Effects of Chemical Warfare Throughout Time on Mental Disorder Symptoms and Brain Executive Functions of Veterans Exposed to Chemical Weapons

authors:

avatar Mohammad Amin Karimi ORCID 1 , 2 , avatar Farhad Avakh 3 , avatar Mohammad Abdollahi ORCID 4 , 5 , avatar Ezatollah Kordmirza Nikoozadeh 6 , avatar Alireza Golaghaei 1 , *

School of Medicine, AJA University of Medical Sciences, Tehran, Iran
School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
School of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran
Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran
Department of Psychology, Payame Noor University, Tehran, Iran
Annals of Military and Health Sciences Research: Vol.21, issue 1; e138012
published online: August 5, 2023
article type: Research Article
received: May 31, 2023
revised: July 16, 2023
accepted: July 17, 2023
DOI: https://doi.org/10.5812/amh-138012

how to cite: Karimi M A, Avakh F, Abdollahi M, Kordmirza Nikoozadeh E, Golaghaei A. Effects of Chemical Warfare Throughout Time on Mental Disorder Symptoms and Brain Executive Functions of Veterans Exposed to Chemical Weapons. Ann Mil Health Sci Res. 2023;21(1):e138012. https://doi.org/10.5812/amh-138012.

Abstract

Background:

During the Iran-Iraq war (1980 - 1988), Iran was subjected to chemical attacks for over five years. These attacks left many mental injuries, especially for the veterans exposed to chemical weapons.

Objectives:

This case-control study compared mental disorder symptoms and brain executive functions of veterans exposed to chemical weapons with healthy individuals.

Methods:

The present study was conducted on veterans exposed to chemical weapons during the war. The control group comprised healthy individuals matched to the cases based on age, gender, occupation, level of education, and place of residence. One hundred seventy participants were included in the study, with 85 individuals in each group. The Symptom Checklist-90-Revised (SCL-90-R) and Nejati questionnaire were used to collect data on the symptoms of mental disorders and brain executive functions. Multivariate analysis of variance was used for data analysis.

Results:

The findings revealed that the total effect of the subscales of mental disorders in all nine domains was significantly higher in veterans exposed to chemical weapons than in healthy individuals (P < 0.05). In addition, the actual impact of the subscales of the executive brain functions of veterans exposed to chemical weapons was significantly lower compared to healthy individuals (P < 0.05).

Conclusions:

Our findings showed that veterans exposed to chemical weapons exhibited higher mental disorder symptoms across all domains than the control group. Moreover, veterans demonstrated weaker cognitive functions in terms of executive brain functions compared to healthy individuals. The implications of these findings are significant for mental health specialists working with veterans exposed to chemical weapons.

1. Background

War is detrimental to any country, with short- and long-term adverse effects. Technological advancements in the last century resulted in the production of mass-destruction weapons, including chemical weapons (1). The mental impact of chemical attacks is often more severe than physical injuries (2). Studies show that nearly one in four returning soldiers have severe mental problems (3), posing societal challenges. Extensive research has explored the relationship between war, stress, physical injuries, and mental health issues among veterans. Symptoms of mental disorders, such as memory malfunction, anxiety (4), depression (5), self-loathing, loneliness, mental health problems (6), stress, and dementia (4), have been confirmed in war victims (7). Irritability and aggression are common behavioral problems experienced by veterans due to their exposure to stressful and life-threatening situations (8). Aggression has various health consequences, including physical ailments, suicide, substance abuse, cardiovascular diseases (9), and chronic pain (10).

As a result of distressing thoughts and impulses, people with obsessive-compulsive disorder (OCD) engage in repetitive behaviors (11). It has been stated that 100 out of every 700 war veterans experience paranoia, which entails persistent distrust and complaints about others (12). Fear greatly disrupts life, causing a severe anxiety disorder (13). According to Fijtman et al. (14), veterans are more likely to be affected by severe mental diseases, such as bipolar disorder, and commit suicide. Even years after the Iran-Iraq war, post-traumatic stress disorder (PTSD) and poor mental health are still severe issues for veterans in Iran (15). With an emphasis on long-term impacts, this study attempts to compare the mental health and problems of veterans exposed to chemical weapons to healthy people.

