably with PTSD more than males

Table 6

T independent test for differences in PTSD and subscales according to sex

	Sex	N	Mean	SD	t	Mean Difference	P
PTSD	Male	193	53.03	13.35	-2.75	-3.6	0.01
	Female	181	56.62	11.89
Reexperiences	Male	193	17.65	4.57	-3.15	-1.35	0.001
	Female	181	18.99	3.61
Avoidance	Male	193	19.99	6.00	-1.75	-1.05	0.08
	Female	181	21.05	5.64
Hyperarousal	Male	193	15.38	4.89	-2.42	-1.2	0.02
	Female	181	16.58	4.68

* p< 0.05, ** p< 0.01, *** p<0.001

Prevalence of PTSD

Using scoring of DSM-IV of one reexperiences symptom, three avoidance, and two arousal symptoms, 248 people rated as PTSD which represented 66.6 % of the sample and 125 persons reported no PTSD (35.5%). The results showed that PTSD was reported more in females compared to males (74.6% vs. 58.9%). This rate reached statistically significant level (X 2 = df = 2, p < 0.001).

Table 7

Sex differences in prevalence of PTSD

* p< 0.05, ** p< 0.01, *** p<0.001

	Male	Female	Total	X2 (10.3)
No PTSD	79	46	125	0.001**
	41.1%	25.4%	33.5%
PTSD	113	135	248
	58.9%	74.6%	66.5%

* p< 0.05, ** p< 0.01, *** p<0.001

In order to find the correlation between total PTSD and  grief reactions , Peasrons coefficient correlation test was performed between total grief items and total PTSD. The results showed  there were statistically significant correlations between grief and total PTSD ( r = 0.37, p = 0.01), intrusion symptoms ( r = 0.25, p = 0.01), avoidance ( r = 0.38, p = 0.01), and hyperarousal  ( r = 0.29, p = 0.01).

Determinants of PTSD scores and traumatic events

In order to find out the predictive effect of traumatic events on PTSD symptoms, total PTSD symptoms was entered as dependent variable in a multiple regression model, with each traumatic event as the independent variables. The results showed that the total PTSD scores were positively associated with the following trauma items: threaten by shooting (B= .17, p< 0.001), deprivation from water or electricity during the war  (B=.14,  p< 0.005), and witnessing assassination of people by rocket (B=.14,  p< 0.007). However threatened to death by being used as human shield to arrest your neighbours by the army was negatively predicted the PTSD (B= -.22,  p< 0.001).

Table 8

Linear Regression analysis of PTSD and traumatic events

	Unstandardized Coefficients		Standardized Coefficients	t	Sig.
	B	Std. Error	Beta
(Constant)	48.611	1.380		35.233	.000
22. Threaten by shooting	4.503	1.404	.176	3.207	.001
26. Threatened to death by being used as human shield to arrest your neighbours by the army	-8.455	1.968	-.222	-4.296	.000
21. Deprivation from water or electricity during the war	4.118	1.465	.145	2.810	.005
15. Witnessing assassination of people by rockets	3.641	1.354	.140	2.689	.007

F = 15.18, p <0.05, R²=0.18

Death anxiety

The results showed that 59.5% said they had  fears of  the punishment in their grave, 51.9% said they had fears of having cancer, 50.5%  said they are worried that death will take someone they  love. While the least common items were: Walking in cemetery frightening them (11%), upset when seeing funnel (10.4%), and afraid visiting the cemetery (9.1%).

