Post-Traumatic Stress Disorder (PTSD) and its Relationship with Future Anxiety among Syrian Refugees in Al-Zaatari Refugee Camp-Jordan in Light of the Corona Pandemic (COVID-19)

Received: 01-Mar-2022, Manuscript No. CSRP-22-55807; Editor assigned: 04-Mar-2022, Pre QC No. CSRP-22-55807 (PQ); Reviewed: 22-Mar-2022, QC No. CSRP-22-55807; Revised: 28-Mar-2022, Manuscript No. CSRP-22-55807 (R); Published: 04-Apr-2022, DOI: 10.3371/CSRP.BMSA.040422

Introduction

This current era is characterized with an era of constant anxiety. That is due to continuous technological development, rapid changes, successive and accelerated world events like wars and forced displacement where wars have now become part of our life. These events’ causalities live now under circumstances of insecurity and fear as a result of awful life condition they have faced. Human communities are exposed to various forms of crises such as wars and the resulting violence, killing, and forced displacement; this exposes refugees and displaced individuals to harsh conditions, painful experiences, and great psychological pressures. Chung, et al. [1] indicate in their study conducted on the results of war in Syria that it has caused to have 8 million citizens displaced within Syrian borders and 4 million Syrian refugees abroad where all of them have been exposed to symptoms of stress resulting from trauma [1]. The results indicate that refugees can develop post-traumatic stress disorder and other psychological problems after experiencing traumatic events during wars. Furthermore, suppression of such feelings can cause more psychological problems which that will eventually lead to anxiety and depression. The United Nations General Assembly has indicated its concern towards repression, violence, detention, torture, material and moral losses that refugees suffer in wars. In addition to that, the concealment of their sufferment leads to high levels of introversion and silence. The inability to express feelings may; cause difficulties in communication with the others on one hand and on the other hand it may cause internal personality disorders. Moreover, the exposure of Syrian refugees to violence has caused the emergence of many symptoms of post-traumatic stress disorder [2].

One of the recent crises that worsen the conditions of refugees in general, and Syrian refugees in particular is the emergence of the COVID-19 pandemic which imposed new challenges on Syrian refugees along with their already existing difficult circumstances, such as interruption of careers and business, disruption of livelihood sources, curfews, interruption of their children education while at the same time fighting corona virus and seeking health services. All of these had a negative impact on refugees' psychological aspect. COVID-19 first case was discovered in Wuhan-China in December 2019 when cases of unknown pneumonia were found by Nishiura, et al. [3]. Since that time, this virus began to spread inside and outside China at an accelerating pace until it invaded most countries in the world. In March 2020, World Health Organization has classified this disease as a pandemic because it had spread to most countries in the world and in large numbers. Corona virus is a group of different viruses that are rapidly spreading and contagious to individuals, it has now been called the severe acute respiratory syndrome virus (SARS COV2) and the resulting disease is called Corona disease (COVID-19). Symptoms of this disease are: fever, cough, general fatigue, loss of sense of smell and taste, headache, breath difficulties and sore throat. These symptoms may vary to be mild, moderate and severe so that it is possible to cause danger to the lives of individuals [4]. As a result of this disease seriousness, countries have taken some precautionary measures to control disease outbreak, these measures include: imposing a partial and complete curfew, scheduling the exit time limits, interrupting the face-to-face education at schools, kindergartens and universities, closing shops and markets, banning parties and social events, closing airports and borders and placing people in quarantine which exacerbated the negative feelings of families and individuals. Moreover, as a result of rapid spread of Corona virus, members of society had been exposed to psychological pressure resulting from feeling boredom, anxiety and tension, fear, insecurity, pessimism and other factors. Human history to this day has always been full of wars and massacres. We have witnessed that many people died as a result of wars. It has been found that these wars lead to psychological disorders for those who suffered from; these disorders might last for many years causing many tragedies and psychological pains. Thousands of survivors are still suffering up until now in complete silence due to the lack of clinical and field studies that detect these disorders. Therefore, they are not provided with the necessary care and medical attention. This prominent disorder that survivors of torture, violence, terrorism and war horrors suffer from is known as post-traumatic stress disorder, it is a serious and independent disorder has its own characteristics and distinctive symptoms [5]. During recent years, Syrian refugees' problem has been emerged as they now constitute the largest refugee group in the world. There is no doubt that the events that they have witnessed or lived through social and economic changes which appear after the war play a major role in the emergence of psychological disorders [6]. It is known that the individual is highly influenced by the society where they are lived in terms of educational, economic social levels. It is the society that prepares individuals for their expected role and helps them to adapt to all the pressures they are facing but at the same time it shows the personality disorder when becomes out of the ordinary [6]. During war time, social and economic variables like death of a parent, brother, relative or even resorting to other countries impose pressure on individuals. Perhaps the most dangerous impacts of war on survivors are psychological and social ones. The rapid change of social and cultural environments contributes in creating many psychological disorders such as anxiety, isolation, and feelings of inferiority [7]. Refugees suffer from multiple psychological and social disorders that negatively impact multiple aspects of their lives. These disorders consist of sadness, grief, anxiety and various forms loss like private properties which might cause a heavy shock to the victim. Furthermore, witnessing traumatic events or going through painful experiences is one of the major causes of diseases and injuries which significantly impact one’s psychological health. As for social disorders, they include social isolation and feeling alienated as a result of moving to new places like crowded refugee camps that have absolutely no means of psychological, social or educational support and that lack to proper health facilities where several people from different social communities accommodate in the same place in addition to the deterioration of educational services [8]. The exposure of individuals, specifically Syrian refugees, to a group of variables as a result of the conditions they suffered due to asylum such as material loss expresses a feeling of future anxiety which appears as a prominent psychological characteristic of Syrian refugees because of feeling fear of unknown future caused by asylum. Future anxiety is one of the types of anxiety related to the individual’s anticipation of future events over a longer period of time in which the past and the present overlap while predicting future events. Syrian refugees forcibly left their homes, jobs and loved ones heading to an unknown future causing this type of anxiety [9]. Future anxiety is also defined as a psychogenic disorder which results from unpleasant past experiences with perceptual distortion of reality and self through recalling unpleasant memories and past experiences while exaggerating the bad ones which drives the person to be in a state of tension and insecurity pushing them to feel helplessness, self-destruction and pessimism. This type of anxiety can lead to multiple disorders including post-traumatic stress disorder.