Chemical agents in weapons cause death, permanent or temporary damage, weakness, paralysis, and disability, impacting executive functions (16). Executive functions include cognitive abilities, namely working memory, inhibitory control, cognitive flexibility, planning, reasoning, and problem-solving (17), mainly associated with the frontal lobe (18). Limited knowledge exists on the long-term effects of chemical gas exposure on human executive functions, but recent studies suggest various impacts (19, 20). Damage to the frontal lobe leads to executive dysfunction (21) and affects daily activities (22). Studies on attention deficit (23) have shown verbal memory deficits among veterans exposed to blast waves (24), non-verbal memory deficits in PTSD patients (25), and impaired future thinking (26), planning (27), attention (28), and cognitive flexibility in individuals with PTSD (29, 30). However, the effects of chemical weapons on veterans’ executive functions remain unexplored. This research compares memory, inhibitory control, attention, planning, decision-making, social cognition, and cognitive flexibility between veterans exposed to chemical weapons and healthy individuals, filling a crucial gap.

Research suggests that veterans’ mental and clinical problems emerge years later (15, 30). While comparing the mental state of veterans exposed to chemical weapons with healthy individuals may not directly impact treatment decisions, it can enhance screening, diagnosis, and intervention strategies. Furthermore, comparing mental conditions can enhance supportive care and rehabilitation efforts for veterans exposed to chemical weapons.

2. Objectives

Considering research gaps, theoretical importance, and the significance of veterans’ mental health, this study seeks to answer the question: How do mental disorders and executive functions differ between veterans exposed to chemical weapons and healthy individuals?

3. Methods

This case-control study was approved by the Research Ethics Committee of Aja University of Medical Sciences (IR.AJAUMS.REC.1400.232) following the World Medical Association’s (Declaration of Helsinki) code of ethics. The participants included veterans exposed to chemical weapons during the Iran-Iraq war and healthy individuals. Sampling was performed through the purposive sampling method. The inclusion criteria were: (1) Age of 44 - 55 years; (2) no prior exposure to warfare-related substances or metals (e.g., chemical agents and occupational exposure to lead and zinc); (3) not drinking alcohol; (4) not using supplemental antioxidants; (5) not taking psychoactive agents; (6) not being affected by chronic or mental illness; (7) not having received radiation therapy, surgery, or anesthesia within the previous year; and (8) ability to comprehend and respond to study-related questions. A total of 85 veterans who had been exposed to chemical weapons and an equal number (85 individuals) of healthy individuals matched in age, gender, education level, and residence were selected. After obtaining informed consent, both groups completed questionnaires on mental disorders (SCL-90), cognitive ability, and demographic information in one session.

The SCL-90 questionnaire, consisting of 90 questions, assessed mental symptoms and distinguished between healthy individuals and those with illness. Each question is rated on a 5-point scale, ranging from “none” to “severe.” The questionnaire comprises nine dimensions, including physical complaints, obsession-incontinence, depression, anxiety, aggression, morbid fear, paranoid thoughts, and psychosis, and entails seven additional questions. The internal reliability of the questionnaire was reported as 0.89, with the highest correlation coefficient for depression (0.95) and the lowest for psychosis (0.77). In Iran, Akhavan Obiri and Shoairi confirmed the scale’s reliability with a Cronbach’s alpha coefficient of 0.97 and a retest coefficient of 0.84. In the present study, the scale’s reliability was confirmed with Cronbach’s alpha coefficients of 0.71, 0.73, 0.73, 0.81, 0.77, 0.73, 0.75, 0.73, 0.74, and 0.76 for physical complaints, obsession-incontinence, sensitivity in mutual relationships, depression, anxiety, aggression, morbid fear, paranoid thoughts, psychosis, and the overall scale, respectively.

The cognitive ability scale developed by Nejati was used to measure executive functions. This 37-item questionnaire assesses memory, inhibitory control, selective attention, decision-making, planning, sustained attention, social cognition, and cognitive flexibility. Responses are given on a Likert scale from rarely, as 1, to almost always, as 4. Nejati reported a Cronbach’s alpha coefficient of 0.83 for this scale, and its validity and reliability were confirmed through significant Pearson’s correlation at a 0.01 level. The present study used Cronbach’s alpha coefficient to calculate the scale’s reliability. The subscales of memory (0.78), inhibitory control and selective attention (0.72), decision making (0.71), planning (0.79), sustained attention (0.74), social cognition (0.76), and cognitive flexibility (0.74) demonstrated reliability, with an overall Cronbach’s alpha of 0.90. The validity of the scale was also confirmed by five experts in the field of psychology.

The research data were analyzed using the SPSS statistical software (version 20.0, USA), employing multivariate analysis of variance (MANOVA) to examine the descriptive information.

4. Results

This study included one hundred and seventy male participants, all former army forces who had participated in the Iran-Iraq war. The participants had a mean age of 49.73±73.49 years, with a range of 44 - 55 years. Among the subjects, 45 individuals (26.5%) had education levels below a diploma, 77 (45.3%) had completed a diploma, and 48 (28.2%) had tertiary education. In terms of employment status, 14 participants (28.2%) were unemployed, 54 (31.8%) were employed as workers, 64 (37.6%) were self-employed, and 38 (22.4%) were retired.