Table 9

Death anxiety items

Items	No	Little	Moderate	Much	Very much
9. I fear the torture of the grave.	8.8	4.8	4.8	22.2	59.4
19. I am afraid of getting cancer.	11.5	6.1	10.4	20.1	51.9
6. I worry that death may deprive me of someone dear to me.	12.6	5.1	6.7	25.1	50.5
10. I fear getting a serious disease.	11.8	6.4	10.4	27.5	43.9
13. I am preoccupied with thinking about what will happen after death.	19.8	7.5	12.3	28.9	31.6
20. I fear death.	34.2	10.2	11	15.8	28.9
5. I am afraid of suffering a heart attack.	21.4	14.7	13.4	22.2	28.3
15. The pain accompanying death terrifies me.	17.9	10.4	13.6	32.1	25.9
7. I am apprehensive of unknown things after death.	16.8	11.8	15.2	32.6	23.5
4. The possibility of having a surgical operation terrifies me.	25.9	15.8	14.7	20.6	23
17. The sight of a dying person frightens me.	20.9	15	15.2	26.7	22.2
8. I am afraid of looking at a corpse.	38	13.9	11.2	15.8	21.1
11. Witnessing the burial procedure terrifies me.	37.4	13.9	13.1	16.6	19
14. I am afraid of sleeping and not waking up again.	29.7	13.6	14.2	23.5	19
2. I fear looking at the dead.	39.8	13.6	13.4	15.8	17.4
1. I fear death whenever I become ill.	32.9	19	12.8	20.6	14.7
18. Talking about death upsets me.	34.8	16	18.7	17.1	13.4
12. I dread walking in graveyards.	46.3	15	12.3	15.5	11
16. I get upset by witnessing a funeral.	45.7	12.8	20.3	10.7	10.4
3. I fear visiting graves.	61.8	10.2	8.8	10.2	9.1

Sex differences in death anxiety

In order to find the differences between males and females in death anxiety, T independent test was done. The results showed that mean death anxiety in males was 37.4 (SD =20) compared to female    mean = 44.9 (SD = 18.5). There were statistically significant differences toward females (t-test=-3.82, t= -3.82, p= 0.001).

Table 10

Sex differences in death anxiety

	Sex	N	Mean	SD	t	p
Death anxiety	Male	192	37.30	19.98	-3.82	0.001**
	Female	181	44.96	18.58

* p< 0.05, ** p< 0.01, *** p<0.001

In order to find the correlation between total death anxiety and  grief reactions, Peasrons coefficient correlation test was performed between total grief items and total death anxiety. The results showed  there was no statistically significant correlations between grief and total death anxiety ( r = 0.11, p = 0.19).

Table 11

Linear Regression analysis of Death anxiety and traumatic events

	Unstandardized Coefficients		Standardized Coefficients	t	Sig.
	B	Std. Error	Beta
(Constant)	27.569	4.694		5.873	.000
30. Forced to leave your home during the war	4.472	2.269	.102	1.971	.049
7. Witnessing killing of a close relative	-8.885	2.370	-.201	-3.749	.000
23. Destroying of your personal belongings during incursion	5.362	2.245	.133	2.389	.017
4. Hearing the sonic sounds of the jetfighters	9.807	4.385	.112	2.237	.026
27. Deprivation from going to toilet and leave the room at home where you was detained	5.200	2.566	.114	2.027	.043

F = 7.26, p <0.05, R²=0.09

General mental health problems

The Palestinians reported different psychological symptoms, the most common symptom was found every thing getting on top of them (42.8%), 29.7% felt that life is entirely hopeless, 29.7% thought of the possibility that you might make away with themselves, 28.3% felt constantly under strain, 27.5%  found at times you couldn't do anything because their nerves were too bad.

Table 12

GHQ-28 items

	%
Found every thing getting on top of you?	42.8
Felt that life is entirely hopeless?	29.7
Thought of the possibility that you might make away with yourself?	29.7
Felt constantly under strain?	28.3
Found at times you couldn't do anything because  your nerves were too bad?	27.5
Had difficulty staying a sleep once you are off?	27
Felt that life isn't worth living?	25.1
Been getting any pains in your head?	24.9
Been getting edgy and bad-tempered?	24.6
Been feeling nervous and strung-up all the time?	24.3
Been able to enjoy your normal day-to-day activities?	23.8
Been feeling run down and out of sorts?	23
Been getting a feeling of tightness or pressure in  your head?	22.7
Lost much sleep over worry?	21.4
Found yourself wishing you were dead and away from it all?	21.4
Been getting scared or panicky for no good reason?	19.3
Been taking longer over the things you do?	15
Been feeling perfectly well and in good health?	13.9
Been feeling the need of a good tonic?	13.4
Felt that you are ill?	13.4
Been having hot or cold spells?	12
Been managing to keep yourself busy and occupied?	11.5
Been satisfied with the way you've carried out your  tasks?	11.2
Felt on the whole you were doing things well?	11
Felt capable of making decisions about things?	10.2
Been thinking of yourself as a worthless person?	9.1
Felt that you are playing a useful part in things?	8.6
Found the idea of taking your own life kept coming  into your mind?	1.9