Post-traumatic stress disorder

Psychologists have focused on studying psychological stress because of its important role in individuals' health due to current era rapid changes and transformations in all dimensions. Stress occurs when an individual feels incapable of facing and dealing with situations. So when they realize that they are unable to balance between the requirements of a situation and their abilities, it creates a lot of pressure [10]. Psychologists and psychiatrists have been interested in investigating stress so they called it “Traumatology”. Now Post Traumatic Stress Disorder is categorized under psychological disorders. The discovery of this disorder is credited to the Vietnam War in the 1970s. Psychological studies revealed that half a million of American veterans suffered from mentioned disorder for 15 years after the end of war. More than 25% of former Yugoslavia population who witnessed the ethnic war suffered from psychological trauma. One study conducted on Bosnian refugees in America reported that 65% of them suffered from this disorder [11]. Post-traumatic stress disorder generates a long-term state of chaos in the psychological life of the individual in which it affects their way of thinking and behaviour. The psychological state is generated as a result of severe emotional trauma or aftermath of accidents especially fires, train collisions [12]. Trauma is defined as any accident that attacks a person and penetrates his defense system with possibility of severely disrupting an individual’s life. This accident may result in personality changes or an organic disease if it is not effectively controlled. It also leads to the emergence of fear and terror [13]. Post-traumatic stress disorder is defined as a long-term disorder of an individual's psychological life that affects his thinking and behaviour. It is a psychological state that includes multiple mental and neurological phenomena as a result of severe emotional trauma, or aftermath of accidents and wars [12]. The Diagnostic Manual (DSM-5) defines post-traumatic stress disorder as: a psychological disorder that results from individual’s exposure to a traumatic event through experiencing or witnessing the event which goes beyond the ordinary limits such as exposure to real death or a threat like wars, witness killings and exposure to torture or sexual assault. The individual’s response to such events includes extreme fear and helplessness [14]. According to the 5th American Diagnostic Statistical Manual of Mental Disorders DSM-5 issued by the American Psychiatric Association, the concept of post-traumatic stress disorder can be defined as a set of psychological, emotional and social reactions resulting from exposure to a traumatic situation involving risk, threat or loss. Sufferers of post-traumatic stress disorder have the following common symptoms:

• High levels of psychological stresses.

• The emergence of traumatic experience signs, and the re-experience of traumatic experience through nightmares, night terrors and the rapid sudden recollection of the details of the traumatic event.

• The emergence of avoidance signs of all stimuli associated with the traumatic or threatening experience.

• Rapid and lasting emotional anticipation.

• Anke, et al. [15] pointed out trauma types including basic trauma which is related to the traumatic experiences by the individual during his growing up, childhood traumas that occur in childhood phase, traumas resulting from explosions and shock resulting from hearing painful news without experiencing the event.

Post-traumatic stress symptoms

Post-traumatic stress symptoms according to the DSM-5 are characterized by repeated exposure to or witnessing a traumatic event such as death, threat or violence to oneself, a family member or those close to him then reliving the traumatic event through disturbing memories and dreams as if he relive the event again with feelings of extreme psychological frustration, avoidance of anything related to the traumatic event, inability to remember an important aspect of the traumatic event, negative and distorted beliefs and perceptions about self, the world and others with a negative emotional state, impairment in social and occupational functioning, exaggerated vigilance and problems in concentration and sleep disturbance provided that these symptoms persist for more than a month [11].