The results presented in Table 1 demonstrate that the average levels of mental disorders among veterans exposed to chemical weapons were higher than those of the general population across all subscales. The highest average score was observed for the depression component, while the lowest average score was associated with the aggression component. In addition, the findings in the table indicate that the average scores of executive brain functions are higher in the normal group than the veterans exposed to chemical weapons across all subscales. Within the group of veterans exposed to chemical weapons, the lowest average score was related to the sustained attention component, while the highest pertained to the memory component. These differences are represented in Figures 1 and 2.

Table 1.

Descriptive Indices of Brain Executive Functions and Mental Disorders separated by Group (n = 85 in Each Group)

GroupMean ± SD
Brain executive functions
Memory
Veteran19.02 ± 2.67
Control21.62 ± 4.16
Inhibitory Control and Selective Attention
Veteran15.00 ± 3.47
Control21.10 ± 3.15
Decision-Making
Veteran13.64 ± 4.06
Control17.51 ± 4.11
Planning
Veteran7.09 ± 1.87
Control9.36 ± 1.96
Sustained Attention
Veteran6.92 ± 2.29
Control9.97 ± 2.25
Social Cognition
Veteran7.54 ± 2.35
Control10.77 ± 3.02
Cognitive Flexibility
Veteran10.94 ± 3.66
Control14.57 ± 3.04
Mental disorders
Physical complaint
Veteran31.82 ± 9.33
Control28.74 ± 9.42
Obsessive-Compulsive
Veteran27.04 ± 10.31
Control23.76 ± 9.76
Sensitivity in Mutual Relationships
Veteran23.80 ± 8.00
Control19.69 ± 6.34
Depression
Veteran31.90 ± 9.18
Control27.91 ± 14.17
Anxiety
Veteran23.83 ± 2.91
Control20.05 ± 10.95
Aggression
Veteran14.94 ± 5.88
Control12.77 ± 7.22
Morbid fear
Veteran17.08 ± 4.88
Control16.68 ± 6.58
Paranoid thoughts
Veteran17.27 ± 10.85
Control14.31 ± 6.07
Psychosis
Veteran25.4 ± 9.82
Control21.88 ± 9.93
Mental disorders components in the veteran and control groups
Mental disorders components in the veteran and control groups
Figure 1.

Mental disorders components in the veteran and control groups

Brain executive functions components in the veteran and control groups
Brain executive functions components in the veteran and control groups
Figure 2.

Brain executive functions components in the veteran and control groups

Levene’s test did not reveal a significant difference in the homogeneity of variance between the two groups (veterans exposed to chemical weapons and the general population) (P > 0.05). Moreover, the results of the Kolmogorov-Smirnov test indicated the normal distribution of the scores (P > 0.05). Therefore, MANOVA was employed to examine the differences between the two groups in terms of mental disorders and executive brain functions.

Based on the MANOVA results (Table 2), the two groups have shown a significant difference in all components of brain executive functions and mental disorders.

Table 2.

Results of Multivariate Analysis of Variance to Compare Brain Executive Functions and Mental Disorders Between the Two Groups

VariablesSum of SquaresHypothesis dfError dfMean SquareFP-ValuePartial Eta Squared
Brain executive functions
Memory287.31168287.323.4770.0010.123
Inhibitory control and selective attention1584.47611681584.476143.8840.0010.461
Decision-making636.7121168636.71238.0310.0010.185
Planning219.1121168219.11259.4740.0010.261
Sustained attention394.5941168394.59476.0640.0010.312
Social cognition444.8531168444.85360.6690.0010.265
Cognitive flexibility561.6531168561.65349.4160.0010.227
Mental disorders
Physical complaint403.7881168403.7884.8560.0340.027
Obsessive-compulsive457.8881168457.5384.5380.0350.026
Sensitivity in mutual relationships716.4761168716.47613.7350.0010.076
Depression676.0061168676.0064.7400.0310.027
Anxiety327.6241168327.6244.2310.0410.025
Aggression199.1531168199.1534.5910.0340.027
Morbid fear656.2121168656.2128.610.0040.049
Paranoid thoughts370.5941168370.5944.7890.0300.028
Psychosis525.8881168525.8885.3870.0200.031

As presented in Table 3, the parametric test one-way ANOVA indicated a significant difference in at least one of the components of mental disorder and brain executive functions between the two groups (P < 0.05).

Table 3.

