Literature and Medicine: Clinical Symptoms of Post-Traumatic Stress Disorder in Contemporary Iranian Fictions

authors:

avatar Masoumeh Mahmoudi 1 , * , avatar Mehdi Pourasghar ORCID 2 , avatar Kamaledin Alaedini ORCID 3

Mazandaran University of Medical Sciences, Sari, Iran
Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
Addiction Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
Iranian Journal of Psychiatry and Behavioral Sciences: Vol.14, issue 3; e91196
published online: August 31, 2020
article type: Research Article
received: May 7, 2019
revised: November 26, 2019
accepted: June 19, 2020
DOI: https://doi.org/10.5812/ijpbs.91196

how to cite: Mahmoudi M, Pourasghar M, Alaedini K. Literature and Medicine: Clinical Symptoms of Post-Traumatic Stress Disorder in Contemporary Iranian Fictions. Iran J Psychiatry Behav Sci. 2020;14(3):e91196. https://doi.org/10.5812/ijpbs.91196.

Abstract

Background:

Some studies indicated that the study of stories in which physical or mental illnesses are described helps to better understand the patient and his/her sickness; but unfortunately, this approach is neglected in the Persian literature. Paying attention to this issue can increase the attractiveness of studying such literary works for the Iranian and non-Iranian audience and can grant new sights to readers, as well.

Objectives:

This research is conducted to describe and explain the symptoms of the PTSD in the characters of modern Persian fiction, based on the clinical symptoms.

Methods:

This is qualitative research. Seven characters from the seven stories were selected purposefully to fit the researcher’s goals. Then, they were analyzed according to the DSM-5 criteria.

Results:

The results indicated that the selected stories represent individuals with PTSD consistent with the clinical criteria for the diagnostic of the disorder. In these stories, the authors, in addition to describing clinical symptoms, have considered inheritance, gender, and cultural factors to create characters in accordance with the specifications of the people who have been damaged in the real world.

Conclusions:

Reading these stories can be useful due to applying descriptions based on clinical criteria for the diagnosis of this disorder (PTSD), and thanks to the use of literary language in representing the victim’s inner and spiritual status, are useful in creating an engagement resulting from a proper understanding of the person who is suffering from such disorder.

1. Background

Overall studies on the relationship between literature and medicine can be divided into two categories: first, researches that examined the literary works on the subject and theme of the sickness, which their description of physical and mental illnesses are useful to recognize and understand physical and mental illnesses during the history of medicine (1, 2). Besides, they provide us with information about effective methods in eradicating humorous attitudes to mental disorders (3). Typically, Dostoevsky’s involvement in epilepsy and the transformation of suffering into the art and the description presented in his writings on this disease have helped physicians to better understand the disease (4, 5). Another study has investigated the depiction of posttraumatic stress disorder (PTSD) in two works of fiction (6). The fictions written by Dumas, Zola, Mann, and Bauby are literary works which referred to diseases and are outstanding examples of the influence of literature on attitudes and cognition of physicians and psychiatrists (7, 8); but the second group of researches reported the amazing impact of storytelling on the human mental and cognitive abilities (9, 10) and confirmed that reading the literary works improves the perception of individuals towards other people (11-13) and their position. Also, it helps in improving the skill of empathy, which is essential for human relations (14, 15). Through their cognitive imagination, literary works help us to understand more about the contents of the human mind (16, 17).

Although many researchers believe in the interaction between fictional literature and medical texts and the effective role of reading literary works in transferring clinical doctrines (18-20) and medical ethics (21, 22), unfortunately, such researches are neglected in the Persian stories and fictions. However, several psychological studies are carried out on Persian literary texts that are mostly based on Freud’s views and in the sphere of analytic psychoanalysis of Yung and his students. Besides, some researchers have examined defense strategies proposed by Ervin Yalom in the behavior of the characters of the contemporary stories (23).

2. Objectives

Since no research is conducted on “how to describe the clinical symptoms of PTSD in characters of modern Persian fictions” and because of the importance of interdisciplinary studies and their status in the current era, the current research was conducted. In the current study, the author attempted to answer the following questions: (1) Do the descriptions provided by authors from PTSD are consistent with what appeared in the scientific literature?; (2) does the writer’s gender influenced the description provided from the disorder?; (3) have the authors considered gender and cultural categories in describing the symptoms of PTSD?