Post-traumatic stress disorder factors

There are many causes of post-traumatic stress disorder but the main reason is experiencing or witnessing something which is disturbing and dangerous such as being a victim of violence or witnessing it, death or serious illness of a loved one, war, fighting, car and plane accidents, hurricanes and fires, violent crimes [16]. In general, there are two strongest factors that determine the psychological consequences of trauma in long term: the individual's experience in facing stressful situations or traumatic events and the level of social support that the individual receives after the traumatic event. The more experience individuals have in the face of traumatic events as well as the more social support the individuals receive especially in the first weeks after the traumatic event, the more it leads to a reduction in stress and psychological symptoms associated with the traumatic event [17,18].The degree of risk of post-traumatic stress disorder depends on the nature of the trauma, the individual's age, gender, personality and other factors such as family and society. As well as there are factors that weaken individual's during the accident in which post-traumatic stress disorder develops into mental health impairment including fixed factors such as psychological upbringing in childhood and demographic factors such as gender or race [19].

Future anxiety

The current era is considered as the era of anxiety due to many changes and complexities that have occurred and are still occurring in human life in various fields and the accompanying psychological problems that have imposed themselves as an inevitable outcome of these rapid and increasing transformations where mankind has become unable to confront or deal with. Anxiety about the future is a type of anxiety that poses a great danger to the individual as it appears as a result of difficult and complex life conditions, increasing pressures of life, increasing requirements of life, the traumatic circumstances and events that the individual goes through which make them anxious, apprehensive and afraid of his future. That leads to a difference in the individual’s balance which has the greatest impact on the individual in terms of mental, psychological, physical and behavioral [20].

Barlow, et al. [21] defines future anxiety as one of anxiety types that poses a threat to the individual life which represented in fear of the unknown resulting from past and present experiences by individual that make them feel insecure, anticipate danger and unstable. This situation leads to have pessimism and despair that may eventually lead to a real and serious disorder such as: depression or a serious neuropsychiatric disorder. The Diagnostic Manual of Mental Disorders (DSM-5) defines future anxiety as one of anxiety common types in the lives of individuals characterized by a vague general feeling full of apprehension, tension and fear of the unknown accompanied by some physical sensations. This is not limited to a specific situation; rather, it extends to other situations in an individual’s life. It is often anonymous where the person has a constant willingness to worry, and it lasts for at least 6 months.

Zaleski , et al. [22] indicates that future anxiety may arise from individuals wrong and illogical thoughts that make them interpret the reality around them as well as the situations, events and interactions wrongly which leads them to have fear and anxiety that make them loose control of feelings and rational thoughts leading to insecurity and psychological stability [17]. This may cause a state of self-confidence lack, inability to face the future, fear and extreme panic from the social and political changes that are expected to occur in the future with negative expectations for the future then it comes the severe psychological revolution that takes different forms in which un justified fear of the unknown (future) with no evidence and material proofs. That’s may lead to live life in a false way depending on lying, deception and hypocrisy in dealing with the reality.

The ambiguity and uncertainty of the future leads to the have feeling of fear, helplessness and inability to live safely, Individuals may feel that the future is painful through a confused view of the future where future anxiety indicates to the long-term impact so prediction of what the future hides has become a source of fear and anxiety which is the most prominent and psychological disorder that individuals suffer as a result of the pressures, complexities of this life and the reality of society including circumstances, events and pressures that permeate it which increase the level of anxiety among individuals [23].

Among the causes of future anxiety are the individuals’ inability to adapt to the problems they suffer from, family disintegration and a sense of not belonging to family society, misperception of future possible events, painful past experiences, pressures of modern life and human ambition and continuous pursuit of self-realization and finding meaning for their existence and the existence of some social events phenomena such as wars and catastrophes [24].There are many signs of future anxiety that can be summarized as follows:

• Cognitive signs: They are the ideas that the individual carries where these ideas are illogical, fluctuating and characterized by distortion that led to have of a pessimistic person about life believing that his life will end soon and that life has become meaningless in addition to extremism in judging situations and people around him [25].

• Behavioral signs: Behavioral signs stem from the individual thoughts. It takes different forms that appear clearly in the individual’s behavior such as withdrawing from situations and not confronting them, avoiding worrisome situations, standing at an ineffective point in life, and a negative temporal orientation such as regression due to the individual’s inability to confront and escaping from situations that could cause him anxiety [26].

• Physical signs: The physical signs can be observed through the biological and physiological reactions that appear on the individual such as breath difficulties, dry throat, cold legs and arms, high blood pressure, exposure to fainting, muscle tension, indigestion, sweating, feeling unwell, increased heart rate, face redness and a numbness feeling [27].

Materials and Methods

Study problem and questions

We have recently noticed the many Syrian refugees moved to Jordan and we, as educational and psychological researchers, must pay attention to this group to find out their problems and help them overcome them. A large part of Syrian refugees suffers from psychological and social problems due to the conditions they were exposed to before asylum, war, killing and destruction. Post-traumatic stress disorder and anxiety of all kinds may be among their most prominent problems. The problem of exposure to a traumatic event leads to suffer from psychological pressures as a result of the challenges that prevent them from achieving their goals and lack of the ability to lead their lives normally as they were in their country [28,29] study indicated that there are many psychological and social problems that appear on refugees including: post-traumatic stress disorder, future anxiety and the inability to adapt with the social environment surrounding them. Therefore, they need help to overcome the problems they suffer from. With the continuation of the Syrian crisis, the number of Syrian refugees has increased dramatically. This crisis has resulted in a major change in the lives of Syrian refugees in various physical, psychological and emotional aspects. It shows the importance of the emotional aspect which plays an important role in psychological adaptation in later life phase [30]. The results of previous studies confirm that the imbalance in the family system as a result of exposure to pressure resulting from asylum, family disintegration, witnessing a traumatic event or the loss of one of its members which may lead to imbalance and feelings of discomfort about the future in addition to improper care methods that do not meet the various emotional needs resulting from asylum and its human conditions may lead to mental disorders [31].

