Israeli civilians under heavy bombardment: prediction of the severity of post-traumatic symptoms

Physical Trauma Following Rocket Warning Sirens in Israel

INTRODUCTION

Civilians constitute a significant wartime target, and trauma accounts for most of their injuries. Air raid sirens have long been used to alert civilians of incoming attacks and have since expanded to warn from natural disasters. Sirens are known to cause significant emotional distress and physiological changes. Injuries inflicted from trauma while moving for shelter have yet to be described in the medical literature.

METHODS

During the recent Israel-Gaza conflict of May 2021, most of Israel's population experienced rocket warning sirens. We collected all adult (18<) patients arriving at a major tertiary medical center emergency department (ED), attesting to having suffered their injury while rushing for shelter. Clinical and demographic data were retrieved and analyzed.

RESULTS

A total of 48 patients were identified, with a mean age of 59.6 ± 20.0. Ten (21%) patients were admitted, and their mean length of stay was 4.4 ± 3.7 days. Women had a higher probability of being hospitalized (42.9% vs. 5.9%, P = .04), and those hospitalized tended to be older (68.8 ± 16.4 vs. 54.8 ± 20.8, P = .06). Elderly patients (65<) had a higher risk of injury. Extremity injuries were most common (50%), before head trauma (29%) and torso injuries (25%). Most patients (38/48, 79.2%) were discharged from the ED, and the rest were hospitalized for observation or surgery. One patient died from a head injury.

CONCLUSIONS

This study implies that injuries while moving for shelter were a prevalent cause of physical injury to Israeli civilians during the Israel-Gaza 2021 conflict. Warning sirens injuries should be given appropriate attention-from prevention by directed media campaigns to post-conflict reimbursement.

Behavioral Self-Blame in PTSD-Etiology, Risk Factors, and Proposed Interventions

BACKGROUND

Feeling out of control during a traumatic event may evoke behavioral self-blame (BSB) to avoid feeling helpless following trauma by restoring one's sense of control. BSB is a common, persistent, and treatment-resistant post-traumatic stress symptom. The present study investigates the etiology and risk factors of BSB following a traumatic event and the reasons for its persistence over time.

METHOD

Subjects were a group of 546 Israeli ex-combat soldiers (M age = 24.93 ± 5.657) registered in an Israel Defense Forces (IDF) combat reaction clinic. All completed the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), the Brief Symptom Inventory (BSI), and the PTSD Checklist for the DSM-5 (PCL-5). Item 10 of the PCL-5 served to measure BSB. The PDEQ and BSI measured distress and feeling out of control during the event. We used descriptive analyses of the data, t-test, and linear regression analysis to reveal the relationship between the research variables.

RESULTS

Feeling out of control during a traumatic event often increases BSB and post-traumatic stress symptoms. A significant correlation emerged between continuing distress characterizing individuals who experience a persistent lack of control and BSB. Female combat soldiers were at a higher risk of BSB than their male counterparts.

CONCLUSION

Loss of control experienced during a traumatic event may result in persistent long-term feelings of lack of control over one's behavior.

Ecological analysis of Pavlovian fear conditioning in rats

Pavlovian fear conditioning, which offers the advantage of simplicity in both the control of conditional and unconditional stimuli (CS, US) presentation and the analysis of specific conditional and unconditional responses (CR, UR) in a controlled laboratory setting, has been the standard model in basic and translational fear research. Despite 100 years of experiments, the utility of fear conditioning has not been trans-situationally validated in real-life contexts. We thus investigated whether fear conditioning readily occurs and guides the animal's future behavior in an ecologically-relevant environment. To do so, Long-Evans rats foraging for food in an open arena were presented with a tone CS paired with electric shock US to their dorsal neck/body that instinctively elicited escape UR to the safe nest. On subsequent test days, the tone-shock paired animals failed to exhibit fear CR to the CS. In contrast, animals that encountered a realistic agent of danger (a looming artificial owl) paired with a shock, simulating a plausible predatory strike, instantly fled to the nest when presented with a tone for the first time. These results highlight the possibility of a nonassociative, rather than standard associative, fear process providing survival function in life-threatening situations that animals are likely to encounter in nature.

