Examining the relationship between resilience and posttraumatic growth

To extend the literature the present study aims to examine the interrelationships between resilience (defined by a lack of posttraumatic stress disorder following trauma) and posttraumatic growth. Two studies were conducted of Israeli: (a) adolescents exposed to terror (N = 2908), and (b) citizens and army personnel following the second Lebanon War (N = 588). Across studies the results showed that high levels of resilience were associated with the lowest posttraumatic growth scores. The results imply that although growth and resilience are both salutogenic constructs they are inversely related. The theoretical and clinical implications of these findings are discussed.

The longitudinal course of posttraumatic stress disorder symptom clusters among war veterans

OBJECTIVE

The aim of this study was to examine the long-term trajectories and interrelationships of posttraumatic stress disorder (PTSD) symptom clusters (intrusion, avoidance, and hyperarousal) in clinical and nonclinical groups of war veterans.

METHOD

Six hundred seventy-five Israeli veterans from the 1982 Lebanon War were assessed. The clinical group consisted of 369 who had combat stress reaction (CSR) during the war, and the nonclinical group consisted of 306 veterans with no antecedent CSR. The 2 groups were matched in age, education, military rank, and assignment. They were prospectively evaluated 1, 2, and 20 years after the war.

RESULTS

The clinical group endorsed a higher number of symptoms than the nonclinical group, both cross-sectionally and across time. In both the clinical and nonclinical groups, the clusters of intrusion, avoidance, and hyperarousal were interrelated at any given point in time and across 20 years. In both groups, avoidance was found to be a particularly stable symptom cluster over time. Finally, hyperarousal levels 1 year after the war were found to play an important role in both groups, as they predicted future avoidance and intrusion symptoms.

CONCLUSIONS

The findings of this study suggest that PTSD is not a monolithic disorder, as symptom clusters differ in several important aspects. Also, the course and severity of symptoms differ between clinical and nonclinical groups. Finally, practitioners are encouraged to focus on the identification and treatment of early hyperarousal due to its prominent role in the development of other PTSD symptoms.

Gender Differences in PTSD in Israeli Youth Exposed to Terror Attacks

Differences between boys' and girls' exposure to terror and posttraumatic symptoms were examined in a sample of 2,999 Israeli adolescents. Gender differences were also assessed regarding perceived social support, religious beliefs, and ideological commitment. Results indicate that girls reported more posttraumatic symptoms than boys, although boys reported twice the rate of very severe symptoms. Differences were also found between boys and girls in levels of fear, religiosity, ideological commitment, and social support, but not regarding exposure. Path analysis revealed that gender is not a direct predictor of posttraumatic stress disorder (PTSD); however, it does have an indirect effect, especially through fear, which was the best predictor of PTSD. Social extrinsic religiosity and ideological intolerance were positive predictors of PTSD. The study concludes that gender differences in PTSD are largely the result of differences in levels of fear and are not due to differences in political ideology, religiosity, or social support.

Subjective age, PTSD and physical health among war veterans

OBJECTIVES

To examine the contribution of posttraumatic stress disorder (PTSD) and physical health to subjective age among war veterans.

METHOD

The sample included 502 veterans of the first Lebanon War who were assessed 20 years after the war by a series of self-report questionnaires. Data analyses included descriptive statistics, hierarchical and logistic regressions.

RESULTS

Veterans with PTSD reported older subjective age than veterans without PTSD. Furthermore, both PTSD and general physical health contributed to subjective age, above and beyond chronological age and negative life events. Among the physical health problems, memory problems and weight gain were found to contribute to older age identity. In addition, the relation between general physical health and subjective age was stronger among veterans without PTSD than among veterans with PTSD.

DISCUSSION

Possible explanations, clinical implications for integrative therapy for elderly PTSD victims, and recommendations for future research are presented.

Trajectories of self-rated health among veterans: a latent growth curve analysis of the impact of posttraumatic symptoms

OBJECTIVES

To examine the effects of combat stress reaction (CSR) and posttraumatic stress symptoms (PTS) on the level and trajectories of self-rated health (SRH) over 20 years after war exposure.