The study showed than mean GHQ-28 was 15.6 (SD =7.1), somatization mean was 4.3 (SD = 2.3), anxiety mean was 5 (SD =2.1), social dysfunction mean was 3.2 (SD =2,3), and depression mean was 3.2 (SD =2.1). Using the previous cutoff point of the GHQ-28 (4/5), the result showed that 90.9% were rated as cases and need further investigation, while 9.1% were not cases.

Determinants of GHQ-28 scores and traumatic events

In order to find out the predictive effect of traumatic events on general mental health symptoms, total GHQ-28 symptoms was entered as dependent variable in a multiple regression model, with each traumatic event as the independent variables. The results showed that the total GHQ scores were positively associated with the following items: Destroying of your personal belongings during incursion (B= .15, p< 0.003), Hearing shelling of the area by artillery  (B=.11,  p< 0.03), witnessing assassination of people by rocket (B=.13,  p< 0.01) and shooting by bullets, rocket, or bombs was negatively predicting mental health (B=-0.13,  p< 0.01).

Table 11

Linear Regression analysis of Death anxiety and traumatic events

	Unstandardized Coefficients		Standardized Coefficients	t	Sig.
	B	Std. Error	Beta
(Constant)	10.236	1.886		5.427	.000
23. Destroying of your personal belongings during incursion	2.296	.764	.158	3.005	.003
3. Hearing shelling of the area by artillery	3.936	1.816	.112	2.167	.031
15. Witnessing assassination of people by rockets	1.887	.757	.130	2.493	.013
17. Shooting by bullets, rocket, or bombs	-2.454	1.018	-.130	-2.410	.016

F = 6.26, p <0.05, R²=0.06

Discussion

This study showed that Palestinians exposed to variety of traumatic events during the War on Gaza. Each one experienced around 12 traumatic events ranged from directed exposure to TV scenes, injury, shelling, and beating to indirect exposure by hearing about the death and bombardment of other areas in the Gaza Strip.  The prevalence of PTSD was 66.6 %. These results consistent with previous research in the area (Thabet et al, 2008a) in study of 200 families from North Gaza and East Gaza found that each parent reported a mean number of 8.5 traumatic events and 60% of parents had symptoms of potential clinical significance of PTSD, and 26.0% reported severe to very severe anxiety symptoms. Also, Thabet et al (2009b in press) in a study aimed to investigate the effect of political violence on 420 adult Palestinians in the Gaza Strip. The study population included living in the Gaza Strip, found that most common traumatic events were, watching mutilated bodies and wounded people on TV (97.1%), hearing the sonic sounds of the jetfighters (94.7%), and witnessing the signs of shelling on the ground (93.2%). Participants reported a mean number of 7.7 traumatic events and 54.4% had symptoms of potential clinical significance of PTSD.

