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

The Psychological Impact of Exposure to Battle on Medics: A Cross-Sectional Study of Ex-Soldiers Who Sought Help From the IDF Combat Reaction Unit

INTRODUCTION

The present study's central aim was to examine two questions: (1) Will there be differences in mental health outcomes between medics and non-medics who sought help at the Israeli Combat Reaction Unit (CRU)? (2) Will there be differences in mental health outcomes between combatants and non-combatants?

MATERIALS AND METHODS

This cross-sectional study included files of 1,474 Israeli Defense Forces ex-service members (89% combatants, of whom 13% were medics; 11% non-combatants, of whom 6% were medics), who filled out questionnaires on admission for evaluation at the CRU.Dependent variables were mental health measures and included two PTSD measures (Clinician-Administered PTSD Scale and PTSD Checklist for DSM-5), Beck Depression Inventory, Dissociative Experience Scale, and Brief Symptom Inventory. Military profession (medics vs. non-medics) and status (combatant vs. non-combatant) were the independent variables. Background variables were also examined.

RESULTS

We found no substantial differences between medics and non-medics in the mental health measures. When looking at combat and non-combat separately, the non-combat medics (CMs), in general, were in better mental health conditions than the other three groups- CMs, non-medic combatants, and non-medic non-combatants-all of whom had similar scores in the mental health measures. However, compared to the rest, non-CMs took considerably longer years before approaching the CRU.

CONCLUSIONS

The elapsed time to seek help for non-MCs was explained by their reluctance to seek help, not being combatants, and being medics who are portrayed as resilient. Recommendations for encouraging this subgroup to seek help were given.

The Impact of Complex PTSD on Suicide Risk in Patients with Bipolar Disorder: A Cross-Sectional Study

BACKGROUND

Patients with bipolar disorder (BD) are more likely than the general population to experience traumatic events, particularly during childhood, and these may predict and be a risk factor for the development of complex PTSD (cPTSD). The presence of multiple traumas plays a relevant role from a psychopathological point of view, but little is known about the effect this may have on suicide attempts in patients with BD.

METHODS

A cross-sectional study was conducted comparing socio-demographic and clinical characteristics, recruiting 344 patients diagnosed with BD I and II, screened for the presence (or absence) of cPTSD using the International Trauma Questionnaire (ITQ). Suicide attempts were assessed directly during the clinical interview and from the patient's medical record.

RESULTS

The results emerging from the study indicate that cPTSD can be considered a risk factor for suicide attempts in patients with BD. Furthermore, evidence is provided to support the idea that cPTSD is highly prevalent in patients with BD and is related to a higher psychopathological burden.

CONCLUSIONS

The results recommend an urgent and comprehensive assessment of suicidal risk in patients with comorbidity of both bipolar disorder and cPTSD. There is a crucial demand for early intervention initiatives and proactive prevention strategies to address the intricate intersection of these mental health challenges.

Predictors of Emotional Distress in Combat Military Flight Engineers

OBJECTIVE

Exposure to distressing sights (DSs) during combat missions may cause emotional distress. The present study aimed to investigate the association between exposure to DSs involving severe injuries and fatalities during rescue missions and emotional distress, in Israeli Air Force (IAF) helicopter flight engineers (FEs).

METHODS

Cross-sectional design using self-report questionnaires. The independent variables included demographics, personal, and military variables-exposure to DSs throughout a whole career service. The dependent variables included Depression (Beck Depression Inventory); State-Trait Anxiety Inventory; Post-traumatic stress disorder (PTSD Checklist-PCL-5); Somatization (Patient Health Questionnaire); Maslach Burnout Inventory; and Coping Strategies (The Brief COPE). The variables PTSD, depression, and anxiety were examined twice: once as dichotomous variables according to the pathology cutoff point and again as a continuous variable to reveal the intensity of symptoms.

RESULTS

Participants were 106 IAF helicopter FEs (mean age = 39.32, SD = 8.75). Linear regression revealed that initial exposure to distressing battlefield sights (i.e., exposure to severe injuries and fatalities) was a predictor of depression symptoms. Career service FEs aged 31-40 were found to be at the highest risk of emotional distress, with a predictive factor for anxiety symptoms. Use of nonadaptive coping strategies was found to predict depressive symptoms, anxiety symptoms, and post-traumatic stress symptoms.