METHODS

A total of 675 veterans comprising two groups, a CSR group (n = 369) and a matched control group without CSR (n = 306), were assessed in a prospective longitudinal design, 1, 2, 3, and 20 years after their participation in the 1982 Lebanon War. SRH and PTS were assessed repeatedly, at each point of measurement.

RESULTS

The CSR participants showed more impaired initial SRH than the controls. Although the CSR group showed an improvement in SRH over time, its SRH level remained lower than that of the control group in all 4 points in time. Initial levels of PTS were associated with more impaired SRH and lower improvement over time. In addition, increased levels of PTS in the first follow-up period were related to poorer SRH, in comparison to the predicted trajectory on the basis of CSR and initial PTS.

CONCLUSIONS

Stress reaction to war trauma affected the trajectory of SRH over a 20-year period. Although the differences between veterans who had shown acute stress reaction and those who had not persisted over the entire period, there was slow improvement in SRH over time among the more impaired CSR group. PTS in the first years after the war slowed this improvement and thus played a key role in the relationship between war trauma and physical health.

Cumulative trauma, PTSD and dissociation among Ethiopian refugees in Israel

OBJECTIVE

The aim of this study was to examine the exposure of Ethiopian refugees to pre-, peri- and post-migration stressful events and their implications for both posttraumatic stress disorder (PTSD) and dissociation.

METHOD

A random sample (N = 478) of three groups of refugees took part in the research ("Moses" immigrants, 1984, n = 165; "Solomon" immigrants, 1991, n = 169; "Family Reunification" immigrants, 1995, n = 144). Exposure to stressful events and posttraumatic symptoms were assessed via the Harvard Trauma Questionnaire (HTQ). Post-migration difficulties were assessed via the Post Migration Living Difficulties (PMLD) scale. Dissociation was evaluated using the Dissociation Experience Scale (DES).

RESULTS

Significant differences were found among the groups in the rates of PTSD (27%, 15%, and 26%, respectively), but no differences were found in dissociation. A significant relationship was found between PTSD symptoms and cumulative trauma among the three groups, but no such relationship was found between dissociation and cumulative trauma. The differences among the groups were discussed in light of the unique characteristics of cumulative trauma, PTSD and dissociation among Ethiopian refugees.

Differentiation of the self and posttraumatic symptomatology among ex-POWs and their wives

War captivity is a highly traumatic experience which sometimes has deleterious effects on both ex-POWs and their wives. This study examined the relationships between posttraumatic stress disorder (PTSD) symptoms and differentiation among male ex-prisoners of war (ex-POWs; n = 103), their wives (n = 82), and comparable controls. Results show that ex-POWs and their wives endorsed more PTSD symptoms than controls. Ex-POWs endorsed more cut-off and fusion than controls, while their wives endorsed only more fusion than control wives. Finally, the relationship between differentiation and PTSD was found to be stronger among ex-POW couples than among control couples. The unique characteristics of war captivity and the relationships between avoidance symptoms and cut-off were suggested as possible explanations.

The psychological toll of the Intifada: symptoms of distress and coping in Israeli soldiers

BACKGROUND

Detrimental effects of military service among the civilian Palestinian population have been reported in soldiers.

OBJECTIVES

To examine the frequency and type of stressors encountered by soldiers in close contact with the CPP and its relationship with post-traumatic symptomatology. We also investigated coping methods and the preferred types of professional help.

METHODS

Using random digit dialing methodology we conducted a phone survey of veteran soldiers, men (n=167) and women (n=59) in close contact with the CPP; the comparison group comprised male veteran soldiers with no CPP exposure (n=74). We used focus groups to develop context-related measures to assess exposure to violent incidents, coping modes and preferred modes of professional assistance. We included measures of traumatic exposure, post-traumatic stress symptoms and post-traumatic stress disorder.