Research in the field of refugees in Jordan is still scattered. There is a shortage of studies available in topics that examined the level of post- traumatic stress disorder and its relationship to future anxiety especially in light of COVID-19 pandemic which added more material, moral and social burdens on Syrian refugees as a result of the career interruption and curfew specifically in Zaatari camp-Sector no.1 for Syrian refugees. Hence, this study aims at identifying the level of post-traumatic stress disorder and its relationship to the level of future anxiety among Syrian refugees in Zaatari camp in light of the Corona pandemic (COVID-19) in the Hashemite Kingdom of Jordan. This study seeks specifically to answer the following questions:

1. What is the level of post-traumatic stress disorder among Syrian refugees in Zaatari camp in light of e COVID-19 pandemic?

2. What is the level of future anxiety among Syrian refugees in Zaatari camp in light of COVID-19 pandemic?

3. Is there a statistically significant correlation at significance level (α=0.05) between post-traumatic stress disorder and future anxiety among Syrian refugees in Zaatari camp in light of COVID-19 pandemic?

The importance of studying

Theoretical importance: The theoretical importance of the study subject is to direct attention to the Syrian refugees who appear to have some psychological and social problems such as: post-traumatic stress disorder and future anxiety. Traumatic events leave negative effects that may last for long periods. Identifying to what extent that Syrian refugees are affected by stress disorder post-traumatic stress and its relationship to future anxiety will contribute effectively to provide scientific indicators to identify and their meet counseling needs. This study also opens the way for other studies trying to benefit from the results that have been concluded to be a breakthrough in building therapeutic counseling programs for this category.

Practical importance: The practical importance becomes clear through reaching results and discovering the level of post-traumatic stress disorder and the level of future anxiety among Syrian refugees in Zaatari camp in Jordan as they suffer from post-traumatic stress disorder and future anxiety disorder which needs therapeutic counseling programs that provide them with psychological and social support in addition to develop the two study scales to be used by researchers especially on the refugee sample.

Study objectives

1. Identifying the level of post-traumatic stress disorder among Syrian refugees in Zaatari camp in light of COVID-19 pandemic.

2. Identifying the level of future anxiety among Syrian refugees in Zaatari camp in light of COVID-19 pandemic.

3. Identifying the relationship between the level of post-traumatic stress disorder and the level of future anxiety among Syrian refugees in Zaatari camp in light of COVID-19 pandemic.

Study limits

• Human limits: The study has been applied to Syrian refugees aged between (20-40 years).

• Spatial boundaries: The study has been applied to Syrian refugees in the Zaatari camp in the Hashemite Kingdom of Jordan in the Mafraq Governorate.

• Time limits: The study has been implemented during the first half of 2020.

Conceptual and procedural definitions

The current study deals with the following concepts and terms:

• Future anxiety: It is a psychogenic disorder resulting from unpleasant past experiences with perceptual and distortion of reality and self through recalling of unpleasant memories and past experiences with amplification of negatives and refutation of the positives of self and reality which lead to a state of tension and insecurity leading the individuals to have self-destruction, apparent helplessness, generalization of failure and anticipation of disasters in addition, it leads to a state of pessimism about the future, anxious thinking about the future, fear of expected future social and economic problems, obsessive thoughts, death anxiety and despair [22]. It is procedurally defined as the degree that the respondent scores on the future anxiety scale prepared for the purposes of this study.

• Refugees: Every person who resides outside the country of his nationality who is unable and unwilling to return due to justified fears on the basis of race, religion or nationality [7]. It is procedurally defined that they are Syrians who were forced by war conditions to migrate from their country to Jordan. They reside in the Zaatari camp in the Mafraq Governorate and their ages range between (20-40) years.

• Previous studies: Al-Adl, et al. [32] has conducted a study to identify the relationship between post-traumatic stress and future anxiety among university students after Covid-19 pandemic on a sample of (412) students from all faculties of Al-Zagazig University. The results of the study indicated that there is statistically significant positive correlation between post- traumatic stress and future anxiety.

• Khairbek conducted a study aimed at identifying psychological trauma among Iraqis after the war "post-traumatic stress disorder" [33]. It is a field study on Iraqis in Damascus to identify gender differences in post-traumatic stress disorder. The study sample consisted of (100) Iraqis who experienced the war in Iraq. Their ages ranged between (20-50) years. The study showed that the members of the research sample had been exposed to trauma. These traumata appeared in a large percentage through depression, sleep problems and nightmares. The results indicated that the average score of severe symptoms is higher than the average score of simple symptoms and that the average score of symptoms in the age category (20-30 years) is higher than the average score of disorder in the category (37-50 years). Small categories were more affected by trauma. The results also indicated that the average degree of male's disorder is higher than females while symptoms were equal for both sexes.