Multivariate Analysis of Variance Results Comparing the Collective Effect of the Mean Scores of Brain Executive Functions and Mental Disorders

Pillai’s TraceValueFHypothesis dfError dfP-ValuePartial Eta Squared
Brain Executive functions0.5730.627 a71620.0010.57
Mental Disorders0.2445.726 a91600.0010.244

a Exact statistic.

5. Discussion

This study compared mental disorders and executive brain functions between veterans exposed to chemical weapons and controls. Veterans had significantly higher average scores in mental disorder indices than healthy individuals in physical complaints, obsession-incontinence, sensitivity in interpersonal relationships, depression, anxiety, aggression, morbid fear, paranoid thoughts, and psychosis. Mental disorders can manifest as physical complaints. Due to war conditions and stresses, veterans were exposed to more mental and physical risks, resulting in increased physical complaints compared to controls. Mental pressures on veterans have led to ambiguity, anxiety, and more physical complaints (31). This explains the higher physical complaint scores in veterans compared to controls (32, 33).

Our results showed that veterans exposed to chemical weapons had more obsessive-compulsive symptoms than controls. Personal crises and significant adverse events can trigger OCD. Mental trauma experienced in war environments can provoke OCD symptoms in soldiers and veterans (34). Veterans had higher sensitivity scores in mutual relationships compared to controls. Previous studies have shown that Iraq and Afghanistan war veterans face multiple mental disorders and encounter difficulties in family relationships (35-37). War-induced anxiety prevents these people from establishing proper relationships, leading to increased sensitivity in mutual relationships (38).

Depression scores were higher in veterans exposed to chemical weapons compared to ordinary individuals. Depression involves various factors, including physical and environmental causes (e.g., poisoning). Considering the dire conditions veterans were exposed to, particularly with chemical weapons, their higher depression scores are justified. However, physical and environmental causes alone cannot account for the high depression scores. Some factors, such as the lack of social support and impaired socioeconomic activities (39), also contribute to the higher depression scores in veterans exposed to chemical weapons than in healthy individuals. These findings are aligned with previous findings (39-41).

In accordance with the results of other investigations (40, 42, 43), anxiety was higher among veterans exposed to chemical warfare compared to controls, likely due to the stress caused by physical conditions and resulting internal conflicts (40). Aggression among these veterans is associated with feelings of shame, depression (44), anxiety (45), and other mental problems (46). Veterans exposed to chemical weapons had higher scores in morbid fear and paranoid thoughts than controls, which can be attributed to mental disorders, including depression and anxiety (12). Similarly, the psychotic score of these veterans was higher than controls, consistent with the studies of Benazzi (47) and Lee and Nathan (48). Depression and anxiety may contribute to psychotic symptoms.

Cognitive function, including memory, inhibitory control, selective attention, decision-making, planning, sustained attention, social cognition, and cognitive flexibility, was significantly lower among veterans exposed to chemical warfare than controls. The difficulty in preventing irrelevant information from entering memory, disorganized memory, and mental confusion contributes to the low memory scores of veterans (20, 49, 50). Binder et al. (51) also noted weak memory function in war soldiers exposed to explosions. Selective attention was weaker in veterans due to attention bias and cognitive impairments (23, 46, 52). Weak executive function in decision-making and planning was observed among veterans, consistent with previous studies (27). Sustained attention scores were lower among veterans, possibly due to impaired cognitive functions (28, 46, 53). Impaired social cognition linked to PTSD affects the ability to understand and respond to others (54).

Finally, our research findings showed lower cognitive flexibility scores in veterans exposed to chemical weapons than controls. Cognitive flexibility is a structure considered part of executive functions and can be measured using behavioral paradigms (55). The critical nodes involved in cognitive flexibility in the context of the surrounding environment consist of the executive control network, which is closely related to attention and working memory (29).

This research, similar to other studies, had certain limitations. For instance, the data collection method relied on self-reporting through research questionnaires, which means that participants’ temporary perspectives may influence the information provided. Furthermore, some of the reported data may be influenced by changes in the participants’ lifestyles as they adapt to the constraints and adverse consequences of chemical exposure on their physical, mental, and social well-being. Therefore, it is recommended to incorporate proper planning strategies to improve the quality of life for these individuals.

5.1. Conclusions

Veterans exposed to chemical weapons had higher mental disorder symptoms across all domains compared to the control group. Veterans also had lower executive brain capabilities than healthy people. These findings show that chemical warfare exposure harms veterans’ mental health and cognition. Veterans had higher rates of mental problems and cognitive impairment due to special stressors and war’s horrific conditions. These results are relevant for mental health professionals treating chemical weapons veterans. This population’s greater mental disorder symptoms and lower cognitive functions can inform focused mental therapies. Specialists can help veterans exposed to chemical weapons by creating programs to reduce mental impacts and improve cognitive performance.