CONCLUSION

A significant association was found between exposure to DSs involving severe injuries and fatalities during rescue missions and anxiety, depression, somatization, and burnout. This population is generally perceived as tough and resilient, and this study has a unique contribution in identifying its vulnerabilities. Psychological intervention is crucial after participating in such missions.

Loneliness in Posttraumatic Stress Disorder: A Neglected Factor in Accelerated Aging?

Prior research suggests that people with Posttraumatic Stress Disorder (PTSD) may experience a form of accelerated biological aging. In other populations, loneliness has been shown to elevate risk for many of the same components of accelerated biological aging, and other deleterious outcomes, as seen in people with PTSD. Although standard diagnostic criteria for PTSD include "feelings of detachment or estrangement from others", the relationship of such feelings to the concept of loneliness remains uncertain, in par potentially due to a failure to distinguish between loneliness versus objective social isolation. In order to catalyze wider research attention to loneliness in PTSD, and the potential contribution to accelerated biological aging, the present paper provides three components: (1) a conceptual overview of the relevant constructs and potential interrelationships, (2) a review of the limited extant empirical literature, and (3) suggested directions for future research. The existing empirical literature is too small to support many definitive conclusions, but there is evidence of an association between loneliness and symptoms of PTSD. The nature of this association may be complex, and the causal direction(s) uncertain. Guided by the conceptual overview and review of existing literature, we also highlight key areas for further research. The ultimate goal of this line of work is to elucidate mechanisms underlying any link between loneliness and accelerated aging in PTSD, and to develop, validate, and refine prevention and treatment efforts.

Adolescents hospitalised for suicidality: biomarkers, social and affective predictors: a cohort study

OBJECTIVES

The present research examines genomics and in vivo dynamics of family context and experienced affect following discharge from psychiatric hospitalisation for suicidal thoughts and behaviours (STBs). The purpose of this paper is to provide an overview of a new model, description of model-guided integration of multiple methods, documentation of feasibility of recruitment and retention and a description of baseline sample characteristics.

DESIGN

The research involved a longitudinal, multimethod observational investigation.

SETTING

Participants were recruited from an inpatient child and adolescent psychiatric hospital. 194 participants ages 13-18 were recruited following hospitalisation for STB.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants underwent a battery of clinical interviews, self-report assessments and venipuncture. On discharge, participants were provided with a phone with (1) the electronically activated recorder (EAR), permitting acoustic capture later coded for social context, and (2) ecological momentary assessment, permitting assessment of in vivo experienced affect and STB. Participants agreed to follow-ups at 3 weeks and 6 months.

RESULTS

A total of 71.1% of approached patients consented to participation. Participants reported diversity in gender identity (11.6% reported transgender or other gender identity) and sexual orientation (47.6% reported heterosexual or straight sexual orientation). Clinical interviews supported a range of diagnoses with the largest proportion of participants meeting criteria for major depressive disorder (76.9%). History of trauma/maltreatment was prevalent. Enrolment rates and participant characteristics were similar to other observational studies.

CONCLUSIONS

The research protocol characterises in vivo, real-world experienced affect and observed family context as associated with STB in adolescents during the high-risk weeks post discharge, merging multiple fields of study.

Posttraumatic stress disorder, complex PTSD and subtypes of loneliness among older adults

OBJECTIVES

Research examining the relationship between loneliness and Complex Posttraumatic Stress Disorder (CPTSD) is scarce, particularly among older adults. CPTSD includes the core symptoms of PTSD along with additional symptoms reflecting "disturbances in self-organisation" (DSO). This study examined the cross-sectional relationships between loneliness (emotional and social loneliness) and CPTSD symptoms (i.e., PTSD and DSO symptoms) in older adults.

METHODS

Structural equation modelling was used to examine these relationships in a nationally representative sample of US adults aged 60-70 years (n = 456).

RESULTS

Controlling for covariates, emotional loneliness was associated with PTSD (β = 0.31) and DSO (β = 0.57) symptoms whereas social loneliness was only associated with DSO symptoms (β = 0.25). The model explained 35.0% of the variance in PTSD symptoms and 71.3% in DSO symptoms.