Religiosity: Protective or Risk Factor for Posttraumatic Distress Among Adolescents Who Were Exposed to Different Types of Acts of Political Violence

This study examined the potential moderating effects of religiosity on the associations between exposure to acts of political violence and posttraumatic stress symptoms (PTS) among Jewish adolescents in Israel. In addition, it examined whether self-reported physical and interpersonal exposure to acts of political violence predicts PTS symptoms beyond the objective exposure effects (i.e., the proximity of participants' place of residence to high-, moderate-, or low-intensity political violence). A representative sample of 2,992 Jewish high school students (Grades 10 and 11) was taken. We used self-reporting to measure the level of religiosity and the Impact of Events Scale-Revised (IES-R) to measure PTS symptoms. Results show that self-reported exposure to acts of political violence adds a significant additional amount of variance to the prediction of PTS symptoms after objective exposure is already included in the regression equation. Religiosity was found as a risk factor for PTS symptoms such that the greater the religiosity of the adolescents, the higher their PTS symptoms. Therefore, prevention interventions should target the vulnerable group of religious Jewish adolescents.

Heightened Levels of Maladaptive Daydreaming Are Associated With COVID-19 Lockdown, Pre-existing Psychiatric Diagnoses, and Intensified Psychological Dysfunctions: A Multi-country Study

The COVID-19 pandemic has been spreading globally since December 2019, bringing with it anxieties, mortal risk, and agonizing psychological suffering. This study aimed to explore the relationship between maladaptive daydreaming (MD)-an addictive mental behavior to vivid fantasy associated with distress and functional impairment-and forced COVID-19 pandemic-related self-isolation and quarantine. Previous literature indicated that individuals employ MD for the regulation of distress and boredom, wish fulfillment, and entertainment experiences. The literature on the impact of the COVID-19 pandemic on mental health identifies a flareup in psychological difficulties in the general population. In this study we explored the associations between the pandemic threat and mental health indices among individuals with MD. We surveyed 1,565 adults from over 70 countries who responded to calls for participants posted in online MD communities and other general social media sites. Probable MD was determined based on an empirically derived cut-off score on a pertinent measure. After controlling for sociodemographic variables, a series of MANCOVAs, followed by post-hoc ANCOVAs, revealed that individuals with probable MD who were observing lockdown restrictions reported having spent more time in fantasy, experienced more intense and vivid daydreaming, and had a stronger urge to daydream than other participants. Similar statistical procedures indicated that, individuals with probable MD who reported pre-existing anxiety and depression disorders described a greater urge to daydream due to the pandemic and greater difficulty to control this addictive behavior. Compared to individuals with likely normal daydreaming, individuals with suspected MD reported more pandemic-attributed deterioration on a wide array of psychological distress indices. Our data show that the current worldwide pandemic threat is connected with an elevated intensity of this addictive form of mental activity, and that MD is associated with the exacerbation of psychological distress and dysfunction rather than with beneficial regulation of the experienced stressor.

Trauma and PTSD in the WHO World Mental Health Surveys

Background: Although post-traumatic stress disorder (PTSD) onset-persistence is thought to vary significantly by trauma type, most epidemiological surveys are incapable of assessing this because they evaluate lifetime PTSD only for traumas nominated by respondents as their 'worst.' Objective: To review research on associations of trauma type with PTSD in the WHO World Mental Health (WMH) surveys, a series of epidemiological surveys that obtained representative data on trauma-specific PTSD. Method: WMH Surveys in 24 countries (n = 68,894) assessed 29 lifetime traumas and evaluated PTSD twice for each respondent: once for the 'worst' lifetime trauma and separately for a randomly-selected trauma with weighting to adjust for individual differences in trauma exposures. PTSD onset-persistence was evaluated with the WHO Composite International Diagnostic Interview. Results: In total, 70.4% of respondents experienced lifetime traumas, with exposure averaging 3.2 traumas per capita. Substantial between-trauma differences were found in PTSD onset but less in persistence. Traumas involving interpersonal violence had highest risk. Burden of PTSD, determined by multiplying trauma prevalence by trauma-specific PTSD risk and persistence, was 77.7 person-years/100 respondents. The trauma types with highest proportions of this burden were rape (13.1%), other sexual assault (15.1%), being stalked (9.8%), and unexpected death of a loved one (11.6%). The first three of these four represent relatively uncommon traumas with high PTSD risk and the last a very common trauma with low PTSD risk. The broad category of intimate partner sexual violence accounted for nearly 42.7% of all person-years with PTSD. Prior trauma history predicted both future trauma exposure and future PTSD risk. Conclusions: Trauma exposure is common throughout the world, unequally distributed, and differential across trauma types with respect to PTSD risk. Although a substantial minority of PTSD cases remits within months after onset, mean symptom duration is considerably longer than previously recognized.