Younan, et al. [34] conducted a study aimed at knowing the level of psychological and behavioral stress among Iraqi refugee students in Australia and its relationship to some demographic characteristics. The study sample consisted of (225) tenth-level students. The results showed that (39.8%) of the students have severe psychological stress, (19.4%) have Moderate stress and (40.7%) have low stress. The results also showed that (35%) of the students who went through a trauma experience in Iraq had visited treatment centers for post-traumatic stress.

Shaheen, et al. [35] conducted a study aimed at knowing the level of psychological and social problems and relationship to future anxiety among teenagers in residential institutions in the West Bank. The study sample consisted of (385) teenagers. The results indicated that psychological and social problems and future anxiety were low and there was a positive correlation between psychological and social problems and future anxiety. Nesterkoy conducted a study to predict the causative factors of depression, anxiety and post-traumatic stress disorder among refugees in Germany [36]. The study sample consisted of (502) refugees. The results indicated that depression, anxiety and post-traumatic stress disorder are associated with lack of health care and loss of family members. They suffer from post- traumatic stress disorder and anxiety disorder to a Moderate degree, and need health and psychological care. Damra conducted a study aimed at knowing the levels of post-traumatic stress among a sample of domestic violence victims of abused women in the light of some variables [37]. The study sample consisted of (129) abused women who were randomly selected. The planned interview was used to determine the type and severity of violence that the woman exposed to and the tool for diagnosing posttraumatic stress. The results indicated the prevalence of post-traumatic stress in an average way among abused women in all sub-dimensions and overall dimension. As well as it indicates that the were differences in the prevalence of post-traumatic stress symptoms among abused women according to the available assistance variable in all dimensions according to the variable of violence frequency in the dimensions of retesting trauma and avoidance. There were no differences in the dimensions of post-traumatic stress among women according to the type of violence. Damra conducted a study aimed at knowing the prevalence of post-traumatic stress disorder symptoms among a sample of refugee children and teenagers residing in Jordan in the light of several variables [38]. The study sample consisted of (500) Iraqi refugee children and teenagers. The results indicated the prevalence of post-traumatic stress symptoms among the sample members in a Moderate average at all dimensions of study tool and total score. It indicates also the presence of statistically significant differences according to the variables of gender, age and period of coexisting with the traumatic event in favor of females and younger children and for a short period of coexistence while there were no differences in the symptoms of post- traumatic stress according to the variable of losing a parent. Ben Yehia conducted a study aimed at finding out the relationship between future anxiety and social support among undergraduate female students at the College of Medicine at King Saud University. The study sample consisted of 175 students. 80 students were medical students and 95 were students of psychology. The results indicated that there are statistically significant differences between the average scores of students with low social support and high social support students in favor of low social support students in the dimensions (Negative life outlook and psychological signs of future anxiety, anxiety over stressful life events and physical signs of future anxiety) while there were no differences in the dimension of negative thinking towards the future, it also indicated that there were no statistically significant differences between the degrees of future anxiety due to the differences in specializations, while there were statistically significant differences in the dimension of stressful life events due to the differences in specializations in favor of female medical students.

Salem conducted a study aimed identifying the prevailing personality factors among victims of war and trauma, the predictive ability of personality factors for post-traumatic stress disorder among victims and their posttraumatic stress level and identifying the relationship of personality factors to the level of post-traumatic stress according to age, sex and the interaction between them [39]. The study sample consisted of 542 individuals, 251 males and 291 females who had been exposed to traumatic events. Post- traumatic stress disorder and personality factors scales were applied. The results indicated that the most dominant personality factor among victims of wars and trauma is the kindness factor and that the level of post-traumatic stress was Moderate. The results also indicated that there was a predictive ability for four personality factors (ego strength, anxiety, adventure and control) in addition to the age variable in post-traumatic stress disorder. The results also indicated that there were no statistically significant differences due to the variable Age, gender and interaction between them.