CONCLUSION

These findings have important implications for treating and understanding PTSD/CPTSD and their correlates among older adults.

Posttraumatic stress disorder and loneliness are associated over time: A longitudinal study on PTSD symptoms and loneliness, among older adults

Loneliness has a pernicious effect on mental health in later life and is likely to have a bidirectional relationship with psychopathology. However, longitudinal research examining loneliness and posttraumatic stress symptoms among older adults is scarce. This study aimed to examine the longitudinal relationship between different types of loneliness (social and emotional) and posttraumatic stress symptoms. Using two waves of an older adult sample (n = 1,276) from the Longitudinal Aging Study Amsterdam (LASA), this longitudinal relationship was examined using a multivariate two wave-latent change score (2W-LCS) model. There were significant, however, very small increases in both posttraumatic stress symptoms and emotional loneliness over time, whereas, average social loneliness scores did not significantly increase/decrease over time. Changes in both social (β = .16) and emotional loneliness (β = .15) were associated with small changes in posttraumatic stress symptoms, consistent with the existence of a longitudinal association between the constructs, net of covariate effects. Results provide evidence of the existence of a longitudinal association between subtypes of loneliness and posttraumatic stress symptoms, among older adults. Results have implications for clinicians who should identify individuals at risk of developing posttraumatic stress symptoms, and for the theory of both posttraumatic stress disorder and loneliness.

Families in the Shadow of Traumatic Experiences: Negative World Assumptions and Family Relationships

World assumptions (WAs) are cognitive schemas concerning an individual's views of themselves, the world, and others. Although it is well established that WAs are negatively distorted by trauma exposure and strongly associated with posttraumatic psychopathology, the potential impact of WAs on close interpersonal relationships remains largely uninvestigated. The current study explored the implications of veterans' and their spouses' WAs on their marital and parental relationships. Male Israeli veterans (N = 213) from the 1973 Yom Kippur War and their wives were assessed for WAs, marital adjustment, and positive parenting 35-37 years postwar. Analyses included actor-partner interdependence modeling with mediators (APIMem) and were conducted separately for the three domains of WAs: world benevolence, world meaningfulness, and self-worth. The results indicated that both husbands' and wives' lower scores for all domain-specific WA scales were associated with lower scores on measures of marital adjustment and positive parenting. Lower scores for both spouses on scales measuring world benevolence and self-worth were associated with a spillover from lower marital adjustment to lower positive parenting. Finally, associations between one spouse's lower WA scores and the other spouse's spillover from lower marital adjustment to lower positive parenting (i.e., cross-spillover effects) were identified for wives' world benevolence ratings and husbands' self-worth, ds = 0.14-0.72. These results point to the detrimental ramifications of negative WAs on family relationships and the dynamics between the marital and parental family subsystems.

Self-Disgust Is Associated With Loneliness, Mental Health Difficulties, and Eye-Gaze Avoidance in War Veterans With PTSD

In the present study, we examined, for the first time, the association between self-disgust, loneliness, and mental health difficulties in war veterans diagnosed with PTSD. For this purpose, we used a mixed methods design, incorporating surveys and a novel eye-tracking paradigm, and compared the findings from the PTSD veteran group (n = 19) to those from a general population group (n = 22). Our results showed that the PTSD veteran group reported almost three times higher scores in self-disgust, and significantly higher scores in loneliness and mental health difficulties (anxiety and depression), compared to the general population. Furthermore, self-disgust mediated the association between loneliness and anxiety symptoms in both groups. The results from the eye-tracking paradigm further showed that veterans with PTSD displayed a self-avoidance gaze pattern, by looking significantly more toward pictures of faces of unknown others and away from their own face—a pattern that was not replicated in the general population group. Higher self-disgust scores were significantly associated with longer total gaze to the pictures of others (vs. the self). Our findings have implications for the role of self-disgust in the mental health of war veterans.