RESULTS

Soldiers who served among the CPP had greater exposure to traumatic events and to civilian-related violent incidents (more than half as victims, and a third as perpetrators); and 17.4% perceived their behavior as degrading civilians. Primary traumatic exposure, perceived health problems and avoidance coping were found to be risk factors for PTS and PTSD. Involvement in incidents that may have degraded Palestinian civilians predicted PTS.

CONCLUSIONS

Friction with the CPP in itself does not constitute a risk factor for psychopathology among soldiers. However, contact with this population entails more exposure to traumatic events, which may cause PTS and PTSD. Furthermore, a relative minority of soldiers may be involved in situations that may degrade civilians, which is a risk factor for PTS. To avoid violent and sometimes degrading behaviors, appropriate psycho-educational and behavioral preparation should be provided.

Does one size fit all? The challenges of establishing a coordinating center for research of post-disaster needs assessment

Needs assessment in the wake of disasters is most significant yet highly complex and challenging. Kessler et al. propose a comprehensive disaster mental health research model. This model has several significant advantages: (1) Pre-prepared plans and resources allow rapid deployment of skilled professionals; (2) Continuity will ensure that lessons learned from one disaster will be retained and used in subsequent disasters; (3) Standardization will provide a solid basis for evaluation and comparison across events; (4) Continuous monitoring of needs over time will enable the capture of a full range of responses including delayed effects; and (5) Will provide a valuable resource for researchers in the field. At the same time, there are a number of challenges that must be considered before the establishment and implementation of the proposed center and use of standardized measures. These challenges are associated with the observation that different disasters give rise to different problems and needs; there is considerable cultural variability; and differential power and agenda of stakeholders may result in a limiting 'tunnel vision' approach that may undermine new developments, creativity, and progress. Ways to overcome these challenges and difficulties that are involved in the implementation of such a model are suggested.

PTSD symptoms, forgiveness, and revenge among Israeli Palestinian and Jewish adolescents

Exposure to political terror and its psychological toll were assessed in 276 Israeli Palestinian and 1,469 Jewish adolescents using self-report questionnaires. Israeli Palestinians displayed more posttraumatic symptoms, higher levels of objective exposure to terror, more negative life events, lower ability to forgive, and a higher need for vengeance than their Jewish counterparts. Although the two groups did not differ in fear levels, Israeli Palestinians expressed more favorable attitudes toward peace. Ethnicity played a major role in explaining the variance of posttraumatic symptomatology. Israeli Palestinians displayed increased vulnerability to mental distress when compared to their Jewish counterparts. The unique roles of subjective fear, attitudes towards peace, forgiveness, and revenge among Israeli Palestinians are discussed.

Posttraumatic growth in adolescence: examining its components and relationship with PTSD

To address gaps in the literature, this study examined the components of posttraumatic growth, and the relationship between growth and posttraumatic stress disorder (PTSD). Participants were from a pooled sample of 4,054 Israeli adolescents exposed to terror of whom 210 (5.5%) met criteria for PTSD. Measures included the Child Post-Traumatic Stress Reaction Index and Posttraumatic Growth Inventory. Principal components analysis showed two correlated components of outward and intrapersonal growth. Regression modeling showed that the relationship between the growth and PTSD measures was linear and curvilinear (inverted-U). These results replicated accounting for heterogeneity in PTSD, exposure and subsamples. Collectively, the results imply that posttraumatic growth in adolescence is characterized by two robust components, and is greatest at moderate posttraumatic stress levels.

Complex trauma of war captivity: a prospective study of attachment and post-traumatic stress disorder

BACKGROUND

Victims of war captivity sometimes suffer from complex post-traumatic stress disorder (PTSD), a unique form of PTSD that entails various alterations in personality. These alterations may involve changes in attachment orientation.

METHOD

The sample comprised two groups of veterans from the 1973 Yom Kippur War: 103 ex-prisoners of war (ex-POWs) and 106 comparable control veterans. They were assessed at two points in time, 18 years and 30 years after the war.

