Document Type : Research paper
Author
Department of Clinical Psychology, Faculty of Science and Health, Koya University, Koya KOY45, Kurdistan Region - F.R. Iraq
Abstract
Objectives: The invasion of Iraq and Syria by the so-called "Islamic State of Iraq and Syria" (ISIS) began in 2014. Most of the people were displaced or forced to migrate in great numbers, and as a result, they suffered from mental and emotional disorders. The purpose of this pilot study is to assess ISIS psychiatric patients and report on possible unusual psychosocial symptoms that may occur among them.
Methods: The prospective multicenter study, which included 18 patients from a community mental health facility within the IDP camp in Ninewa, included nine former ISIS members and nine general controls both groups suffering MDD and PTSD. The purpose of this study was to screen for unusual signs and symptoms using a semi-structured interview and a mental health assessment.
Results: There were a total of nine patients from ISIS affiliates, with an average age of 29 years. The ISIS patients met DSM-V diagnostic criteria for MDD, PTSD, and unusual psychosocial symptoms, but the control group only met DSM-V diagnostic criteria for general mental illnesses, not unusual psychosocial symptoms. This is the first time that uncommon psychosocial symptoms including low self-esteem, dread, suicidal thoughts, aggressive behavior, self-blaming, isolation, and disguising identity have been identified among ISIS psychiatric patients.
Conclusion: Extremist groups, particularly ISIS affiliates, are thought to have a considerable prevalence rate of uncommon symptoms, which are thought to be unique to them. Future studies should be encouraged in order to understand more about these unique and unusual characteristics in order to find a more effective therapy and it may be recognized as a novel syndrome.
Keywords
Main Subjects
INTRODUCTION
Iraq has endured extraordinarily tough conditions for more than four decades, including political persecution, community violence, and extended combat. These traumatic events have had a significant negative impact on people s physical and mental health. Internal displacement has been a major concern affecting the mental health of Iraqis, particularly since the invasion of the Islamic State of Iraq and Syria (ISIS)(Darya, 2022). ISIS, also known as Islamic state in Iraq and al-Sham (ancient name of Syria), is a radical Sunni Muslim organisation whose main aim was to restore the state of Islam or caliphate in the region of Iraq, Syria, Israel, Jordan, P alestine and some parts of Turkey. Following the severe attacks in some parts of Iraq and Syria by ISIS at the beginning of 2014, people in Iraq and Syria witnessed a massive internal wave of displacement and migration from the areas of attack to the safer zone that is under government control (Kizilhan, 2020; Hosseini, 2019). One of the most prominent ISIS offensives in Iraq was the so-called Northern Iraq offensive in August 2014. In this offensive, ISIS brought a large part of the Northern Iraqi area, including Ninewa Plains, under its control (Jäger and others, 2019). Figure 1 shows the disputed and ISIS-controlled areas of Iraq in 2015 and 2018.
figure 1:Map showing conflicts in Iraq during 2015 and 2018 due to ISIS:(adapted from BBC News,March 2018).
After the war between Iraq and ISIS, both civilians and ISIS survivors were left as residents in Iraqi internally displaced people (IDP) camps. In general, psychiatric disturbances and other mental health issues are recognised as urgent problems among refugees and IDPs. Recent studies indicate that refugees and IDPs frequently suffer from several mental health issues, including depression, anxiety, and PTSD (Ammar and Nohra, 2014).
Academic research that examines mental health problems among the members of terrorist groups is very limited, and there have been a small number of studies specifically comparing the mental health status of those who engage with terrorist personnel or groups (Johnson and Hobfoll, 2010). Nevertheless, examining the mental and psychological symptoms of ISIS members is particularly rare, but recent research on lone-actor terrorism has found a high prevalence of mental health disorders among offenders, such as personality disorders, bipolarity, and depression ( Corner, Gill, and Mason, 2016). However, there have been no studies done so far that focus on the psychological burden of ISIS patients admitted to mental healthcare. This study aims to assess the mental health status among ISIS psychiatric patients.