Appreciating the 4 "Ts" of Loneliness When Providing Psychiatric Care for the Lonely Patient

Loneliness can be evaluated from a 4-concept viewpoint of territory, threat, trauma and trust (4 Ts). Territory refers to an area of ownership that is controlled on a daily basis and is fundamental to one's daily life. Lonely individuals often manage boundaries by gaining greater control over their physical environment by territorial behavior. They guard personal territory well as the only area where they can exert dominance and feel safe. Perceptions of social isolation or loneliness increase vigilance for threats, decrease trust, and heighten feelings of vulnerability. Clinical teams caring for the lonely must be especially attentive to a history of prior trauma. Clinicians who ask permission, who pay attention to nonverbal cues, distance, and speed as they enter the lonely person's space, and who respect boundaries may be more successful in gaining trust. Achieving trust diminishes the risk of physical harm, while allowing lonely persons the perceived control they need to permit health care interventions. Veterans are at higher risk for loneliness. Given their military training, they may be particularly attentive to boundaries, protecting the perimeter, watching for threats, and defending their space. In this article, we discuss the successful mental health treatment of a lonely male veteran in a Veterans Affairs Medical Center, by paying attention to the 4 Ts of loneliness. We used a 4-step approach of validation, mentalization, reality testing, and socialization to decrease the sense of threat as we sought acceptance to the patient's territory, followed by building trust and working on past trauma.

Attachment Orientations Moderate the Self-Amplifying Cycle of Posttraumatic Stress Disorder and Negative Cognitions—A Seven-Year Longitudinal Study

Introduction: We examined whether attachment orientations moderated the self-amplifying cycle of Posttraumatic Stress Disorder (PTSD) and negative cognitions, decades after the trauma ended.

Method: We sampled Israeli veterans from the 1973 Yom Kippur War and assessed PTSD severity and cognitions about the self and the world, twice—35 (T1) and 42 (T2) years after the war. At T1, we assessed participants’ attachment orientations (anxiety, avoidance).

Results: Findings provided support for a self-amplifying cycle of PTSD severity and negative cognitions about others’ benevolence during the seven-year study period. Findings also indicated that this self-amplifying cycle was significant only among veterans who scored relatively high on attachment anxiety but not among those who had less anxious attachment. Attachment avoidance also moderated the prospective contribution of negative cognitions about the self and others to PTSD severity seven years later.

Discussion: The psychological mechanisms underlying the observed effects of attachment orientations were discussed.

Complex posttraumatic stress disorder (CPTSD) following captivity: a 24-year longitudinal study

Background: The World Health Organization(WHO) International Classification of Diseases, 11th version (ICD-11), has proposed a new trauma-related diagnosis of complex posttraumatic stress disorder (CPTSD), separate and distinct from posttraumatic stress disorder (PTSD). However, to date, no study has examined CPTSD over time. Objectives: This prospective study aimed to examine predictors and outcomes of latent classes of PTSD and CPTSD following war captivity. Method: A sample of 183 Israeli former prisoners of the 1973 Yom Kippur War (ex-POWs) participated in a 24-year longitudinal study with three waves of measurements (T1: 1991, T2: 2008, and T3: 2015). Participants completed validated self-report measures, and their cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA). Results: Estimated rates of PTSD and CPTSD were high at all waves, with PTSD rates higher than CPTSD. A Latent Class Analysis (LCA) identified three main classes at T2: (1) a small class with low probability to meet PTSD and CPTSD clusters criteria (15.26%); (2) a class high only in PTSD symptoms (42.37%) and (3) a class high only in CPTSD symptoms (42.37%). Importantly, higher levels of psychological suffering in captivity at T1 were associated with higher odds of being in the CPTSD class at T2. In addition, CPTSD at T2 was more strongly associated with low self-rated health, functional impairment, and cognitive performance at T3, compared to the PTSD only class. Conclusions: Adulthood prolonged trauma of severe interpersonal intensity such as war captivity is related to CPTSD, years after the end of the war. Exposure to psychological suffering in captivity is a risk factor for future endorsement of CPTSD symptoms. CPTSD among ex-POWs is a marker for future dire mental health and functional consequences.