References

  • 1.

    Azarmi S, Farsi Z, Sajadi SA. [The role of nurse in adaptation of veterans with amputee]. Mil Caring Sci. 2015;2(1):48-54. Persian. https://doi.org/10.18869/acadpub.mcs.2.1.48.

  • 2.

    Dyball D, Bennett AN, Schofield S, Cullinan P, Boos CJ, Bull AMJ, et al. Mental health outcomes of male UK military personnel deployed to Afghanistan and the role of combat injury: analysis of baseline data from the ADVANCE cohort study. Lancet Psychiatry. 2022;9(7):547-54. [PubMed ID: 35717965]. https://doi.org/10.1016/S2215-0366(22)00112-2.

  • 3.

    Asgharnejad Farid AA, Mirmohammadali M, Ahadi H, Nasiri A. [Evaluation of the effectiveness of cognitive-behavioral therapy and acceptance and commitment -therapy of psychosocial needs of veterans]. Iran J War Public Health. 2020;12(3):157-64. Persian. https://doi.org/10.52547/ijwph.12.3.157.

  • 4.

    Pasinetti GM, Trageser KJ, Harary JM, Gleason TC. Editorial: Psychiatric Disorder in Veterans. Front Psychiatry. 2021;12:666719. [PubMed ID: 33986702]. [PubMed Central ID: PMC8110818]. https://doi.org/10.3389/fpsyt.2021.666719.

  • 5.

    Grau PP, Sripada RK, Ganoczy D, Weinstein JH, Pfeiffer PN. Outcomes of Acceptance and Commitment Therapy for depression and predictors of treatment response in Veterans Health Administration patients. J Affect Disord. 2023;323:826-33. [PubMed ID: 36529407]. https://doi.org/10.1016/j.jad.2022.12.025.

  • 6.

    Rodriguez KE, LaFollette MR, Hediger K, Ogata N, O'Haire ME. Defining the PTSD Service Dog Intervention: Perceived Importance, Usage, and Symptom Specificity of Psychiatric Service Dogs for Military Veterans. Front Psychol. 2020;11:1638. [PubMed ID: 32849004]. [PubMed Central ID: PMC7396623]. https://doi.org/10.3389/fpsyg.2020.01638.

  • 7.

    Finnegan A, Randles R. Prevalence of common mental health disorders in military veterans: using primary healthcare data. BMJ Mil Health. 2022. [PubMed ID: 35042763]. https://doi.org/10.1136/bmjmilitary-2021-002045.

  • 8.

    Wolfs EML, van Lutterveld R, Varkevisser T, Klaus J, Geuze E, Schutter D. Lower cerebello-cortical functional connectivity in veterans with reactive aggression symptoms: A pilot study. J Psychiatr Res. 2023;159:42-9. [PubMed ID: 36657313]. https://doi.org/10.1016/j.jpsychires.2023.01.023.

  • 9.

    Shin HJ, Rosen CS, Greenbaum MA, Jain S. Longitudinal correlates of aggressive behavior in help-seeking U.S. veterans with PTSD. J Trauma Stress. 2012;25(6):649-56. [PubMed ID: 23225031]. https://doi.org/10.1002/jts.21761.

  • 10.

    Sippel JL, Daly JE, Poggensee L, Ristau KD, Eberhart AC, Tam K, et al. Modernization of a Large Spinal Cord Injuries and Disorders Registry: The Veterans Administration Experience. Arch Rehabil Res Clin Transl. 2022;4(4):100237. [PubMed ID: 36545529]. [PubMed Central ID: PMC9761267]. https://doi.org/10.1016/j.arrct.2022.100237.

  • 11.

    Aldea MA, Michael K, Alexander K, Kison S. Obsessive-Compulsive Tendencies in a Sample of Veterans With Posttraumatic Stress Disorder. J Cogn Psychother. 2019;33(1):33-45. [PubMed ID: 32746420]. https://doi.org/10.1891/0889-8391.33.1.33.

  • 12.

    Achte K, Jarho L, Kyykka T, Vesterinen E. Paranoid disorders following war brain damage. Preliminary report. Psychopathology. 1991;24(5):309-15. [PubMed ID: 1784707]. https://doi.org/10.1159/000284731.

  • 13.

    Russell PD, Judkins JL, Blessing A, Moore B, Morissette SB. Incidences of anxiety disorders among active duty service members between 1999 and 2018. J Anxiety Disord. 2022;91:102608. [PubMed ID: 36029531]. https://doi.org/10.1016/j.janxdis.2022.102608.

  • 14.

