Assessment of Psychological Stressors among Psychiatric Patients in Kirkuk City

Objective: To assess the psychological stressors and some socio-demographic variables among psychiatric patients.


Introduction
Stressors are events or situations which may have an abnormal effect on someone, these effects called stress reaction which include acute stress disorders, post traumatic disorder, adjustment disorders stressful events may precipitate major depressive episodes and behavioral disorders categorized under symptomatologies of major psychiatric disorders such as schizophrenia and bipolar disorders.Acute stress disorders are either related to anxiety responses if the stressors are related to threatening life events or depressive responses if the stressors are related to loss acute stress disorders states that the onset should be while or after experiencing the distressing event and requires that the condition last for at least two days and for no more than four weeks. Post traumatic disorder is a delayed reaction to intensely stressful events such as floods, earth quakes, man maid calamite such as major fires, rape or serious physical assault the features of post-traumatic stress syndrome are hyper arousal, re-experiencing of stressful event and avoidance of the reminders. (1) Adjustment disorders, refers to the psychological reactions arising in relation to adapting to new circumstances including divorce, separation, a major change of work, migration ,birth of handicapped child, bereavement, the onset of a terminal illness, and sexual abuse. Adjustment disorders may present with depression, anxiety, and mixedanxiety. Depression, the diagnosis of adjustment disorders cannot made when diagnostic criterion for another psychiatric disorders are met. (2) One third of the individuals in stressful situations are prone to the negative effects of stressors this effect depend on certain variables such as family dynamics, education, cultural restrictions, previous similar experiences, pre-morbid personality, severity duration and frequency of exposures to stresses these variables will yield an abnormal thought about the effects of stresses which will affect the behavior that follow the stressor. (3) Individuals using positive dynamics during or immediately after exposure to stressors will pass the event successfully and gain a good experience in dealing with similar stresses in the future with less mental distress. Other individuals who are using negative dynamics may lose a lot of their mental and physical resources'' in the first exposure to the stressor so the next exposure will create a lot of harmful mental suffering. (4) The complexity of stressors on the course of psychiatric disorders had at least three considerations firstly the effect is remote in time from the effect such as, childhood experiences partly determine the occurrence of emotional difficulties in adult life, secondly a single stressor may lead to several affects such as deprivation of parental affection in childhood has been reported to predispose to antisocial behavior, suicide and depression, thirdly stresses had an indirect mechanism in exerting their effect on the course of psychological disorders such as in genetic predisposition to depression may be mediated in part through psychological factors concerned with stressor. Individuals differ genetically in their liability to select those environmental phenotypes which put them at relatively high risk of experiencing stressors with certain pattern of behavior referred to as psychological disorder. Further more emotional and behavioral abnormalities in close relatives result from shared genetic inheritance if they exposed to similar stressor. (5) Coping mechanisms in stressful situations either consciously done by using problem solving strategy and asking help from others or by using emotion reducing strategies such as positive reappraisal of the problem, ventilation, avoidance, confrontation or by using un conscious mental defense mechanisms such as repression, denial, conversion, reaction formation, sublimation according to psychodynamic approach. It is important to avoid maladapted coping strategies such as alcohol and drug abuse, deliberate self harm or unrestrained displayed feelings and aggressive behaviors. The purpose of this study was to assess the psychological stressors and some socio-demographic variables among psychiatric patients.

Methodology
To achieve the objectives of the study quantitative design (descriptive study) was carried out from first of November 2015 to 10 th May 2016, to assess the role of stressors on the pathogenesis of psychiatric disorders in Kirkuk, Iraq Non probability (purposive) sample consisting of 130 patients (66 female & 64 male) were chosen from the out patients department of psychiatry in Azadi teaching hospital. Through extensive review of relevant literatures, a questionnaire was constructed for the purpose of the study, the format composed of three parts the first part assessed the socio-demographic characteristics including age, gender, marital status, educational level of occupation, economy and residence.
The second partassessed the medical data related to stressors. The third part included data related to psychiatric assessments including the current diagnosis by the consultant psychiatrist on call, relapse rates patients response and compliance to treatment, social and familial support, pre-morbid personality,and childhood crisis: (2) for Yes, and (1) for No. The data collection process was performed from the period 3 rd January 2016 up to the 20 th of March 2016.
To ensure the validity of the study experts of different specialties' related to the field of the study from medicaland nursing college university of Kirkuk were asked to review face and content validity of study.
The data were collected through individual interviewing technique by demonstrating the objectives of the current study from voluntarily participants after obtaining verbal consent from them. Data were analyzed by descriptive statistic applied which includesfrequency distribution and percentage. Table (1) demonstrates the socio-demographic characteristics of the whole study sample. The table shows that the highest percentage of age group (29.2%) was between (30-39) years.The lowest percentage (0.7%) was for the age group (>70) years old. According to the gender, the female formed (51%), while the male formed (49%) in the whole study. As for the marital status, the majority of the subjects (52.3%) were married, while (1.3%) of them were separated.   Total   (3) show the psychiatric morbidity relation with the age and gender in the study sample, the highest frequency of depression is female and constitute frequency (28) and age group (30-49 years) constitute frequency (7).According to the mixed neurotic disorder the highest frequency were male and constitute frequency (14) and age group (30-39 years) constitute frequency (7).As for schizophrenia the highest frequency were male and constitute frequency (10) and age group (20-49 years) constitute frequency (3). In relation to the Somatization disorders the frequencies were almost equal between male and female groups. According to the PTSD the highest frequency were among male groups and constitute a frequency (8) with in age group between (50-59 years) According to the bipolar disorder the highest frequency were female and constitute frequency (9) with in age group between (50-59 years). As for personality disorder the highest frequency were male and constitute frequency (4) with in age group between (15-19 years) (3) Table (4) shows that (67) patients registered stressors as genuine event related to their current illness. The Migration affected (19) patients, while chronic stress was the most effective in genesis and relapse of psychiatric morbidity in a frequency of (28), deaths constitute (11) patients, failures affected (9) patients. The romantic events affected (12) patients, other kinds of stressors just (5) patient and those who hadn't experienced stressors were (46). The (52) Patients experienced the stressors before the illness, while (42) patients admitted that their complaints were worsening after experiencing of stressors. Event while (36) had experienced just one stressor event.