Posttraumatic stress disorder and relationship functioning: A comprehensive review and organizational framework

Posttraumatic stress disorder (PTSD) is associated with impairments in relationship functioning. Beyond the abundance of research that has demonstrated this basic link, more recent research has begun to explore possible mediators and moderators of this association. The present paper reviews and synthesizes existing literature in the context of an overarching organizational framework of potential ways in which PTSD impacts relationship functioning. The framework organizes findings in terms of specific elements of PTSD and comorbid conditions, mediators (factors that are posited to explain or account for the association), and moderators (factors that are posited to alter the strength of the association). Specific symptoms of PTSD, comorbid symptoms, and many of the potential mediators explored have extensive overlap, raising questions of possible tautology and redundancy in findings. Some findings suggest that non-specific symptoms, such as depression or anger, account for more variance in relationship impairments than trauma-specific symptoms, such as re-experiencing. Moderators, which are characterized as individual, relational, or environmental in nature, have been the subject of far less research in comparison to other factors. Recommendations for future research and clinical implications of the findings reviewed are also presented.

Trajectories of attachment in older age: interpersonal trauma and its consequences

Previous studies suggest that attachment insecurities may increase after trauma exposure, an effect documented only at a group level. This study explores the heterogeneity of changes over time and examines the associations of the nature of the traumatic event (interpersonal and nonpersonal), and its consequences (posttraumatic stress disorder [PTSD] and loneliness) with attachment trajectories. Two groups of Israeli veterans participated: 164 former prisoners-of-war and 185 combat veterans. Attachment was assessed at four points (1991-2015). Risk factors were evaluated in 1991. Using latent growth mixture modeling, trajectories of attachment insecurities were explored. Three avoidance trajectories (stability, decrease, inverse u-shaped) and two anxiety trajectories (stability, decrease) were identified. The inverse u-shaped avoidance trajectory was associated with captivity, humiliation, loneliness, and PTSD, and stable avoidance was associated with loneliness. Stable anxiety was associated with captivity and loneliness. Attachment insecurities can change during aging and persist decades after a trauma. Trauma-related risk factors are related to more deleterious trajectories.

Traumatization, Loneliness, and Suicidal Ideation among Former Prisoners of War: A Longitudinally Assessed Sequential Mediation Model

Although highly researched among veterans, the underlying mechanisms of suicidal ideation (SI) among former prisoners of war (ex-POWs), especially in the long-term, have rarely been investigated. Furthermore, while posttraumatic stress symptoms (PTSS) and loneliness have been individually associated with veteran SI, and both may be differentially implicated by captivity versus war traumas, the interplay between them has yet to be examined. Filling this gap, the current longitudinal study examined a hypothetical sequential model wherein war captivity, compared with combat-induced trauma, is implicated in worse PTSS, which is then implicated in worse loneliness and PTSS, which together may explain subsequent SI. Two groups of Israeli veterans of the 1973 Yom Kippur War, 163 ex-POWs and 185 matched non-captive veterans were assessed 18 (T1) and 30 (T2) years after the war. Analyses indicated that compared with war, captivity was implicated in worse PTSS, which was implicated in worse loneliness, and these worked in tandem to implicate SI. Loneliness, however, was not directly affected by the type of trauma, nor was its relation to SI linked to its implication in subsequent PTSS. These results may inform future research and clinical practice as the study underscores the importance of both PTSS and loneliness in ex-POWs' long-term SI.

Role of neuroinflammation and sex hormones in war-related PTSD

The susceptibility to develop posttraumatic stress disorder (PTSD) is greatly influenced by both innate and environmental risk factors. One of these factors is gender, with women showing higher incidence of trauma-related mental health disorders than their male counterparts. The evidence so far links these differences in susceptibility or resilience to trauma to the neuroprotective actions of sex hormones in reducing neuroinflammation after severe stress exposure. In this review, we discuss the impact of war-related trauma on the incidence of PTSD in civilian and military populations as well as differences associated to gender in the incidence and recovery from PTSD. In addition, the mutually influencing role of inflammation, genetic, and sex hormones in modulating the consequences derived from exposure to traumatic events are discussed in light of current evidence.