METHODS
Study design and setting
The present study is a clinical study from the clinical samples that comprised consecutive therapeutic assessments and which were done in the IDP camps mental health facilities. The patients were tested, diagnosed, and provided mental health and psychosocial services at IDP camps such as Hamam Al-Halil, Jaddeh, Nimrud, and Salamiya, all of which are located in Iraq s Ninewa Governorate. Former ISIS members and their families, as well as other ordinary IDPs, are sheltered in these camps. Psychological follow ups were delivered 12 times over the course of a year, one follow up session per patient every month, during normal clinical visits. A year is a reasonable amount of time to assess and study any indications of unusual symptoms.
Sampling
In this study, 21 patients were recruited as a sample. There were (n=12) ISIS patients and (n=9) non-ISIS patients. Inclusion criteria for the study were all cases of former ISIS members in Iraq who were admitted to mental health facilities within the camps. The exclusion criteria were non-ISIS patients. Therefore, after screening the patients for inclusion criteria, three individuals refused to participate in the study, and nine patients (eight females and one male) were recruited as an ISIS group, the reasons for female sample dominance was that most of the male ISIS members were either killed in war or imprisoned. Only females and very few male ISIS affiliates were transferred to the IDP camps.
Further, a similar number of patients matched for gender were recruited from the non-ISIS group. They were diagnosed with the same mental disorders as the control group in order to identify atypical psychosocial symptoms in the ISIS group. both control group and ISIS members resided in the IDP camps, and this helped us to easily target them in comparison with other settings such as in detention centres.
The participants of the current study were all Iraqis from different governorates, including Ninewa, Kirkuk, and Salah Al-Din. Following the war, displaced persons from both groups were transferred to IDP camps in Ninewa. Numerous people suffered from mental and psychological disorders because of the terrible battle, and many stakeholders, local and international non-governmental organisations (NGOs) offered mental health and psychosocial support to all people, regardless of affiliation.
The patients were examined using semi-structured interviews after giving a written consent. Clinically, they were tested, evaluated, and diagnosed using DSM-V criteria. No structured assessment tools like MINI/SCID were used because these tools were not available and could not be used to assess unusual clinical symptoms. Patients provided socio-demographic, clinical, and consent information within the clinical setting.
Assessments
Assessment is the main focus of the present study and both groups were carried out in different phases. Continuous clinical assessments was performed from the beginning of the study until the end. The data were obtained and extracted from the patients during clinical visits and follow up. Intervention and screening/history taking was used to assess and observe the unusual symptoms.
Furthermore, a psychiatric assessment is very different from a surgical or medical assessment.
History taking is often very long and very important to understand the unique individual background.
The mental and physical state examination is performed.
Assessment can be therapeutic
The patients were also asked for any family losses (killed or imprisoned). Figure 2 illustrates the outline of the psychiatric assessment that has been carried out during this clinical research work. Family history of mental health was interrogated in detail to make sure that there was no genetic link to their current situation. Mental health was assessed by observing speech, behaviour, perception, etc.
Figure 2:Outline of the assessments procedure.
It is very important to assess the risk associated with the patient, and this was repeated for every visit for any new risk.
Therapeutic intervention
The author followed a standard psychotherapeutic treatment protocol, which included subsequent sessions, depending on the availability of patients and the severity of their conditions. One session per month was scheduled. Each session lasted 45 to 55 minutes, and there was an average of 12 sessions delivered throughout the year.
They were given cognitive-behavioural therapy (CBT) for depressed patients and eye movement desensitisation and reprocessing (EMDR) plus CBT for traumatised cases.
The entire therapeutic intervention was carried out without the use of any medications. However, the therapeutic intervention was not the aim of this study, but regular repeated pre-intervention assessments was used to confirm diagnoses and to observe for possible unusual symptoms.
RESULTS
A total of nine ISIS patients were identified among the referrals of patients from IDP camps. The age range was from 18 to 40 years, with a mean age of 29.8 years.
All of the patients of interest were former ISIS members and belonged to an ISIS affiliation. Some of them were in higher positions in their group. After the victory of the Iraqi army, they survived and transferred into the local IDP camps as residents for re-integration and social cohesiveness. Psychosocial services were provided under the supervision of trained psychologists because the ISIS affiliates had been manipulated and trained by ISIS.