3. Methods

This is qualitative research, which investigated seven characters of stories using the purposeful sampling method to fit the researcher’s goals. Then, the stories were analyzed according to the diagnostic and statistical manual of mental disorders, 5th edition (DSM-5) criteria. The stories are described in the following: Adamhay-e Ghayeb (absent people) (24), Engar Gofteh Boodi leily (It’s as if you had said leily) (25), Osaneye Baba Sobhan (The legend of Baba Sobhan (26), Dr. N Zanash ra Bishtar az Mossadegh Doost Darad (Dr. N loves his wife more than Mossadegh) (27), Zamin-e Sookhteh (The burned earth) (28), Jazireh Sargardani (Wandering Island) (29), Sag va Zemestane Boland (dog and long winter) (30). After selecting the stories, the clinical symptoms of the disorder were identified in the selected stories and texts based on the DSM-5 criteria (31) and then were analyzed. The defined criteria for detecting PTSD using the DSM-5 are described in Table 1.

Table 1.

The Names of the Stories and Symptoms Described in Them

DSM-5 Diagnostic Criteria for PTSDAdamhaye Ghayeb (Taqi Modaresi)Engar Gofteh Boodi Leily (Sepideh Shamloo)Osaneye Baba Sobhan (Mahmoud Dolat Abadi)Jazireh Sargardani (Simin Daneshvar)Doctor N… (Shahram Rahimian)Zamine Sokhte (Ahmad Mahmoud)Sagh va Zemestane Boland (Shahrnush Parsipour)
A) Criterion: (exposure to actual or threatened death, serious injury or sexual violence in one (or more) of the following ways:
1- Direct experience of traumatic event(s).*
2- Witnessing in person the event(s) as it occurred to others.****
3- learning that the traumatic event(s) occurred to a close family member or a close friend. The event(s) must have been violent or accidental.**
4- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s).
B) Criterion: (presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the occurrence of traumatic event(s):
1- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).******
2- Recurrent distressing dreams in which the content and/or effect of the dream is related to the traumatic event(s).****
3- Dissociative reactions (e.g. flashbacks) in which the individual feels or acts as if the traumatic event(s) is recurring.*
4- Intense or prolonged physiological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5- Marked physiological reactions to reminders of the traumatic event(s).****
C) Criterion: (Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the occurrence of the traumatic event(s), as evidenced by one or both of the following:
1- Avoidance of or efforts to avoid distressing memories, thoughts, or feeling about or closely associated with the traumatic event(s).
2- Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations). that arouse distressing memories, thoughts, or feeling about or closely associated with the traumatic event(s).*
D) Criterion: Negative alterations in recognition and mood associated with the traumatic event(s).
1- Inability to remember an important aspect of the traumatic event(s). Typically, due to dissociative amnesia and is not related to other factors such as head injury, alcohol, or drugs).
2- Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.***
3- Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. **
4- Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). *
5- Markedly diminished interest or participation in significant activities.**
6- Feeling of detachment or estranged from others.******
7- Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).******
E) Criterion: (Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic) event(s) occurred, as evidenced by two (or more) of the following):
1- Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. ****
2- Reckless or self-destructive behavior.****
3- Hypervigilance.***
4- Exaggerated startle response.*
5- Problems with concentration,
6- Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).*******
F) Criterion (duration of the disorder is more than 1 month).*******
G) Criterion (the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning).*******
H) Criterion (the disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or other medical condition(s). *******

4. Results

The results showed the fictional characters in the selected stories when confronting the traumatic experiences and events (they revealed symptoms that are consistent with the diagnostic clinical criteria of the disorder). The experience of dealing with actual death or threat of death and awareness about the catastrophic events occurred for close relatives, and the persistence of the symptoms resulting from that event were found in the aforementioned stories.

Moreover, throughout their stories, the authors mentioned how traumatic events can cause anxiety in individuals by changing their social role and degrading their social status, which is effective in treating PTSD symptoms. The conversance of the authors in describing the impact of the experienced trauma on the affected person has led to the compliance of the description of the characters in the aforementioned stories in full with the clinical diagnostic criteria of PTSD and the correct illustration of the disorder in the characters of the stories. Meanwhile, the authors have considered the inherited, gender, and cultural factors associated with PTSD in addition to the clinical symptoms in their stories. This reflects the authors’ ability to create truthful and believable texts, which can influence the readers and improve their relationship with the story. Moreover, the writers of these works have used the literary language to describe the inner and subjective states of the affected people. They used the metaphorical language to describe the mental and physical states of suffering individuals and their families. These authors could create personalities that fit the characteristics of people who are damaged in the real world.

