© Springer International Publishing AG 2017Ghassan Soleiman Abu-Sittah, Jamal J. Hoballah and Joseph Bakhach (eds.)Reconstructing the War Injured Patientdoi.org/10.1007/978-3-319-56887-4_18
18. Healing the Scars Within: Psychological Support for the War-Injured
Department of Psychiatry, American University of Beirut, Bliss St., Hamra, Beirut, 11-0236, Lebanon
Department of Psychiatry, American University of Beirut, Riad El-Solh, Beirut, 11-0236, Lebanon
KeywordsInjuryWoundTraumaMental healthPsychotherapyPTSDRehabilitationReintegrationReconstructive surgeryMind-bodyArabMilitaryCombat
Introduction: Why Include a Mental Health Chapter in a Surgery Textbook?
The relationship between mind and body has been often researched and documented in the biomedical literature [1, 2]. Many chronic and progressive medical illnesses, which get manifested in the human body, have been found to have psychological ramifications . Data from the US population-based National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) suggest that certain medical conditions at baseline contributed to the incidence of psychiatric disorders (DSM-IV substance use, mood and anxiety disorders) at a 3-year follow-up . Based on data from the WHO World Health Surveys conducted in 60 countries, 9.3–18% of individuals with chronic diseases were significantly more likely to be diagnosed with depression compared to those without a disease, and this comorbidity produced greater decrements in health .
The opposite is also true whereby emotional psychological distress may manifest physically and medically such as in the case of somatic symptom disorder . A review of the literature pointed out that the prevalence of this widespread clinical phenomenon can vary from 12 to 57.9% in the primary health care . A recent study in Qatar  indicated that somatic symptoms were significantly associated with depression (15.3%), anxiety (8.7%), and stress disorders (19.2%). It’s also been found that people dealing with daily life stressors may impact their long-term physical health, more specifically, individuals characterized with heightened affective reactivity style have a higher risk of reporting a chronic physical health condition 10 years later . Hence, the mind-body interaction has been proven to exist and often affects medical care if it is not taken into consideration. This is especially the case of traumatic injuries requiring reconstructive surgery which is the topic of this book.
Around one-third of people hospitalized with a traumatic injury developed a psychiatric disorder when assessed a year after initial admission, mainly with the following: depression, generalized anxiety disorder, post-traumatic stress disorder, and agoraphobia . Moreover, the healing phase of the body through surgeries and other treatments can be also experienced as traumatic and affecting the mental status of the patient. When one’s life has turned upside down in a split of a second, it would take unfortunately months and sometimes years to absorb the incident, accept it, create a new life around it, and move on. Easier said than done of course, hence the need for psychological support and treatment for victims of such accidents is not only essential but necessary to help the patient move into a new life: the postaccident and the posttreatment life. Therefore the presence of this chapter is to emphasize the need of a holistic multidisciplinary team and intervention in the treatment of individuals who suffered a traumatic injury and need reconstructive surgery.
Trauma and Mind-Body Interaction
Exposure to traumatic event can lead to enduring physiological and psychological changes. According to the fifth edition of the Diagnostic and Statistical Manual , the diagnostic criteria for post-traumatic stress disorder (PTSD) entail exposure to a traumatic event as well as having symptoms from the following four clusters: reexperiencing, avoidance, negative cognitions and mood, and arousal. People with trauma constantly relive their past by misinterpreting neutral stimuli as potential threats consequently, this gets manifested in their altered physiological and stress hormonal functioning . They can also have elevated psychophysiological arousal reactions to external cues (such as sounds and sights) and internal trauma reminders (such as thoughts or feelings) . Intense emotional reactions experienced during disturbing events could lead to conditioned long-term responses. Typically, once the threat has passed, the body’s biological system should be able to shut down the high alert “flight or fight response”; however, in traumatized individuals, cortisol fails to do so which leads to ongoing activation . Research suggests that exposure to a single traumatic event could result in negative health events in the following body systems : brain; cardiovascular (changes in systolic blood pressure, atrioventricular defects, increased risk for coronary events); immunological (variable response patterns); musculoskeletal (increased risk for fibromyalgia and other diseases); neuroendocrine (dysregulated HPA axis); reproductive (increased menstrual and pelvic pain, sexual problems, infertility, miscarriage, preterm delivery, and low birth weight of fetus); and gastrointestinal functioning (changes in contractile responses of the colon, exaggerated arousal and dysrhythmic gastric activity, increased risk to develop IBS or ulcers).