RESULTS

Ex-POWs suffered from more post-traumatic symptoms than controls at both measurements points and these symptoms increased only among ex-POWs from Time 1 to Time 2. In addition, both attachment anxiety and attachment avoidance increased with time among ex-POWs, whereas they decreased slightly or remained stable among controls. Finally, the increases in attachment anxiety and avoidance were positively associated with the increase in post-traumatic symptoms among both study groups. Further analyses indicated that early PTSD symptoms predicted later attachment better than early attachment predicted later PTSD symptoms.

CONCLUSIONS

The results suggest that: (1) complex traumas are implicated in attachment orientations and PTSD symptoms even many years after captivity; (2) there is an increase in attachment insecurities (anxiety, avoidance) and an increase in PTSD symptoms decades after the captivity; (3) and post-traumatic stress symptoms predict attachment orientations better than attachment orientations predict an increase in PTSD symptoms.

Acute stress responses: A review and synthesis of ASD, ASR, and CSR

Toward the development of a unifying diagnosis for acute stress responses this article attempts to find a place for combat stress reaction (CSR) within the spectrum of other defined acute stress responses. This article critically compares the diagnostic criteria of acute stress disorder (ASD), acute stress reaction (ASR), and CSR. Prospective studies concerning the predictive value of ASD, ASR, and CSR are reviewed. Questions, recommendations, and implications for clinical practice are raised concerning the completeness of the current acute stress response diagnoses, the heterogeneity of different stressors, the scope of expected outcomes, and the importance of decline in function as an indicator of future psychological, psychiatric, and somatic distress.

The relationships between posttraumatic stress symptom clusters and marital intimacy among war veterans

This study examined (a) the relationships between posttraumatic stress disorder (PTSD) symptom clusters and marital intimacy among Israeli war veterans and (b) the role of self-disclosure and verbal violence in mediating the effects of PTSD avoidance and hyperarousal symptoms on marital intimacy. The sample consisted of 219 participants divided into 2 groups: ex-prisoners of war (ex-POWs; N = 125) and a comparison group of veterans who fought in the same war but were not held in captivity (N = 94). Ex-POWs displayed higher levels of PTSD symptoms and verbal violence and lower levels of self-disclosure than did controls. Although ex-POWs and controls did not differ in level of marital intimacy, they did, however, present a different pattern of relationships between PTSD clusters and intimacy. In ex-POWs, self-disclosure mediated the relations between PTSD avoidance and marital intimacy. Verbal aggression was also found via indirect effect of hyperarousal on marital intimacy. The results point to the importance of self-disclosure and verbal violence as interpersonal mechanisms for the relations between posttraumatic symptoms on marital intimacy of ex-POWs.

Investigation of exposure-symptom relationships in a context of recurrent violence

Preliminary investigations of disasters, including terrorism, have identified degree of exposure as a highly reliable predictor of trauma symptoms. However, this effect has not been consistently demonstrated in studies conducted in Israel. One explanation for this may be found in the different mechanisms that influence the relationship between exposure and symptoms in situations of recurrent versus one-time terror events. We examined traumatic symptoms and response to life events as variables which may be affected by repeated exposure to violence. Students from Tel Aviv University (n=65) and the College of Judea and Samaria, in the West Bank (n=47), completed measures of exposure to terrorism, trauma symptoms, life event stress reactions, and psychopathology. As in previous studies, no relationship between the overall degree of terror-related exposure and trauma symptoms was found for either group. General level of anxiety mediated the relationship between terror-related trauma symptoms and life event stress reactions. For the Ariel group, exposure to terror was related to anxiety and hostility. Direct terror-related exposure was negatively related to life event stress for the Tel Aviv group. In summary, our findings suggest that the exposure-symptom relationship may function differently in a context of ongoing threat than in a context of single-event terror.