Members of both the control and intervention groups were evaluated, and diagnosed with psychiatric disorders, specifically PTSD and MDD that were proven by the presence of signs and symptoms. In each group, five patients had MDD, while four were diagnosed with PTSD. According to the result of the current study a set of uncommon psychological indications, including 16 unusual psychosocial symptoms, were identified among ISIS psychiatric patients. Table 1 provides a list of unusual symptoms observed in one or more ISIS patients which were not seen in the control subject.
| No. | ISIS patient unusual symptoms | Causes and effects of unusual symptoms |
|---|---|---|
| 1 | Low self-esteem, feelings of inadequacy and worthlessness, and a sense of loss, grief, despair, unhappiness, and sorrow. | This has to do with sentiments of betrayal, as well as dread and shame at how they were treated as ISIS members and as criminals. |
| 2 | Changing identities, they try to obscure themselves by concealing their face from people; in this sense, they use a scarf as a disguise in public places, including during treatment sessions. | This is due to societal stigma, preconceptions, and discrimination, as well as apprehension and shame about their past. |
| 3 | Stay vigilant and resist being arrested, humiliated, kidnapped, or degraded by individuals or armed forces. | This sensation is linked to feelings of protection and security, as well as the dread of being identified as a former ISIS member. |
| 4 | Always fear of being exposed, for threatening, assaulting and retaliation against the community. | This sensation is linked to feelings of protection and security, as well as the dread of being identified as a former member of ISIS. |
| 5 | Pessimists have the lowest degree of resilience and well-being since they feel helpless, hopeless and that no-one cares. | This symptom is typical in practically all psychiatric patients, but in ISIS cases, it refers to a loss of power, authority, and dignity, which leaves them without hope and unable to think about the future. |
| 6 | Passive personalities are unable to assert even their most fundamental rights. | Because of social stigma and stereotypes, as well as feelings of humiliation, worthlessness, and a lack of value as a result of their identity. |
| 7 | Long-standing scepticism and overall suspicion of others. | This is not a set idea, such as a paranoid delusions, but rather a dread of their identities being exposed and the way others regard them, making them feel more vulnerable to harassment, intimidation and arrest. |
| 8 | Aggression, outbursts and impulsivity. | They are hypersensitive and quickly insulted due to their sense of being guarded and distrustful, as well as stereotypes and prejudice. |
| 9 | Suicidal ideation and self-destructive behaviour. | Because they have lost everything in life, including dignity, power and authority, as well as any hope for the future. |
| 10 | Isolation and withdrawal from everyone and everything, including limited access to public venues like hospitals and community centres. | This is due to prejudice, stereotyping, and stigmatisation, not because of lingering traumatic occurrences, but fear of community and how others treat them as ISIS members. |
| 11 | Self-blaming, self-flagellation, and a sense of being cut off from reality and trapped in nightmares. | Due to guilt, a shattered sense of dignity, and a life in a precarious position due to lack of assets |
| 12 | Nightmares, insomnia and sleep problems are all common. | Rather than the other cases, their nightmares feature war-related signals, weapon sounds, and occasionally dreams of incarceration, degradation and humiliation. |
| 13 | They are ignorant, wounded inside, lonely, and disconnected from society. | This perception was based on a comparison between their previous and current circumstances, in which they had power, authority, and property but no longer did. |
| 14 | Extreme feelings of social panic and social stigma. | This symptom is caused by a sense of unlikeness, dissimilarity, and how people perceive them as adversaries, rather than a fear of becoming the focus of attention, as people with social anxiety disorder experience. |
| 15 | Stay at home as much as possible and only go outside at special times. | Feeling insecure and uncomfortable. |
| 16 | There is an excessive amount of family worry among people with male children and adolescents. | Because they feel that having a male adolescent puts them at risk of being imprisoned, murdered, or armed by the community. |
DISCUSSION
Research into the investigation of psychological disturbances of those who engage and affiliate with terrorist personnel or groups is limited and it is particularly rare in the case of ISIS affiliates. A study by Kizilhan and Noll-Hussong, which was conducted among former ISIS child soldiers, indicates that PTSD and other mental disorders are highly prevalent (Kizilhan and Noll-Hussong, 2018), but a declaration about uncommon symptoms has never been reported. In contrast, this study aimed to reveal possible unusual psychosocial symptoms among ISIS patients.
Recent literature suggests that most of the survivors of war or terrorist activities, whether they would be the attackers or the attacked, suffered from MDD and PTSD. A study by Gerdau and his colleagues indicates that about 43 per cent of terror attack victims meet the DSM-V diagnostic criteria for PTSD, about 40 per cent meet the criteria for MDD, and about 26 per cent meet the criteria for both disorders (Gerdau and others, 2017).