Trauma and War Injuries
Physical trauma, burns, and congenital anomalies account for a big share of the global surgical burden and all of these conditions can be treated with corresponding plastic surgeries . With reference to the battlefield, up to 40% of the surgical cases at a field hospital in Afghanistan required the presence of plastic surgeons working solo or with the medical team on the case . At AUB-MC with the professional expertise existing in the area of reconstructive surgery, and with many wars occurring in the middle east region, and thus many war injuries, it is only natural that our hospital becomes a catchment area for these cases needing such prolonged specialized treatments.
As an example, the major threat in the current wars in Iraq and Afghanistan comes from improvised explosive devices (IEDs) , which account for most deaths and battlefield injuries in more than one area of the body (poly-trauma) [16, 17]. Physical impairments consisting of problems with extremities, mobility, spinal cord injury, or missing limbs among US ex-military personnel co-occurred with mental health disorders including PTSD (range 2%–59%), anxiety (range 16.1–35.5%), depression (range 9.7–46.4%), psychological distress (range 13.4–36%), and to a lesser extent with alcohol misuse (range 2.2–26.2%) as indicated in a systemic review .
Another systematic review  indicated that veterans screening positive for traumatic brain injury (TBI) were three times more likely to have PTSD and were twice more likely to suffer from depression and substance use disorders. Blasts and explosions are the main cause of traumatic brain injury (TBI) . Alarmingly, up to 23% of military service members returning from deployment suffer mild TBI symptoms , which have considerable overlap with PTSD symptoms. This can pose a diagnostic challenge and a possible case of missed diagnoses. Relevantly, researchers examined the neuropsychological performance outcomes of veterans with a history of mild TBI (with or without loss of consciousness during deployment), PTSD, and depression and claimed that PTSD and depression symptoms were the only contributors to decrements in performance on cognitive tasks post injury .
A retrospective review of clinical records for US military personnel injured in Iraq and Afghanistan  indicated that amputee patients had higher rates of developing physical health complications (such as infections, anemia, septicemia, and thromboembolic disease) as well as mental health disorders related to mood, sleep, pain, and post-concussion syndrome.
In a review, the prevalence estimates of combat-related PTSD in US Iraq war veterans were between 4 and 17% and between 4 and 7% among UK Iraq war veterans . Combat-related PTSD was associated with worse social and occupational functioning, reduced quality of life, and had a high comorbidity with other psychiatric disorders mainly substance use disorders, mood, anxiety, and personality disorders . Regardless of the length of time spent at the Homeland war in Croatia, veterans with PTSD were more likely to develop a range of somatic diseases whether cardiovascular, dermatological, musculoskeletal, pulmonary, and metabolic in comparison to people not exposed to war . In a randomized controlled pain treatment trial held at the VA primary care clinics, veterans with chronic pain and a comorbid diagnosis of PTSD and/or depression were more likely to report greater levels of pain severity, worse quality of life, and higher levels of functional impairment . Furthermore, more than one in five of returning veterans reported having difficulty coping with grief over the death of someone close, and it was found that grief was a unique significant predictor of high somatic complaints (sleep, musculoskeletal pain, fatigue, and back pain) and occupational impairments .
Among the many issues patients struggle with is the dividing line between their life before and after the accident, which to them is life changing. In addition, themes such as loss of limbs, loss of status at work, loss of colleagues, grieving these losses, separation from ones family and work place, and anxiety about the future are quite common.
Based on all the above literature and studies, it is quite clear that the relation between the medical and physical condition of patient with his/her psychological state is related with one affecting the other quite closely. This is even more the case with severely injured patients due to traumatic accidents.
