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It's been four months since the war in the North ended, and the telephone at Rambam Medical Center's department for anxiety and stress is still ringing. The 20 or so calls a week indicate that for many, the war has not been forgotten, and the struggle for normalcy continues.

"During the war, hospitals in the North treated some 3,000 people suffering from anxiety," says Prof. Ehud Klein, head of the hospital's psychiatric unit. "Most experienced missile strikes and were evacuated to hospital. However, the number of people suffering from anxiety is probably larger. It is important to recall that during the war, around 1 million people were living in shelters and were exposed to missile threats, and others were in transit, searching for a safe haven. Many people developed an anxious response and did not immediately go to an emergency room: Perhaps they were waiting for the war to end; perhaps they were afraid to go while the sirens were wailing and missiles were falling; perhaps they were not aware that they or their children were suffering from anxiety. So for many people, treatment waited until after the war."

In late August, the Health Ministry decided to allocate resources to treat those suffering from war-related anxiety.

"Because the mental health clinics lack manpower and there is a long wait to obtain treatment, the Health Ministry decided to set up special treatment centers at hospitals in the north ," says Klein. "Another consideration was reaching the entire population and the concern that if treatment were provided through psychiatric institutions, many would not seek treatment, for fear of being stigmatized."

During the war, 390 citizens suffering from anxiety came to Rambam. After the war, some 270 adults and 50 children came to the anxiety and stress center set up at the Haifa hospital; there are currently 170 adults and 36 children in treatment.

"Our experience shows that after a traumatic event such as a war, approximately 15-20 percent of the population is likely to suffer from post-traumatic stress disorder (PTSD)," explains Klein. The relatively small number of people seeking treatment may stem from a lack of awareness or embarrassment.

Klein describes the three main characteristics of PTSD: "Constantly re-experiencing a trauma - things that happen in everyday life remind the person of the trauma, and he relives the experience and the fear as if it were happening now. Avoidance - a person suffering from anxiety tries to avoid situations that remind him of the trauma, such as going to a place where a missile fell or where he was when a siren sounded. In its extreme form, avoidance can paralyze a person, limit his activities and even cause him to go into seclusion. Over-alertness - the person suffering from anxiety is in a state of constant alertness and excessive nervousness, and suffers from quick outbursts, concentration problems, sleep disturbances and an accelerated heart rate."

He says three groups are most prone to PTSD: people who have suffered from mental health problems or experienced a crisis, depression or anxiety; people who developed an anxiety response immediately after the event - over-alertness, increased heart rate, nervousness or sleep disturbances - that did not pass after three or four weeks; and people who experienced a trauma in the past, such as an accident or sexual assault, that was reawakened as a result of the war. "A woman who was raped 20 years ago contacted us; somehow she got over it and managed to build a new life. The events of the war took her back, and she came and talked not about a missile or a siren, but that she was finding herself reliving the rape," says Klein.

Recognizing the problem

Rachel (not her real name), the child of Holocaust survivors, contacted the center after the war. Her mother suffered from anxiety and her father is ailing. Rachel, a married mother of two, was an active and independent woman. During the war, when the sirens sounded, she could not reach a shelter before the missiles struck. Rachel started having anxiety attacks and moved into a shelter. After the war, she agreed to return to her home only in response to family pressure, but she was afraid to sleep in the bedroom. She started sleeping while standing in the living room, next to a suitcase of her belongings. She experienced anxiety, unease, over-alertness and sleep disturbances, and refrained from going outside.

"Rachel's treatment focused on making her function again," relates Dr. Irit Ben Ari, the clinical coordinator of Rambam's center. "She gradually returned to sleeping in the bedroom and acquired tools to cope with the symptoms of anxiety. The war reawakened earlier traumatic experiences related to her childhood home. The treatment focused on processing the feelings and emotions from the past. Now her condition has improved considerably. She is working part time, leaves the house more and has resumed functioning at home. The anxiety still causes her to refrain from many things she did in the past, and she still needs treatment."