5. Discussion

As illustrated in Table 1 fictional descriptions apply to various words of the clinical symptoms indicated in the scientific questionnaires to diagnose the disorder. In Dr. N story, the psychological weakness resulting from the disorder caused problems for Dr. N with his relatives. It’s been a long time since he was arrested and tortured; however, the apparent chaos, dipsomania, and irritable behavior, avoiding from others (18, 32), efforts to avoid external reminders, persistent negative emotional state (e.g., fear, horror, anger or shame), and insomnia indicate the persistence of PTSD (33, 34) in this person (27).

During interrogations, they told him that they have arrested his wife to torture her. To save his wife, Dr. N must betray Mossadegh (the ex-prime minister) and must speak out against him in a radio interview. Dr. N is frightened by the screams of his wife being kept in another room and afraid that the interrogators rape her, so he agrees to have a radio interview. It seems that Dr. N is so frightened due to the threat of sexual violence against his wife, and although he knows that the investigators have deceived him by this matter, but his mind is still involved in the subject and PTSD symptoms remain with him, and even it leads to some disorders relevant to PTSD:

Malektaj said, “Mohsen, you are getting crazy, both crazy and drunkard. From the day you came out of jail you are drunk all the time. You are getting more immoral and more intolerable.”

His mother says, “Mohsen, open the door I want to talk to you. I want to know why you have incarcerated yourself in this house for a year” (28).

The interrogator’s manners in prison make Hussein anxious (35-37). Besides, the inappropriate atmosphere at home, along with failure in love, led to his unusual and irrational behavior after his release from prison.

The interrogator takes the gun to Hossein’s forehead (Houri’s brother) and threatens to kill him, then he hits Hossein’s head with the gun strongly, which causes Hossein to panic. Although it happened several months ago, but remembering it disquiets Hossein so that whatever reminds him that moment is also frightening to him. He is sometimes sad and sometimes very happy:

“Hossein had closed his eyes. I sat down next to him. I wet the towel and put it on his forehead. It seems that his mind was not there; thus he suddenly jumped up and shouted: “No, no ... and threw the towel. He looked at me in amazement for a moment and then, … So sorry” (30).

“I hadn’t seen him like that for a while, his eyes flashed from behind glasses, and he was happy. He told me that he had never liked summer, but now he knew that it is the best season. It’s the season of life ... and now he’s completely well. It didn’t look like that ... He was thin and pale and his hands were shaking” (30).

In the story of Jazireh Sargardani (Wandering Island), “Touran” is the grandmother of Hasti and one of the subordinate characters of the story. Turan’s son and daughter-in-law go to the market for shopping and Touran’s son gets shot and killed in a political street fight. Reminding the old memories, successive crying, hypervigilance, hyperphagia, physical reactions, bitterness, and tinnitus are examples of descriptions of the author about this character:

“Again, he felt a little bit anxious. He ran out of breath. His mouth became bitter and dry. His ear rang. It was as if someone was dragging a wet and cold broom on his back” (29).

In the story of the Zamin-e Sookhteh (The Burned Earth), “Shahed” is distressed with the death of his brother in the war zone. That made “Shahed” hypervigilance and very sensitive to airstrikes and bombing or anti-aircraft and red alert.

Suddenly the sound of the explosion shook us. The “Shahed” jumped up and screamed. He turned around and rushed down the stairs of the basement (28).

In the novel of Engar Gofteh Boodi Leily (it’s as if you had said Leily), Leily, the story’s main character, reviews and experiences the scene of her husband’s death in the sleep and awakens repeatedly throughout the story:

“Its thirteen years since the day the bombs were dropped on the neighbor’s house and you were thrown out of the porch and died and left me alone (25).

In the novel of Adamhay-e Ghayeb (the absent people), “Irandokht” after the self- immolation and death of her mother can’t communicate with others and suffers from masochism. She burned her leg with boiling water in the bath.

The writer of Osaneye Baba Sobhan (the legend of baba Sobhan) also used features in the description of “Mosayeb” that indicate PTSD. “Mosayeb’s” brother is killed with a knife in front of his eyes. Disregard for health and signs of persistent fatigue, irritable behavior and angry outbursts, reckless or self-destructive behavior, laconic speech and feeling of detachment or estranged from other are specifications that describe this character:

He was thinner, and there was a sign of constant tiredness all over his body, but he was ready to hustle. If the door of the yard was locked, he would break the door and run out. He would writhe in himself and disrupt whatever was on his way (26).

Mossayeb twisted the handles of the motorcycle, and people rolled over. Mossayeb was neighing like a horse. He laughed and started the motorcycle, which was a mix of horror. He could not control its handlebars, so it escaped and ricocheted off. Out of the way, it was crushed down to a tree that looked like a giant, and both-Mossayeb and the motorcycle - were thrown like two pieces of iron into the air and come down, while hearts of the people in front of the coffee shop collapsed (26).