The contribution of stressful life events throughout the life cycle to combat-induced psychopathology

This study examines the contribution of prewar life events, war exposure, and postwar life events to combat-induced psychopathology among 425 Israeli War veterans from the Lebanon War. Data was collected at two time points (1983 and 2002). The sample included veterans with and without combat stress reaction (CSR). Battle intensity and subjective experience of risk in war were associated with CSR. Negative childhood life events, CSR, PTSD in 1983 and postwar negative life events were associated with PTSD in 2002. Furthermore, a path analysis revealed that CSR mediated the relation between battle intensity and PTSD in 2002. Our findings suggest that stressful life events throughout the life cycle contribute significantly to veterans' posttraumatic symptomatology, above and beyond combat exposure.

The contribution of loneliness and posttraumatic stress disorder to marital adjustment following war captivity: a longitudinal study

This prospective study examined the relative contribution of loneliness and posttraumatic stress disorder (PTSD) to marital adjustment among Israeli veterans of the 1973 Yom Kippur war. Specifically, we examined the mediating role of loneliness as measured in 1991 in the association between PTSD as measured in 1991 and marital adjustment as measured in 2003. Our sample consisted of 225 participants divided into 2 groups: ex-prisoners of war (ex-POWs) (N = 122) and a comparison group comprised of veterans who fought in the same war but who had not experienced captivity (N = 103). The findings demonstrate that ex-POWs display lower levels of marital adjustment and higher levels of PTSD than controls. Loneliness was found to mediate the relationship between PTSD as measured in 1991 and marital adjustment as measured in 2003 for both ex-POWs and controls. Further, for ex-POWs, loneliness contributes to marital adjustment above and beyond the contribution of PTSD as measured in 2003. The theoretical implications of loneliness for the marital relationships of traumatized ex-POWs are discussed.

The mental health impact of terrorism in Israel: a repeat cross-sectional study of Arabs and Jews

OBJECTIVE

Since September 2000 Israeli society has been subjected to numerous deadly terror attacks. Few studies have studied the comparative mental health vulnerability of minorities and majorities to continuous terror attacks.

METHOD

Two telephone surveys (N = 512 and 501) on two distinct representative samples of the Israeli population after 19 months and after 44 months of terror. The Arab minority and Jewish majority were compared on measures of exposure to terrorism, posttraumatic stress symptomatology, feeling depressed, coping, sense of safety, future orientation, and previous traumatic experiences.

RESULTS

After 19 months of terrorist attacks Arab Israelis and Jewish Israelis reacted roughly similarly to the situation, however after 44 months of terror, posttraumatic symptom disorder in the Arab population increased three-fold, posttraumatic symptomatology doubled and resiliency almost disappeared.

CONCLUSION

We suggest that certain conditions inherent to political conflict situations may potentially put minorities at risk and may only be observable as terrorism-related stressors become chronic.

Posttraumatic stress disorder and posttraumatic growth among Israeli ex-pows

In this article, the authors present a prospective study that dealt with pathological (posttraumatic stress disorder; PTSD) and salutary (posttraumatic growth; PTG) outcomes of captivity and the correlates of those outcomes among a sample of ex-prisoners of war (POWs) and a control group of combat veterans. Posttraumatic stress disorder and its correlates were assessed in 1991 and 2003, and PTG was assessed in 2003. The results indicate that ex-POWs exhibited higher levels of PTSD and PTG than did the controls. In addition, both linear and quadratic associations between PTSD and PTG were found. The authors discuss some unresolved issues related to assessment of PTG and salutary outcomes, and outline directions for future research.

Factor structure and concurrent validity of the world assumptions scale

The factor structure of the World Assumptions Scale (WAS) was assessed by means of confirmatory factor analysis. The sample was comprised of 1,710 participants who had been exposed to trauma that resulted in whiplash. Four alternative models were specified and estimated using LISREL 8.72. A correlated 8-factor solution was the best explanation of the sample data. The estimates of reliability of eight subscales of the WAS ranged from .48 to .82. Scores from five subscales correlated significantly with trauma severity as measured by the Harvard Trauma Questionnaire, although the magnitude of the correlations was low to modest, ranging from .08 to -.43. It is suggested that the WAS has adequate psychometric properties for use in both clinical and research settings.