Gharaibeh conducted a study aimed at identifying the level of posttraumatic stress disorder and coping strategies among Syrian refugee teenagers in Jordan [40]. The study sample consisted of 500 male and female teenagers from the Zaatari camp of Syrian refugees in Jordan. To achieve the objectives of the study, the researcher prepared a scale for post-traumatic stress disorder and a scale for coping strategies. The results showed that the level of post-traumatic stress disorder among the sample members was Moderate and there were no statistically significant differences in the level of post-traumatic stress disorder due to the variables of gender and length of stay in Jordan as well it showed that the most prominent coping strategies among teenagers were at a high level and there were statistically significant differences in the field of religiosity and social support due to the gender variable in favor of males. The results also indicated a positive correlation between post-traumatic stress disorder and coping strategies. Habib conducted a study aimed at knowing future anxiety and its relationship to the level of ambition among Basra University students [41]. The study sample consisted of 100 male and female students. The researcher used the future anxiety scale and the level of ambition scale. The results showed that the sample had future anxiety and it indicated a high level of ambition with no statistically significant correlation between future anxiety and the level of ambition. Jabbar and Zaza, et al. [42] conducted a study aimed at identifying the impact of the Syrian crisis on the psychological health of children in Zaatari camp in Jordan. The study sample consisted of (216) Syrian refugee children who were randomly selected from Zaatari camp, Ramtha and Amman governorate. The results indicated that anxiety, depression and psychosomatic symptoms among refugee children were Moderate. It also showed that there were statistically significant differences in the level of prevalence of anxiety and depression due to the variable place of refuge and in favor of refugees in Zaatari camp compared to their counterparts in the city of Ramtha and Amman governorate. Comments on previous studies by reviewing previous studies, we note that some of them have attempted to detect various psychological disorders specifically post- traumatic stress disorder among a sample of Iraqi refugees and victims of domestic violence in Jordan [34,37, 38]. Other studies aimed at identifying the level of post-traumatic stress disorder and coping strategies among Syrian refugee teenagers in Jordan such as the study of Gharibeh [43]. The study of Salem attempted to identify the prevailing personality factors among victims of wars and trauma and to identify the predictive ability of personality factors with personality disorder [39]. Some studies such as Nesterko attempted to predict the causative factors of depression, anxiety and post-traumatic stress disorder among refugees [36]. While other studies dealt with future anxiety among universities students and its relationship to variables such as the level of ambition [41,42]. Jabbar study attempted to identify the impact of the Syrian crisis on psychological health such as anxiety and depression [43]. Hence, the uniqueness of this study is that it attempts to discover the level of post-traumatic stress disorder and the level of future anxiety and the relationship between them among a sample of Syrian refugees in Zaatari camp in light of COVID-19 pandemic in Mafraq Governorate in Jordan which previous studies did not address.

Study methodology

The study used the descriptive correlative approach due to its relevance to the subject of the study. This approach is based on describing the phenomenon and knowing the extent to which the variables are related to each other.

The study population and its sample: The study population consisted of all Syrian refugees in Sector No.1 who are approximately (12 thousand) Syrian refugees in Zaatari camp. The study tools were applied to a sample of (654) Syrian refugees including (335) males and (319) females, aged between (20-40) years old and they were chosen in the simple way according to Stephen Sampthon's equation (5%).

Study tools

→ Post-traumatic stress disorder scale: The scale was developed through a review of educational literature and previous studies: [11,39,44,45]. The scale designed initially from (25) paragraph aiming at measuring post-traumatic stress disorder

Scale validity: The validity of the scale was verified in two ways:

Content validity: The content of scale validity was verified by presenting it to ten arbitrators who have expertise in psychological and educational counseling and psychological health to ensure the appropriateness of the paragraphs for the target group, to determine the suitability of the paragraphs linguistic formulation and to take their observations into account in the development of the scale by deleting, modifying and adding paragraphs to the scale. The criterion (80%) was adopted as the percentage of agreement between the arbitrators on one paragraph. In light of this criterion, some paragraphs were modified, in which three paragraphs were deleted so that the number of scale paragraphs is now (22). In addition, some linguistic formulations were modified.

Construction validity (internal consistency): The scale was applied on a sample of (30) Syrian refugees from the study population and outside its sample. The correlation coefficients of each paragraph with total score were found by using the Pearson Coefficient, and illustrates this: Table 1 shows that most of the paragraph's correlation coefficients of post-traumatic stress disorder scale ranged between (0.77-0.38), and that the correlation coefficients have statistically significant at the significance level (α=0.05). The number of scale paragraphs become (40) paragraphs.

Scale stability

The stability of the scale has been verified in two ways:

• Re-application approach: the researchers have applied the scale to (30) Syrian refugees from outside the study sample then after two weeks passed, the scale has been re-applied again on the same group where the overall scale stability coefficient is (0.83).

• Internal consistency approach: by using Cronbach's alpha equation, the stability coefficient of the total score is (0.81).

Scale correction

The answer to each of scale’s paragraphs is graded on five-answer scale (strongly disagree, disagree, neutral, agree, strongly agree) according to the applicability of the paragraph’s content to the sample. The answer scale can be converted into points so that the answer takes strongly disagree (one point), disagree (two points), neutral (three points), agree (four points), and strongly agree (five points) in the case of positive paragraphs. The answer scale is reversed in the case of negative paragraphs. The high score indicates a high degree of post-traumatic stress disorder. The answer ranges from between (40-200). The following statistical grading has been used to distribute the arithmetic means according to the criterion that measured each paragraph: Category length=alternatives higher limit alternatives lower limit/number of levels, Category length=(5-1)/3=1.33, and thus the limits of the three levels are as follows:

1. 1.33=2.33, (1-2.33) is a low degree.

2. 34+1.33=3.67, (2.34-3.67) is a Moderate degree.

3. 68+1.33=5, (3.68-5) is a high score.

2. Future anxiety scale: The future anxiety scale has been developed by referring to the theoretical literature and previous relevant studies such as Khattab, et al. studies [46, 47] and the scale consist in its initial form of paragraph aiming at measuring future anxiety.