Our study showed that 61.1% of the people who lost someone close were enjoying good memories of lost person, 45.8% feel that, even though he/she is gone, he/she is still an important part of his life, 40.3% can't stop thinking about the person who died when I want to think about other things, and 34.7% think about getting revenge on whoever is responsible for his/her death. Those findings congruent with cultural norms of considering the dead person during war will be as martyr and will go to heaven and lost here is not permanent and that the dead person is alive in heaven and looking to their action in the daily life. Our study showed that females had more grief scores than males and also women reported more death anxiety symptoms than men, among possible explanations for the gender effect is simply that men were less willing to admit openly to their fears. Women may be ‘‘closer to their feelings’’ than men (Kastenbaum, 2000, p. 119). Kastenbaum also suggested that the greater concern about death reported by women may stem from the fact that they are most often the primary caretakers for the dying. Another explanation for gender differences in death anxiety invokes the concept of locus of control. Sadowski, Davis, and  Loftus-Vergari (1979) measured death anxiety along with locus of control and found that women were both more concerned about death and more externally controlled.   Our results consisted with Abdel-Khalek, (2005)  study of Egyptian normal participants (non-clinical), anxiety disorder patients, and patients suffering from schizophrenia, and addicts  found gender differences were statistically significant on the Arabic Version of Death Anxiety in which females attained higher mean scores than their male counterparts in the three categories—normal participants (non-clinical), anxiety disorder patients, and patients  suffering from schizophrenia—as well as the total group of males versus females. Our finding is congruent with previous results (Abdel-Khalek, 2002a, 2002b; Dattel & Neimeyer, 1990; Kastenbaum, 1992 and manifested strongly in Arab samples (Abdel-Khalek, 1986, 2003).  Our study is also consistent with Catherine So-Kum et al (2002) in study aims to explore various psychosocial correlates associated with how Chinese react to death and dying of  282 Chinese college students Results showed that younger as compared with older participants and women as compared with men tended to be more death anxious. Those with low levels of self-efficacy and external health control orientations were more likely to report a high level of death anxiety.

The study showed than mean GHQ-28 was 15.6, somatization mean was 4.3, anxiety mean was 5, social dysfunction mean was 3.2, and depression mean was 3.2. Using the previous cutoff point of the GHQ-28 (4/5), the result showed that 90.9% were rated as cases and need further investigation, while 9.1% were not cases. Our mean mental health problems rated by GHQ was higher than the mean mental health problems rated by the same instrument, Cardozo  et al (2000) in study of prevalence of psychiatric morbidity associated with the war in Kosovo, Estimated mean total score based on a possible GHQ-28 questions was 11.1. Although we found that the GHQ-28 was well accepted and easy to administer, the interpretation of the results for prevalence estimates is not straightforward unless an optimal cutoff score is established for the specific population. Goldberg et al (1998) have suggested that a mean score will provide a rough guide to the best threshold; however, this would always result in a general psychiatric morbidity prevalence of approximately 50%.  Also the results of this study was consistent with previous study validity of this instrument in Arab culture in which the mean GHQ-28 for the referred cases for community mental health centers was 14.9 compared to only 8.3 of the controls (Thabet et al, 2005). This study results were higher than the rate of psychiatric caseseness found in study of survivor of the Piper Alpha oil platform disaster which took place on 6 July 1988, resulting in the deaths of 167 men and leaving 59 survivors. It involved the complete destruction above sea level of the platform at 193 km northeast of Aberdeen, a city in the Grampian region of Scotland. The study showed that after 10 years 44% of the traced survivors (16/36) scored above 4 in GHQ-28 (Hull et al 2002). This study showed that the best predictive traumatic events for mental health problems were destroying of your personal belongings during incursion, hearing shelling of the area by artillery, witnessing assassination of people by rocket, while shooting by bullets, rocket, or bombs was negatively predicting mental health. This combination of direct and indirect traumatic events  predication of mental health problems denoting that not only trauma may lead to mental health problems but, there may be other contributing factors which increase the risk for mental health problems  in Palestinians living in area of war and conflict such as siege, unemployment, increase family members, and overcrowdings.

Conclusions: This study revealed that adults victims of last War on Gaza and living in area of conflict and war for long time are exposed to different traumatic events ranging from indirect to indirect trauma and the international laws to protect the civilians during the conflict and establishing save haven for families caught in war. New programs for women who were at risk of PTSD, death anxiety, and grief to improve their mental health and coping strategies to deal with such reactions.

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