Discussion
This study indicated that most of the people prone to psychiatric disorders are from adult group. These groups are nearly always take the responsibilities of their family as regard income , protection and decision making ; the extreme range groups almost dependent on this group especially at time of exposure to stressors. In the Table (1) there is nearly equal distribution of psychiatric disorders, between the two sexes. Most of the studies refer high morbidity in female side. (6) The difference may be related to small size of the sample in this study. Short period of the study besides that all the patients are selected from one center. That is Azadi teaching hospital outpatient clinics. Patients who were consulting other clinics were neglected. Another fact is that stressors are affecting both sexes.
In multi-axial ways which adds burden on both sexes almost equally. Being married will add extra load and responsibilities upon the individuals during periods of exposure to stressors although the family can support the patient member. In terms of psychological and social protection, the single group had their extended families that plays similar role in supporting the psychiatric patient. (7) The widow & divorced & separated groups were minorities respectively may be due to social restrains as lack of support to bring them to psychiatric attention. The (Majority of the psychiatric patients) regarding the Level of education are unable to continue their high studies either due to the effect of the illness or if the onset was started early in life may interfere with complicated studying circumstances. (8) The financial state play a major role in the causation and prevention of psychiatric disorders. In terms of fulfilling the basic biological and social requirements and in providing medical support for the patients. The low financial group neglects their patients in terms of bringing them to psychiatric attention in the hospital especially the mild & moderate illnesses for the sake of fulfilling other life requirements. (9) The positive effect of being employed or having a free job diminished to equalizing the jobless type of patients due to complexity of the circumstancesrelated to stressors life, besides that the extended oriental families many share their income for the sake of all. The high percentage of psychiatric morbidity among urban groups. May indicate the easy approach to nearby psychiatric attention centers. While the rural group are far away because there is no psychiatric units their and due to security reasons they need a lot of time & effort to reach Kirkuk city besides the faith healers play a major role in dealing with psychiatric patients. In rural areas which lessen their presentation in this study. (10) The table (2) regard to co-morbidities of psychiatric illness with other organic illness. Alcohol intake &smoking & drug abusing, may add more difficulties in management of these illnesses and prolong the course of treatment. These variables are more evident in depressive illnesses genesis and play a role in the genesis and relapse of psychiatric morbidity.
In relation to depressive disorder these results are similar to the results of previous studies. In the category of mixed neurotic disorder or anxiety like disorders are collected together such as phobia, stress reaction, grief, and drug abuse. The table (2) results are similar to the results of similar studies like but with difference of male/female distribution in our study, male are more affected, this may be due to psychiatric stigma, which is more evident in females for which they consult private clinics rather than state hospitals. (11) The table (3) showsgender distribution similar to other studies but male/female ratio were (1/2) in those studies. While in our study they are nearly equally distributed. The difference can be due to small size of our sample and the considerable number of female is send to faith healer by their families. When the abnormal features are evident according to cultural roles so they are less registered in psychiatric units. As regard to PTSD (post traumatic stress disorder) our results are similar to the results in other studies but with low female incidence. The difference may be explained on the base of most of the terror victims were male. While females were less in contact with severe life threatening stressors in the months preceding this study. The high female ratio in somatoform disorders is similar to international studies which can be explained on the bases of that females are more expressive of symptoms related to this disorder than males. Who may hide their symptoms by alcohol & drug abuse low expression symptoms is due to social & cultural restrains further more. The females are more prone to be abused in certain societies with unstable political or security circumstances.
In table (4) the small number of patients with personality disorders about (3.8%) of the total morbidity patients. Can be explained on the basis that personality disorders are related to multi factorial etiology besides long exposure to stressors during critical periods of personality development, besides the majority of personality disorder patient may express themselves in co morbidities with other psychiatric illnesses, mainly mood disorders. The effects of stressors were more evident on depressive illnesses, (44 out of 56) patients (78%) of depressive group. Chronic stress & migration were more effective stressors in this group. The effect of stressors is exclusive event in depression.