    Fijtman A, Clausen A, Kauer-Sant'Anna M, V. A. Mid-Atlantic MIRECC Workgroup. Electronic address: john.fairbank2@va.gov, Morey R. Trauma history in veterans with bipolar disorder and its impact on suicidality. J Psychiatr Res. 2023;157:119-26. [PubMed ID: 36463626]. https://doi.org/10.1016/j.jpsychires.2022.10.063.

  • 15.

    Karami GR, Ameli J, Roeintan R, Jonaidi-Jafari N, Saburi A. Impacts of mustard gas exposure on veterans mental health: A study on the role of education. Ind Psychiatry J. 2013;22(1):22-5. [PubMed ID: 24459369]. [PubMed Central ID: PMC3895307]. https://doi.org/10.4103/0972-6748.123604.

  • 16.

    Aupperle RL, Melrose AJ, Stein MB, Paulus MP. Executive function and PTSD: disengaging from trauma. Neuropharmacology. 2012;62(2):686-94. [PubMed ID: 21349277]. [PubMed Central ID: PMC4719148]. https://doi.org/10.1016/j.neuropharm.2011.02.008.

  • 17.

    Cristofori I, Cohen-Zimerman S, Grafman J. Executive functions. Handb Clin Neurol. 2019;163:197-219. [PubMed ID: 31590731]. https://doi.org/10.1016/B978-0-12-804281-6.00011-2.

  • 18.

    Baez AC, Dajani DR, Voorhies W, Parlade MV, Alessandri M, Britton JC, et al. Parsing Heterogeneity of Executive Function in Typically and Atypically Developing Children: A Conceptual Replication and Exploration of Social Function. J Autism Dev Disord. 2020;50(3):707-18. [PubMed ID: 31728807]. https://doi.org/10.1007/s10803-019-04290-9.

  • 19.

    Chao LL, Lenoci M, Neylan TC. Effects of post-traumatic stress disorder on occipital lobe function and structure. Neuroreport. 2012;23(7):412-9. [PubMed ID: 22453299]. https://doi.org/10.1097/WNR.0b013e328352025e.

  • 20.

    Sheppard KW, Cheatham CL. The Balance Between n-6 and n-3 and its Relation to Executive Function. In: Watson RR, Preedy VR, editors. Omega Fatty Acids in Brain and Neurological Health. Cambridge, USA: Academic Press; 2019. p. 43-62. https://doi.org/10.1016/b978-0-12-815238-6.00004-3.

  • 21.

    Zimmerman BJ. A social cognitive view of self-regulated academic learning. J Educ Psychol. 1989;81(3):329-39. https://doi.org/10.1037/0022-0663.81.3.329.

  • 22.

    Flaks MK, Malta SM, Almeida PP, Bueno OF, Pupo MC, Andreoli SB, et al. Attentional and executive functions are differentially affected by post-traumatic stress disorder and trauma. J Psychiatr Res. 2014;48(1):32-9. [PubMed ID: 24199652]. https://doi.org/10.1016/j.jpsychires.2013.10.009.

  • 23.

    Samadi R, Razaghi Kashani EM, Kami M, Rezaei O. Executive Function and Attention Deficits in Post-Traumatic Stress Disorder: A Study on Iranian War Veterans. Iran Rehabil J. 2018;16(1):17-24. https://doi.org/10.29252/nrip.irj.16.1.17.

  • 24.

    Grande LJ, Robinson ME, Radigan LJ, Levin LK, Fortier CB, Milberg WP, et al. Verbal Memory Deficits in OEF/OIF/OND Veterans Exposed to Blasts at Close Range. J Int Neuropsychol Soc. 2018;24(5):466-75. [PubMed ID: 29362020]. https://doi.org/10.1017/S1355617717001242.

  • 25.

    Jelinek L, Jacobsen D, Kellner M, Larbig F, Biesold KH, Barre K, et al. Verbal and nonverbal memory functioning in posttraumatic stress disorder (PTSD). J Clin Exp Neuropsychol. 2006;28(6):940-8. [PubMed ID: 16822734]. https://doi.org/10.1080/13803390591004347.

  • 26.

    Brown AD, Root JC, Romano TA, Chang LJ, Bryant RA, Hirst W. Overgeneralized autobiographical memory and future thinking in combat veterans with posttraumatic stress disorder. J Behav Ther Exp Psychiatry. 2013;44(1):129-34. [PubMed ID: 22200095]. https://doi.org/10.1016/j.jbtep.2011.11.004.

  • 27.