In stories of Engar Gofteh Boodi Leily (it’s as if you had said Leily), Zamin-e Sookhteh (the burned earth), and Jazireh Sargardani (wandering island) incidents cause stress (i.e. act as stressful factor), but in the stories of Dr. N (Dr. N loves his wife more than Mossadegh), the Sag va Zemestane Boland (dog and long winter), and Osaneye Baba Sobhan (the legend of baba Sobhan) the stress-creating factors are society, Individual status, and roles. In the Sag va Zemestane Boland (dog and long winter) and Dr. N (Dr. N loves his wife more than Mossadegh), the political and social conditions and the attempts made to change them cause the disorders. In the Osaneye Baba Sobhan (the legend of baba Sobhan) poverty and the inadequate economic structures caused conflicts and problems. Another important point in the aforementioned stories is the inherent readiness of the characters to suffer from the disorder (35). In Adamhay-e Ghayeb (the absent people), “Touran Dokht”, is mentally vulnerable (like her mother) and she becomes psychotic with incidents that happen. In the story of Sag va Zemestane Boland (dog and long winter), “Houri” and her brother are psychologically distressed when they are in a state of stress.

All characters of the above-mentioned stories, are victims who often think of the worst part of their memories (36). Some fictional characters of the investigated stories have symptoms of PTSD in their behavior which made them constantly worried about the loss of their child (25), grandchild (30), or brother (28). Besides, in the examined stories the cultural and gender differences are effective in the incidence and severity of psychological problems. Dipsomania (27, 31, 37), reckless or self–destructive behavior, are the main characters of males, and for the affected women, behaviors such as hyperphagia (30) and Self-immolation (24) are more prevalent. Some scholars reported a higher prevalence of PTSD in females than males, while some reported an equal prevalence (38).

Throughout the stories, terrible and bitter events that resulted in the mental illness of victims are described. Story writers either have experienced the disorder themselves or have seen them in the people around them; for example, Simin Daneshvar has experienced the sudden death of her husband (Jalal Al-Ahamad) and Ahmad Mahmoud went to war zones after his brother’s death in war and wrote the story of “the burned earth” when returned. His son said: “he was terribly crying when writing the chapter related to the death of Khalid” (39). Such experiences affect the accurate and scientific description of the disorders in the stories.

The final point in the reviewed literary texts is using a literary and metaphorical language to describe the symptoms of PTSD, which is effective in inducing the suffered character’s inner feelings to the reader and making her/his to better understand and experience of the disorder described. “Dowlat Abadi” used the following descriptions in the story of the osaneye baba Sobhan (the legend of baba Sobhan) to describe the gaunt appearance and lack of communication with others, laconic speech, avoiding intercourse with others, and the inability to overcome this situation:

“Mosayeb was dried up like a wheat bush being in the sun of summer. He said nothing, even a word” (26).

“The dragon was twisted around my neck” (26).

“Irandokht inclined backward easily and followed Zahra Soltan as a cotton doll” (24).

“I was in the dust” (25).

“My knees weaken and I put my palms on my temples and sit down, and the ground seems to be empty under my feet, as if I fall in darkness, vacuity, and cold” (28).

The understanding of the metaphorical language used in the literary context can be useful for enhancing the skills of medical staff in narrating and interpreting the patient’s condition (40). It also improves their ability to understand the data reported by patients about their personal and social life (41, 42). Fiction invites us to experience the emotions of other people, without experiencing real-world problems (43, 44). In other words, fictional literature is a gentle teacher (45). The importance of empathic relationships between the physician and the patient is extremely high, so that some believe that understanding the patient is an inseparable part of the diagnosis of the disease (46, 47).

5.1. Conclusions

This research showed that the studied works of contemporary Iranian literature can represent the behavior and mentality of a person with PTSD and can help the reader to understand the victim. These stories can be useful due to applying descriptions based on clinical criteria for the diagnosis of this disorder (PTSD) and thanks to the use of literary language in representing the victim’s inner and spiritual status in creating an engagement resulting from a proper understanding of the person who is suffering from such disorder. These texts provide a more humanized view of the disease or disorder and a context for descriptions of symptoms. Therefore, studying these works, in addition to familiarization with contemporary Iranian literature, can be useful for better understanding and interaction, and are suggested to be read for those who deal with such patients. The limitation of the current study is to focus on matching the clinical symptoms with the symptoms mentioned in the stories. It is suggested that in such stories, the verbal metaphors related to the disorder be extracted and the impact of their awareness on therapists be measured using the appropriate scientific methods.

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