The current study confirms and indicates that ISIS patients suffer from a variety of psychological issues such as PTSD and MDD in addition to unusual psychosocial symptoms. Present study revealed 16 unusual psychosocial symptoms that were not found in non-ISIS individuals (control group). A spontaneous explanation and patient confirmation validated these 16 unusual signs. When the author observed these signs during patient visits and follow ups with ISIS patients, they explained the causes and effects and confirmed all of the symptoms which are explained in Table 1.
Excessive fear and anxiety, as well as a sense of alienation and hiding one s face with a scarf or other covering in an attempt to conceal identity, are rare symptoms. In comparison to non-ISIS cases with the same diagnoses, ISIS patients were excessively pessimistic, with feelings of grief, gloom, and sorrow. The ISIS patients had the lowest level of resilience and well-being among all patients.
The ISIS patients were marginalised and excluded from society. This is due to the fear of being identified as a member of ISIS and mistreated, as opposed to PTSD patients who isolate themselves to avoid circumstances that trigger traumatic memories. Excessive scepticism and suspicion were also observed in the ISIS patients, resulting in feelings of social stigma, prejudice, and fear of degradation from others, this even restricting their access to public locations when they were needed, such as healthcare centres, community centres, and marketplaces. Moreover, they were also reluctant to provide the information needed for the session protocol form in advance of the research because they were afraid it would be used against them.
All the signs are present in most ISIS patients. However, some of it was only identified in specific samples, such as the sign There is an excessive amount of family worry among people with male children and adolescents which was only observed in those who had male children and not in those who didn t.
The sign of suicidal ideation and self-destructive behaviour is most commonly seen in younger ISIS patients. The sign long-standing scepticism and overall suspicion of others are primarily observed among those in positions of high authority within the ISIS organisation, such as an Amir s wife (Islam military leaders), because they were involved in several crimes at the time and are now afraid that everyone would suspect them and take revenge. Furthermore, the sign aggression, outbursts, and impulsivity is more common in traumatised patients. Despite the fact that these symptoms have only been identified in patients with PTSD and MDD, I believe that similar atypical symptoms may occur among ISIS patients with other psychological disorders.
The current study suggests that research on psychiatric disorders among radical groups, particularly ISIS, may shed light on the aetiology of certain psychiatric disorders. The future research encouraged to conduct a study among ISIS psychiatric patients to promote the idea of unusual psychological symptoms that might be called ISIS syndrome. According to the present study, the ISIS syndrome is a psychosocial condition that has certain atypical symptoms in addition to other mental disorders like MDD and PTSD. The term syndrome, on the other hand, refers to a very specific condition. This is a preliminary attempt, and we may not be able to call it a syndrome based on this study only, but we will continue to work on these findings in our future research on mental health among radical and terrorist groups, especially ISIS affiliates.
Limitations
The limitation of the current study is the small sample size and a gender imbalance. The author was unable to find an adequate sample size for generalisations due to a small number of ISIS members willing to engage in public and participate in studies as well as due to the deaths and imprisonment of male ISIS affiliates. There were insufficient male ISIS affiliates available to be recruited. A further study with a larger sample size and greater gender balance is needed to support the result.
CONCLUSION
Regardless of the fact that ISIS members are at an increased risk of getting psychiatric disorders such as PTSD and MDD, according to the findings of this study, self-doubt, alienation, inferiority complex, poor self-expression, intense dread, social scepticism, distrust, and massive social withdrawal were among the atypical psychological signs among ISIS psychiatric patients. All of these signs have a potential link to identities and affiliations. Research to learn more about these signs and symptoms should be promoted.
Acknowledgments
I d like to express my gratitude to all of the participants and colleagues who helped with this study, with a special appreciation to Professor Reinhard Heun for his support in editing the paper.
Conflict of interest:
The author declares no conflict of interest.
Funding:
None.
Informed patient consent:
Patients have provided their approval and written consent to participate in the study intervention sessions and for their clinical information to be recorded in the journal.
Ethical approval:
The Kscien organisation for scientific research has accepted this study for scientific purpose, and the author affirms that he has received all necessary patient permission forms.
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