    McDaniel JT, Hascup ER, Hascup KN, Trivedi M, Henson H, Rados R, et al. Psychological Resilience and Cognitive Function Among Older Military Veterans. Gerontol Geriatr Med. 2022;8:23337214221081400. [PubMed ID: 35252475]. [PubMed Central ID: PMC8891840]. https://doi.org/10.1177/23337214221081363.

  • 28.

    Scott JC, Matt GE, Wrocklage KM, Crnich C, Jordan J, Southwick SM, et al. A quantitative meta-analysis of neurocognitive functioning in posttraumatic stress disorder. Psychol Bull. 2015;141(1):105-40. [PubMed ID: 25365762]. [PubMed Central ID: PMC4293317]. https://doi.org/10.1037/a0038039.

  • 29.

    Ben-Zion Z, Fine NB, Keynan NJ, Admon R, Green N, Halevi M, et al. Cognitive Flexibility Predicts PTSD Symptoms: Observational and Interventional Studies. Front Psychiatry. 2018;9:477. [PubMed ID: 30337890]. [PubMed Central ID: PMC6180246]. https://doi.org/10.3389/fpsyt.2018.00477.

  • 30.

    Nazari I, Mohammadi M, Nazeri G. [Effectiveness of Gestalt therapy on Post Traumatic Stress Disorder (PTSD) symptoms on veterans of Yasuj city]. Armaghane danesh. 2014;19(4):295-304. Persian.

  • 31.

    Basharpoor S, Shahmohammadzadeh Y. [The role of alexithymia and emotional expressivity in predicting somatization symptoms among students of mohaghegh Ardabili University during 2014-2015]. J Rafsanjan Univ Med Sci. 2015;13(10):961-72. Persian.

  • 32.

    Cloitre M, Cohen LR, Edelman RE, Han H. Posttraumatic stress disorder and extent of trauma exposure as correlates of medical problems and perceived health among women with childhood abuse. Women Health. 2001;34(3):1-17. [PubMed ID: 11708684]. [PubMed Central ID: PMC5918463]. https://doi.org/10.1300/J013v34n03_01.

  • 33.

    Sullivan K, Barr N, Kintzle S, Gilreath T, Castro CA. PTSD and Physical Health Symptoms Among Veterans: Association with Child and Relationship Functioning. Marriage Fam Rev. 2016;52(7):689-705. https://doi.org/10.1080/01494929.2016.1157122.

  • 34.

    Barrera TL, McIngvale E, Lindsay JA, Walder AM, Kauth MR, Smith TL, et al. Obsessive-compulsive disorder in the Veterans Health Administration. Psychol Serv. 2019;16(4):605-11. [PubMed ID: 29792474]. https://doi.org/10.1037/ser0000249.

  • 35.

    Meis LA, Erbes CR, Kramer MD, Arbisi PA, Kehle-Forbes SM, DeGarmo DS, et al. Using reinforcement sensitivity to understand longitudinal links between PTSD and relationship adjustment. J Fam Psychol. 2017;31(1):71-81. [PubMed ID: 27077237]. [PubMed Central ID: PMC6791525]. https://doi.org/10.1037/fam0000195.

  • 36.

    Hannan SM, Orcutt HK. Emotion dysregulation as a partial mediator between reinforcement sensitivity and posttraumatic stress symptoms. Pers Individ Differ. 2013;55(5):574-8. https://doi.org/10.1016/j.paid.2013.04.028.

  • 37.

    Tull MT, Gratz KL, Latzman RD, Kimbrel NA, Lejuez CW. Reinforcement Sensitivity Theory and emotion regulation difficulties: A multimodal investigation. Pers Individ Differ. 2010;49(8):989-94. https://doi.org/10.1016/j.paid.2010.08.010.

  • 38.

    Wells TS, Miller SC, Adler AB, Engel CC, Smith TC, Fairbank JA. Mental health impact of the Iraq and Afghanistan conflicts: a review of US research, service provision, and programmatic responses. Int Rev Psychiatry. 2011;23(2):144-52. [PubMed ID: 21521083]. https://doi.org/10.3109/09540261.2011.558833.

  • 39.

    Eskandari H. The Survey of Veterans’ Depression and Anxiety and its Relationship with Veterans’ Social-Economic Activities. J Milit Med. 2015;16(4):197-203.

  • 40.

    Ahmadi K, Reshadatjoo M, Karami G. Comparison of depression, anxiety and stress rate between chemical warfare victims and healthy persons in Sardasht Iran. J Babol Univ Med Sci. 2010;12(1):44-50.

  • 41.

    Liu Y, Collins C, Wang K, Xie X, Bie R. The prevalence and trend of depression among veterans in the United States. J Affect Disord. 2019;245:724-7. [PubMed ID: 30699861]. https://doi.org/10.1016/j.jad.2018.11.031.