Association of DSM-IV Posttraumatic Stress Disorder With Traumatic Experience Type and History in the World Health Organization World Mental Health Surveys

IMPORTANCE

Previous research has documented significant variation in the prevalence of posttraumatic stress disorder (PTSD) depending on the type of traumatic experience (TE) and history of TE exposure, but the relatively small sample sizes in these studies resulted in a number of unresolved basic questions.

OBJECTIVE

To examine disaggregated associations of type of TE history with PTSD in a large cross-national community epidemiologic data set.

DESIGN, SETTING, AND PARTICIPANTS

The World Health Organization World Mental Health surveys assessed 29 TE types (lifetime exposure, age at first exposure) with DSM-IV PTSD that was associated with 1 randomly selected TE exposure (the random TE) for each respondent. Surveys were administered in 20 countries (n = 34 676 respondents) from 2001 to 2012. Data were analyzed from October 1, 2015, to September 1, 2016.

MAIN OUTCOMES AND MEASURES

Prevalence of PTSD assessed with the Composite International Diagnostic Interview.

RESULTS

Among the 34 676 respondents (55.4% [SE, 0.6%] men and 44.6% [SE, 0.6%] women; mean [SE] age, 43.7 [0.2] years), lifetime TE exposure was reported by a weighted 70.3% of respondents (mean [SE] number of exposures, 4.5 [0.04] among respondents with any TE). Weighted (by TE frequency) prevalence of PTSD associated with random TEs was 4.0%. Odds ratios (ORs) of PTSD were elevated for TEs involving sexual violence (2.7; 95% CI, 2.0-3.8) and witnessing atrocities (4.2; 95% CI, 1.0-17.8). Prior exposure to some, but not all, same-type TEs was associated with increased vulnerability (eg, physical assault; OR, 3.2; 95% CI, 1.3-7.9) or resilience (eg, participation in sectarian violence; OR, 0.3; 95% CI, 0.1-0.9) to PTSD after the random TE. The finding of earlier studies that more general history of TE exposure was associated with increased vulnerability to PTSD across the full range of random TE types was replicated, but this generalized vulnerability was limited to prior TEs involving violence, including participation in organized violence (OR, 1.3; 95% CI, 1.0-1.6), experience of physical violence (OR, 1.4; 95% CI, 1.2-1.7), rape (OR, 2.5; 95% CI, 1.7-3.8), and other sexual assault (OR, 1.6; 95% CI, 1.1-2.3).

CONCLUSION AND RELEVANCE

The World Mental Health survey findings advance understanding of the extent to which PTSD risk varies with the type of TE and history of TE exposure. Previous findings about the elevated PTSD risk associated with TEs involving assaultive violence was refined by showing agreement only for repeated occurrences. Some types of prior TE exposures are associated with increased resilience rather than increased vulnerability, connecting the literature on TE history with the literature on resilience after adversity. These results are valuable in providing an empirical rationale for more focused investigations of these specifications in future studies.

The differential impact of terrorism on two Israeli communities

The authors evaluated 2 cohorts of individuals from different Israeli communities (Sderot and Otef Aza) that are repeatedly subjected to potentially lethal missile attacks. Although both communities border the Gaza Strip and face similar levels of threat, the authors hypothesized that the Sderot cohort would endorse higher rates of stress-related symptoms because it has fewer mitigating economic and psychosocial resources. The authors further hypothesized that there would be a significant relationship between exposure to terror and psychopathology regardless of community context. To test these predictions, the authors compared the levels of exposure to terror, posttraumatic stress disorder (PTSD), and depression in representative samples of adults from the 2 communities (n = 298 and n = 152, respectively). Residents of Sderot had a much higher rate of probable PTSD (35.2% vs. 6.6%), and community context was the most important predictor of PTSD and depression. The study also revealed a significant relationship between exposure and psychopathology, but for Sderot residents only. The conclusion is that researchers, mental health workers, and policy makers should pay attention to the influence of community characteristics, such as the availability of resources, the general sense of support, and the level of solidarity, on the mental health response to exposure to terror.

Ongoing exposure versus intense periodic exposure to military conflict and terror attacks in Israel

The manifestation of posttraumatic stress disorder (PTSD) symptoms in two clinical samples in Israel (N = 212) was examined. Individuals suffering ongoing exposure to shelling were compared with subjects exposed to intense periodic exposure. Elevated arousal and avoidance symptoms, but not intrusion were reported in the ongoing exposure group. When compared by age, young participants in the ongoing exposure group had significantly lower PTSD scores, whereas no differences were found between participants among the intense periodic exposure age groups. No gender differences in symptoms were found among participants from intense periodic exposure, whereas in the other ongoing group the difference was in avoidance. Results are discussed in light of past research on exposure to terrorism.