Trauma comes in many forms and it can be broadly defined as the enduring negative effects following exposure to “overwhelming and psychologically injurious” event  and the subjective experience of feeling “afraid and alone” . Accordingly, before any treatment approach is considered, it is essential to ensure safety, self-care, and stabilization for the patient and their families . Treatment approaches are based on the symptoms displayed through extensive assessment.
Trauma-focused individual cognitive-behavioral therapy (CBT) has been shown to be the most effective treatment modality for trauma including PTSD whether administered in the form of prolonged exposure (PE) or cognitive processing therapy (CPT) . Approaches such as PE, which help a person revisit a traumatic memory from a safe base, also addressed comorbid conditions such as depression, generalized anxiety symptoms, anger, and guilt feelings . A review of randomized control trials offered further support for those trauma-focused therapies and indicated that PE and CPT contributed to clinically meaningful improvements in 49–70% of the military population diagnosed with PTSD; however, 60–72% of the patients retained their PTSD diagnosis following the intervention . Therefore, many trauma-related symptoms do not resolve with talk therapy alone. A recent shift in psychotherapy supports mind-body treatment modalities that focus calming the nervous system as a complement to the traditional treatment approaches and those include yoga, mindfulness, eye movement desensitization and reprocessing (EMDR), expressive arts and imagery .
Dr. Bessel Van der Kolk , a renowned clinician and researcher in the field of trauma, explained that “when we look at trauma, we find that bodies and minds behave and react to the world as if under siege”. He adds: “trauma is about having physical sensations, emotions, and feelings that are happening right now that don’t belong here” . Meditation, imagery (a form of relaxation technique), and acupuncture were the most frequently offered mind-body practices in veteran and active duty members worldwide as suggested in a recent systematic scoping review . Engaging the body, mind, and brain in treatment are crucial for better self-regulation in traumatized individuals.
Effect of Mental Health on Wound Healing and Physical Rehabilitation
Individuals with trauma symptoms have significantly higher frequency and severity of pain, and greater cardiorespiratory, gastrointestinal, and medical health complaints . Stress responses can interfere with the wound healing process after trauma. Wound can be defined as the “disruption of normal tissue structure and function” . A systematic review of 22 articles and a meta-analysis of 11 studies  suggested that psychological stress was associated with impaired healing or dysregulation of a biomarker related to wound healing in both cutaneous and mucosal tissue types. Studies considered had investigated any form of negative mental state, or subjective experience to stress on the healing process of a wound (wound physical size, biomarkers, and wound complications). A medium effect size (r = −0.42) (95% CI = −0.51 to −0.32) (P < 0.01) was demonstrated across various methodological studies  aiming to quantify the relationship between stress and different wound types and experimental models including chronic clinical wounds, experimentally created punch biopsy and blister wounds, and tape-stripped skin damage. Prolonged stress responses (to pain or non-pain related stressors) intensifies the sympathetic and neuroendocrine activity, spreads pain and inflammation, and elevates cortisol secretions which facilitates the consolidation of fear-based emotional memories . All those changes interfere with the physical rehabilitation of injured individuals, impairing the healing process and exacerbating the pain experience. Thus, psychological treatment and support will invariably help in the medical and physiological healing of the patient.
Impact of Religion and Family on ARAB Psyche
Both Muslims and Christians see adversity as part of God’s plan such that Muslims find comfort in the notion that all things are predetermined by God while Christians believe that God has a purpose for all things . In the Arab region, health is expressed in the “realm of gratitude to God”  such that it is God’s will to grant good health or illness. Differences on destiny and free will beliefs can affect how a person copes with their situation and how proactively they engage with the health care system when sick. For instance, Muslims strongly believe that the process of healing begins through seeking supplication from the Divine and through the reliance on human agents: family members, religious healers, health care providers, and the community .
In addition to religion, family and kinship are the foundations of the Arab society. The extended family system is considered crucial for the spiritual growth of Arab family members  and “sets the sociological ecology of psychological development in traditional milieus” . Family values, cultural attitudes, and interactions styles get internalized. Patterns of authority, submission, emotional interdependence within families, and religious teachings shape the formation of young Arab adult identities.