  • 42.

    Hasani Tabatabai L, Shaker Dioulagh A. [Comparison of Stress and Social Support between Veterans and Non-Veterans; Case Study of Urmia City, Iran]. Iran J War Public Health. 2017;9(3):141-6. Persian. https://doi.org/10.18869/acadpub.ijwph.9.3.141.

  • 43.

    Trahan MH, Ausbrooks AR, Smith KS, Metsis V, Berek A, Trahan LH, et al. Experiences of student veterans with social anxiety and avoidance: A qualitative study. Soc Work Ment Health. 2018;17(2):197-221. https://doi.org/10.1080/15332985.2018.1522607.

  • 44.

    Taft CT, Pless AP, Stalans LJ, Koenen KC, King LA, King DW. Risk factors for partner violence among a national sample of combat veterans. J Consult Clin Psychol. 2005;73(1):151-9. [PubMed ID: 15709842]. https://doi.org/10.1037/0022-006X.73.1.151.

  • 45.

    Berkowitz L. On the formation and regulation of anger and aggression. A cognitive-neoassociationistic analysis. Am Psychol. 1990;45(4):494-503. [PubMed ID: 2186678]. https://doi.org/10.1037//0003-066x.45.4.494.

  • 46.

    Mirdoraghi F, Hashemabady G, Mashhadi A. Cognitive and behavioral inhibition in veterans with-and without post-traumatic stress disorder. J Mil Med. 2012;14(1):41-7.

  • 47.

    Benazzi F. Psychotic versus nonpsychotic bipolar outpatient depression. Eur Psychiatry. 1999;14(8):458-61. [PubMed ID: 10683632]. https://doi.org/10.1016/s0924-9338(99)00221-7.

  • 48.

    Lee A, Nathan KI. Understanding Psychosis in a Veteran With a History of Combat and Multiple Sclerosis. Fed Pract. 2019;36(Suppl 4):S32-5. [PubMed ID: 31296981]. [PubMed Central ID: PMC6604979].

  • 49.

    Gold JM, Barch DM, Feuerstahler LM, Carter CS, MacDonald AW, Ragland JD, et al. Working Memory Impairment Across Psychotic disorders. Schizophr Bull. 2019;45(4):804-12. [PubMed ID: 30260448]. [PubMed Central ID: PMC6581132]. https://doi.org/10.1093/schbul/sby134.

  • 50.

    de Guise E, Degre C, Beaujean O, Julien J, Lague-Beauvais M, Dagher J, et al. Comparison of executive functions and functional outcome between older patients with traumatic brain injury and normal older controls. Appl Neuropsychol Adult. 2022;29(5):1174-87. [PubMed ID: 33372562]. https://doi.org/10.1080/23279095.2020.1862118.

  • 51.

    Binder LM, Storzbach D, Anger WK, Campbell KA, Rohlman DS; Portland Environmental Hazards Research Center. Subjective cognitive complaints, affective distress, and objective cognitive performance in Persian Gulf War veterans. Arch Clin Neuropsychol. 1999;14(6):531-6. [PubMed ID: 14590580].

  • 52.

    Vasterling JJ, Brailey K, Constans JI, Sutker PB. Attention and memory dysfunction in posttraumatic stress disorder. Neuropsychology. 1998;12(1):125-33. [PubMed ID: 9460740]. https://doi.org/10.1037//0894-4105.12.1.125.

  • 53.

    Schmidt EA, Schrauf M, Simon M, Fritzsche M, Buchner A, Kincses WE. Drivers' misjudgement of vigilance state during prolonged monotonous daytime driving. Accid Anal Prev. 2009;41(5):1087-93. [PubMed ID: 19664450]. https://doi.org/10.1016/j.aap.2009.06.007.

  • 54.

    Janssen PGJ, van Est LAC, Hilbink M, Gubbels L, Egger J, Cillessen AHN, et al. Social cognitive performance in posttraumatic stress disorder: A meta-analysis. J Affect Disord. 2022;297:35-44. [PubMed ID: 34606811]. https://doi.org/10.1016/j.jad.2021.09.082.

  • 55.

    Monsell S. Task switching. Trends Cogn Sci. 2003;7(3):134-40. [PubMed ID: 12639695]. https://doi.org/10.1016/s1364-6613(03)00028-7.

Ahmad Mahdavi
2024-05-20 03:21:30
Thank you for this study, the Iranian people were victims of chemical warfare during the imposed war.The use of chemical weapons by the Iraqi regime caused immense suffering and long-lasting effects. It is crucial to remember and honor the victims of these horrific attacks and to work towards preventing such atrocities from happening again in the future.

reply