Scale validity: The validity of the scale has been verified in two ways:

Content validity: The content validity of the scale has been verified by presenting it to ten arbitrators with expertise in psychological and educational counseling and psychological health to ensure the paragraphs appropriateness for the target group, to determine the suitability of paragraphs linguistic formulation and to take their observations into account in the development of the scale by deleting, modifying and adding paragraphs to the scale. The criterion (80%) was adopted as the percentage of agreement between the arbitrators for a single paragraph. In light of this criterion, some paragraphs were modified, two paragraphs were deleted. The number of scale paragraphs is now (21). In addition, some linguistic formulations were modified.

Content validity: The content validity of the scale has been verified by presenting it to ten arbitrators with expertise in psychological and educational counseling and psychological health to ensure the paragraphs appropriateness for the target group, to determine the suitability of paragraphs linguistic formulation and to take their observations into account in the development of the scale by deleting, modifying and adding paragraphs to the scale. The criterion (80%) was adopted as the percentage of agreement between the arbitrators for a single paragraph. In light of this criterion, some paragraphs were modified, two paragraphs were deleted. The number of scale paragraphs is now (21). In addition, some linguistic formulations were modified.

Construction validity (internal consistency): The scale has been applied to a sample of (30) Syrian refugees from the study population and outside its sample. The correlation coefficients for each paragraph with the total score were found by using the Pearson Coefficient, and Table 2 illustrates this: Table 2 shows that most of the paragraph's correlation coefficients of future anxiety scale ranged between (0.82-0.35), except paragraphs no 4,16. The correlation coefficients have statistically significant at the significance level (α=0.05). The number of scale paragraphs become (31) paragraphs.

Scale stability: The stability of the scale has been verified in two ways:

Re-application approach: the researchers have applied the scale to (30) Syrian refugees from outside the study sample then after two weeks passed, the scale has been re-applied again on the same group where the overall scale stability coefficient is (0.82).

Internal consistency approach: by using Cronbach's alpha equation, the stability coefficient of the total score is (0.80).

Scale correction: The answer to each of scale’s paragraphs is graded on five-answer scale according to the applicability of the paragraph’s content to the sample. The answer scale can be converted into points so that the answer takes strongly disagree (one point), disagree (two points), neutral (three points), agree (four points), and strongly agree (five points) in the case of positive paragraphs. The answer scale is reversed in the case of negative paragraphs. The high score indicates a high degree of future anxiety. The answer ranges from between (33-155). The following statistical grading has been used to distribute the arithmetic means according to the criterion that measured each paragraph: Category length=alternatives higher limit- alternatives lower limit/number of levels, Category length=(5-1)/3=1.33, and thus the limits of the three levels are as follows:

1+1.33=2.33, (1-2.33) is a low degree.

2.34+1.33=3.67, (2.34-3.67) is a Moderate degree.

3.68+1.33=5, (3.68-5) is a high score.

Study procedures

• Reviewing the theoretical literature and previous studies, determining the study title and its variables and obtaining official approvals.

• Determine the study sample.

• Preparing and developing study measures and ensuring their validity and reliability.

• Choosing an exploratory sample from the study population and from outside its sample to verify the validity and reliability of the tools.

• Applying study tools on a sample of Syrian refugees in Zaatari camp.

• Coming up with study results and recommendations.

Statistical treatment

To answer the study questions, the following statistical treatments have been used:

• To answer the first and second questions, the arithmetic means and standard deviations of subjects' scores on both post-traumatic stress disorder and future anxiety scales have been calculated.

• To answer the third question, Pearson's correlation coefficients for the subjects' scores on both (post-traumatic stress disorder and future anxiety) scales have been extracted.

Results and Discussion

Results related to the first question: What is the level of post-traumatic stress disorder among Syrian refugees in Zaatari camp in light of COVID-19 pandemic?

To answer this question, the arithmetic means and standard deviations of Syrian refugees' responses on post-traumatic stress disorder scale were extracted, and Table 3 shows the results. The results of the current question show that the total degree of post-traumatic stress disorder is a Moderate degree with an arithmetic mean (3.53) and a standard deviation (0.83). The paragraphs have been also distributed between the Moderate and high levels, where the some paragraphs indicate an Moderate level such as (I can't express my emotions and feelings, I feel bored and uncomfortable in dealing with others and I have trouble in remembering parts of the traumatic event) while some paragraphs indicate high degree such as (I avoid thoughts and feelings associated with the traumatic event, Repeated disturbing dreams and nightmares related to the traumatic event and I can't focus on getting things done. This indicates that the study sample is distributed between Moderate and high levels of post-traumatic stress.

It is clear that there is a Moderate level of post-traumatic stress disorder among Syrian refugees in Zaatari camp. This indicates the presence of a clear psychological disorder and problem that affects their social and professional performance. This result can be explained through the traumatic events that the Syrian refugees witnessed or experienced in their country during war and fighting such as the bombing of planes, watching the wounded and dead of their relatives, the actual injury in the war, the loss of a loved one and the material losses like their jobs and homes in addition to the difficulties they faced on the way to seek refuge and access to Jordan and moving to an unknown fate which was reinforced by the conditions imposed by the Corona pandemic such as closures, curfews, the lack of educational, health and psychological services in the camps, and the lack of suitable infrastructure which led to a Moderate level of posttraumatic stress disorder. This disorder has been clearly appeared through the results obtained by the Syrian refugee's response on the post-traumatic stress disorder scale and the appearance of the main symptoms of disorder in their answers on the scale such as feeling of fear, tension, retrieval of painful memories through dreams and nightmares and difficulty in sleeping for more than a month. The study concurs with the study of Yunnan which indicates the presence of a Moderate level of post-traumatic stress disorder of the study members. It also differs from the results of Shaheen study in terms that psychological and social problems have a low degree. It also differs from the study that post-traumatic stress disorder is high among the study sample.