"Those around victims of PTSD need to be sensitive and realize the difficulties they face," says Rambam's chief psychologist, Dr. Yolanda Kader. "Saying 'pull yourself together' will not help. It is important to remember that resuming normal functioning entails ups and downs. Friends and family sometimes become impatient and lack understanding, when it seems the person is returning to normal and then regresses. People are not aware that this is part of the process."

The anxiety and stress center can be contacted independently via a doctor's referral. The center has a hotline - (04) 854-2100 - and callers are asked to leave their details.

"In the first stage there is a telephone interview, and then there is an evaluation," says Prof. Klein. "Based on the evaluation, the patient is summoned for an interview with a social worker or psychologist. After the interview, psychiatrists, psychologists and social workers discuss the method and length of treatment, after which there is a follow-up."

Treatment usually takes up to 12 sessions, depending on the severity of the case. "The patient receives tools to cope with the anxieties and flashbacks," says Klein. "For example, if a person perceives every sudden noise as a siren, and panics, we teach him to neutralize the mental association. When he heard an ambulance before the war, he didn't think it was an alarm, and now he must reassociate this sound with everyday noises. We integrate relaxation techniques into the treatment, and teach the person how to attain calm and sometimes introduce guided exposure to stimuli, such as a siren."

Michael (not his real name), 28, became the head of his family after his father died, supporting his mother and younger siblings financially and emotionally. During the war, a missile fell near their home. Fragments damaged the building, his younger brother was lightly injured, and his mother suffered from anxiety and shock. While all this was happening, Michael gathered his strength and supported the family. But after a short time, he started suffering from trembling, tension and unease. He had trouble falling asleep, suffered from nightmares and felt guilty for his brother's injury. He stopped working and functioning, and wasn't able to gather the strength to take care of bureaucratic arrangements.

"At first, the therapist taught Michael relaxation techniques to control the physical symptoms," says Ben-Ari. "Then they worked with him on changing his perceptions of his ability to help his family. He was made to understand that protecting his brother was beyond his capabilities, and that it was not his fault. At the same time, he received support and was encouraged to do things for his family and for himself. The eight sessions focused on restoring his abilities while helping him to understand that sometimes we cannot do everything."

Starting with parents

At the center, children are treated in a room filled with a range of toys, including dolls and cars. "PTSD is expressed in children as developmental regression," says the director of the early childhood, youth and adolescent mental health unit at Rambam, Dr. Petra Zakheim. "For example, a child goes back to wetting his bed, a child demands a pacifier again, a child who would walk to school alone suddenly starts crying and clinging to his parents. Other symptoms may include eating and concentration difficulties, sleep disruptions, self-seclusion and social problems."

Zakheim says that sometimes parents delay treatment. "Parents believe that if they wait, time will do the trick and the child will resume functioning. But the problem won't be resolved; it will only worsen," she says. "The growing number of patients indicates that children's crises and the symptoms were not grasped in time, and that there is a lack of awareness among parents."

Zakheim says the unit is treating children of a variety of ages. "Among others, there is an 8-year-old boy who runs to the safe room every time he hears a sudden noise; a girl who since the war has refused to go to school, is afraid to leave her house and has difficulty parting from her parents; and a 14-year-old girl who can sleep only in her mother's bed."

Treating children sometimes starts with the parents, Zakheim says. "Parents are often involved in the child's treatment. If the parents are anxious, it sometimes trickles down to the children. Sometimes we see that the parents very much want to protect their children and they are filled with guilt feelings for not doing this during the war. Without realizing it, the parents block healthy and independent parts of their children's behavior, and that places a lot of tension on the family."

The treatment is very similar to that for adults: talking, creating behavioral changes and working on cognitive perception. "When it comes to young children who have difficulty expressing themselves, we use a game," she says. "The therapist plays with them using a doll and a toy ambulance. During the course of the game, the therapist tries to analyze what the child is expressing and to intervene. If the child lets the dolls run and fall, the therapist can, for example, intervene and show that the doll is evacuating the wounded, saving and helping others, that she is not helpless and that what is happening to her has meaning."