Network analysis of persistent complex bereavement disorder in conjugally bereaved adults

Persistent complex bereavement disorder (PCBD) is a bereavement-specific syndrome characterized by prolonged and impairing grief. Most research on this syndrome rests on the traditional latent variable model, whereby symptoms reflect an underlying entity. The network (or causal system) approach offers an alternative framework for understanding PCBD that does not suffer from limitations inherent in the latent entity approach. The network approach to psychopathology conceptualizes the relation between symptoms and disorder as mereological, not reflective. That is, symptoms do not reflect an inferred, unobservable category or dimension, but rather are themselves constitutive of the disorder. Accordingly, we propose that PCBD constitutes a causal system of mutually reinforcing symptoms that arise following the death of a loved one and settle into a pathological equilibrium. In this study, we used data from the Changing Lives of Older Couples database to identify symptoms central to PCBD, to distinguish the PCBD network from an overlapping but distinct network of depression symptoms, and to examine how previously identified risk factors may contribute to the maintenance or development of PCBD. Together, these findings provide an important first step toward understanding the nature and etiology of the PCBD network.

Loneliness among older veterans in the United States: results from the National Health and Resilience in Veterans Study

OBJECTIVES

This study examined the current prevalence, and demographic, military, health, and psychosocial correlates of loneliness in a contemporary nationally representative sample of older U.S. veterans.

METHODS

Two thousand twenty-five veterans aged 60 years and older participated in the National Health and Resilience in Veterans Study. Loneliness was assessed using a questionnaire adapted from the Revised UCLA Loneliness Scale. A broad range of demographic, military, health, and psychosocial variables was also assessed.

RESULTS

44% of veterans reported feeling lonely at least some of the time (10.4% reported often feeling lonely). Greater age, disability in activities of daily living, lifetime traumas, perceived stress, and current depressive and post-traumatic stress disorder symptoms were positively associated with loneliness, and being married/cohabitating, higher income, greater subjective cognitive functioning, social support, secure attachment, dispositional gratitude, and frequency of attending religious services were negatively associated with loneliness. The largest magnitude associations were observed for perceived social support, secure attachment style, and depressive symptoms.

CONCLUSIONS

Loneliness is prevalent among older veterans in the United States, and associated with several health and psychosocial variables. These results suggest that multifactorial interventions that emphasize bolstering of social support and reduction of depressive symptoms may help mitigate loneliness in the rapidly growing population of older veterans.

The relationship of PTSD to negative cognitions: a 17-year longitudinal study

With the growing interest in the role of cognitions in PTSD, this prospective study examined the course and bi-directional relationship between post-trauma cognitions and symptoms of PTSD. A sample of Israeli combat veterans, including former prisoners of war, was assessed in 1991, and later followed up in 2003 and 2008. PTSD symptoms were measured at three time points. Cognitions concerning the self and the world were measured twice. Applying autoregressive cross-lagged (ARCL) modeling strategy, initial PTSD symptoms predicted subsequent negative cognitions but not vice versa. In addition, repeated measures design revealed that individuals with chronic PTSD symptoms had relatively negative cognitions that further amplified with time. More specifically, increasingly negative cognitions were documented among ex-prisoners of war. The main findings suggest that negative cognitions are fueled by PTSD and that in chronic PTSD there is an amplification of pathogenic outcomes over time. Discussion of the findings is in the context of current cognitive models of PTSD.

Military deployment: the impact on children and family adjustment and the need for care

PURPOSE OF REVIEW

Over a million children and their families have now experienced the stress of the deployment of a family member during the recent wars in Iraq and Afghanistan. Whereas there is an extensive clinical literature about the developmental challenges facing children and issues of family adjustment, there is a lack of systematic research. This review summarizes the findings of recent publications.

RECENT FINDINGS

Some veterans develop posttraumatic stress disorder as a consequence of their experiences. This condition drives many of the adverse changes in the families of returning veterans through the effects on intimacy and nurturance in their families of withdrawal, numbing and irritability that are components of posttraumatic stress disorder. There is the more general challenge that all families and children face when a partner/parent deploys of role ambiguity consequent on anxiety that is provoked by the threat that deployed family members experience. A study of Kuwaiti military showed that mothers' anxiety had the greatest impact on the children of deployed fathers, although absence of posttraumatic stress disorder in mothers could mitigate the effects of their fathers' posttraumatic stress disorder. Intervention programs are described, but there is a poverty of their evaluation.

SUMMARY

A substantial advantage of focusing on family adjustment is that it can facilitate access to mental healthcare for veterans while assisting families' positive adaptation.