The results related to the second question: What is the level of future anxiety among Syrian refugees in Zaatari camp in light of COVID-19 pandemic?

To answer the current question, the arithmetic means and standard deviations of the Syrian refugees' responses on the future anxiety scale have extracted, and Table 4 shows the results.

The results of the current question show that the total degree of future anxiety is a Moderate degree with an arithmetic mean (3.66) and a standard deviation (0.90). The paragraphs have been were also distributed between the Moderate and high levels where some paragraphs indicate a Moderate level such as (I live in a state of conflict between my reality and what I aspire to in the future, I feel insecure when I think about the future. and I do not trust my ability to overcome the difficulties of future life) while some paragraphs indicate high degree such as (I feel like the future is so vague that it's hard to imagine what it will be like, Failure makes me hopeless about the future, The challenges and difficulties of life make me afraid of the future. This indicates that students are distributed between Moderate and high levels of future anxiety.

This result can be explained by the fact that the Syrian refugees suffer from the problem of future anxiety because of the painful events they experienced which led to the loss of their property, sources of income and the loss of people from their families which led to a have feeling of untrusted future, anticipating bad future events and predicting the ambiguous future which is heading towards the unknown after forced asylum to escape from the disasters of wars to Jordan where they face difficult conditions during the asylum, the lack of financial sources support, housing and the requirements of daily life and education for family members. Moreover, this situation worsened due to what was imposed by the COVID-19 pandemic by imposing a curfew and home quarantine which led to the cut of simple financial resources and the accumulation of personal and family responsibilities which led to the cognitive reinforcement that the future is catastrophic as well as the pessimism of the future escalated in addition to thinking about difficulties that tomorrow will bring in achieving goals and ambitions with the feeling that life is not good and the lack of a sense of security and tranquility about the future. The study concurs with the study of Habib as it differs from the results of Shaheen study that future anxiety is low.

The results related to the third question: Is there a statistically significant correlation at the significance level (α ≤ 0.01) between posttraumatic stress disorder and future anxiety among Syrian refugees in Zaatari camp in light of COVID-19 pandemic?

To answer the current question, the Pearson correlation coefficient has been extracted to identify the relationship between post-traumatic stress disorder and future anxiety among Syrian refugees in Zaatari camp, and Table 5 shows the results. The results in the current question indicate that there is a positive correlation coefficient between post-traumatic stress disorder and future anxiety. The correlation coefficient is at level (0.79) which is a statistically significant value at the level (α ≤ 0.01) which indicates that higher post-traumatic stress disorder that refugees have, the higher degree of future anxious appears.

Conclusion

The result that we have positive correlation can be explained by the higher level of post-traumatic stress disorder that Syrian refugees in the Zaatari camp have, the higher level of future concern appeared representing in violent, painful crises, events and experiences that the Syrian refugees have experienced since the beginning of the war in Syria and the accompanying human, moral, physical, social, educational and health losses in addition to displacement, forced migration, leaving their country of origin and the difficulties imposed by the Corona COVID-19 pandemic in the country of displacement as well as that displacement increased feelings of fear and anxiety over the future as the future is ambiguous and unclear which generated a state of frustration and pessimism about the future with reference to sleep problems and disturbances such as disturbing dreams and nightmares caused by the traumatic event which leads to a feeling of fear, anxiety, withdrawal, avoidance and imbalance in psychological, social and physical balance. Anxiety increases specifically in terms of future anxiety as a result of the accumulation of life pressures, the existence of financial crisis, the absence of social justice, fear of not raising children with good education and fear for their future. It eventually results in an increase in future anxiety and creates a dark and negative view of the future.

Recommendations

The study recommendations are:

• Conducting therapeutic counseling programs to reduce post-traumatic stress disorder and future anxiety among Syrian refugees in Zaatari camp in Jordan.

• Conducting more descriptive correlational studies dealing with other psychological concepts such as depression on other samples of refugees.

• The need to pay more attention to provide psychological and social support to refugees in their various locations through international organizations.

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Citation: Alzaben, Mamduh Baniah Lafee, Abdallah Salem Farhan Almahaireh, Fatima Eid Zaid AL-Adwan, and Mohammad Rajeh Mohammad Sulaiman, et al. " Post-Traumatic Stress Disorder (PTSD) and its Relationship with Future Anxiety among Syrian Refugees in Al-Zaatari Refugee Camp-Jordan in Light of the Corona Pandemic (COVID-19).� Clin Schizophr Relat Psychoses 16S (2022). Doi:10.3371/CSRP.BMSA.032222

Copyright: � 2022 Alzaben MBL, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.